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 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.

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.

scholarly journals Combined MPFL Reconstruction and Tibial Tubercle Transfer for Patellofemoral Instability

2014 ◽  
Vol 30 (6) ◽  
pp. e14
Author(s):  
Chris Hadley ◽  
Brandon Eck ◽  
Fotios Tjoumakaris ◽  
Matthew Pepe ◽  
Luke Austin ◽  
...  
Keyword(s):  
Patellofemoral Instability ◽  
Mpfl Reconstruction ◽  
Tibial Tubercle ◽  
Tibial Tubercle Transfer

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 Acute patellofemoral instability in children and adolescents

Joints ◽  
2016 ◽  
Vol 04 (01) ◽  
pp. 047-051 ◽  
Author(s):  
Pierluigi Antinolfi ◽  
Matteo Bartoli ◽  
Giacomo Placella ◽  
Andrea Speziali ◽  
Valerio Pace ◽  
...  
Keyword(s):  
Children And Adolescents ◽  
Medial Patellofemoral Ligament ◽  
Patellofemoral Instability ◽  
Rehabilitation Program ◽  
Mpfl Reconstruction ◽  
Anatomical Reconstruction ◽  
Targeted Interventions ◽  
Physeal Sparing ◽  
Patellar Stabilization ◽  
Bone Abnormalities

Patellofemoral problems are considered to be among the most frequent causes of knee pain in children and adolescents. Correcting bone abnormalities through specific and targeted interventions is mandatory in skeletally immature patients. Medial patellofemoral ligament (MPFL) reconstruction is the preferred procedure, but there are several important precautionary considerations that the surgeon must take into account. it must always be remembered that MPFL rupture is the result, not the cause, of an altered extensor mechanism; therefore, patellar stabilization with MPFL reconstruction is only the first step to be accomplished in the management of an MPFL rupture. If other anatomical alterations are encountered, alternative/additional surgical procedures should be considered. If MPFL rupture occurs without associated anatomical or functional knee alterations, an ap propriate rehabilitation program after MPFL reconstruction should be sufficient to achieve a good outcome.In conclusion, an acute patellar dislocation should be managed conservatively unless there is evidence of osteochondral damage or medial retinaculum lesions. Osseous procedures are contraindicated in children, while MPFL anatomical reconstruction with “physeal sparing” is the primary surgical option.

Age at Time of Surgery but Not Sex Is Related to Outcomes After Medial Patellofemoral Ligament Reconstruction

2019 ◽  
Vol 47 (7) ◽  
pp. 1638-1644 ◽  
Author(s):  
Laurie A. Hiemstra ◽  
Sarah Kerslake
Keyword(s):  
Quality Of Life ◽  
Medial Patellofemoral Ligament ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Mpfl Reconstruction ◽  
Linear Regression Models ◽  
Level Of Evidence ◽  
Time Of Surgery ◽  
Patient Reported

Background: Medial patellofemoral ligament (MPFL) reconstruction has become a well-accepted procedure for recurrent patellofemoral instability. Despite a growing volume of research assessing surgical results, the relationship of age and sex to outcomes after MPFL reconstruction surgery is unclear. Purpose: To investigate whether age at the time of surgery or sex influenced patient-reported quality of life and clinical outcome after MPFL reconstruction for recurrent lateral patellofemoral instability. Study Design: Cohort study; Level of evidence, 3. Methods: Between January 2010 and May 2016, 328 patients underwent primary patellofemoral stabilization. Demographic and clinical data were collected preoperatively. Patients completed the Banff Patellofemoral Instability Instrument (BPII) at the pre- and postoperative visits and were assessed clinically at 12 and 24 months. To assess the effects of age at surgery and sex on BPII, multiple linear regression models were fit predicting BPII at 12 and 24 months. An unadjusted regression was applied with the predictors being age at the time of surgery and sex. A second regression model was applied adjusting for age at first dislocation, grade of trochlear dysplasia, knee hyperextension, and the WARPS/STAID score—a measure of the risky patellofemoral instability characteristics of the patient. Results: Of 328 patients, 298 (91%) had complete data and minimum 12-month BPII scores available for analysis. There were 11 redislocations in the cohort (3.4%), all in female patients. When stratified by sex, baseline characteristics were not statistically different except for higher age at first dislocation ( P = .022) as well as higher WARPS/STAID scores ( P = .006) for males. Age at the time of surgery was statistically significant for each postoperative follow-up, with lower BPII scores apparent for each 10-year increase in age at the time of surgery. In the adjusted model, the WARPS/STAID score was significantly associated with the preoperative BPII score. For the 24-month postoperative BPII scores, age at time of surgery and preoperative WARPS/STAID score were both significant. Lower BPII scores were apparent for each 10-year increase in age at the time of surgery, as well as for lower scores on the WARPS/STAID classification. Conclusion: This study demonstrated that when adjusted for risky pathoanatomy, neither age at first dislocation nor sex influences patient-reported quality of life outcomes after MPFL reconstruction. Age at the time of surgery was correlated with outcome, with lower BPII scores apparent for each 10-year increase in age at the time of MPFL reconstruction.

scholarly journals Patella dislocations and patellofemoral instability: a current concepts review

2021 ◽  
Vol 20 (3) ◽  
Author(s):  
Benjamin R Garrett ◽  
Michael L Grundill
Keyword(s):  
Patellar Dislocation ◽  
Surgical Intervention ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Tibial Tubercle ◽  
First Episode ◽  
Level Of Evidence ◽  
Lateral Patellar Dislocation ◽  
Consensus Statements ◽  
Patella Dislocations

ABSTRACT Lateral patellar dislocation affects young, active patients with an incidence rate of 5.8 per 100 000. The management of first episode dislocations is non-surgical in the majority of cases, unless associated pathology dictates surgical intervention. Approximately 40% of cases that are treated non-surgically will develop recurrent patellofemoral instability. Evidence supports surgical intervention in these cases; however, the best approach is debatable. Most research and consensus statements agree that medial patellofemoral ligament reconstruction (MPFLR) should be performed in most cases. Additional procedures can be used 'a la carte' according to certain conditions or pathology. A tibial tubercle osteotomy (TTO) is usually indicated in patients with maltracking and/or patella alta, but the direction and degree of correction must be carefully considered. Trochleoplasty is technically demanding and should be reserved for a select few patients with severe trochlear dysplasia. It should be performed by an experienced knee surgeon due to the high risk of inadvertent complications. Level of evidence: Level 5 Keywords: patellofemoral instability, patellar dislocation

Clinical Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability Among Patients With Trochlear Dysplasia

2018 ◽  
Vol 46 (4) ◽  
pp. 883-889 ◽  
Author(s):  
Joseph N. Liu ◽  
Jacqueline M. Brady ◽  
Irene L. Kalbian ◽  
Sabrina M. Strickland ◽  
Claire Berdelle Ryan ◽  
...  
Keyword(s):  
Patellar Instability ◽  
Ligament Reconstruction ◽  
Medial Patellofemoral Ligament ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Mpfl Reconstruction ◽  
Trochlear Groove ◽  
Return To Sports ◽  
Medial Patellofemoral Ligament Reconstruction

Background: Medial patellofemoral ligament (MPFL) reconstruction has become one of the most common and widely used procedures to regain stability among patients with recurrent lateral patellar dislocation. While recent studies demonstrated low recurrence rates, improved patient-reported outcome measures, and a high rate of return to sports, limited literature explored its effectiveness as an isolated intervention in the context of trochlear dysplasia. Purpose: To determine the efficacy of isolated MPFL reconstruction in treating patellar instability in the setting of trochlear dysplasia. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of consecutive patients who underwent uni- or bilateral medial patellofemoral ligament reconstruction for patellofemoral instability with a minimum 2-year follow-up. No osteotomies were included. Pre- and postoperative assessment included ligamentous laxity, patellar crepitus, tilt, translation, apprehension, and radiographic features, including tibial tubercle-trochlear groove (TT-TG) distance, Dejour classification, and Caton-Deschamps index. Results: A total of 121 MPFL reconstructions were included. Mean age at surgery was 23.8 years, and 4.4 dislocation events occurred before surgery. Mean follow-up was 44 months; 76% of patients were female. Mean preoperative TT-TG ratio was 13.5, and mean Caton-Deschamps ratio was 1.2; 92% of patients had Dejour B, C, or D trochlear dysplasia. Kujala score improved from 55.0 preoperatively to 90.0 ( P < .001). Almost all patients (94.5%) were able to return to sports at 1 year, with 74% returning to the same or higher level of play. Only 3 patients reported a postoperative dislocation or subluxation event. Discussion: For patients without significantly elevated TT-TG distances or significant patella alta, isolated MPFL reconstruction provides a safe and effective treatment for patellofemoral instability, despite the presence of trochlear dysplasia. Most patients are able to return to sports by 1 year postoperatively at the same or higher level of play.

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