Early Postoperative Rapid Rehabilitation Yields More Favorable Short-term Outcomes in Patients Undergoing Patellar Realignment Surgery for Recurrent Patellar Dislocation: A Prospective Randomized Controlled Study.

BACKGROUND: Use of a rapid rehabilitation protocol for postoperative recovery after recurrent patellar dislocation (RPD) has gradually gained attention; nonetheless, evidence of its safety and effectiveness is lacking. PURPOSE: To compare the short-term postoperative outcomes of early rapid rehabilitation with those of conservative rehabilitation in patients with RPD. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 50 patients with RPD who underwent tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction were enrolled between January 2018 and February 2019. Postoperatively, the patients were randomly assigned to either the early rapid group (rapid group; n = 25 patients) or the conservative group (control group; n = 25 patients) for rehabilitation training. The rapid group underwent faster progression in weightbearing and range of motion (ROM) training. Knee joint functional scores, ROM, bilateral thigh circumference differences, and imaging data were recorded preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively for comparison. Postoperative complications were recorded over the 24-month follow-up period. RESULTS: The baseline data did not significantly differ between the 2 groups. Postoperatively, compared with the control group, the rapid group had higher Tegner scores at 6 weeks and 3 months; higher Lysholm scores at 3 and 6 months; higher International Knee Documentation Committee scores at 6 weeks, 3 months, and 12 months; better ROM; and smaller bilateral thigh circumference differences at 24 months (P < .05 for all). However, no differences were observed in the Tegner, Lysholm, and International Knee Documentation Committee scores at 24 months postoperatively. At the 6-week and subsequent follow-up visits, the Caton and Insall indices were lower in the control group than in the rapid group (P < .01 for all). Moreover, compared with the control group, the rapid group had a lower incidence of patella baja at 24 months (0% vs 17%) and fewer complications during the whole follow-up period (P < .01). CONCLUSION: Early rapid postoperative rehabilitation appears to be safe and effective for patients who undergo tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction to treat RPD. In the short term, this approach was shown to be more advantageous than conservative rehabilitation in improving functional scores, allowing an earlier return to daily activities, although the lack of difference at 24 months implies no long-term benefits. In addition, it potentially helped to prevent the occurrence of complications, including patella baja. REGISTRATION: ChiCTR1800014648 (ClinicalTrials.gov identifier).

Adductor Canal Block Combined with General Analgesia for Patients with Recurrent Patellar Dislocation Undergoing "3-in-1" Procedure Surgery: A Prospective Randomized Controlled Trial.

OBJECTIVE: Patellar dislocation is a common injury in sports medicine. While surgical treatment is an important option, pain is severe after surgery. This study compared the analgesic effect and early rehabilitation quality between adductor canal block combined with general analgesia (ACB + GA) and single general analgesia (SGA) after recurrent patellar dislocation (RPD) for "3-in-1" procedure surgery. METHODS: From July 2018 to January 2020, a prospective randomized controlled trial was conducted in analgesia management after RPD for "3-in-1" procedure surgery. The 40 patients in the experimental group received ACB (0.3% ropivacaine 30 mL) + GA, while the 38 patients in the control group received SGA. Patients in both groups received "3-in-1" procedure surgery, standardized anesthesia, and analgesia during hospitalization. The outcomes included the visual analog scale (VAS), quadriceps strength, Inpatient Satisfaction Questionnaire (IPSQ), Lysholm scores, and Kujala scores. Total rescue analgesic consumption and adverse events were also recorded. One-way analysis of variance (ANOVA) was used to compare continuous variables between groups and chi-square or Fisher's exact tests were used to compare count data. Nonparametric Kruskal-Wallis H tests evaluated ranked data. RESULTS: No significant differences in resting VAS scores were observed at 8, 12, and 24 h postoperatively. However, the flexion and moving VAS scores of the ACB + GA group were significantly lower than those of the SGA group (p < 0.05). Meanwhile, the first triggering of rescue analgesics was advanced in the SGA group (p < 0.0001), and the dose of opioid analgesics was significantly higher (p < 0.0001). The quadriceps strength of the ACB + GA group was higher than that of the SGA group at 8 h postoperatively. The IPSQ of the ACB + GA group was significantly higher 24 h postoperatively. We observed no significant differences in Lysholm and Kujala scores between the two groups at 3 months after surgery. CONCLUSIONS: Early analgesia management of ACB + GA showed excellent analgesia effectiveness and a positive hospitalization experience for RPD patients undergoing "3-in-1" procedure surgery. Moreover, this management was good for early rehabilitation.

Clinical and radiological results after one hundred fifteen MPFL reconstructions with or without tibial tubercle transfer in patients with recurrent patellar dislocation-a mean follow-up of 5.4 years.

PURPOSE: Medial patellofemoral ligament reconstruction (MPFLR) shows low recurrent rates and high satisfaction. Reports on outcome at mid-term follow-up in a large cohort with or without tibial tubercle transfer (TTT) are scarce. METHODS: One hundred six patients (115 knees; 24.3 ± 8.7 years) with recurrent patellar dislocation underwent MPFLR with ipsilateral gracilis autograft and were included in this retrospective follow-up study. In 43 knees, simultaneous TTT was performed for patellar maltracking due to patella alta or increased tibial tubercle trochlear groove distance (TT-TG). Kujala and subjective knee scores were recorded pre- and post-operatively. RESULTS: Eighty-seven percent of the patients were satisfied at a mean follow-up of 5.4 ± 3.1 years. The Kujala score increased in 81.7% of all knees from 50.9 to 76.2 points (p < 0.01). Patients with a decreased Kujala score were not different in terms of follow-up time, age, trochlear dysplasia, or post-operative patellar height. The decline was related to an increase in pain, whereas functional scores remained identical. There were six patients with persisting instability, three with patellar re-dislocation. Re-operation was necessary in 24 patients (21.2%), mainly for implant removal after TTT and loss of flexion. Performing TTT had no significant influence on the subjective outcome. Patients with more than eight years of follow-up (n = 27) did not show any difference in the subjective outcome parameters, or in osteoarthritis progression. CONCLUSION: MPFLR with and without TTT is a reliable treatment option for recurrent patellar dislocation without deterioration at mid-term follow-up. Persisting pain is a major post-operative issue that seems to be unrelated to patellofemoral anatomy.

Early functional rehabilitation after patellar dislocation-What procedures are daily routine in orthopedic surgery?

INTRODUCTION: Patellar dislocation and rupture of the medial patellofemoral ligament (MPFL) are frequently seen in daily orthopedic practice. Besides initial non-surgical treatment, surgery and subsequent rehabilitation are crucial for restoring stability in the femoropatellar joint. This study investigated current rehabilitation strategies after patellar dislocation because knowledge on this topic has been severely limited so far. MATERIALS AND METHODS: The current rehabilitation protocols of 42 orthopedic and trauma surgical institutions were analyzed regarding their recommendations on weight bearing, range of motion (ROM), and use of movement devices and orthosis. All protocols for conservative treatment and postoperative rehabilitation after MPFL reconstruction were compared. Descriptive and statistical analyses were carried out when appropriate. RESULTS: The different rehabilitation strategies for conservative and surgical treatment after patellar dislocation showed a tendency towards earlier functional rehabilitation after surgical MPFL reconstruction than after conservative treatment. Both surgical and conservative treatment involved initial restrictions in weight bearing, ROM, and use of movement devices and orthosis at the beginning of rehabilitation. The rehab protocols showed a significant earlier full weight bearing after surgical MPFL reconstruction (p > 0.001). Due to the presence of other parameters for early functional treatment, the absence of an indication for using orthosis (surgical: 44%, conservative: 33%; p = 0.515) or start of unlimited ROM of the knee (surgical: 4.9 weeks, conservative: 5.7 weeks; p = 0.076) showed by trend an earlier functional strategy after MPFL reconstruction than after conservative therapy. CONCLUSIONS: Both conservative and surgical treatment after patellar dislocation showed restrictions in the early phase of the rehabilitation. Earlier functional therapy was more common after MPFL reconstruction than after conservative treatment. Further clinical and biomechanical studies on rehabilitation strategies after patellar dislocation are needed to improve patient care und individualized therapy.

Adolescent and Caregiver-derived Utilities for Traumatic Patella Dislocation Health States.

INTRODUCTION: The treatment of a first-time traumatic patella dislocation in children and adolescents remains controversial. Preference-based health utility assessments can provide health-related quality of life information for orthopaedic conditions and their subsequent treatment. The purpose of this study was to determine utilities for pediatric acute traumatic patella dislocation and subsequent treatment health states from both children with patellar dislocation, and their parents. METHODS: Adolescents with acute first-time patella dislocations and their parents were identified. Six patella dislocation health states were defined: (1) Immediate post injury (Injury), (2) Postdislocation and nonoperative treatment with physical therapy (Rehabilitation), (3) Immediately poststabilization surgery (Postsurgical), (4) Recurrent dislocation after treatment (Recurrent dislocator), (5) Stable knee after initial treatment but unable to participate in sport at previous level (Stable return to lower function), and (6) Stable knee after initial treatment and fully able to participate in sport at previous level (Stable return to same function). Classic feeling thermometer utilities acquisition was performed, with self-report (patient) and proxy-report (parent) interviews performed separately. Patients' physical activity levels were collected using the UCLA Activity Score and the HSS Pedi-FABS. Comparisons between groups were made using Mann-Whitney U test and Wilcoxon signed-rank test. RESULTS: Ninety-five adolescents and 95 parents were included. Median (interquartile range) patient utilities for Injury, Rehabilitation, Postsurgical, Recurrent dislocator, Stable return to lower function, and Stable return to same function health states were: 25 (10 to 45), 50 (35 to 62.5), 30 (15 to 48.5), 20 (10 to 40), 70 (50 to 80), and 100 (100 to 100), respectively. Caregiver-derived utilities for children going through these health states were: 25 (10 to 49.5), 50 (25 to 60), 40 (15 to 60), 20 (5 to 40), 60 (50 to 77.5), and 100 (100 to 100). Stable return to a lower function was assigned a significantly higher utility by adolescents than their caregivers (P=0.03); highly active adolescents assigned a significantly higher utility to achieving a stable return to same function (P=0.02) while assigning significantly lower utility to health states in which they were not fully participating in sport. CONCLUSIONS: Adolescents and their parents felt that successful treatment of an acute patella dislocation was equivalent to perfect health (utility=1); however, adolescents assigned a significantly higher utility to a stable but lower functioning health state compared with their parents. Baseline functional status is an important modifier of health state preference-highly active adolescents assign a significantly greater disutility to health states in which they are not participating in sports at their regular level of play. These findings provide insight into the health-related quality of life impact for acute patella dislocations and their management, and potentially support minimizing time out of play and more aggressive treatment of first time acute patellar dislocations in athletic adolescents. LEVEL OF EVIDENCE: Level III.

Does different duration of non-operative immobilization have an effect on the redislocation rate of primary patellar dislocation? A retrospective multicenter cohort study.

BACKGROUND: Immobilization devices such as plaster splints, casts and braces have been used for first time patellar dislocation (FTPD) in order to prevent redislocation. This study evaluates different non-operative immobilization regimes upon rates of redislocation. METHODS: A retrospective cohort study with a study population of 1366 in which 601 subjects under 30years with FTPD were included from three hospitals. Exclusion criteria were osteochondral fracture, ligament injury and subluxation. Subjects were divided into five groups; unknown/none, two weeks of brace, two weeks of brace followed by bandage, four weeks of brace and six weeks of brace with increasing of range of motion. Radiographs were evaluated for trochlear dysplasia (TD), patella alta, trochlear depth and growth zone. Crude analysis and logistic regression adjusted for radiographic assessments, age, gender and rehabilitation was done in STATA® with significance p≤0.05. RESULTS: Forty-five point eight percent were between 15 and 19years and 51.4% were male. One hundred sixty-three experienced redislocation (27.1%). Logistic regression was performed at 404 subjects and showed that rehabilitation, gender, TD, patella alta, and growth zone had no significant odds ratio (OR) on redislocation. The duration of brace demonstrated no significant OR in reducing redislocation. Subjects between 20 and 29years showed lower OR in redislocation (95% CI) of 0.27 (0.11; 0.64, p=0.003). CONCLUSION: This study demonstrated no difference in duration of brace treatment in reducing patella redislocation after FTPD. Rehabilitation and predisposal factors such as TD, trochlear depth, patella alta and open growth zone did not influence the redislocation rate. Increasing age reduced risk of redislocation.

Functional testing and return to sport following stabilization surgery for recurrent lateral patellar instability in competitive athletes.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy are commonly used to treat recurrent lateral patellar instability, yet there are limited available data on return to sport (RTS) following these procedures. The purpose of this study is to evaluate patient factors associated with excellent functional outcomes, including successful RTS, following surgical stabilization including MPFL reconstruction in competitive athletes with recurrent lateral patellar instability. METHODS: Athletes undergoing primary MPFL reconstruction for recurrent lateral instability from 2005 to 2013 were identified at a single institution. Concomitant procedures, such as tibial tubercle osteotomy (TTO), were included. Patient demographic information, including BMI, gender, age, and pre-injury Tegner score, was recorded. In addition, radiographs were reviewed for pre-operative patellar height (Caton-Deschamps index) and trochlear dysplasia (Dejour classification). All patients underwent a standardized rehabilitation/post-operative protocol, with isokinetic strength and functional testing being performed at 6 months post-operatively. Final Tegner scores, RTS status, subjective instability ratings, and Kujala scores were collected at a minimum of 2 years. Chi-squared analysis for categorical variables and Wilcoxon rank-sum analysis for continuous variables were used to determine the relationship between the previously mentioned patient and knee characteristics with isokinetic data, RTS status, or Kujala scores. RESULTS: Thirty-nine athletes (23 male, 16 female) at a mean age of 17.5 ± 2.9 years (range, 13-26) underwent primary MPFL reconstruction (32 autografts, seven allografts) for recurrent patellar instability with a mean follow-up of 47.0 ± 16.4 months. Sixteen patients (41%) underwent concomitant tibial tubercle osteotomies. Isokinetic data collected at 6 months post-operatively demonstrated mean knee flexion and extension strength deficits of 15.8 ± 10.1% and 21.4 ± 14.3%, respectively, compared to the contralateral leg (p < 0.001 for both). Patients who underwent concomitant tibial tubercle osteotomy (p = 0.04), males (p = 0.01) and those with patella alta (p = 0.04) had weaker 6-month isokinetic testing. Thirty-three of the thirty-nine (85%) athletes were able to RTS at a mean of 8.1 ± 3.9 months. Patients undergoing MPFL with concomitant TTO (p = 0.02) returned to sport at a slower rate. One patient (3%) reported an episode of recurrent dislocation requiring revision surgery. Kujala and Tegner scores at final follow-up were 91.1 ± 6.3 and 6 (range, 4-9), respectively. CONCLUSION: Surgical stabilization including MFPL reconstruction for recurrent lateral patellar instability is an effective procedure for returning athletes to competitive sports. However, strength deficits persist at 6 months after surgery, especially in those undergoing concomitant TTO, which may delay return to sport. Physicians can use these results to counsel patients that return to competitive sports is safe with good clinical outcomes and low rate of recurrence at 4-year follow-up; however, predisposing factors, like a lateralized tibial tubercle, should be addressed if necessary, but athletes should be counselled that a slower recovery and longer return to sport time may be expected. LEVEL OF EVIDENCE: IV.

Longitudinal Change of Medial and Lateral Patellar Stiffness After Reconstruction of the Medial Patellofemoral Ligament for Patients with Recurrent Patellar Dislocation.

BACKGROUND: Longitudinal changes in patellar stiffness following reconstruction of the medial patellofemoral ligament for recurrent patellar dislocation at full extension are unknown. METHODS: Fifteen consecutive patients (three men and twelve women, with a mean age of twenty-two years) with seventeen knees were matched by sex and age to thirty-two reference subjects in this prospective study. The follow-up period was a minimum of twenty-four months. The medial patellofemoral ligament reconstruction used an autograft semitendinosus tendon and an interference screw system with or without lateral release under 10 N of laterally directed force. The medial patellar stiffness and lateral patellar stiffness were measured in 0° of knee extension using the Patella Stability Tester preoperatively; postoperatively at three, six, twelve, and eighteen months; and at the time of the latest follow-up. Before and after the surgical procedure, patients were evaluated for apprehension and Kujala and Lysholm scores; radiographic examinations were performed to evaluate changes, including osteoarthritic changes. RESULTS: The medial stiffness of the affected side before the surgical procedure was significantly lower than the lateral stiffness (p = 0.004) and the stiffness for healthy reference knees (p = 0.004). Medial stiffness three months after the surgical procedure was significantly elevated compared with lateral values (p = 0.027), preoperative values (p < 0.001), and reference group values (p = 0.002); reached the reference level by six months; and was maintained for up to two years. Furthermore, medial stiffness and lateral stiffness were well balanced after six months and this balance was sustained for up to two years postoperatively. No recurrent dislocation occurred during the follow-up period; one patient experienced apprehension. Postoperative radiographic findings and clinical scores were significantly improved at the time of the latest follow-up (p < 0.05). One knee progressed to patellofemoral osteoarthritis. CONCLUSIONS: The value for medial stiffness was significantly improved three months after medial patellofemoral ligament reconstruction compared with the preoperative and lateral values and returned to the reference level by six months. Medial stiffness and lateral stiffness of the patella were well balanced by six months and retained that balance for up to two years, with good clinical results. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Norwich Patellar Instability Score: Validity, internal consistency and responsiveness for people conservatively-managed following first-time patellar dislocation.

BACKGROUND: This paper assessed the validity, internal consistency, responsiveness and floor-ceiling effects of the Norwich Patellar Instability (NPI) Score for a cohort of conservatively managed people following first-time patellar dislocation (FTPD). METHODS: Fifty patients were recruited, providing 130 completed datasets over 12 months. The NPI Score, Lysholm Knee Score, Tegner Level of Activity Score and isometric knee extension strength were assessed at baseline, six weeks, six and 12 months post-injury. RESULTS: There was high convergent validity with a statistically significant correlation between the NPI Score and the Lysholm Knee Score (p<0.001), Tegner Level of Activity Score (p<0.001) and isometric knee extension strength (p<0.002). Principal component analysis revealed that the NPI Score demonstrated good concurrent validity with four components account for 70.4% of the variability. Whilst the NPI Score demonstrated a flooring-effect for 13 of the 19 items, no ceiling effect was reported. There was high internal consistency with a Cronbach Alpha value of 0.93 (95% CI: 0.91 to 0.93). The NPI Score was responsive to change over the 12 months period with an effect size of 1.04 from baseline to 12 months post-injury. CONCLUSIONS: The NPI Score is a valid tool to assess patellar instability symptoms in people conservatively managed following FTPD. LEVEL OF EVIDENCE: Level II.

The double-pulley technique for anatomical double-bundled medial patellofemoral ligament reconstruction.

INTRODUCTION: Majority of the current medial patellofemoral ligament (MPFL) reconstruction techniques vary with respect to methods of fixation on the patella. In an effort to maximise the area of patellar footprint coverage and minimise the complication of patellar fracture, we developed a procedure that implemented the double-pulley suture anchors technique. DESIGN: Prospective case series. SETTING: A primary medical centre in Kaohsiung, Taiwan. PATIENTS AND METHODS: Eighteen consecutive patients (18 knees) who met the inclusion criteria underwent the aforementioned operation between January 2010 and March 2012. Patients were evaluated using functional scores (Kujala and Tegner-Lysholm scores), apprehension test, and radiographic examination (congruence angle and patellar tilting angle) preoperatively and at the follow-up. RESULTS: The mean follow-up was 35 months. A firm endpoint to lateral patellar translation was noted in all patients at the last follow-up with a mean lateral translation quadrant of 1.5 (improved from 3.5 preoperatively, p<0.001). Both clinical and radiographic assessment improved significantly (p<0.001); the mean Kujala score improved from 55.3±6.8 preoperatively to 95.2±3.5 at the last follow-up; TegnerLysholm from 43.6±8.1 to 93.6±6.8; the mean congruence angle improved from 20.6°±2.1° preoperatively to -5.2°±2.4° at the last follow-up; and the patellar tilting angle from 23.8°±2.3° to 9.6°±1.3°. CONCLUSION: The double-pulley patellar fixation technique, by having a result that is comparable with those of other studies that used aperture fixation techniques, can be a promising surgical option for anatomically reconstructing the medial petellofemoral ligament.

Rehabilitation following first-time patellar dislocation: a randomised controlled trial of purported vastus medialis obliquus muscle versus general quadriceps strengthening exercises.

BACKGROUND: We aimed to define whether distal vastus medialis (VM) muscle strengthening improves functional outcomes compared to general quadriceps muscle strengthening following first-time patellar dislocation (FTPD). METHODS: Fifty patients post-FTPD were randomised to either a general quadriceps exercise or rehabilitation programme (n=25) or a specific-VM exercise and rehabilitation regime (n=25). The primary outcome was the Lysholm knee score, and secondary outcomes included the Tegner Level of Activity score, the Norwich Patellar Instability (NPI) score, and isometric knee extension strength at various knee flexion ranges of motion. Outcomes were assessed at baseline, six weeks, six months and 12months. RESULTS: There were statistically significant differences in functional outcome and activity levels with the Lysholm knee score and Tegner Level of Activity score at 12months in the general quadriceps exercise group compared to the VM group (p=0.05; 95% confidence interval (CI): -14.0 to 0.0/p=0.04; 95% CI: -3.0 to 0.0). This did not reach a clinically important difference. There was no statistically significant difference between the groups for the NPI score and isometric strength at any follow-up interval. The trial experienced substantial participant attrition (52% at 12months). CONCLUSIONS: Whilst there was a statistical difference in the Lysholm knee score and Tegner Level of Activity score between general quadriceps and VM exercise groups at 12months, this may not have necessarily been clinically important. This trial highlights that participant recruitment and retention are challenges which should be considered when designing future trials in this population. LEVEL OF EVIDENCE: Therapeutic study, Level I.

Surgical treatment of congenital patellar dislocation in skeletally mature patients: surgical technique and case series.

BACKGROUND: Congenital patellar dislocation is a rarely encountered condition and is readily treated in childhood to prevent lasting disability, knee pain, decreased range of motion and ambulation problems. This condition is very rarely seen in skeletally mature patients, and the treatment of the condition represents a challenge to the orthopedic surgeon. SURGICAL TECHNIQUE AND METHODS: Patients were treated with soft tissue reconstruction and tibial tubercle transfer with or without a prior medial close-wedge distal femoral osteotomy, depending on the degree of valgus deformity. We, then, searched the database of our orthopedics center for cases of congenital patellar dislocation in skeletally mature patients who were surgically treated. We collected a total of five knees and analyzed the cases according to the type of surgery performed and difference between pre- and postoperative functions. RESULTS: Five knees with congenital patellar dislocation were treated. The mean age of the patients was 29.6 years, and mean follow-up time was 4.3 years. Mean preoperative range of motion was 65°, and it increased to a mean of 105.5° after surgical treatment. The mean preoperative Kujala score was 29.2 and increased to 67.2 after surgical treatment. DISCUSSION: Congenital patellar dislocations that are allowed to proceed to adulthood are difficult to treat, and surgical treatment depends on the degree of deformity of the patella and of the knee joint. This study shows that surgical treatment is able to correct the deformity and provide better knee function.

Return to sport after patellar dislocation or following surgery for patellofemoral instability.

Patellofemoral instability may occur in a young population as a result of injury during sporting activities. This review focuses on return to sport after one episode of dislocation treated no operatively and as well after surgery for chronic patellofemoral instability. With or without surgery, only two-thirds of patients return to sports at the same level as prior to injury. A high-quality rehabilitation programme using specific exercises is the key for a safe return to sporting activities. To achieve this goal, recovery of muscle strength and dynamic stability of the lower limbs is crucial. The focus should be directed to strengthen the quadriceps muscle and pelvic stabilizers, as well as lateral trunk muscle training. Patient education and regularly performed home exercises are other key factors that can lead to a successful return to sports. The criteria for a safe return to sports include the absence of pain, no effusion, a complete range of motion, almost symmetrical strength, and excellent dynamic stability. Level of evidence IV.

Minimally invasive medial patellofemoral ligament reconstruction with fascia lata allograft: surgical technique.

The present paper describes a new minimally invasive anatomic medial patellofemoral ligament reconstruction, using a fascia lata allograft as graft source and arthroscopy to obtain balanced fixation throughout the range of motion.

Medial retinaculum plasty versus medial patellofemoral ligament reconstruction for recurrent patellar instability in adults: a randomized controlled trial.

PURPOSE: The purpose of this study was to evaluate the clinical results of medial retinaculum plasty (MRP) and medial patellofemoral ligament reconstruction (MPFLR) with concomitant lateral retinacular release with respect to imaging and functional results. METHODS: Seventy patients with recurrent patellar instability were randomly divided into 2 groups based on their birth years (even/odd), receiving either MRP or MPFLR. Lateral retinacular release was also performed in all patients. Preoperatively, all patients received magnetic resonance imaging to evaluate the injury to the medial patellofemoral ligament. Computed tomography was performed before surgery and at follow-up. The subjective symptoms and functional outcome were evaluated preoperatively and postoperatively with the Kujala score, the Tegner activity score, and a subjective questionnaire. The physical apprehension test was examined, and redislocation was recorded. RESULTS: Patients were followed up for a mean period of 40 months (range, 24 to 55 months). The measurement results for the congruence angle, patellar tilt angle, and patellar lateral shift decreased significantly from the pretreatment measurements to the normal range at the latest follow-up, without a statistically significant difference between the 2 groups (P > .05). The median Kujala score had significantly improved after surgery. However, no statistically significant difference was found between the 2 groups at the latest follow-up (P > .05). In 6 cases in the MRP group (19%) and 3 in the MPFLR group (9%), we found patellar lateral shift that exceeded 1.5 cm but was less than 2.0 cm with a firm endpoint for the apprehension test, without a significant difference between the 2 groups. CONCLUSIONS: This prospective randomized study showed that MPFLR for recurrent patellar instability could achieve good clinical results, with a good congruous patellofemoral joint and good knee function. MRP could yield similar results to MPFLR for recurrent patellar instability in adults with medial patellofemoral ligament injuries from the patella or midsubstance portions. LEVEL OF EVIDENCE: Level II, prospective comparative study.

The Lyon's sulcus-deepening trochleoplasty in previous unsuccessful patellofemoral surgery.

PURPOSE: Trochleoplasty is a relatively rare operation with few published results and it remains a technically demanding procedure which requires careful patient selection. The ideal candidate for surgery remains to be elucidated, and some authors consider it as a good revision option in cases of previous unsuccessful operations for persisting patellar dislocation with underlying trochlear dysplasia. The purpose of this study is to record the results from the application of sulcus-deepening trochleoplasty in patients with trochlear dysplasia and previous unsuccessful surgery for patellar dislocation. METHODS: Twenty-two patients (24 knees) were operated upon during the period 9/1993-9/2006; they had undergone surgery for patellofemoral instability and had persistent patellar dislocation, and were followed-up for a mean of 66 months (24-191). Trochleoplasty was performed in all patients using the same technique and rehabilitation protocol. Additional soft-tissue and bony operations were performed in every case. RESULTS: Of all cases, 29.1% had type B and 70.9% had type D trochlear dysplasia. After trochleoplasty, no patient had a patellar re-dislocation up to the last follow-up. Pain decreased in 72% and the apprehension sign was negative in 75% of the cases (p < 0.01). Sulcus angle decreased from 153° ± 14° to 141° ± 10° (p < 0.01), TT-TG distance decreased from 16 ± 6 mm to 12 ± 2 mm (p < 0.001), and patellar tilt decreased from 31° ± 14° to 11° ± 8° (p < 0.0001). Mean pre-operative Kujala score was 44 (25-73) and at the latest follow-up it increased to 81 (53-100), (p < 0.001). At the time of final follow-up, there was no case of patellofemoral arthritis. CONCLUSIONS: Trochlear dysplasia is a key factor in the treatment of recurrent patellar dislocation and its correction could be included in the surgical options. Sulcus-deepening trochleoplasty is an acceptable revision option for the surgical treatment of patients with persisting patellar dislocation and high-grade trochlear dysplasia.

Roturas tendinosas bilaterales del aparato extensor de la rodilla: serie de casos / Bilateral tendon tears of the extensor mechanism of the knee: a series of cases

Las roturas bilaterales del aparato extensor de la rodilla son infrecuentes y se asocian clásicamente a enfermedades sistémicas. Estas lesiones pueden ser óseas, de patela o tuberosidad tibial anterior, musculares o tendinosas. Las más comunes de todas son las fracturas de rótula, seguidas de roturas del tendón cuadricipital o rotuliano. Las roturas bilaterales tanto del tendón rotuliano como cuadricipital, al ser infrecuentes, pueden ser infradiagnosticadas retrasando el tratamiento quirúrgico y la posterior rehabilitación; suelen ser traumáticas. En la literatura existen publicaciones sobre algunos casos de roturas tendinosas bilateral del aparato extensor de la rodilla asociadas a enfermedades sistémicas como isuficiencia renal, diabetes mellitus o artritis reumatoide o al uso prolongado de quinolonas o corticoides. En este trabajo describimos 4 casos clínicos de roturas tendinosas bilaterales del aparato extensor, sin y con enfermedades sistémicas asociadas (AU)

Bilateral injuries of the knee extensor mechanism are uncommon and are generally related to systemic diseases. Such injuries may be muscle tears, bone fractures (patella and tibial tubercle) and tendinous disruptures. Patella fractures are described as being the most common of these, followed by injuries of the quadriceps and patellar tendons. As bilateral disruption of either patellar and/or quadricipital tendons is uncommon, it may be underdiagnosed, thus delaying the surgical treatment and subsequent rehabilitation. They are generally traumatic. There are publications in the literature on some cases of bilateral tendinous disruptions of the knee extensor complex associated to systemic diseases such as renal failure, diabetes mellitus or rheumatoid arthritis or the continued use of steroids or fluoroquinolones. We report four cases of bilateral knee tendon disruption in patients with and without systemic disease (AU)

Inestabilidad menisco-ligamentosa e inestabilidad por debilidad muscular. A propósito de una lesión del nervio femoral / Meniscus-ligament instability due to muscle weakness. A case report of a femoral nerve injury

Se presenta un caso de lesión del nervio femoral, que ocasionó una clínica de claudicación mecánica de miembro inferior, atribuida en un principio a una inestabilidad por meniscopatía y rotura parcial del tendón rotuliano. Se hace una revisión de la etiología y clínica de las lesiones del nervio femoral, y se explican una serie de conceptos que permiten diferenciar la inestabilidad verdadera por lesión meniscal o ligamentosa y la claudicación por atrofia muscular. El etiquetar correctamente la causa de una inestabilidad de la rodilla es un factor clave para orientar el tratamiento de forma conservadora o quirúrgica (AU)

We present a case of femoral nerve injury that caused knee instability, initially attributed to a meniscopathy and a partial patellar tendon tear. A review is made of the etiology and clinical findings of femoral nerve injuries. In addition, a series of concepts regarding the differences between true instability due to meniscal or ligamentous injury and muscular atrophy are explained. Correctly labeling the cause of knee instability is an important factor to orient towards either conservative or surgical treatment (AU)

Incidence and radiologic predictor of postoperative patellar instability after Fulkerson procedure of the tibial tuberosity for recurrent patellar dislocation.

PURPOSE: Excellent results of anteromedialization of the tibial tuberosity for recurrent patellar dislocation have been reported; however, the contribution of the preoperative anatomic factors to postoperative patellar instability has not been well established. The purpose of this study was to investigate the mid-term results and the incidence of postoperative patellar instability after Fulkerson procedure for recurrent patella dislocation, and to determine the radiologic predictor of the postoperative patellar instability. METHODS: Sixty-two knees of 41 patients underwent Fulkerson procedure with or without lateral retinacular release for recurrent patellar dislocation and were followed-up for 85-155 months. Predisposing anatomic factors for recurrent patellar dislocation were evaluated preoperatively, including valgus knee alignment (femorotibial angle), patella alta (Insall-Salvati ratio), trochlear dysplasia (trochlear depth), lateral patellar displacement (congruence angle) and lateral malposition of the tibial tuberosity (tibial tuberosity-trochlear groove distance). The relationship between the measurements of anatomic factors and postoperative patellar instability, which was defined by the patellar re-dislocation or residual apprehension after surgery, was analyzed. RESULTS: The Fulkerson score and the Kujala score were significantly improved from the median of 65 (35-80) points and 68 (36-82) points preoperatively to 95 (60-100) points and 92 (57-100) points at the final follow-up, respectively. Three knees (4.8%) experienced postoperative patellar re-dislocation and 4 knees (6.5%) showed the positive apprehension sign at the final follow-up. The statistical analysis showed that the postoperative patellar instability correlated with only patella alta. CONCLUSION: Patella alta was the only predictor of postoperative patellar instability after Fulkerson procedure. These results indicated that isolated Fulkerson procedure should not be indicated for recurrent patellar dislocation with severe patella alta. LEVEL OF EVIDENCE: Case-control study, Level III.

A national survey of the physiotherapy management of patients following first-time patellar dislocation.

OBJECTIVES: The purpose of this study was to determine how musculoskeletal physiotherapists in acute National Health Service (NHS) hospitals manage patients following a first time patellar dislocation. DESIGN: National survey study. SETTING: All NHS acute hospitals with an accident and emergency and/or an orthopaedic department were surveyed. PARTICIPANTS: 306 institutions were surveyed. INTERVENTIONS: Each institution was sent a 14 question self-administered questionnaire pertaining to the assessment, treatment, evaluation and outcome of patients following a first time patellar dislocation. After 3 weeks, all non-respondents were sent a reminder letter. After a further 3 weeks, those who had not responded by this time were sent a final reminder and copy of the questionnaire. RESULTS: The survey response rate was 59%. The respondents indicated that first-time patellar dislocation was not a common musculoskeletal disorder managed by NHS physiotherapists, constituting an average of 2% of caseloads. The results suggested that physiotherapists most commonly assess for reduced quadriceps or VMO capacity, gait, patellar tracking and glide, and knee effusion when examining patients following a first-time patellar dislocation. The most common treatments adopted are reassurance, behaviour modification followed by proprioceptive, knee mobility, quadriceps and specific VMO exercises. CONCLUSIONS: Generic lower limb assessment and treatment strategies are widely used to manage this patient group. Given the previous paucity in this literature, further study is now recommended to assess the efficacy of these interventions to provide UK physiotherapists with an evidence-base to justify their management strategies.