scholarly journals Current Concepts in the Treatment of Patellofemoral Instability

2018 ◽  
Vol 1 (1) ◽  
Author(s):  
Gary Ulrich, BS ◽  
Hemant Pandit, FRCS (Orth), DPhil (Oxon)
Keyword(s):  
Patellar Dislocation ◽  
Clinical Presentation ◽  
Young Patients ◽  
Patellofemoral Instability ◽  
High Energy ◽  
Tibial Tubercle ◽  
Extensive Literature ◽  
Trochlear Groove ◽  
Cochrane Central Register ◽  
Orthopedic Surgeons

Background and Hypothesis:  Patellofemoral instability represents a disabling condition, which presents primarily in active, young patients with an increased incidence in the female sex. A patellar dislocation can occur from a high-energy trauma or from an atypical anatomy, such as trochlear dysplasia, patellar dysplasia, patella alta, increased tibial tuberosity-trochlear groove (TT-TG) distance, increased Q-angle, and ligamentous laxity. When a patient presents with patellofemoral instability, the orthopedic surgeon faces many decisions regarding the treatment. Since the risk of a second dislocation after an acute dislocation resides at approximately 17%, many orthopedic surgeons treat the first patellar dislocation non-operatively barring the patient lacks any atypical anatomy. However, after a second dislocation, the likelihood of recurrent dislocations increases to approximately 50%, which directs most orthopedic surgeons to surgical treatment. The current work reviews the anatomical predispositions, clinical presentation, and treatment of patellofemoral instability.   Experimental Design or Project Methods:  The review was constructed via an extensive literature search utilizing the databases of MEDLINE/PubMed, SportDiscus, CINAHL, and Cochrane Central Register of Controlled Trials.   Results:  Multiple treatments exist for patellofemoral instability, which include non-operative treatment, MPFL reconstruction, tibial tubercle osteotomy, and trochleoplasty, along with many other procedures. Each case requires a tailored approach to successfully treat the patellofemoral instability.   Conclusion and Potential Impact:  Patellofemoral instability represents a potentially debilitating condition of anterior knee pain and limited activity. Understanding the anatomical predispositions, clinical presentation, and treatment of patellofemoral instability marks the first step to caring for patients with this condition.

scholarly journals Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability

2021 ◽  
Vol 10 (14) ◽  
pp. 3035
Author(s):  
Robert C. Palmer ◽  
David A. Podeszwa ◽  
Philip L. Wilson ◽  
Henry B. Ellis
Keyword(s):  
Patellar Dislocation ◽  
Patellar Instability ◽  
Medial Patellofemoral Ligament ◽  
Lateral Displacement ◽  
Patellofemoral Instability ◽  
Femoral Anteversion ◽  
Transverse Plane ◽  
Tibial Tubercle ◽  
Trochlear Groove ◽  
Tibial Torsion

Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Previous studies have estimated the incidence of acute patellar dislocation at 43 per 100,000 children younger than age 16 years. The medial patellofemoral ligament (MPFL) complex is a static soft tissue constraint that stabilizes the patellofemoral joint serving as a checkrein to prevent lateral displacement. The causes of PFI are multifactorial and not attributed solely to anatomic features within the knee joint proper. Specific anatomic features to consider include patella alta, increased tibial tubercle–trochlear groove distance, genu valgum, external tibial torsion, femoral anteversion, and ligamentous laxity. The purpose of this paper is to provide a review of the evaluation of PFI in the pediatric and adolescent patient with a specific focus on the contributions of coronal and transverse plane deformities. Moreover, a framework will be provided for the incorporation of bony procedures to address these issues.

Association between Patellofemoral Anatomy and Chondral Lesions of the Knee in Patellofemoral Instability

2021 ◽  
Author(s):  
Olivia O'Malley ◽  
Aliya Choudhury ◽  
Alexandra Biggs ◽  
Alina J. Humdani ◽  
Oliver Brown ◽  
...  
Keyword(s):  
Tilt Angle ◽  
Patellar Dislocation ◽  
Lateral Meniscus ◽  
Patellofemoral Instability ◽  
Patellar Height ◽  
Tibial Tubercle ◽  
Trochlear Groove ◽  
Sulcus Angle ◽  
Chondral Lesions ◽  
Chondral Injury

AbstractChondral injury is a serious consequence of patellar dislocation and patellofemoral instability (PFI). There is limited data on the relationship between radiological features such as sulcus angle and patellar height to the presence, location, and severity of chondral lesions. The purpose of this study was to determine the association of anatomical variants in patellofemoral instability with injuries sustained due to patellar dislocation. A cohort of 101 patients who had four or more episodes of dislocation or instability undergoing isolated arthroscopy or arthroscopies at the time of corrective realignment surgery were identified. The prevalence of chondral, ligamentous, and meniscal injuries was determined and correlated to the sulcus angle, tibial tubercle trochlear groove distance, and patellar height on magnetic resonance imaging (MRI) scans. A total of 101 patients was identified. At arthroscopy, the patella demonstrated the highest incidence of chondral injury (68%) followed by the trochlear groove (40%). Lateral meniscal injuries were noted in 6% of patients, medial meniscal injuries in 2%, and anterior cruciate ligament (ACL) injury in 3%. Chondral injuries were graded using the Outerbridge criteria and there was a correlation between more severe chondral injuries and a greater tilt angle (p = 0.05). The occurrence of injury to the lateral meniscus was associated with a higher Insall–Salvati ratio (p = 0.05). More severe chondral injuries are seen in patients with a greater tilt angle.

The Difference between Computed Tomography and Magnetic Resonance Imaging Measurements of Tibial Tubercle–Trochlear Groove Distance for Patients with or without Patellofemoral Instability: A Systematic Review and Meta-analysis

2019 ◽  
Vol 33 (08) ◽  
pp. 768-776 ◽  
Author(s):  
Si Heng Sharon Tan ◽  
Beatrice Ying Lim ◽  
Kiat Soon Jason Chng ◽  
Chintan Doshi ◽  
Francis K.L. Wong ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Computed Tomography ◽  
Magnetic Resonance ◽  
Patellofemoral Instability ◽  
Tibial Tubercle ◽  
Control Group ◽  
Trochlear Groove ◽  
Resonance Imaging ◽  
The Mean ◽  
Ct And Mri

AbstractThe tibial tubercle–trochlear groove (TT–TG) distance was originally described for computed tomography (CT) but has recently been used on magnetic resonance imaging (MRI) without sufficient evidence demonstrating its validity on MRI. The current review aims to evaluate (1) whether there is a difference in the TT–TG distances measured using CT and MRI, (2) whether both the TT–TG distances measured using CT and MRI could be used to differentiate between patients with or without patellofemoral instability, and (3) whether the same threshold of 15 to 20 mm can be applied for both TT–TG distances measured using CT and MRI. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRSIMA) guidelines. All studies that compared TT–TG distances either (1) between CT and MRI or (2) between patients with and without patellofemoral instability were included. A total of 23 publications were included in the review. These included a total of 3,040 patients. All publications reported the TT–TG distance to be greater in patients with patellofemoral instability as compared to those without patellofemoral instability. This difference was noted for both TT–TG distances measured on CT and on MRI. All publications also reported the TT–TG distance measured on CT to be greater than that measured on MRI (mean difference [MD] = 1.79 mm; 95% confidence interval [CI]: 0.91–2.68). Pooling of the studies revealed that the mean TT–TG distance for the control group was 12.85 mm (95% CI: 11.71–14.01) while the mean TT–TG distance for patients with patellofemoral instability was 18.33 mm (95% CI: 17.04–19.62) when measured on CT. When measured on MRI, the mean TT–TG distance for the control group was 9.83 mm (95% CI: 9.11–10.54), while the mean TT–TG distance for patients with patellofemoral instability was 15.33 mm (95% CI: 14.24–16.42). Both the TTTG distances measured on CT and MRI could be used to differentiate between patients with and without patellofemoral instability. Patients with patellofemoral instability had significantly greater TT–TG distances than those without. However, the TT–TG distances measured on CT were significantly greater than that measured on MRI. Different cut-off values should, therefore, be used for TT–TG distances measured on CT and on MRI in the determination of normal versus abnormal values. Pooling of all the patients included in the review then suggest for 15.5 ± 1.5 mm to be used as the cut off for TT–TG distance measured on CT, and for 12.5 ± 2 mm to be used as the cut-off for TT–TG distance measured on MRI. The Level of evidence for this study is IV.

scholarly journals Tibial Tubercle–Roman Arch Distance: A New Measurement of Patellar Dislocation and Indication of Tibial Tubercle Osteotomy

2020 ◽  
Vol 8 (4) ◽  
pp. 232596712091487 ◽  
Author(s):  
Zijie Xu ◽  
Hua Zhang ◽  
Binjie Fu ◽  
Sheikh Ibrahimrashid Mohamed ◽  
Jian Zhang ◽  
...  
Keyword(s):  
Relative Position ◽  
Patellar Dislocation ◽  
Trochlear Dysplasia ◽  
Tibial Tubercle ◽  
Trochlear Groove ◽  
Tibial Tubercle Osteotomy ◽  
Distance Measurements ◽  
Significant Difference ◽  
Reliable Parameter ◽  
And Control

Background: The surgical indication for tibial tubercle osteotomy (TTO) has been based on a tibial tubercle–trochlear groove (TT-TG) distance of 20 mm or greater in patients with patellar dislocation. However, the measurement of this parameter is less reliable in patients with trochlear dysplasia. Hypothesis: The novel measurement of tibial tubercle–Roman arch (TT-RA) distance would be a reliable parameter for identifying the relative position of the tibial tubercle in patients with patellar dislocation, especially those with trochlear dysplasia. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 56 patients with a diagnosis of patellar dislocation and 60 volunteers (60 knee joints) without a history of lower extremity pain or injury were included in our study. The TT-RA distance, TT-TG distance, and some femoral anatomic parameters were assessed by use of computed tomography. The measurements were performed by a radiologist and an orthopaedic surgeon in a blinded and randomized fashion. The difference in each parameter between the study and control groups was analyzed through use of an unpaired t test. Receiver operating characteristic curve analysis was performed to evaluate the discriminatory capacity of the included parameters. The cutoff values of the included measurements with specificity and sensitivity were calculated. In addition, the TT-TG distance and TT-RA distance were analyzed using the Dejour classification to evaluate the intraclass correlation coefficient (ICC) of each parameter in different types of femoral trochlea. Result: A significant difference for TT-RA distance was found between the study group (23.24 ± 4.41 mm) and control group (19.15 ± 4.24 mm) ( P < .001). The TT-RA distance had an area under the curve of 0.757. At a value greater than 23.74 mm, TT-RA distance had 53.57% sensitivity and 88.33% specificity for patellar dislocation. The ICCs of TT-RA distance measurements were excellent in all Dejour classifications (>0.939), whereas the ICCs of TT-TG distance measurements were relatively lower than the ICCs of TT-RA distance measurements. According to the data from included healthy individuals, the pathological TT-RA distance threshold was 26 mm. Conclusion: Compared with TT-TG distance, the TT-RA distance is a more reliable parameter for identifying the relative position of the tibial tubercle in patients with trochlear dysplasia. For patients with a TT-RA distance greater than 26 mm, surgery should be considered to correct the malposition of the tibial tubercle.

How Do Axial Scan Orientation Deviations Affect the Measurements of Knee Anatomical Parameters Associated with Patellofemoral Instability? A Simulated Computed Tomography Study

2017 ◽  
Vol 31 (05) ◽  
pp. 425-432 ◽  
Author(s):  
Ran Xiong ◽  
Cheng Chen ◽  
Li Yin ◽  
Xiaoyuan Gong ◽  
Jiangming Luo ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Cruciate Ligament ◽  
Patellofemoral Instability ◽  
Ct Scanning ◽  
Tibial Tubercle ◽  
Trochlear Groove ◽  
Patellar Tilt ◽  
Sulcus Angle ◽  
Scan Data ◽  
Anatomical Parameters

AbstractThe purpose of this study was to detect the correlation between axial scan orientation discrepancy and the knee anatomical parameters associated with patellofemoral instability during computed tomography (CT) scanning. CT scan data of 16 knees from 16 healthy subjects were retrieved. The reslicing processes were performed to simulate different axial scan orientations generated due to leg adduction/abduction during CT scanning. Eight parameters (tibial tubercle to trochlear groove [TT-TG], tibial tubercle to posterior cruciate ligament [TT-PCL], patellar tilt, lateral trochlear inclination, sulcus angle, trochlear depth, trochlear facet asymmetry, and trochlear condyle asymmetry) of five angles (neutral zero, 4/8 degrees of adduction and 4/8 degrees abduction) were quantified. All eight parameters showed varying degrees of deviations to the different axial scan orientations. TT-TG, patellar tilt, lateral trochlear inclination, and trochlear condyle asymmetry were relatively sensitive to axial scan orientation changes, whereas TT-PCL, sulcus angle, trochlear depth, and trochlear facet asymmetry were relatively insensitive. Although the sensitivities are various, surgeons should be aware of this situation and make necessary corrections.

scholarly journals Outcomes And Reoperation Rates After Tibial Tubercle Transfer And Medial Patellofemoral Ligament Reconstruction

2020 ◽  
Vol 8 (3_suppl2) ◽  
pp. 2325967120S0012
Author(s):  
Dax T. Varkey ◽  
Jacob Gorbaty ◽  
Susan Odum ◽  
Dana P. Piasecki ◽  
James E. Fleischli
Keyword(s):  
Knee Pain ◽  
Ligament Reconstruction ◽  
Medial Patellofemoral Ligament ◽  
Patellofemoral Instability ◽  
Reoperation Rate ◽  
Tibial Tubercle ◽  
Trochlear Groove ◽  
Medial Patellofemoral Ligament Reconstruction ◽  
Tibial Tubercle Transfer ◽  
Reoperation Rates

Objectives: Patellofemoral instability (PFI) is a painful condition affecting approximately 7 patients per 100,000 in the US. Unfortunately, as many as 50% of young patients with patellar dislocations can go on to recurrent instability and have debilitating symptoms. With a wide range of operative techniques, and subsequent reoperation and complication rate cited in the literature, it becomes challenging to create an appropriate algorithm with which to treat patients. The goal of our study was to determine the reoperation rate, risk factors for reoperation, and patient reported outcomes after Tibial Tubercle Transfer (TTT), Medial Patellofemoral Ligament Reconstruction (MPFLR), or a combination of the two, for patellofemoral instability surgery. Methods: We retrospectively identified patients who underwent MPFLR and TTT by querying the surgical database at our single institution from 2002-2018 for CPT codes associated with the procedures (CPT-27418, CPT-27427). Patients were included if they had an MPFLR and/or TTT performed for PFI whether recurrent or single dislocation. Patients were excluded if either additional ligamentous reconstruction was performed simultaneously, indications for the procedure was for a condition other than PFI or if records were incomplete. 497 patients were eligible to be included. Radiographic measurements, demographic parameters, and subsequent revision procedures and their indications were identified. A modified anterior knee pain survey was conducted by mail and with follow-up phone survey. Chi-Square Tests or Fishers Exact Test were used to compare differences for categorical data and Wilcoxon rank sum tests were used to compare the non-parametric pain scores. A multivariable logistic regression was used to determine the association between patient demographics, radiographic parameters and procedure type. Results: The overall rate of reoperation amongst all patients was 25.6%. The rate of reoperation for MPFL alone (19.9%) was lower than that of TTT alone (34.8%) or both procedures simultaneously (26.4%) (P = .007). There was a trend towards increased major reoperation rates and revision stabilization procedures in patients with isolated TTT (P = .16). There was no association with tibial tubercle to trochlear groove (TTTG) distance and the rate of reoperation (P = .99). A preoperative Dejour classification D was associated with a higher reoperation rate (28%) than those with Dejour A-C (P=.43). A Caton-Deschamp ratio >1.3 increased the odds of having a revision stabilization surgery (odds ratio 2.303). Patients who had a revision surgery for any reason were more likely to report pain while walking compared to those who did not (P = <.0001). Conclusion: The overall reoperation after PFI surgery is higher than previously reported. Patients who underwent further procedures were more likely to report continued knee pain when walking. Our results would suggest that patients with trochlear dysplasia and patella alta are more likely to undergo future procedures for instability, and may benefit from more aggressive initial treatment, such as MPFLR and TTT in combination.

scholarly journals Increased tibial tubercle-trochlear groove and patellar height indicate a higher risk of recurrent patellar dislocation following medial reefing

2021 ◽  
Author(s):  
Marc-Daniel Ahrend ◽  
Tobias Eisenmann ◽  
Moritz Herbst ◽  
Boyko Gueorguiev ◽  
Gabriel Keller ◽  
...  
Keyword(s):  
Patellar Dislocation ◽  
Recurrent Dislocation ◽  
Patellar Height ◽  
Tibial Tubercle ◽  
Trochlear Groove ◽  
Recurrent Patellar Dislocation ◽  
Patellar Tilt ◽  
Level Of Evidence ◽  
Sulcus Angle ◽  
Patellar Shift

Abstract Purpose Identifying anatomical risk factors on recurrent dislocation after medial reefing is important for deciding surgical treatment. The present study aimed to retrospectively analyze the preoperative magnetic resonance imaging (MRI)-based parameters of patients treated with medial reefing and whether these parameters lead to a higher risk of recurrent dislocation. Methods Fifty-five patients (18.6 ± 6.6 years) who underwent medial reefing after primary traumatic patellar dislocation (84% with medial patellofemoral ligament [MPFL] rupture) were included. Patients were followed up for at least 24 months postoperatively (3.8 ± 1.2 years) to assess the incidence of recurrent patellar dislocation. In patients without recurrent dislocation, the Kujala and subjective IKDC scores were assessed. Moreover, the tibial tubercle-trochlear groove (TT-TG), sulcus angle, patellar tilt, patellar shift, and lateral trochlea index (LTI) were measured. The patellar height was measured using the Caton-Dechamps (CDI), Blackburne-Peel (BPI), and Insall-Salvati index (ISI). The cohort was subclassified into two groups with and without recurrent dislocation. Differences between groups were analyzed with respect to the MRI parameters. Results Forty percent had a pathological sulcus angle of > 145°, 7.2% had an LTI of < 11°, 47.3% had a patellar tilt of > 20°, and 36.4% had a TT-TG of ≥ 16 mm. Increased patellar height was observed in 34.5, 65.5, and 34.5% of the patients as per CDI, BPI, and ISI, respectively. Nineteen (34.5%) patients suffered from recurrent dislocation. Compared with patients without recurrent dislocation, those with recurrent dislocation had a significantly lower LTI (p = 0.0467). All other parameters were not significantly different between the groups. Risk factor analysis showed higher odds ratios (OR > 2), although not statistically significant, for MPFL rupture (OR 2.05 [95% confidence interval 0.38–11.03], LTI (6.6 [0.6–68.1]), TT-TG (2.9 [0.9–9.2]), and patellar height according to ISI (2.3 [0.7–7.5]) and CDI (2.3 [0.7–7.5])). Patients without recurrent dislocation had a Kujala score of 93.7 ± 12.1 (42–100) points and an IKDC score of 90.6 ± 11.7 (55.2–100) points. Conclusion Anatomical, MRI-based parameters should be considered before indicating medial reefing. A ruptured MPFL, an LTI < 11°, a TT-TG ≥ 16 mm, a patellar tilt > 20 mm, and an increased patellar height according to ISI and CDI were found to be associated, although not significantly, with a higher risk (OR > 2) of recurrent patellar dislocation after medial reefing. Thorough preoperative analysis is crucial to reduce the risk of recurrent dislocation in young patient cohorts. Level of evidence Level IV

scholarly journals Current methods of patellar instability imaging in children. Selection of the best treatment approach

2018 ◽  
Vol 6 (2) ◽  
pp. 29-36 ◽  
Author(s):  
Alexander A. Sautenko ◽  
Egor V. Ogarev ◽  
Alexander G. Eltsin ◽  
Vladimir N. Merkulov ◽  
Dmitry S. Mininkov
Keyword(s):  
Patellar Dislocation ◽  
Patellar Instability ◽  
Multislice Ct ◽  
Diagnostic Algorithm ◽  
Treatment Method ◽  
Optimal Treatment ◽  
Tibial Tubercle ◽  
Trochlear Groove ◽  
Patellar Tilt ◽  
Selection Of

Background. Patellar instability is a common problem in pediatric patients. Up to 2%–3% of all knee injuries are associated with acute patellar dislocation. According to the data in the literature, patients aged 10–17 years are at the highest risk of patellar dislocation and subsequent instability. These patients must be evaluated according to the proposed algorithm to select the optimal treatment method. Aim. To diagnose patellar instability in children and subsequently select the optimal treatment method based on acquired data. Materials and methods. The study is based on data acquired through the examination and treatment of 147 patients at the 9th Department of Pediatric Traumatology and Orthopedics. Great emphasis was put on computed tomography (CT) data, its essential parameters, which require the most thorough analysis, and assessment methods. These parameters include patellar tilt, dysplasia of the distal metaepiphysis of the femur, the tibial tubercle–trochlear groove index, and the rotational relation of the femur and tibia. Results. A novel algorithm for patient examination using CT is proposed. Data obtained by multislice CT (MSCT) had a significant influence on the selection of the surgical method for treating patients with patellar instability. Conclusion. The examination of patients with patellar instability using MSCT in adherence to the proposed diagnostic algorithm allows the selection of the optimal treatment method, which will increase the likelihood of rapid recovery of patients and their return to the level of activity similar to that before injury.

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

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