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Patellofemoral Joint Reconstruction for Patellar Instability: Medial Patellofemoral Ligament Reconstruction, Trochleoplasty, and Tibial Tubercle Osteotomy.

ABSTRACT: Recurrent patellar instability can be very debilitating and may require surgical intervention. A thorough workup must be completed in this subset of patients. Risk factors for recurrent instability include patella alta, trochlear dysplasia, an increased tibial tubercle-trochlear groove distance, and insufficiencies in the medial retinacular structures. Necessary treatment of these risk factors, once identified, should be addressed surgically. Patellofemoral reconstruction must be individually tailored to each patient's anatomy and may necessitate medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, or trochleoplasty in any combination or as a standalone procedure. This article details our technique for surgical treatment of recurrent patellar instability with a medial patellofemoral ligament reconstruction, an open trochleoplasty, and a tibial tubercle osteotomy for patients with severe trochlear dysplasia, an increased tibial tubercle-trochlear groove distance, or patella alta.

SUBMITTER: Dean CS

PROVIDER: S-EPMC4885951 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:PurposeTo confirm which method provides lower rate of recurrent instability and superior clinical outcomes.MethodWe searched PubMed, Embase and Web of Science for the trials involving one intervention or both for patellar instability: medial patellofemoral ligament reconstruction (MPFLR) with and without tibial tubercle osteotomy (TTO). The postoperative Kujala score, Lysholm score, Tegner scores and the rate of recurrent instability (dislocation or subluxation) were analyzed as the primary clinical outcome parameters in a random or fixed effects meta-analysis.ResultsIn total, 43 articles met inclusion criteria after full-text review. A total of 2046 patients were analyzed. The overall mean age was 20.3 years (range, 9.5-60.0 years), with a mean follow-up time of 3.2 years (range, 1-8 years). The mean Kujala scores in MPFLR and MPFLR + TTO were 89.04 and 84.44, respectively. There was significant difference in Kujala scores between MPFLR and MPFLR + TTO (MD = 4.60, 95%CI: 1.07-8.13; P = 0.01). The mean Lysholm scores in MPFLR and MPFLR + TTO were 90.59 and 88.14, respectively. There was no significant difference in Lysholm scores between MPFLR and MPFLR + TTO (MD = 2.45, 95%CI: -3.20-8.10; P = 0.40). The mean Tegner scores in MPFLR and MPFLR + TTO were 5.30 and 4.88, respectively. There was no significant difference in Tegner scores between MPFLR and MPFLR + TTO (MD = 0.42, 95%CI: -0.39-1.23; P = 0.31). At final follow-up, the rates of recurrent instability in MPFLR and MPFLR + TTO were 3% and 4%, respectively. There was no significant difference in the rates between MPFLR and MPFLR + TTO (OR = 0.99, 95%CI: 0.96-1.02; P = 0.4848).ConclusionMPFLR and MPFLR + TTO are effective and reliable treatments in the setting of patellofemoral instability. MPFLR seems to show a better performance in functional outcomes than MPFLR + TTO. Moreover, their rates of recurrent instability are very low, and no significant difference exists.

Project description:PurposeTo compare and contrast the various rehabilitation protocols for medial patellofemoral ligament (MPFL) reconstruction and MPFL reconstruction plus tibial tubercle osteotomy (TTO) published online by academic orthopaedic surgery residency programs and private practice institutions throughout the United States.MethodsWe performed a systematic electronic search of MPFL reconstruction rehabilitation protocols in academic orthopaedic surgery residency programs in the United States using Google's search engine (www.google.com) based on the Fellowship and Residency Electronic Interactive Database Access System (FREIDA). Private practice organizations publishing MPFL reconstruction or MPFL reconstruction-TTO rehabilitation protocols that were found on the first page of search results were also included, but no comprehensive search for private practice protocols was performed. Protocols specifying an MPFL reconstruction with TTO were included for separate review because of altered weight-bearing status postoperatively. A list of comparative criteria was created to assess the protocols for the presence and timing of the various rehabilitation components.ResultsFrom the list of 189 U.S. academic residency programs, as well as additional private practice protocols found in the Google search, 38 protocols were included for review (31 protocols for isolated MPFL reconstruction and 7 protocols for MPFL reconstruction plus TTO). A return to full range of motion by week 6 was recommended by 15 (48.4%) of the isolated MPFL reconstruction protocols and 6 (85.7%) of the MPFL reconstruction-TTO protocols. Six weeks of knee brace wear was recommended by 13 isolated MPFL reconstruction protocols (43.3%) and 4 MPFL reconstruction-TTO protocols (57.1%). Moreover, 6 isolated MPFL reconstruction protocols (19.4%) and 3 MPFL reconstruction-TTO protocols (42.9%) recommended use of a patellar stabilizing brace postoperatively.ConclusionsThere is substantial variability among rehabilitation protocols after MPFL reconstruction, as well as MPFL reconstruction plus TTO, including postoperative range of motion, weight-bearing status, and time until return to sport. Furthermore, many online protocols from academic orthopaedic surgery residency programs and private practices in the United States fail to mention several of these parameters, most notably functional testing to allow patients to return to sport.Clinical relevanceProper rehabilitation after MPFL reconstruction with or without TTO is an important factor to a patient's postoperative outcome. This study outlines the variability in online rehabilitation protocols after MPFL reconstruction with or without TTO published online by academic residency programs and private practice institutions.

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Patellofemoral Joint Reconstruction for Patellar Instability: Medial Patellofemoral Ligament Reconstruction, Trochleoplasty, and Tibial Tubercle Osteotomy.

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