Treatment Of Recurrent Patellar Dislocation Research Articles

Surgical treatment for recurrent patellar dislocation with severe torsional deformities:Double-level derotational osteotomy may not have a clear advantage over single-level derotational osteotomy in improving clinical and radiological outcomes.

The purpose of this study was toinvestigate whether double-level (femur + tibia) derotational osteotomy is superior to single-level femoral derotational osteotomy for recurrent patellar dislocation with severe femoral and tibial rotational deformities (femoral anteversion >30° and external tibial torsion >30°). Between January 2015 and June 2020, a total of 115 knees with recurrent patellar dislocation treated with combined medial patellofemoral ligament reconstruction (MPFL-R) and derotational osteotomies were evaluated after a minimum follow-up of 2 years. Among these cases, 15 knees that underwent double-level derotational osteotomy were included in the double-level group, which was propensity-matched in a 1:2 ratio to a single-level group of patients who underwent single-level femoral derotational osteotomy (30 knees). The clinical and radiological outcomes were evaluated and compared between the groups. Furthermore, the foot progression angle was measured preoperatively and 2 years after surgery. The patient-specific variables did not differ significantly between the double-and the single-level groups after propensity score matching. The postoperative mean foot progression angle was significantly lower in the double-level groupthan in the single-level group (9° ± 8° vs. 15° ± 11°; p = 0.014); however, there were no statistically significant differences between the groups in terms of any other clinical and radiological assessments. For patients with severe femoral and tibial torsional deformities (femoral anteversion >30° and external tibial torsion >30°), the double-level derotational osteotomy is superior to single-level osteotomy in maintaining normal foot progression angle, but it does not show an advantage in terms of patient-reported outcomes, radiological resultsand redislocation rate at minimum 2 years of follow-up. Furthermore, concomitant excessive external tibial torsion (>30°) did not have an adverse effect on clinical outcomes in patients who underwent derotational distal femoral osteotomy with MPFL-R due to excessive femoral anteversion. Level III.

Derotational distal femur osteotomy with medial patellofemoral ligament reconstruction can get good outcomes in the treatment of recurrent patellar dislocation with excessive TT-TG and increased femoral anteversion.

Surgery is the main treatment for recurrent patellar dislocation (PD). However, due to the complexity of anatomical factors, there is still a lack of consensus on the choice of combined surgical methods. This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament reconstruction combined with derotational distal femur osteotomies (MPFLR + DDFO) and combined with tibial tubercle osteotomies (MPFLR + TTO) for recurrent PD with increased femoral anteversion angles (FAA) and excessive tibial tubercle-trochlear groove (TT-TG) distance. In this retrospective analysis, MPFLR + DDFO and MPFLR + TTO patients from 2015 to 2020 were included. Group A (MPFLR + DDFO, n = 42) and B (MPFLR + TTO, n = 46) were formed. Clinical outcomes included physical examinations, functional outcomes (Kujala, Lysholm, International Knee Documentation Committee (IKDC), visual analog scale (VAS) and intermittent and persistent osteoarthritis pain scale (ICOAP), Tegner scores), and complications. The Caton-Deschamps index (CD-I), patellar title angle, patellar congruence angle, patella-trochlear groove distance, TT-TG distance, and FAA were used to assess radiological outcomes. All clinical outcomes improved significantly in both groups, but Group A had significantly better postoperative scores than Group B (Kujala: 89.8 ± 6.4 vs. 82.9 ± 7.4, P < 0.01; Lysholm: 90.9 ± 5.1 vs. 81.3 ± 6.3, P = 0.02; IKDC: 87.3 ± 9.0 vs. 82.7 ± 8.0, P < 0.01; Tegner: 6.0 (5.0, 9.0) vs. 5.0 (4.0, 8.0), P = 0.01). However, there was no significant difference in the VAS and ICOAP scores between the two groups. No dislocation recurrences occurred. Radiological outcomes improved significantly in both groups, but Group A had better outcomes. After surgery, the patellar height of 88.5% (23/26) patients in Group A and 82.8% (24/29) patients in Group B was restored to normal (the Caton-Deschamps index <1.2). Both MPFLR + TTO and MPFLR + DDFO obtained satisfactory clinical and radiological outcomes in the treatment of recurrent PD with increased FAA and excessive TT-TG. However, the outcomes of MPFLR + DDFO were better and should be considered a priority. MPFLR + TTO may be not necessary for such patients.

Diagnosis and treatment of recurrent patellar dislocation with knee extensor device combined with rearrangement.

This study aimed to investigate the clinical effects of combining knee extension mechanism (EM) with rearrangement in the treatment of recurrent patellar dislocation (RPD). Eighty-four patients with RPD admitted to the First Affiliated Hospital of Kunming Medical University were included. In this work, all patients received routine computed tomography (CT) examinations. In addition, the evaluation factors of EM combined with rearrangement therapy in RPD patients were analyzed using logistic regression. Lysholm and Kujula scores, femoral canal width, patellar canal width, patellar tilt angle (PTA), and lateral patellar displacement (LPD) were significantly increased at 1 and 3 years after treatment (p < 0.05). LPA was significantly decreased, while the tibial tuberosity trochlear groove of the femur (TT-TG) demonstrated no considerable differences (p > 0.05). The good rate of the short-term Insall-Salvati index was 78.6%, and that of the long-term Insall-Salvati index was 76.1%. The combination of the knee extension device and rearrangement therapy has a higher rate of short-term and long-term Insall-Salvati index (ISI) excellence. In addition, the range of motion of the knee joint increased significantly, and the Q Angle decreased significantly (p < 0.05). Logistic regression analysis showed that age and ISI were highly correlated with the evaluation of therapeutic effects in patients with RPD. EM combined with rearrangement in the treatment of RPD had positive short-term and long-term efficacy, high application value, and age, which can be popularized in clinical applications and have positive diagnostic value.

Derotational distal femoral osteotomy improves subjective function and patellar tracking after medial patellofemoral ligament reconstruction in recurrent patellar dislocation patients with increased femoral anteversion: A systematic review and meta-analysis.

The purpose of this study is to systematically review and quantitatively analyse the clinical outcomes of combined derotational distal femoral osteotomy (D-DFO) and medial patellofemoral ligament reconstruction (MPFL-R) in the treatment of recurrent patellar dislocation (RPD) with increased femoral anteversion angle (FAA). This study was performed in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality Of Systematic Reviews) Guidelines. PubMed, Embase, Web of Science and Cochrane Library databases were searched to identify studies reporting clinical outcomes of combined D-DFO and MPFL-R in RPD patients with increased FAA. Data on patient-reported outcome measures, radiological parameters, patellar tracking as revealed by J-sign and complications were extracted based on the inclusion criteria. The Methodological Index for Non-Randomized Study score was used for quality assessment. Review Manager and R statistical software were used to perform the statistical analysis. Eleven studies with a total of 569 knees in 553 patients were included. Patients were predominantly female (79%). The weighted mean of FAA decreased from 33.6° to 13.0° (weighted mean difference = 20.59; p < 0.00001) after the combined procedure. Significant improvements (p < 0.00001) were identified in the Lysholm score (weighted mean: 55.5 vs. 80.4), International Knee Documentation Committee (IKDC) score (weighted mean: 52.8 vs. 78.6) and Kujala score (weighted mean: 54.5 vs. 80.6). The incidence of residual J-sign ranged from 14.3% to 38.3% with an overall pooled rate of 28.2% (95% confidence interval = 22.8%-33.6%). The overall redislocation rate was 1.1%. No patients experienced surgical site infection or bone nonunion. Two studies compared the clinical outcomes of MPFL-R with and without D-DFO. Compared with isolated MPFL-R, the combined procedure yielded a better Lysholm score (weighted mean: 84.9 vs. 79.3, p < 0.0001), IKDC score (weighted mean: 84.1 vs. 79.9, p = 0.001), Kujala score (weighted mean: 84.3 vs. 79.4, p < 0.0001) and a lower residual J-sign rate (26/97 [26.8%] vs. 44/105 [41.9%], p = 0.02), respectively. The combination of D-DFO and MPFL-R led to improved clinical outcomes and a low redislocation rate in patients with RPD and increased FAA. Additional D-DFO can achieve more favourable results in subjective function and patellar tracking than isolated MPFL-R in the setting of excessive FAA. Level IV.

Reconstruction of medial patellofemoral ligament with adductor magnus tendon for recurrent patellar dislocation in children: a retrospective comparative cohort study

BackgroundThe purpose of current retrospective study was to explore the outcomes of using the adductor magnus tendon to reconstruct the medial patellofemoral ligament in the treatment of recurrent patellar dislocation in children.MethodThirty-two children with recurrent patellar dislocation were selected. Sixteen cases in the conservative group, seven males and nine females, with an average age of 11.81 ± 1.28 years; sixteen cases in the surgical group, eight males and eight females, with an average age of 11.56 ± 1.15 years. All patients had no surgery history. The IS index (> 1.2), Q angle (> 20°) and tibial tubercle–femoral trochlear groove (TT–TG) distance (> 20 mm) were measured by X-ray and MRI. The conservative group was treated with closed reduction and a brace, and the surgical group received surgical treatment. Two years after surgery, congruence angle (CA) (− 6° to 6°) and lateral patellofemoral angle (LPFA) (7.7°–18.7°) were measured by X-ray image and all children were evaluated based on Kujala and Lysholm scores. The re-dislocation rate was recorded. Analysis was performed by t test and chi-square with the statistical SPSS software. P < 0.05 was considered a statistically significant difference. Furthermore, we measured the length (mm) of the adductor tendon and MPFL in three knee cadaveric specimens, and also observed the positional relationship between the two structures.ResultThere were no significant differences in sex, age, injury site between groups (P > 0.05). Patients in the two groups were followed up for 2 years in average. Among the 16 cases in the conservative group, 7 cases (43.75%) had recurrence of patellar dislocation, while none of recurrence in the surgical group (P < 0.05). The Lysholm score of the surgical group (94.63 ± 8.99) was significantly better than that of the conservative group (79.31 ± 18.90), and the Kujala score of the surgery group (95.25 ± 10.32) was also significantly better than that of the conservative group (77.06° ± 14.34°) (P < 0.05). The CA and LPFA of the two groups of patients after treatment were significantly recovered. The CA (− 5.81° ± 7.90°) in the surgical group was significantly better than that in the conservative group (20.94° ± 8.21°), and the LPFA (6.44° ± 3.22°) was also significantly better than that in the conservative group (− 9.18 ± 11.08), and the difference is statistically significant (P < 0.05). We found it through autopsy that adductor magnus tendon was 124.33 ± 1.53 mm long, MPFL was 48.67 ± 2.08 mm, and the femoral insertion of the adductor magnus tendon was adjacent to the MPFL femoral insertion.ConclusionReconstruction of Medial patellofemoral ligament with the adductor magnus tendon, fixing with PEEK suture anchors on the patellar side, can achieve satisfactory results in the treatment of children with recurrent patellar dislocation. Compared with conservative treatment, the rate of recurrence is lower and the stability of the patella is better.

Advances in peripatellar osteotomy for treating recurrent patellar dislocation

To summarize the progress of research related to the surgical treatment of recurrent patellar dislocation by peripatellar osteotomy in clinical practice, in order to provide reference for clinical treatment. The recent literature on peripatellar osteotomy for recurrent patellar dislocation at home and abroad was reviewed, and the bony structural abnormalities, imaging diagnosis, and treatment status were summarized. Abnormalities in the bony anatomy of the lower limb and poor alignment lead to patellofemoral joint instability through the quadriceps pulling force line and play an important role in the pathogenesis of recurrent patellar dislocation. Identifying the source of the deformity and intervening with peripatellar osteotomy to restore the biomechanical structure of the patellofemoral joint can reduce the risk of soft tissue surgical failure, delay joint degeneration, and achieve the target of treatment. In the clinical diagnosis and treatment of recurrent patellar dislocation, the factors causing patellofemoral joint instability should be comprehensively evaluated to guide the selection of surgery and personalized treatment.

A Combined Surgical Approach for Recurrent Patellar Dislocation in Adolescents With Patella Alta and Increased Tibial Tuberosity-Trochlear Groove Distance: Improved Clinical Outcomes but Decreased Posterior Tibial Slopes in Skeletally Immature Patients at Minimum 4-Year Follow-Up

Purpose(1) To report the clinical and radiological outcomes of a surgical technique combining anatomic medial patellofemoral ligament (MPFL) reconstruction and tibia tuberosity transfer in adolescents with patella alta and elevated tibial tuberosity-trochlear groove (TT-TG) distance, in the treatment of recurrent patellar dislocation (RPD); (2) To investigate the potential risks of growth arrest or developmental deformities associated with this combined technique. MethodsMedical records of patients underwent the combined surgery were reviewed from 2015 to 2019. This study included adolescents aged between 14 and 18 years with a Caton-Deschamps index (CDI) greater than 1.30 and TT-TG distance greater than 20mm, with a minimum follow-up of 4 years. Radiological examinations including lateral views and full-length posteroanterior standing radiographs were investigated to assess patella height by CDI, posterior tibia slope (PTS) angle, side-to-side difference (SSD) in bone length, and lower extremity alignment by hip-knee-ankle (HKA) angle; CT-scans and MRI profiles were investigated to evaluate TT-TG distance and staging of growth plate closure. Other evaluations included preoperative and postoperative physical examination, Kujala score, and Tegner activity score. The patients were stratified into 3 subgroups according to a MRI-based staging system of the growth plate closure, and each outcomes were analyzed. A cohort-specific minimal clinically important difference (MCID) estimation was performed using standard error of measurement. ResultsThe average age at the time of surgery was 16.1 years (range, 14.1-17.8). The average follow-up was 5.6 years (range, 4.0-7.6). No recurrent dislocation occurred, no clinically significant deformity or axis deviation was encountered. Postoperative patellar height by CDI was 1.00±0.11 (range, 0.81-1.15). No significant differences were found in pre- and postoperative HKA angle and SSD in femur/tibia length among all subgroups. A significantly decreased PTS angle was found in patients with open growth plates, from 10.2±1.7° preoperatively to 8.1±1.0° postoperatively (P=.015). The Kujala score and Tegner score both significantly improved, from 65.5±13.9 preoperatively to 90.4±7.2 postoperatively in Kujala score (P <0.001), and from 4.0±1.1 preoperatively to 4.7±1.3 postoperatively in Tegner score (P <0.001). Of the whole cohort, 63.1%, 100%, 47.1% and 94.1% patients achieved the MCID for PTS angle, CDI, Tegner score, and Kujala score respectively. ConclusionThis combined technique is safe and effective in treating RPD in skeletally mature adolescents with concurrent patella alta (CDI > 1.30) and TT-TG distance > 20mm, permitting patients to have improved knee function and low complication rates. Nonetheless, patients with open growth plates demonstrated a decrease in PTS, which might predispose the knee to recurvatum and osteoarthritis in the long-term. Study DesignRetrospective therapeutic case series; level of evidence, Ⅳ.

Comparison of Habitual Versus Recurrent Patellar Dislocation in Children and Adolescents: Differences in Radiological Features.

Recurrent patellar dislocation (RPD) and habitual patellar dislocation (HPD) in flexion are frequently encountered in children and adolescents. To compare the radiological features of RPD and HPD in children and adolescents. Cross-sectional study; Level of evidence, 3. Imaging data were collected from patients aged 9 to 15 years who received surgical treatment for HPD or RPD at a single institution between June 2015 and September 2020. The prevalence of trochlear dysplasia, tibial tubercle lateralization, and lower limb rotational deformity was assessed through hip/knee/ankle computed tomography (CT) using the following quantitative indicators: trochlear depth index, lateral trochlear inclination, sulcus angle, tibial tubercle-trochlear groove (TT-TG) distance, ratio of TT-TG distance to femoral width, TT-TG angle, femoral anteversion angle, and tibial external rotation angle. The morphology of trochlea and patella were graded on knee CT using the Dejour and Wiberg classification. The Insall-Salvati index and Caton-Deschamps index were used to evaluate the height of the patella on lateral view radiographs. To evaluate lower limbs malalignment, the mechanical lateral distal femoral angle and medial proximal tibial angle were measured on weightbearing full-length radiographs. The collected data were analyzed and compared between the HPD and RPD groups. Enrolled were 15 patients (21 knees) diagnosed with HPD and 18 patients (22 knees) diagnosed with RPD. The age of first dislocation was significantly younger in the HPD group (7.6 ± 3.4 vs 11.2 ± 1.4 years; P = 0.003). Knees in the HPD group had a significantly higher proportion of Dejour type C dysplasia (57.1% vs 4.5%; P < .005) and Wiberg type 3 patella (66.7% vs 9.1%; P < .001). There were statistically significant differences between the groups in the trochlear depth index (HPD vs RPD: 1.1 ± 1.7 vs 2.2 ± 1.5 mm; P = .039), sulcus angle (170.3° ± 13.7° vs 157.3° ± 16.0°; P = .007), Insall-Salvati index (1.1 ± 0.2 vs 1.3 ± 0.2; P = .034), and tibial external rotation angle (31.3° ± 7.8° vs 38.4° ± 8.5°; P = .009). Patients in the HPD group presented with poorer trochlear and patellar development, lower patellar height, and less tibial external rotation compared with patients in the RPG group.

Outcomes After Derotational Distal Femoral Osteotomy for Recurrent Patellar Dislocations With Increased Femoral Anteversion: A Systematic Review and Meta-analysis.

An increased femoral anteversion angle (FAA) is a predisposing factor for recurrent patellar dislocations (RPDs), and combined procedures including derotational distal femoral osteotomy (DDFO) have been shown to be good options. To investigate the safety and effectiveness of combined DDFO on clinical and radiological outcomes to treat RPDs with an increased FAA. Systematic review; Level of evidence, 4. This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. We searched 7 databases for articles from inception to March 10, 2023, that reported outcomes after combined DDFO in patients with an RPD and increased FAA. Two reviewers independently extracted data and assessed study quality. Outcomes evaluated were functional scores, redislocation rates, complications, satisfaction, and radiological parameters. A meta-analysis was performed to pool functional scores, with data reported as mean differences (MDs) and 95% confidence intervals (CIs). Included were 8 studies of 189 knees from 183 patients, with a mean patient age of 22.4 years and a mean follow-up of 33.4 months. The mean preoperative FAA ranged from 31° to 42.70°, and the mean postoperative FAA ranged from 10° to 19.08°. Significant improvements were found in the Kujala score (MD, 26.96 [95% CI, 23.54 to 30.37]), Lysholm score (MD, 26.17 [95% CI, 22.13 to 30.22]), visual analog scale score for pain (MD, -2.61 [95% CI, -3.12 to -2.10]), and Tegner activity score (MD, 1.33 [95% CI, 0.86 to 1.79]). No subluxation or redislocation occurred. The overall complication rate was 10.6%, and most of the complications were pain (60%) and limited knee activity (20%). The overall satisfaction rate was 83.3%. The patellar tilt angle significantly decreased from 40.7° ± 11.9° to 20.5° ± 8.7° and from 26.35° ± 6.86° to 11.65° ± 2.85° in 2 studies. Combined DDFO was found to be safe and effective for the treatment of RPDs and an increased FAA by addressing both patellar dislocations and torsional malalignment. However, because of the lack of comparisons, it remains to be investigated when DDFO should be combined in such patients.

3D Printed Models of Trochlear Dysplasia and Trochleoplasty Simulation for Trainee Education

Trochlear dysplasia is a major contributor to patellofemoral instability and subsequent failure of isolated soft tissue reconstruction procedures in the treatment of recurrent patellar dislocation and/or subluxation. Trochleoplasty procedures aim to address abnormal osseous trochlear morphologic factors that contribute to patellar maltracking. However, teaching these techniques is limited by the lack of reliable training models for trochlear dysplasia and trochleoplasty simulation. Although a cadaveric knee model of trochlear dysplasia for trochleoplasty simulation has been recently described, cadaveric knees are less amenable for use in trochleoplasty planning and surgeon training because of the absence of reliable, natural dysplastic anatomic relationships, such as suprapatellar spurs due to the rarity of dysplastic cadavers and the high cost of cadaveric specimens. Furthermore, readily available sawbone models represent “normal” osseous trochlear morphology and are difficult to modify and bend due to their material composition. Given this, we have developed a cost-effective, reliable, and anatomically accurate three-dimensional (3D) knee model of trochlear dysplasia for trochleoplasty simulation and trainee education.

A clinical, radiological and isokinetic evaluation in patients with recurrent patellar dislocation undergoing MPFL reconstruction according to Avikainen: a prospective study evaluating early degenerative changes after a minimum 10-year follow-up period

BackgroundThe aim of the study was to conduct a comprehensive functional and radiological follow-up assessment in patients at least 10 years after adductor magnus MPFL reconstruction, and to assess the presence of early degenerative changes.MethodsThe mean age at the time of surgery was 16 years (range: 8 to 18 years, SD 2.5). The follow-up examination was performed at least 10 years following adductor magnus MPFL reconstruction (mean 11 years). Twenty-one patients (26 operated knees) attended the follow-up. The mean age at follow-up was 25.1 years (range 20–29 years).ResultsThe significant improvement observed at 3 years, indicated by the Kujala and Lysholm scores, was maintained after 10 years of follow-up (p < 0.001). A single recurrence of dislocation was noted in three patients. A significant improvement in radiological parameters was noted. No significant difference in the incidence of chondromalacia, of any degree, was observed compared to controls.Significantly higher quadriceps peak torque was noted for both angular velocities (60 and 180°/sec) compared to the preoperative readings (p < 0.001). Knee flexors were found to be significantly stronger at both 60 and 180°/sec at 10 years follow-up examination (p = 0.008 and p < 0.001 respectively).ConclusionThe use of MPFL reconstruction according to Avikainen yields improvements in clinical and radiological results which are maintained throughout the observation period. No significantly greater articular cartilage degeneration was noted in patients after surgical treatment for recurrent patellar dislocation compared to healthy peers.Trial registrationRegistered on Clinical Trails.gov with ID: PMMHRI-BCO.67/2021-A.

Comparison of patellar anchor fixation graft and graft through patellar tunnel reconstruction of medial patellofemoral ligament in the treatment of recurrent patellar dislocation: A protocol for a meta-analysis of comparative studies.

Recurrent patellar dislocation (RPD) occurs in people who have their own patellofemoral dysplasia and who have not been properly treated after their first patellar dislocation. For RPD where conservative treatment is ineffective, medial patellofemoral ligament (MPFL) reconstruction is the first choice for surgical treatment, but there are various and controversial ways of MPFL reconstruction and fixation. Initially, more scholars adopted the patellar lateral tunneling (PT) approach to contain and stabilize the graft, but with the newer materials and techniques, some experts adopted the lateral patellar anchor fixation (AF) of the graft, which can avoid the collateral damage caused by the patellar lateral tunneling and can obtain the same definite efficacy. Therefore, a meta-analysis must be performed to provide evidence whether there is a difference between AF and PT reconstruction of the MPFL in the treatment of RPD. We will search, with no time restriction, without any restriction of language and status, the time from the establishment of the database to October 2022, on the following databases: PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang Data (WF), Chinese Scientific Journals Database (VIP), and Chinese databases SinoMed (CBM) electronic databases. The electronic database search will be supplemented by a manual search of the reference lists of included articles. We will apply the risk-of-bias tool of the Cochrane Collaboration for randomized controlled trials to assess the methodological quality. Risk-of-Bias Assessment Tool for Non-randomized Studies was used to evaluate the quality of comparative studies. Statistical analysis will be conducted using RevMan 5.4 software. This systematic review and meta-analysis will evaluate the functional outcomes of the two fixation modalities, AF and PT, in reconstructing MPFL for RPD. The findings of this study will provide a basis for clinical judgment of whether there is a difference between the two forms of AF and PT reconstructed MPFL for RPD.

Addition of Tibial Tubercle Osteotomy to Combined MPFL Reconstruction and Lateral Retinacular Release not Recommended for Recurrent Patellar Dislocation in Patients with 15 to 20 mm TT-TG.

Surgery is the primary treatment for recurrent patellar dislocation. However, there is still a lack of consensus regarding the choice of combined surgical methods due to the complexity of the anatomical factors. This study aimed to investigate the efficacy and radiological changes in medial patellofemoral ligament reconstruction (MPFLR) and lateral retinacular release (LRR) with and without tibial tubercle osteotomy (TTO) for recurrent patellar dislocation in patients with a tibial tubercle-trochlear groove (TT-TG) distance of 15 to 20 mm. Fifty-four patients were enrolled in this retrospective study between 2010 and 2014. The average patient age was 21.6 ± 5.0 years. All patients underwent MPFLR and LRR, and in 18 patients, these procedures were combined with TTO. Patients were evaluated preoperatively and postoperatively for patellar lateral shift, patellar tilt angle, TT-TG distance, Q-angle, Caton-Deschamps index (CDI), Kujala, and Lysholm scores. The minimally clinical important difference was used to compare clinical outcomes between two groups. In the mean follow-up of 82.6 ± 15.9 months, functional scores improved significantly in both groups (p < 0.01). There were no significant differences in postoperative function scores between the two groups (Kujala, p = 0.25, mean difference = 1.5, 95% confidence interval [CI]: -1.4-4.4; Lysholm, p = 0.76, mean difference = -0.6, 95% CI: -5.9-4.7). Additionally, TTO significantly decreased Q-angle (23.6 ± 2.4 vs. 17.4 ± 2.9, p < 0.01), TT-TG (17.1 ± 1.5 vs. 10.4 ± 1.8, p < 0.01), and CDI (1.18 ± 0.12 vs. 1.08 ± 0.07, p < 0.01). Combined MPFLR and LRR with and without TTO are both effective techniques for recurrent patellar dislocation. Additional osteotomy can correct patellar alta and tibial tubercle lateralization. However, given that there were no significant differences in postoperative functional scores or recurrence rate between groups, we may not recommend TTO in addition to MPFLR and LRR in patients with TT-TG of 15 to 20 mm. Long-term and prospective cohort studies are required to assess further outcomes.

Dynamic versus static medial patellofemoral ligament reconstruction technique in the treatment of recurrent patellar dislocation: a randomized clinical trial protocol

BackgroundThe redislocation rate of conservatively treated patella instability is high. One of the leading surgical strategies is medial patellofemoral ligament reconstruction. Over-tensioning is one of the most challenging complications in static medial patellofemoral ligament reconstruction as the graft used for reconstruction is isometric and the anatomical MPFL is a mostly dynamic structure. As an alternative to established static reconstruction techniques, dynamic graft techniques have been introduced for stabilizing the patella with the aim of providing a more physiological reconstruction of the medial patellofemoral ligament. To date, data on clinical outcomes are scarce and on biomechanical outcomes of the dynamic MPFL reconstruction are lacking. Here, we present the protocol of a randomized clinical trial for comparing clinical and biomechanical outcomes of dynamic versus static medial patellofemoral ligament reconstruction.MethodsThis study is a prospective, single blinded, randomized, multicenter, multimodal (clinical and biomechanical) clinical trial. Patients with recurrent patella dislocation requiring isolated MPFL reconstruction will be recruited and randomized to the dynamic or static reconstruction technique. Participants will be followed up for 2 years with a total of five follow-ups. Preoperative magnetic resonance imaging, upright radiographs, surgical reports and patient records will be evaluated, and clinical and functional outcomes will be measured. Patient-reported knee function and anterior knee pain as assessed with the Kujala score will serve as primary outcome. For biomechanical outcome, pre- and postoperative evaluations will be performed to assess isokinetic muscle strength, gait asymmetry, joint kinematics and kinetics, and timing of muscle activity.DiscussionThe results of the study will clarify whether the reported surgery success for patella stabilization via dynamic MPFL reconstruction is due to muscle contraction or to the passive tenodesis effect combined with clinical outcome measures. With this study, we will provide much needed information on knee biomechanics after dynamic versus static MPFL reconstruction to provide evidence to support orthopedic surgeons in evidence-based decision-making in their quest for surgical techniques most favorable for their patients.Trial registration The study protocol was registered at clinicaltrials.gov (NCT04849130). Registered 19 April 2021, https://clinicaltrials.gov/ct2/show/NCT04849130.

Preoperative serum calcium could be a prognostic factor for surgical treatment of recurrent patellar dislocation: a retrospective study

BackgroundSurgical treatment for recurrent patellar dislocation (RPD) could yield good outcomes. While, unsatisfactory recovery still exists in some cases. For all prognostic factors, serum biomarkers have rarely been investigated. This study aimed to evaluate the prognostic value of preoperative serum calcium level, a widely used serum biomarker, in surgical treatment for RPD.Study designRetrospective study.MethodsNinety-nine patients with RPD were enrolled in the study. Preoperative serum calcium was acquired from routinely tested blood 1 day prior to operation. Demographic data, characteristics of RPD, postoperative functional outcomes were obtained. The association between preoperative calcium and postoperative functional outcomes (Kujala, Lysholm, Tegner, IKDC and KOOS score) was determined by correlation analysis and multivariate linear regression analysis. Poor recovery was determined as Kujala score below 80. The receiver operating characteristic (ROC) curve was used to assess the prognostic value of preoperative calcium.ResultsPatients were followed up for a mean period of 2.45 ± 1.33 years. All clinical scores showed significant improvement at the latest follow-up. Correlation and multivariate linear analyses indicated that serum calcium level was an important factor related with the prognosis of surgical treatment for RPD. According to the ROC curve, the cut-off value for preoperative calcium was 2.225 mmol/L. The clinical outcomes of patients with a preoperative blood calcium < 2.225 mmol/L was significantly worse than that with a higher calcium level. The correspondent sensitivity was 0.812 with a specificity of 0.633.ConclusionOperative treatment for RPD achieved good results, while in some cases the functional scores remain inferior. As a serum biomarker, preoperative calcium could be prognostic for outcomes after surgical treatment for RPD.

Новый метод хирургического лечения пациентов с привычным вывихом надколенника: анализ первичных результатов

Introduction Surgical options used to treat recurrent patellar dislocations (RPD) in different countries include release of the lateral tendon retinaculum, tibia medialization, fixation of an autologous graft to the hip, transplantation of the ipsilateral gracilis tendon and medial patellofemoral ligament reconstruction. The methods may not completely eliminate the dislocation to ensure patellar stability and we undertook to develop a new surgical technique. The objective was to identify advantages and disadvantages of the new methodology for the treatment of RPD through comparative analysis. Material and methods 28 patients with RPD of varying degrees treated in the Department of Sports Trauma, State Institution "RSNPMCTO" the Ministry of Health of the Republic of Uzbekistan between 2015 and 2018 were reviewed. Dislocations were graded as average (grade 2; n = 3, 10.7 %) and grade 3 (n = 25; 89.3 %). Five (17.8%) of 28 patients had impaired m. vastus medialis and 23 (82.2 %) were diagnosed with impairment and defect of the retinaculum patella mediale. The patients underwent physical, laboratory, radiological and instrumentation (ultrasound, magnetic resonance imaging, diagnostic arthroscopy) examinations. Results Arthroscopic procedure of the knee joint with autoplasty patellar stabilization using the m. gracilis tendon and a biodegradable screw resulted in good outcomes (n = 27; 96.4 %) and a fair result in a patient (3.6 %) with grade 3 RPD due to synovitis, bursitis and pain in the knee joint; no poor results reported. Conclusion The patients could completely regain the limb functions through arthroscopic procedure of the knee joint with autoplasty patellar stabilization using the m. gracilis tendon and a biodegradable screw, optimization of surgical treatment strategy with regard to severity of displacement and injury to the soft tissues at the medial aspect of the patella.

Medial patellofemoral ligament reconstruction for recurrent patellar dislocation allows a good rate to return to sport.

Recurrent patellar dislocation is a frequent knee disorders in young, active patients. Medial patellofemoral ligament reconstruction (MPFLR) can restore knee stability and function, but the rate of return to sports is less clear. The aim of this study was to evaluate rate of return to sport following treatment of recurrent patellar dislocation with isolated MPFLR. Between 2011 and 2018, 113 patients with recurrent patellar dislocation were treated with isolated MPFLR at an academic center. Pre-injury sports participation and Tegner score, pre-operative subjective IKDC score, time to return to sports, and post-operative Tegner and subjective IKDC scores were collected, with a minimum of follow-up of 2years. One hundred and three patients (91%) were evaluated at a mean of 4.5 ± 2.5-year post-operative. 92 patients (89%) participated in sports prior to onset of patellar instability. At final follow-up, 84 of these 92 patients (91%) were able to return to sports. The mean time from surgery to return to sports was 10.4 ± 8.6months (range: 2-48months). 62 patients (67%) returned to the same (50 patients) or higher (12 patients) level. 22 patients (26%) returned at a lower level. 19 of these patients attributed this decreased participation to ongoing knee problems. The median Tegner score was noted to decrease from 5 pre-injury to 4 post-operatively (p = 0.02). Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients, with 67% of patients returning to the same or higher level than pre-injury. Mean time to return to sports was 10months and post-operative Tegner score was noted to be modestly decreased from pre-injury level. IV.

Derotational Femoral Osteotomy for Treating Recurrent Patellar Dislocation in the Presence of Increased Femoral Anteversion: A Systematic Review.

Background:Studies on the clinical outcomes of derotational femoral osteotomy to treat recurrent patellar dislocation in the presence of increased femoral anteversion are limited.Purpose:To investigate the role of derotational femoral osteotomy in the treatment of recurrent patellar dislocation in the presence of increased femoral anteversion.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review was performed according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) by searching the Medline, Embase, Web of Science, and Cochrane Library databases through February 10, 2021. Included were studies of skeletally mature patients presenting with recurrent patellar dislocation and exhibiting increased femoral anteversion who subsequently underwent derotational femoral osteotomy. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. The basic characteristics of each study were recorded and analyzed: characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications.Results:A total of 6 studies with 163 patients (170 knees) were included. Sample sizes ranged from 7 to 66 patients, and the patients were predominantly women (range, 79%-100%). The mean age and follow-up ranges were 18 to 28 years and 16 to 44 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting pre- and postoperative outcomes, significant improvements were found in the Lysholm score (from 24.8 to 44.1), Kujala score (from 15.8 to 41.9), International Knee Documentation Committee score (from 11.0 to 28.0), and visual analog scale for pain (from 2.0 to 3.7). All studies reported postoperative complications, giving an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period.Conclusion:For recurrent patellar dislocation in the presence of increased femoral anteversion, combination treatment with derotational femoral osteotomy led to favorable clinical outcomes with a low redislocation rate. However, there was no consensus among researchers on the indications for derotational femoral osteotomy in the treatment of recurrent patellar dislocation.

Abnormal femur rotation in patients with recurrent patellar dislocation: A study on upright standing three-dimensionally reconstructed EOS images

BackgroundThe measurements of lower extremity rotational deformities in patients with recurrent patellar dislocation (RPD) in the standing position are available with the application of the EOS imaging system. The aim of our case–control study was to identify the differences on the femur rotation between the supine and standing positions, and to investigate the differences of anatomical and functional femur rotation between RPD patients and controls. MethodsThirty-five lower extremities affected by RPD from 30 patients and 27 intact lower extremities from 27 controls with acute meniscus tear or anterior cruciate ligament injury were recruited. Anatomical femoral anteversion (AFA), functional femoral anteversion (FFA), femorotibial rotation (FTR) and distal femoral torsion (DFT) of all subjects were measured with the EOS imaging system. Computed tomography scans were carried out to analyze the AFA and FFA in the supine position in PRD patients. The differences in FFA between supine and standing position and in AFA, FTR and DFT between RPD and controls were analyzed. The predictor importance of each variable on RPD was observed after cluster analysis. ResultsThe EOS images were available in all subjects. The FFA was significantly smaller in the standing position than in the supine position (P < 0.05) in RPD patients. When comparing with the controls, RPD patients showed higher AFA, FTR and DFT (P < 0.05) but comparable FFA (P < 0.05). The cluster model prompted that FTR and DFT had higher predictor importance than AFA. ConclusionLarger AFA but comparable FFA in patients with RPD than the controls in an upright standing position suggested more internally rotated distal femur in the RPD patients. AFA may be inadequate and FFA should also be considered while planning the treatment for RPD. DFT and FTR should be taken into consideration when evaluating the abnormalities in femur rotation in RPD patients.

Closing-wedge distal femoral osteotomy combined with medial patellofemoral ligament reconstruction for recurrent patellar dislocation with genu valgum

BackgroundMedial patellofemoral ligament reconstruction (MPFLR) is a well-established procedure for addressing recurrent patellar dislocation (RPD) in young patients. However, despite being a promising procedure for RPD with genu valgum, there is a scarcity of reports on simultaneous MPFLR and closing-wedge distal femoral osteotomy (CWDFO). The purpose of the present study was to observe and analyse the clinical and imaging findings of CWDFO combined with MPFLR for RPD with genu valgum.MethodsFrom May 2015 to April 2018, 25 patients with RPD and genu valgum were surgically treated in our department. Anteroposterior long-leg, weight-bearing, lower-extremity radiographs, lateral radiographs and computed tomography (CT) scans of the patellofemoral joint were obtained, and the anatomical femorotibial angle (aFTA), mechanical lateral distal femoral angle (mLDFA), weight-bearing line rate (WBLR), patellar height, patellar lateral shift (PLS) and tibial tubercle–trochlear groove (TT-TG) distance were analysed. Validated knee scores, such as the Kujala, Lysholm, visual analogue scale (VAS) scores and Tegner socres, were evaluated preoperatively and 2 years postoperatively.Results25 patients, with an average age of 19.8 years (14–27), were evaluated. During the 2-year follow-up period, all patients were able to achieve a better sports level without any problems, with no recurrence of patellar instability. Compared with preoperation, the aFTA, mLDFA, WBLR and PLS showed statistically significant improvement following the procedure (p < 0.001). Meanwhile, no significant differences in the Insall index and TT-TG distance were found. The mean Kujala score, average Lysholm score, VAS score and Tegner socres showed significant postoperative improvement.ConclusionsCWDFO combined with MPFLR is a suitable treatment for RPD with genu valgum, and can lead to significant improvement in the clinical and imaging findings of the knee in the short term.