Modified Langenskiöld Procedure for Congenital Patella Dislocations in Pediatric Patients

Background: Great difficulty and more failures were the descriptions of the treatment of congenital patella dislocation in pediatric patients. This study aims to evaluate the outcomes of patients with congenital patellar dislocations treated with the modified Langenskiöld procedure. Methods: The medical records of 16 knees in 11 patients with a diagnosis of congenital patella dislocation were collected from September 2016 to March 2019. They were treated with the modified Langenskiöld procedure. The mean follow-up period was 37.8 months. The outcome measures were the Lysholm score, Kujala score, patellar stability, and knee range of motion. Results: Eleven patients, namely, eight girls and three boys, with 16 knees were enrolled. The mean age at the time of operation was 3.1 years. The post-operative mean Lysholm score was 94.8 (SD 5.1; 87–100), whereas the Kujala score was 95 (SD 5.9; 86–100). There were no recurrent dislocations, and all patients had full extension postoperatively. Conclusion: The modified Langenskiöld procedure is a promising solution for the treatment of congenital patella dislocations. Level of evidence: Level IV; Case Series; Treatment Study

Chronic Patellar Tendon Rupture Reconstructed with Hamstring Graft – A Case Report

Neglected patella tendon rupture which are presented 6 weeks after injury are rare but it can be disabling. Aim of study is to determine the outcomes of chronic patellar tendon rupture reconstructed using hamstring graft. This case report concerns a 26 year-old man who came with complaints of weakness of legs, difficulty in climbing stairs up and down, difficulty in getting up from squatting position. X-ray of Right knee showed high riding patella. MRI showed full thickness rupture of ACL. The patient was operated with a combination of Chen et al and ganga hospital SR Sundararajan7. Our outcome was also excellent with no extensor lag, Kujala score was 94.1, Lysholm score was 92.3. From our study it is found that even in chronic neglected cases of patellar tendon rupture, good functional results can be obtained by repair using hamstring graft.

Does arthroscopic patellar denervation with high tibial osteotomy improve anterior knee pain?

Purpose Patellofemoral (PF) joint osteoarthritis (OA) is a major cause of anterior knee pain. Combined PF and medial tibiofemoral (TF) OA is common in older adults. We evaluated the effect of arthroscopic patellar denervation (PD) in patients with combined TF and PFOA after malalignment correction. Methods Forty-five patients [females/males, 27/18; age, 30–59 years (45.5 ± 8.50); mean body mass index, 25.15 ± 3.04 kg/m2] were treated in our department from March 2017 to March 2019. The patients were randomised into 2 groups: group A included 22 patients who underwent open-wedge high tibial osteotomy (OWHTO) and arthroscopic PD and group B included 23 patients who underwent OWHTO without denervation. The effect of denervation was statistically and clinically evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS) and Kujala (anterior knee pain score) score. Results After 24 months, 40 patients were available for the final follow-up. The final values of KOOS and the Kujala score were significantly different between the groups (p < 0.001). For group A, the average KOOS improved from 42.73 to 72.38 (p < 0.001) and the Kujala score improved from 42 to 74.1 (p < 0.001), whereas in group B, the average KOOS improved from 39.22 to 56.84 (p < 0.001) and the Kujala score improved from 39.7 to 56.4 (p < 0.001). Conclusion Adding arthroscopic PD to OWHTO relieves anterior knee pain in patients with combined TF and PFOA and improves knee joint function and quality of life. Level of evidence Level I prospective randomised control clinical trial.

Patella baja after intramedullary nailing of tibial fractures, using an infrapatellar/transtendinous approach, predicts worse patient reported outcome

Purpose After intramedullary nailing of tibial shaft fractures using an infrapatellar/transtendinous approach, several patients suffer anterior knee pain. We suspect that the approach is associated with soft tissue scars and the development of a postoperative patella baja. The goal of the study is to investigate whether the development of patella baja is associated with worse subjective outcomes. Methods We retrospectively analyzed all patients in our orthopedic trauma department between 2011 and 2020 who underwent tibial fracture fixation via intramedullary nailing via an infrapatellar/transtendinous approach. Pre- and postoperative lateral knee x-rays were evaluated by measurement of the Insall-Salvati Index, and nail tip position. All patients were asked to answer the self-assessment Kujala questionnaire and Lysholm questionnaire. Results We included 78 patients (age: 44 ± 18 years) with a minimum follow-up of 12 months. Mean follow up was 59 ± 25 months. We included 50 male and 28 female patients. Patella baja detected by Insall-Salvati Index could be observed in 8 (10.3%) patients. Patients with patella baja showed significant worse function measured by the Kujala score 54 ± 18 vs. 80 ± 14 (p < 0.01). Likewise, Lysholm score did show significant differences between both groups (60 ± 24 vs. 86 ± 11; p < 0.01). Nail tip position was not associated with worse subjective function. Conclusions Patella baja in patients after tibial intramedullary nailing via an infrapatellar/transtendinous approach, is associated with worse subjective function and increased pain.

Outcomes following Medial Patellofemoral Ligament Reconstruction with Allograft (177)

Objectives: Medial patellofemoral ligament reconstruction (MPFLR) using allograft tissue has several potential benefits including the absence of donor site morbidity, ability to predict graft parameters, and decreased operative time. The purpose of this study was to evaluate the outcomes of patients following MPFLR with allograft. Our hypothesis was that there would be a low rate of recurrent instability, and excellent clinical outcomes reported. Methods: A retrospective review of athletes who underwent MPFL Reconstruction, with a minimum of 12-month follow-up was performed. Recurrent instability (including re-dislocation and subluxation), Visual Analogue Scale (VAS) score, Kujala score, satisfaction, and whether they would undergo the same surgery again, were evaluated. Results: Overall, follow up was attained for 131 patients with 141 knees (73.4%). The mean patient age of 25.0 years, 67.4% females, and mean time to follow-up was 46.8 months (12-111). At final follow up, the mean VAS score was 1.4 ± 2.0, the mean Kujala score was 84.8 ± 15.6, the mean satisfaction score was 84% ± 26.0, and 117 (83.0%) would undergo the same procedure again if required. There was 17 (12.0%) patients that had recurrent instability, with 2 being re-dislocations (1.4%). A further procedure was performed in 14 patients (9.9%). There were no intra-operative complications in our series. Conclusions: There was a low rate of recurrent instability following MPFLR with allograft, with excellent patient reported outcomes, and a low complication rate.

Patient-Reported Outcomes and Risk Factors for Decreased Improvement after Patellofemoral Arthroplasty

Patellofemoral arthroplasty (PFA) is acknowledged as the method for the treatment of isolated patellofemoral osteoarthritis (PFOA). Few previous studies have assessed the patient-reported outcomes (PROs) and risk factors of less improvement of PROs in patients undergoing PFA. A retrospective analysis was performed, including all patients who had undergone PFA. Pre- and postoperative PROs included the Oxford Knee Score (OKS) and Kujala score. Univariate and multivariate statistical analyses were performed to assess influencing factors of less improvement of PROs including the demographic factors (gender, age, body mass index, smoking, opioid usage, and duration of symptoms [DOSs]), surgical factors (concomitant surgery), and imaging factors (trochlear dysplasia [TD], patellar height, the degree of PFOA). A total of 46 PFAs were analyzed with a mean follow-up of 37 ± 7 months. The mean age at surgery was 61.1 ± 7.7 years. Patients showed significant improvement in all PROs (p < 0.001). Patients with TD preoperatively have greater improvement in OKS and Kujala score postoperatively (19.2 ± 5.0 vs. 23.1 ± 3.6, p = 0.038). Longer DOSs (≥1 year) had a greater mean improvement in OKS and Kujala score (p = 0.011 and p = 0.000). According to the measurement of patella height, patients with patella alta (Caton–Deschamps index [CDI] ≥1.3) showed less improvement in both OKS and Kujala score (p = 0.000 and p = 0.002). PFA is a safe and efficient surgery with good PROs. Patella alta with a CDI ≥1.3 and duration of preoperative symptoms ≤ 1 year were risk factors for decreased OKS and Kujala score improvement, while the preoperative presence of TD was significantly predictive factors for increased OKS improvement.

A Patellofemoral Chondropathy Quantification from Vibroarthrography: A Preliminary Study

Objective: To preliminarily investigate if the proposed parameter derived from the knee vibroarthrographic (VAG) signals, namely the VAG score, could potentially be used to quantify the patellofemoral chondropathy. Materials and Methods: Five subjects with meniscus injury as an indication for arthroscopy were recruited for the present preliminary crosssectional study. Prior to the arthroscopy, the Kujala scores were assessed and the knee VAG signals were recorded from all the subjects. Subjects were asked to actively perform the knee flexion-extension for three cycles in the supine position while recording the VAG signal. The proposed VAG score was defined as the power spectral density of the signal in the frequency of 450 to 1,000 Hz. Patellofemoral chondropathy was arthroscopically graded using French Society of Arthroscopy system (SFA) score and SFA category. Results: The SFA score was significantly strongly correlated with the VAG score (r=0.87, p=0.02) but not with the Kujala score (r=–0.79, p=0.11). Likewise, the SFA category was significantly correlated with the VAG score (r=0.98, p<0.01) but not with the Kujala score (r=–0.67, p=0.22). Conclusion: The proposed signal-based VAG score was demonstrated to be preliminarily able to better assess the patellofemoral chondropathy non-invasively, compared to the Kujala score, which is questionnaire-based. Keywords: Chondropathy; Vibroarthrographic signal; SFA score; SFA category; Kujala score

Higher Rate of Patellofemoral Problems After Anterior Cruciate Ligament Reconstruction using Hamstring Autograft

Background: Patellofemoral problems are not uncommon among post-anterior cruciate ligament (ACL) reconstruction patients. Hamstring autograft harvesting-related factor is one of the suspected causes. A lack of tibiofemoral internal rotation force due to strength deficit causes the patella tends to shift laterally. Purposes: Peroneus longus tendon has been proposed as an alternative graft source due to its adequate tensile strength and minimal donor site morbidity to the knee biomechanics, including the patellofemoral joint. This tendon does not cross the knee joint and thus does not affect patellofemoral alignment and biomechanics. This study aims to compare patellofemoral problems between hamstring and peroneus longus autograft harvested-patients following ACL reconstruction. Material and methods: Thirty-one subjects who underwent primary single-bundle ACL reconstruction between September 2018 and September 2019 and met the inclusion criteria were grouped into the hamstring group (n=16) and peroneus longus group (n=15). Both groups were evaluated retrospectively. The follow-up assessment was conducted on the phase II rehabilitation program. The assessed variables were pain, crepitus, and the Indonesian-validated Kujala score. Results: No significant differences in pain and crepitus were found between both groups. There were significant differences in the Kujala score between both groups (P < .001). The peroneus longus group reported an averagely higher score than the hamstring group. Conclusion: Single bundle ACL reconstruction using peroneus longus tendon autograft produces less patellofemoral symptoms and functional limitation than using hamstring tendon autograft.

Comparison of total patellectomy and osteosynthesis with tension band wiring in patients with highly comminuted patella fractures: a 10–20-year follow-up study

Background The purpose of this study was to evaluate and compare the long-term clinical outcomes between the total patellectomy and osteosynthesis with tension band wiring in patients with highly comminuted patella fractures. Methods Between January 1987 and December 2003, this retrospective study included a total of 35 patients (mean age, 51.4±16.8 years) with a minimum of 10 years follow-up period, comprising 29 males and 6 females, who were divided into the total patellectomy group (17 patients) or the open reduction and internal fixation (ORIF) group (18 patients) in the Third Affiliated Hospital of Hebei Medical University. We retrospectively collected patient demographics and data on the type of trauma, fracture type, and postoperative complications. Clinical outcomes including knee range of motion (ROM), 36-Item Short-Form Health Survey (SF-36) score [including physical component score (PCS) and mental component score (MCS)], Knee Injury and Osteoarthritis Outcome Score (KOOS), and Kujala score were evaluated and compared between the two groups. Biodex System dynamometer was used to quantitatively evaluate quadriceps femoris muscle power following measurement of peak torque. Results The mean follow-up periods of the total patellectomy group and the ORIF group were 17.2±5.6 and 16.8±4.9 years, respectively. There were no significant differences between the two groups of patient demographics in terms of the number of patients, age, sex, injury side, time to surgery, type of trauma, and fracture classification (p>0.05). Total patellectomy was comparable to osteosynthesis with tension band wiring in terms of ROM [injured knee: 120.4±3.1° vs 118.6±3.3°; uninjured knee: 126.5±2.8° vs 127.3±1.7°; both p>0.05], peak torque [Injured knee: 96.2±2.3 vs 97.3±2.6, N· m; Uninjured knee: 107.6±2.1 vs 106.3±1.8, N· m; both p>0.05], SF-36 score [PCS: 64.1±18.0 vs 61.5±17.9; MCS: 55.1±13.8 vs 54.3±12.4; both p>0.05], KOOS score [76.3±12.1 vs 73.4±11.7; p>0.05], and Kujala score [67.6±11.8 vs 70.8±11.9; p>0.05] at the final follow-up, while total patellectomy had significantly shorter operation time than ORIF group (47.5±12.1 vs 68.8±22.3, min, p<0.05). In the total patellectomy group, complications occurred in 6 of 17 cases (35.3%), and all occurred with calcification. In the ORIF group, complications occurred in 12 of 18 cases (66.7%), including 2 cases of infection (11.1%), 1 case of non-union (5.6%), 2 cases of implant failure (11.1%), 2 cases of soft tissue irritation (11.1%), and 5 cases of patellofemoral arthritis (27.8%). Conclusions Total patellectomy technique was a safe and reliable alternative treatment for treating patients with highly comminuted patella fractures when anatomically reduction and rigid fixation were difficult, although it caused relatively higher rates of calcification.

Management of Patellar Instability: A Network Meta-analysis of Randomized Control Trials

Background: Multiple surgical options exist for the treatment of patellar instability; however, the most common procedures involve either a reconstruction of the medial patellofemoral ligament (MPFL) or a repair/plication of the MPFL and medial soft tissues. Purpose: To perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature to compare MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability. Study Design: Systematic review and network meta-analysis; Level of evidence, 1. Methods: The literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability were included. Clinical outcomes included recurrent instability (including both dislocations and subluxations), redislocation, and Kujala score. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using the statistical software R. The treatment options were ranked using P scores. Results: There were 13 RCTs with a total of 789 patients, all with a minimum follow-up of 24 months. There were 150 patients treated using MPFL reconstruction, 353 treated using MPFL repair, and 286 treated nonoperatively. Overall, MPFL reconstruction had the highest P score (0.9967) and resulted in a significantly lower recurrence rate than did MPFL repair (odds ratio [OR], 0.42; 95% CI, 0.07-0.72) and nonoperative management (OR, 0.09; 95% CI, 0.03-0.32). In addition, MPFL repair resulted in a significantly lower recurrence rate than did nonoperative management (OR, 0.42; 95% CI, 0.25-0.70). MPFL reconstruction had the highest P score (0.9651) and resulted in a significantly higher Kujala score than did nonoperative management (mean difference, 10.45; 95% CI, 0.41-20.49) but not MPFL repair (mean difference, 0.15; 95% CI, 0.03-0.68). Subgroup analysis revealed that MPFL reconstruction had the highest P score for all outcomes in those with first-time dislocation. Conclusion: The current study demonstrated that MPFL reconstruction results in the lowest rate of recurrent patellar instability and best functional outcomes as measured using the Kujala score.