scholarly journals CURRENT PRACTICE TRENDS IN THE SURGICAL MANAGEMENT OF PATELLOFEMORAL INSTABILITY; A SURVEY OF THE PEDIATRIC RESEARCH IN SPORTS MEDICINE (PRiSM) SOCIETY

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0009
Author(s):  
Curtis VandenBerg ◽  
Natalya Sarkisova ◽  
J. Lee Pace ◽  
Jason Rhodes ◽  
Daniel W. Green
Keyword(s):  
Surgical Management ◽  
Sports Medicine ◽  
Mechanical Axis ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Loose Body ◽  
Pediatric Research ◽  
Treatment Algorithms ◽  
Diagnostic Measurement ◽  
First Time

Background: Patellofemoral instability in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. Surgical options and treatments are heterogeneous among orthopaedic surgeons. The purpose of this study is to survey members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding their practice and treatment for patellofemoral instability and to identify trends in management of patellofemoral instability in children and adolescents nationwide. Methods: A 27-question multiple choice online survey was distributed to the members of the PRiSM Society. The survey was sent via email 3 times over a six week time span after which time the survey was closed. Members were asked about clinical and imaging evaluation, methods of conservative treatment, surgical indications, and surgical techniques when treating patellofemoral instability. Results: 65/70 (93%) of respondents reported performing surgery for patella instability more than 5 times in the past year. Of these 65, 56 respondents completed the questionnaire in its entirety. While some trends regarding treatment emerged, the respondent data demonstrated the large discrepancies in practice patterns that exist nationwide. 48% (27/56) of respondents obtained an MRI for patients with a 1+ knee effusion or greater on exam within one week after a first-time traumatic patellar dislocation while 20% (11/56) obtain an MRI in all patients presenting with a patella dislocation. To assess skeletal maturity, 75% (42/56) of respondents obtained knee x-rays to evaluate the physes around the knee, whereas 53% (30/56) obtained a hand x-ray to assess bone age. 41% (23/56) of respondents reported that surgical intervention for fragment refixation or loose body removal is indicated anytime there is evidence of a loose body or osteochondral fragment regardless of fragment size. 11% (6/56) reported only performing osteochondral fracture repair when the fragment was large enough to repair. If surgery is performed for an osteochondral loose body, 38% (21/56) of respondents performed an MPFL reconstruction. 59% (33/56) reported performing the MPFL reconstruction in children and adolescent athletes with hamstring allograft, while 30% (17/56) prefer autograft (hamstring, quadriceps). MRI was strongly preferred over CT when considering a tibial tubercle anteromedialization. TT-TG distance is the diagnostic measurement of choice with no respondents selecting TT-PCL as their preferred diagnostic measurement. The indication for surgical correction of angular deformity in the setting of patellar instability had mixed responses. 18% (10/56) would indicate surgery when the mechanical axis is lateral to the center of the lateral femoral condyle, while others considered this angular correction only when the patient is skeletally immature or when the mechanical axis is lateral to the lateral tibial spine. For surgical recommendations in a patient with significant trochlear dysplasia, 46% (26/56) reported no surgical management of trochlear dysplasia in first-time surgery while 41% (23/56) reported no surgical management of trochlear dysplasia in first-time or revision surgery. Conclusion: There was significant heterogeneity among respondents that highlights a lack of consensus regarding optimal diagnostic and treatment algorithms. Understanding management trends nationwide may help practicing surgeons gain insights and develop evidence based treatment algorithms to best serve patients with this condition.

scholarly journals Current practice trends in the surgical management of patellofemoral instability: a survey of the Paediatric Research in Sports Medicine (PRiSM) Society

2021 ◽  
pp. 1-6
Author(s):  
Curtis D. VandenBerg ◽  
Natalya Sarkisova ◽  
J. Lee Pace ◽  
Jason Rhodes ◽  
Sofia Hidalgo Perea ◽  
...  
Keyword(s):  
Children And Adolescents ◽  
Surgical Management ◽  
Sports Medicine ◽  
Fragment Size ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
The United States ◽  
Loose Body ◽  
Mpfl Reconstruction ◽  
Tibial Tubercle

Purpose Patellofemoral instability (PFI) in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. The purpose of this study was to identify trends in management of PFI in children and adolescents in the United States and nationwide. Methods A 27-question multiple choice survey was distributed in 2018 to the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding treatment of PFI in paediatric and adolescent patients. Results In all, 56 of the respondents who were orthopaedic surgeons that manage patellar instability in children and adolescents and had performed PFI surgery more than five times in the past year completed the entire survey. A total of 41% of respondents reported that surgery for fragment refixation or loose body removal was indicated when a loose body or osteochondral fragment was evident, regardless of fragment size. Overall, 74% reported that if surgery was performed for an osteochondral loose body, primary repair (36%) or reconstruction (38%) of medial patellofemoral ligament (MPFL) was also completed. A total of 89% of members reported MPFL reconstruction in the absence of alignment or rotational abnormalities, tibial tubercle lateralization or trochlear dysplasia in skeletally immature patients; 59% reported performing the MPFL reconstruction with hamstring allograft, while 30% prefer autograft (hamstring, quadriceps). For patients with significant trochlear dysplasia, 87% reported no surgical management of trochlea in first-time or in revision surgery. Conclusion There is a lack of consensus regarding optimal diagnostic and treatment algorithms in the management of PFI, however, consistent trends have emerged among paediatric sports medicine surgeons. Level of Evidence Level V – survey of expert opinion and experience

scholarly journals Patellofemoral Instability

2021 ◽  
Author(s):  
Deepak V. Patel ◽  
Iciar M. Dávila Castrodad ◽  
Jennifer Kurowicki ◽  
Vincent K. McInerney ◽  
Anthony J. Scillia
Keyword(s):  
Risk Factors ◽  
Functional Disability ◽  
Nonoperative Management ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Loose Body ◽  
Adolescent And Young Adult ◽  
Lateral Release ◽  
Trochlear Groove ◽  
Q Angle

Recurrent patellofemoral instability is a common cause of knee pain and functional disability in adolescent and young adult patients, resulting in loss of time from work and sports. There are numerous factors that contribute to recurrent patellofemoral instability; these factors include tear of the medial patellofemoral ligament (MPFL), weakening or hypoplasia of the vastus medialis obliquus (VMO), trochlear dysplasia, increased tibial tuberosity-trochlear groove (TT-TG) distance (>20 mm), valgus malalignment, increased Q angle, malrotation secondary to internal femoral or external tibial torsion, patella alta, and generalized ligamentous laxity. A detailed history and a thorough physical examination are crucial to clinch an early, accurate diagnosis. Imaging studies play an important role to confirm the clinical diagnosis and also help to identify concomitant intra-articular pathologies. Initially, nonoperative management (including the use of physical therapy, patellar taping or brace) is offered to patients with acute, first-time patellar dislocations and most patients respond well to this mode of treatment. Surgical treatment is indicated for patients who have post-trauma osteochondral fracture or loose body; predisposing anatomical risk factors; recurrent, symptomatic instability; and who have failed an adequate trial of nonoperative management. Surgical treatments include MPFL reconstruction, proximal or distal realignment procedures, and trochleoplasty. Lateral release is often performed in combination with other procedures and seldom performed as an isolated procedure. An individualized case-by-case approach is recommended based on the underlying anatomical risk factors and radiographic abnormality.

Effect of Isolated Medial Patellofemoral Ligament Reconstruction in Patellofemoral Instability Regardless of Predisposing Factors

2020 ◽  
Author(s):  
Jae Ik Lee ◽  
Mohd Shahrul Azuan Jaffar ◽  
Han Gyeol Choi ◽  
Tae Woo Kim ◽  
Yong Seuk Lee
Keyword(s):  
Medial Patellofemoral Ligament ◽  
Trochlear Dysplasia ◽  
Case Series ◽  
Patellofemoral Instability ◽  
International Knee Documentation Committee ◽  
Predisposing Factors ◽  
Mpfl Reconstruction ◽  
Patellar Tilt ◽  
Case Series Study

AbstractThe purpose of this study was to evaluate the outcomes of isolated medial patellofemoral ligament (MPFL) reconstruction, regardless of the presence of predisposing factors. A total of 21 knees that underwent isolated MPFL reconstruction from March 2014 to August 2017 were included in this retrospective series. Radiographs of the series of the knee at flexion angles of 20, 40, and 60 degrees were acquired. The patellar position was evaluated using the patellar tilt angle, sulcus angle, congruence angle (CA), and Caton-Deschamps and Blackburne-Peel ratios. To evaluate the clinical outcome, the preoperative and postoperative International Knee Documentation Committee (IKDC) and Lysholm knee scoring scales were analyzed. To evaluate the postoperative outcomes based on the predisposing factors, the results were separately analyzed for each group. Regarding radiologic outcomes, 20-degree CA was significantly reduced from 10.37 ± 5.96° preoperatively to −0.94 ± 4.11° postoperatively (p = 0.001). In addition, regardless of the predisposing factors, delta values of pre- and postoperation of 20-degree CA were not significantly different in both groups. The IKDC score improved from 53.71 (range: 18–74) preoperatively to 94.71 (range: 86–100) at the last follow-up (p = 0.004), and the Lysholm score improved from 54.28 (range: 10–81) preoperatively to 94.14 (range: 86–100) at the last follow-up (p = 0.010). Isolated MPFL reconstruction provides a safe and effective treatment for patellofemoral instability, even in the presence of mild predisposing factors, such as trochlear dysplasia, increased patella height, increased TT–TG distance, or valgus alignment. This is a Level 4, case series study.

scholarly journals Failure Analysis in Patients With Patellar Redislocation After Primary Isolated Medial Patellofemoral Ligament Reconstruction

2020 ◽  
Vol 8 (6) ◽  
pp. 232596712092617 ◽  
Author(s):  
Matthias J. Feucht ◽  
Julian Mehl ◽  
Philipp Forkel ◽  
Andrea Achtnich ◽  
Andreas Schmitt ◽  
...  
Keyword(s):  
Revision Surgery ◽  
Medial Patellofemoral Ligament ◽  
Femoral Tunnel ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Tibial Tuberosity ◽  
Mpfl Reconstruction ◽  
Tunnel Position ◽  
Femoral Tunnel Position ◽  
Valgus Malalignment

Background: Reconstruction of the medial patellofemoral ligament (MPFL) has become a popular surgical procedure to address patellofemoral instability. As a consequence of the growing number of MPFL reconstructions performed, a higher rate of failures and revision procedures has been seen. Purpose: To perform a failure analysis in patients with patellar redislocation after primary isolated MPFL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing revision surgery for reinstability after primary isolated MPFL reconstruction were included. Clinical notes were reviewed to collect demographic data, information on the primary surgery, and the mechanism of patellar redislocation (traumatic vs nontraumatic). Preoperative imaging was analyzed regarding femoral tunnel position and the prevalence of anatomic risk factors (ARFs) associated with patellofemoral instability: trochlear dysplasia (types B through D), patella alta (Caton-Deschamps index >1.2, patellotrochlear index <0.28), lateralization of the tibial tuberosity (tibial tuberosity–trochlear groove distance >20 mm, tibial tuberosity–posterior cruciate ligament [TT-PCL] distance >24 mm), valgus malalignment (mechanical valgus axis >5°), and torsional deformity (internal femoral torsion >25°, external tibial torsion >35°). The prevalence of ARF was compared between patients with traumatic and nontraumatic redislocations and between patients with anatomic and nonanatomic femoral tunnel position. Results: A total of 26 patients (69% female) with a mean age of 25 ± 7 years were included. The cause of redislocation was traumatic in 31% and nontraumatic in 69%. Position of the femoral tunnel was considered nonanatomic in 50% of patients. Trochlear dysplasia was the most common ARF with a prevalence of 50%, followed by elevated TT-PCL distance (36%) and valgus malalignment (35%). The median number of ARFs per patient was 3 (range, 0-6), and 65% of patients had 2 or more ARFs. Patients with nontraumatic redislocations showed significantly more ARFs per patient, and the presence of 2 or more ARFs was significantly more common in this group. No significant difference was observed between patients with anatomic versus nonanatomic femoral tunnel position. Conclusion: Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction. Before revision surgery, a focused clinical examination and adequate imaging including radiographs, magnetic resonance imaging (MRI), standing full-leg radiographs, and torsional measurement with computed tomography or MRI are recommended to assess all relevant anatomic parameters to understand an individual patient’s risk profile. During revision surgery, care must be taken to ensure anatomic placement of the femoral tunnel through use of anatomic and/or radiographic landmarks.

Isolated Medial Patellofemoral Ligament Reconstruction Can Be an Effective Procedure in Patellofemoral Instability with Risk Factors

2019 ◽  
Vol 33 (10) ◽  
pp. 992-997 ◽  
Author(s):  
Fabian Blanke ◽  
Kathrin Watermann ◽  
Maximilian Haenle ◽  
Andreas Feitenhansl ◽  
Carlo Camathias ◽  
...  
Keyword(s):  
Risk Factors ◽  
Clinical Outcome ◽  
Medial Patellofemoral Ligament ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Effective Procedure ◽  
Mpfl Reconstruction ◽  
Trochlear Groove ◽  
Severe Problem ◽  
Outcome Scores

AbstractPatellofemoral instability is a severe problem in young and active patients. This pathology is influenced by ligamentous, bony, and neuromuscular parameters. The reconstruction of the medial patellofemoral ligament (MPFL) evolved to a primary procedure, but combined procedures were more frequently performed in the past years. However, additional operative procedures are associated with increased morbidity and no absolute indication can be identified in the literature. This study is intended to clarify whether addressing only ligamentous influence factors (MPFL) in chronic patellofemoral instability is sufficient to produce good clinical outcomes, or whether other risk factors influence the results negatively and should also be treated at some point. In 52 patients with chronic patellofemoral instability patellar height according to Caton-Deschamps, trochlear dysplasia according to Dejour, the leg axis, the femoral antetorsion, tibial tubercle (TT)–trochlear groove, and TT–posterior cruciate ligament distance were evaluated. All patients were treated with isolated MPFL reconstruction. After a minimum follow-up period of 24 months (24–36 months), the clinical outcome results were calculated using the scoring system according to Lysholm and Tegner. Correlation between clinical outcome scores and anatomic risk factors were calculated. The analysis was performed using a standard statistical software package (JMP version 12, SAS Institute, Cary, NC). The average postoperative Lysholm score increased significantly from 57.23 ± 19.9 to 85.9 ± 17.2 points (p < 0.0001) after isolated MPFL reconstruction. Moreover, the Tegner and Lysholm scores significantly improved both in patients without and with different risk factors postoperative. There were no significant differences in the outcome sores between the groups. Even the degree of trochlear dysplasia (types I–III) did not influence the results. Finally, there was no significant correlation found between all collected risk factors and the postoperative outcome scores. Isolated MPFL reconstruction can be an effective procedure in patients with patellofemoral instability and mild to moderate risk factors.

scholarly journals Joint Space Injection for Osteitis Pubis in an Airborne Jump Injury: A Case Report

2019 ◽  
Vol 185 (7-8) ◽  
pp. e1298-e1299
Author(s):  
Jackson P Beall ◽  
Joshua J Oliver ◽  
Rachel E Bridwell ◽  
Scott E Young
Keyword(s):  
Sports Medicine ◽  
Groin Pain ◽  
Pubic Symphysis ◽  
Joint Space ◽  
Treatment Modalities ◽  
Osteitis Pubis ◽  
Jump Exercise ◽  
Repetitive Stress ◽  
First Time

Abstract Osteitis Pubis (OP) is groin pain caused by overloading stresses on the pubic symphysis. This is often caused by the repetitive stress seen in competitive sports, but can also be caused by rapid acceleration or deceleration. It is a diagnosis of exclusion made after other entities such as fracture or infection are ruled out. It is often treated conservatively with rest, Non-Steroidal Anti-inflammatories (NSAIDS), and Physical Therapy (PT). After these treatment modalities have failed, intra-articular injection with local anesthetics and steroids can be considered. We report a case of a 22-year-old Male Active Duty Army Soldier who presented with OP immediately after landing during a routine Airborne Jump exercise. The Soldier reported landing in such a way that his feet did not impact the ground at the same time, creating a sheering force on his pelvis. Following two months of failed treatment involving NSAIDS and PT, the patient was referred to Sports Medicine where he received an injection of 1 mL of 1% lidocaine and 40 mg of triamcinolone into the pubic symphysis joint space. Shortly afterward the patient endorses complete resolution of his symptoms without return of symptoms at 1-month follow-up. Although injection of the pubic symphysis with local anesthetic and steroids has been previously described, this is the first time it has been described in a jump injury.

scholarly journals Clinical Outcomes after Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability

2017 ◽  
Vol 5 (3_suppl3) ◽  
pp. 2325967117S0012
Author(s):  
Joseph N. Liu ◽  
Jacqueline Munch ◽  
Claire Berdelle Ryan ◽  
Irene L. Kalbian ◽  
Sabrina M. Strickland ◽  
...  
Keyword(s):  
Ligament Reconstruction ◽  
Medial Patellofemoral Ligament ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Patient Reported Outcome Measures ◽  
Patient Reported Outcome ◽  
Return To Sports ◽  
Medial Patellofemoral Ligament Reconstruction ◽  
Patient Reported

Objectives: Medial patellofemoral ligament (MPFL) reconstruction has become an increasingly popular means to regain stability in the setting of recurrent lateral patellar dislocation, with nearly twice the number of medical centers performing reconstruction of the MPFL and outcomes reported on nearly double the number of patients in recent years. While recent studies have demonstrated improved patient reported outcome measures and a high rate of return to sports, limited literature has explored its effectiveness as an isolated intervention in the context of trochlear dysplasia. The purpose of this study was to determine the efficacy of isolated MPFL reconstruction in treating patellar instability in the setting of trochlear dysplasia. Methods: This was a retrospective review of consecutive patients who underwent unilateral or bilateral medial patellofemoral ligament reconstruction for patellofemoral instability. No osteotomies were included. All patients with minimum 2 year follow up were included. Pre- and postoperative assessment included ligamentous laxity, patellar crepitus, tilt, translation, and apprehension, and radiographic features including tibial tubercle-trochlear groove (TT-TG) ratio, Dejour classification, and Caton Deschamps ratio. Final follow up consisted of patient reported outcome measures including the Kujala score, International Knee Documentation Committee (IKDC) score, Lysholm score, and visual analog scale (VAS). Results: 105 MPFL reconstructions were included. Average age at surgery was 23.8 years (SD 9.7, range 12.1 - 57.0) with an average BMI of 23.4 (SD 4.7, range 16.3-43.6) and an average of 4.4 (SD 6.8) dislocation events prior to surgery. Average follow up was 44 months (range 24-111). 76% of patients were female. Average preoperative TT-TG ratio was 13.5 (SD 3.9, range 3.2-22) and Caton Deschamps ratio was 1.2 (SD 0.2, range 0.9-1.6); 74.5% of patients had Dejour C or D trochlear grooves. Kujala score improved from 54.5 (SD 3.8) preoperatively to 87.2 (SD 2.1) at 2 year follow up (p < 0.0001), Lysholm improved from 57.7 (SD 3.6) to 86.4 (SD 2.0) (p < 0.0001), IKDC improved from 52.1 (SD 3.8) to 79.5 (SD 2.6) (p < 0.0001), and VAS pain score improved from 2.9 (SD 0.3) to 1.7 (SD 0.3) (p<0.017). 78.9% of patients were able to return to sports at 1 year, with 69% returning to the same or higher level of play. At minimum 2-year follow up, only 5 patients reported either a postoperative dislocation or subluxation event. Conclusion: This study is the largest single series to report on the effectiveness of isolated MPFL reconstructions in a cohort of patients with a high incidence of trochlear dysplasia. In patients with normal TT-TG ratios, isolated medial patellofemoral ligament reconstruction provides safe and effective treatment for patellofemoral instability, despite the presence of Dejour class C or D trochlear grooves. Most patients are able to return to sports by 1 year postoperatively at the same or higher level of play.

Sign in / Sign up

Export Citation Format

Share Document