Tibial derotational osteotomy for idiopathic tibial torsion: A systematic review of surgical indications based on clinical presentation and measurement technique.

PURPOSE: The aim of this systematic review was to identify the surgical indications of tibial derotational osteotomy (TDO) in patients with idiopathic external tibial torsion (ETT) and identify common measurement thresholds for surgical correction. METHODS: A systematic search of MEDLINE and Embase via Ovid, Cochrane Library via Wiley, Web of Science, Scopus, SPORTDiscus via EBSCOhost, ClinicalTrials.gov, WHO ICTRP and Global Index Medicus databases was performed with search terms reflecting the concepts of idiopathic tibial torsion, TDOs, and surgical indications. Studies reporting surgical indications and measurement methods of idiopathic tibial torsion in patients who underwent TDO were included. Two authors independently screened articles and extracted data that was characterized with descriptive statistics. RESULTS: Seventeen studies were identified for inclusion, with 460 tibias and 351 patients. Nearly all patients who underwent surgery had either anterior knee pain or patellar instability, even if other indications were present. Of all included patients, the most common surgical indications for TDO were anterior knee pain (88%), patellar instability (59%), gait dysfunction (41%) and cosmetic deformity (12%). Twelve studies (71%) cited multiple of these indications as reasons for surgery. On physical exam, tibial torsion was measured most commonly by thigh-foot angle (59%) (TFA) and transmalleolar axis (24%) (TMA). In terms of TFA, the most frequently reported cut-off for ETT was >30° (35%). Computerized tomography (CT) was used by nine studies (53%). The most common CT axes used to measure ETT were the TMA with respect to the posterior tibia condylar axis or the bicondylar tibia axis. CONCLUSION: Anterior knee pain and/or patellar instability are common indications for TDO in patients with idiopathic tibial torsion. Standardized TFA thresholds (>30°) and CT measurement methods (TMA and posterior tibia condylar or bicondylar tibial axis) may help further establish objective surgical indications. LEVEL OF EVIDENCE: IV.

Psychological responses during latter rehabilitation and return to sport following ACL reconstruction surgery.

CONTEXT: Despite positive physical outcomes of anterior cruciate ligament reconstruction (ACLR) many athletes do not return to sport following ACLR. OBJECTIVE: To determine if there were differences between athletes who returned to play and those who did not return to sport after ACLR in patterns of psychological responses to injury over the latter course of rehabilitation and return to sport. DESIGN: Case-control study. SETTING: Comprehensive orthopedic medical center referrals. PARTICIPANTS: Thirty-nine recreational and competitive athletes (13-58 years, 21 males) with first ACL tear were observed over the course of the study. MAIN OUTCOME MEASURE: Return to sport. RESULTS: Fifty-two percent of participants returned to play by 9-months post-ACLR. Returners showed a linear decrease in re-injury anxiety from 4- to 9-months post-ACLR while non-returners showed a linear decrease from 4- to 6-months post-ACLR and then a leveling off from 6- to 9-months. Returners showed linear and quadratic effects on perceived limitations to ability with a decrease from 4- to 9- months post-ACLR that accelerated over time while non-returners decreased linearly over time. No significant differences were found between returners and non-returners in knee self-efficacy, perceived percent recovery, and psychological distress. CONCLUSIONS: Results suggest re-injury anxiety and perceived limitations to ability are psychological constructs on which returners and non-returners differ and therefore may be points of intervention to increase the likelihood of return to sport.

A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

Quadriceps Tendon Lengthening for Obligatory (Habitual) Patellar Dislocation in Flexion.

Obligatory patella dislocation in flexion is an uncommon form of patellar instability, where the patella is located in extension and dislocates with every episode of knee flexion. This results in dramatically altered patellofemoral kinematics and can be extremely debilitating due to extensor strength deficits and lack of knee confidence in flexion. Concomitant pathology, which is often seen, includes a tight lateral retinaculum and a shortened extensor mechanism. Lengthening the extensor mechanism is a critical part of successful patellar stabilization, and has not been well-reported. Herein, we present a technique of quadriceps lengthening for the treatment of obligatory patellar dislocation.

Distalization of the Tibial Tubercle for Patellar Stabilization Combined With Medial Patellofemoral Ligament Reconstruction: Length of Distalization or Residual Patella Alta and its Affect on Outcome.

BACKGROUND: Previous research supports that distal translation of the tibial tubercle osteotomy (dTTO) for patients with recurrent lateral patellar dislocation (R-LPD) and patella alta is effective for surgical patellar stabilization. HYPOTHESIS/PURPOSE: The main purpose of this article is to evaluate (1) the results of modifying the surgical threshold and postoperative goal of patellar height measurements for surgical stabilization originated in the "menu à la carte" approach to patellar surgical stabilization and (2) the relationship between the distance distalized in millimeters and postoperative complications. Our hypothesis was that dTTO with medial patellofemoral ligament reconstruction (MPFL-R) will successfully stabilize the patella with improvement in outcome scores and few complications, using a modification of the original menu à la carte as our surgical algorithm. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 68 consecutive patients with R-LPD underwent dTTO and MPFL-R for surgical patellar stabilization by a single surgeon between May 2009 and September 2015. Surgical indications were R-LPD combined with patella alta. The surgical threshold for dTTO was Caton-Deschamps index (CDI) or Insall-Salvati ratio ≥1.4 and/or a patellar trochlear index <0.15. The postoperative surgical goal for patellar height was a CDI of 1.1 to 1.2. Length of the distalization was computed by using the CDI measurement as the primary intraoperative guide and measured intraoperatively with a ruler. Clinical, radiographic, and patient outcome measures were reviewed. RESULTS: The mean CDI preoperatively was 1.40 and postoperatively it was 1.09. The mean distalization was 9.9 mm (range, 4-15 mm). Three patients (4.4%) had frank R-LPD postoperatively. Ten patients had residual patella alta (CDI >1.2), with 1 redislocation. Mean postoperative CDI in the recurrent dislocation group was 1.13 (range, 1.06-1.25) as compared with 1.09 (range, 0.92-1.35) in the nonrecurrent group (P = 0.65). Complications included 3 tibial fractures (4.4%) and postoperative knee arthrofibrosis in 6 patients (8.8%), with mean distalization greater in the arthrofibrosis group (P = .04). Knee injury and Osteoarthritis Outcome Score (KOOS) values improved in all domains, including a 31-point increase in Quality of Life. CONCLUSION: dTTO with MPFL-R for patients with patella alta leads to a high rate of normalization of patellar height measurements (87%) and patellar stabilization (95.6%). Residual patella alta is not associated with an increased risk of recurrence. The length of dTTO up to 15 mm is not associated with an increase in postoperative complications, except for an increased prevalence of arthrofibrosis (8.8%).

Patellofemoral arthroplasty: expert opinion.

Isolated patellofemoral osteoarthritis (PFOA) is a common cause of anterior knee pain in patients over the age of 40 years. Patellofemoral arthroplasty (PFA) is an option to address PFAO when the non-operative or joint preserving management has failed.The goals of PFA are to reduce pain and increase function of the knee in a bone and ligament preserving fashion while maintaining or optimizing its kinematics. Over the last decades advances have been made in optimizing implants designs, addressing complications and improving functional and patient reported outcomes. Appropriate patient selection has proven to be imperative. Proper surgical technique and knowledge of pearls and pitfalls is essential.The indications and surgical technique for patellofemoral arthroplasty will be reviewed here.Level of evidence: Therapeutic Level V.

Putting it all Together: Evaluating Patellar Instability Risk Factors and Revisiting the "Menu".

Management of the patient with multiple risk factors for recurrent patellar instability is complex. Surgeons must possess familiarity with the anatomic risk factors that are associated with first time and recurrent instability events and weigh them in the patient's individualized surgical "menu" options for surgical patellar stabilization. Addressing individual risk factors, pairing imaging findings with physical examination, and thoughts on prioritizing risk factors to determine which should be prioritized for surgical correction are discussed.

Rotational Deformity-When and How to Address Femoral Anteversion and Tibial Torsion.

Rotational deformity is a less common cause of patellar instability than trochlear dysplasia and patella alta. In some cases, rotational deformity is the primary bony factor producing the instability and should be corrected surgically. More research is needed on what are normal values for femoral version and tibial torsion, as well as when the axial plane alignment needs to be corrected. Many tools can be used to evaluate the axial plane and surgeons should be familiar with each of them. Understanding the advantages and disadvantages of each site for osteotomy will help the surgeon choose the most appropriate osteotomy.

Trochlear Development in Children From 1 Month to 10 Years of Age: A Descriptive Study Utilizing Analysis by Magnetic Resonance Imaging.

BACKGROUND: Understanding the morphology of cartilage/bony maturation in preadolescents may help explain adult trochlear variation. PURPOSE: To study trochlear morphology during maturation in children and infants using magnetic resonance imaging (MRI). STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty-four pediatric cadaveric knees (10 male and 14 female knees; age, 1 month to 10 years) were included. High-resolution imaging of the distal femoral secondary ossification center was performed using 7-T or 9.4-T MRI scanners. Three-dimensional MRI scans were produced, and images were reformatted; 3 slices in the axial, sagittal, and coronal planes images were analyzed, with coronal and sagittal imaging used for image orientation. Biometric analysis included lateral and medial trochlear height (TH); cartilaginous sulcus angle (CSA); osseous sulcus angle (OSA); trochlear depth; and trochlear facet (TF) length symmetry. Sex comparisons were considered when ≥1 specimen from both sexes of the same age was available; these included 11 knees spanning 4 age groups (ages 1, 3, 4, and 7 years). RESULTS: The analysis of trochlear morphology showed a lateral TH greater than the medial TH at all ages. The thickest cartilage was found on the lateral TF in the younger specimens. Regarding the development of osseous and cartilaginous trochlear contour, a cartilaginous sulcus was present in the 3-month-old specimen and continued to deepen up to the age of 4 years. The shape of the osseous center evolved from round (1 month) to oval (9 months) to rectangular (2 years); no distinct bony trochlear sulcus was present, although a well-formed cartilaginous sulcus was present. The first evidence of formation of a bony sulcus was at 4 years. By the age of 7 to 8 years, the bony contour of the adult distal femur resembled its cartilaginous contour. Female samples had a shallower CSA and OSA than did the male ones in all samples that had a defined OSA. CONCLUSION: Female trochlear grooves tended to be shallower (flatter). The lateral trochlea was higher (TH) and wider (TF length) during growth than was the medial trochlea in both sexes; furthermore, the development of the osseous sulcus shape lagged behind the development of the cartilaginous sulcus shape in the authors' study population. CLINICAL RELEVANCE: Bony anatomy of the trochlear groove did not match the cartilaginous anatomy in preadolescent children, suggesting that caution should be used when interpreting bony anatomy in this age group.

Patellar Instability and Dislocation: Optimizing Surgical Treatment and How to Avoid Complications.

Patellar instability is a common problem seen by the orthopedic surgeon. Surgery is indicated in recurrent dislocation to improve patellar tracking and ligamentous restraint in order to decrease risk of recurrence, osteochondral injury, and eventual progression to arthritis. Preoperative imaging studies identify anatomic risk factors that increase risk of patellar dislocation to inform surgical decision making. Surgical management starts with medial patellofemoral ligament reconstruction, which is effective in many cases. Tibial tubercle osteotomy realigns the extensor mechanism and is useful in cases of lateralized tibial tubercle or patella alta. For patients with trochlear dysplasia, both tibial tubercle osteotomy and trochleoplasty are options to prevent recurrent dislocation. Chondral lesions are common and, depending upon symptomology and size, can be addressed with débridement, structural grafting, or cell-based treatment. To maximize outcomes, comprehensive preoperative diagnosis and planning must be combined with meticulous surgical technique. Unfortunately, there is minimal evidence to guide when a soft-tissue ligament reconstruction is sufficient versus when is it necessary to correct and alter the bony anatomy. This chapter covers the individualized decision making and surgical pearls for these techniques to improve outcomes and minimize perioperative complications.

Patellar-Trochlear Morphology in Pediatric Patients From 2 to 11 Years of Age: A Descriptive Analysis Based on Computed Tomography Scanning.

BACKGROUND: Despite the critical role the trochlea plays in patellofemoral (PF) pathology, the development of the trochlea is poorly understood. The purpose of this study was 2-fold: (1) Describe quantitative osseous and soft tissue anatomy of the patella and trochlea in skeletally immature cadaveric specimens utilizing known measurements used in PF instability, and (2) evaluate additional measurement techniques in the sagittal plane as they relate to PF morphologic development. METHODS: Thirty-one skeletally immature fresh frozen cadaveric knees between the ages of 2 and 11 years old were evaluated using 0.625 mm computed tomography scans. In the axial plane, measurements included condylar height asymmetry, trochlear facet asymmetry, trochlear depth, osseous sulcus angle, cartilaginous sulcus angle, patella sulcus angle, and tibial tubercle-trochlear groove distance. In the sagittal plane, measurements included previously undescribed measurements of trochlear length and condylar height asymmetry which are based on the anterior femoral cortex. RESULTS: Analysis of trochlear morphology using condylar height asymmetry (both axial and sagittal), trochlear facet asymmetry, and trochlear depth and length demonstrated an increase in the size of the medial and lateral trochlea as age increased. There was more variability in the change of size of the medial trochlea (height, length, and facet length) than the lateral trochlea. The osseous sulcus angle, cartilaginous sulcus angle, and patella sulcus angle decreased (became deeper) with age until after 8 years and then plateaued. CONCLUSIONS: This cadaveric analysis demonstrated that there is an increase in the medial and lateral trochlear height as age increased by all measurements analyzed. The findings also demonstrate that the shape of the patella and trochlea change concurrently, which suggests that there may be interplay between the 2 during development. These new sagittal measurement techniques evaluating the medial, central, and lateral trochlear height and length with respect to age may help guide clinicians when investigating patellar instability in skeletally immature patients. LEVELS OF EVIDENCE: Level IV.

Concepts of the Distal Medial Patellar Restraints: Medial Patellotibial Ligament and Medial Patellomeniscal Ligament.

The important medial patellar ligamentous restraints to lateral dislocation are the proximal group (the medial quadriceps tendon femoral ligament and the medial patellofemoral ligament) and the distal group [medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML)]. The MPTL patellar insertion is at inferomedial border of patella and tibial insertion is in the anteromedial tibia. The MPML originates in the inferomedial patella, right proximal to the MPTL, inserting in the medial meniscus. On the basis of anatomy and biomechanical studies, the MPTL and MPML are more important in 2 moments during knee range of motion: terminal extension, when it directly counteracts quadriceps contraction. In a systematic review on MPTL reconstructions 19 articles were included detailing the clinical outcomes of 403 knees. All were case series. Overall, good and excellent outcomes were achieved in >75% of cohorts in most studies and redislocations were <10%, with or without the association of the medial patellofemoral ligament. The MPTL is a relevant additional tool to proximal restraint reconstruction in select patient profiles; however, more definitive clinical studies are necessary to better define surgical indications.

Anatomic Risk Factors for Focal Cartilage Lesions in the Patella and Trochlea: A Case-Control Study.

BACKGROUND: Focal cartilage lesions in the patellofemoral (PF) joint are common. Several studies correlated PF risk factors with PF instability, anterior knee pain, and PF arthritis; however, there is a lack of evidence correlating those factors to PF focal cartilage lesions. PURPOSE: To evaluate the influence of the anatomic PF risk factors in patients with isolated focal PF cartilage lesions. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients with isolated PF focal cartilage lesions were included in the cartilage lesion group, and patients with other pathologies and normal PF cartilage were included in the control group. Multiple PF risk factors were accessed on magnetic resonance imaging scans: patellar morphology (patellar width, patellar thickness, and patellar angle), trochlear morphology (trochlear sulcus angle, lateral condyle index, and trochlear sulcus depth), patellar height (Insall-Salvati ratio and Caton-Deschamps index), axial patellar positioning (patellar tilt, angle of Fulkerson), and quadriceps vector (tibial tuberosity-trochlear groove distance). RESULTS: A total of 135 patients were included in the cartilage lesion group and 100 in the control group. As compared with the control group, the cartilage lesion group had a higher sulcus angle (P = .0007), lower trochlear sulcus depth (P < .0001), lower angle of Fulkerson (P < .0001), lower patellar width (P = .0003), and higher Insall-Salvati ratio (P < .0001). From the patients in the cartilage lesion group, 36% had trochlear dysplasia; 27.6%, patella alta; and 24.7%, abnormal patellar tilt. These parameters were more frequent in the cartilage lesion group (P < .0001). Trochlear lesions were more frequent in men, presented at an older age, and had fewer associated anatomic risk factors. Patellar lesions, conversely, were more frequent in women, presented at younger age, and were more closely associated with anatomic risk factors. CONCLUSION: PF anatomic abnormalities are significantly more common in patients with full-thickness PF cartilage lesions. Trochlear dysplasia, patella alta, and excessive lateral patellar tilt are the most common correlated factors, especially in patellar lesions.

Proximal medial patellar restraints and their surgical reconstruction.

Reconstruction of the medial patellofemoral ligament (MPFL) has been increasing as a surgical solution for treatment of recurrent lateral patellofemoral dislocation. Recent attention has been given to fibers extending from the femur to the quadriceps tendon, proximal to the MPFL, termed the medial quadriceps tendon-femoral ligament. This article briefly reviews the proximal medial patellar restraints and surgical procedures for their reconstruction.

Correction to: Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction.

Unfortunately, the middle name of author was incorrectly published as Jorge A. Chahla instead of Jorge Chahla in the original article.

High tibial osteotomy with modern PEEK implants is safe and leads to lower hardware removal rates when compared to conventional metal fixation: a multi-center comparison study.

PURPOSE: Various implant materials have been used in medial, opening-wedge high tibial osteotomy (HTO) including traditional metal and modern polyetheretherketone (PEEK) implants. The purpose of this study was to compare metal and PEEK implants and determine safety, varus deformity correction, as well as short- to mid-term hardware removal and arthroplasty rates. METHODS: HTO performed with metal and PEEK implants were reviewed between 2000 and 2015 at two institutions with a minimum of 2 years follow-up. Postoperative complications, radiographic measures, and osteotomy union were compared between groups using Kruskal-Wallis and Fisher's exact testing. Survival free of hardware removal and arthroplasty was compared between groups using Kaplan-Meier testing. Risk factors for HTO conversion to arthroplasty were examined using Cox proportional hazards regression. RESULTS: Ninety-five HTOs were performed in 90 patients (59 M, 31 F) using 50 metal and 45 PEEK implants. Mean follow-up was 4.2 years (range 2.0-16.5). Two metal and two PEEK HTO patients experienced nonunions, resulting in revision HTO at a mean of 1.0 years postoperatively (range 0.4-1.4 years). Both implant groups demonstrated similar, significant improvements in coronal deformity, with mean angulation improving from 6.0° and 5.4° varus preoperatively to 1.1° and 1.0° valgus postoperatively for the metal (p < 0.01) and PEEK groups (p < 0.01), respectively. 2- and 5-year hardware removal-free survival was 94% and 94% for PEEK, which was significantly superior to 80% and 73% observed for metal (p = 0.02). 2- and 5-year arthroplasty-free survival was similar for the metal (98% and 94%) and PEEK groups (100% and 78%) (n.s.). HTO performed for focal cartilage defects was observed to demonstrate decreased arthroplasty risk (HR 0.36, p = 0.03) when compared to HTO performed for osteoarthritis. CONCLUSIONS: Both metal and PEEK implants were found to be effective in obtaining and maintaining coronal varus deformity correction, with 88% overall arthroplasty-free survival at 5 years. Metal fixation demonstrated a higher rate of hardware removal while HTO performed for medial compartment osteoarthritis predicted conversation to arthroplasty. LEVEL OF EVIDENCE: III.

Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction.

PURPOSE: The scientific literature concerning the anatomy of medial soft-tissue stabilizers of the patella is growing exponentially. Much of the surgical literature has focused on the role of the medial patellofemoral ligament (MPFL) and techniques to reconstruct it, yet our understanding of its anatomy has evolved during the past several years. Given this, we report on the current understanding of medial patellofemoral anatomy and implications for reconstruction. METHODS: Current and historical studies of medial patellar anatomy were reviewed, which include the MPFL and medial quadriceps tendon femoral ligament (MQTFL), as well as that of the distal medial patellar restraints, the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML). In addition to the reported findings, the authors' anatomic descriptions of each ligament during their dissections were identified and recorded. RESULTS: Despite the name of the MPFL, which implies that the ligament courses between the femur and patella, recent studies have highlighted the proximal MPFL fibers that attach to the quadriceps tendon, known as the MQTFL. The MPFL and MQTFL have also been referred to as the medial patellofemoral complex, reflecting the variability in anatomical attachment sites. The MPFL accounts for only half of the total restraint to lateral patellar displacement, and the remaining contributions to patellar stability are derived from the combination of the MPTL and MPML, which function primarily in greater degrees of knee flexion. CONCLUSION: The understanding of the complexity of the medial patellar stabilizers continues to evolve. Although MPFL reconstruction is gaining wide acceptance as a procedure to treat patellar instability, it is important to recognize the complex and changing understanding of the anatomy of the medial soft-tissue stabilizers and the implications for reconstruction. LEVEL OF EVIDENCE: V.