1,721,020 research outputs found
Accuracy of Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction: The Effect of a Nearly True-Lateral Fluoroscopic View
No full textBackground: Reconstruction of the medial patellofemoral ligament (MPFL) is an established operative procedure for patients with recurrent episodes of lateral patellar instability. However, recent articles have reported remarkable complication rates, with nonanatomic femoral tunnel positioning in up to 64% of patients. Purpose: To evaluate the sensitivity of femoral tunnel placement using lateral fluoroscopic guidance to minor degrees of deviation from the true-lateral view using established radiographic landmarks. Study Design: Controlled laboratory study. Methods: Six human cadaveric femora were used for this study. A 6-mm radiopaque eyelet was used to mark the native femoral insertion of the MPFL according to previously described radiographic landmarks. Radiographic landmarks were also applied with the femur positioned in 2.5 degrees and 5 degrees of internal and external rotation, respectively, and with the femur in 2.5 degrees and 5 degrees of hip abduction and adduction, respectively. The distance between the center of the 6-mm eyelet to the center of the native femoral MPFL insertion, as established in the true-lateral view, was measured and determined as the degree of shift in each position. Results: Hip adduction, abduction, and internal and external rotations of 2.5 degrees resulted in a shift from the native femoral MPFL insertion point to a more distal (adduction), proximal (abduction), anterior (internal rotation), and posterior location (external rotation) of 2.7 0.7, 2.0 0.7, 2.7 +/- 1.1, and 3.0 +/- 1.3 mm, respectively (all P < .05). Malpositioning increased to a distance of 5.0 +/- 0.7 mm distally, 3.6 +/- 1.0 mm proximally, 5.2 +/- 0.8 mm anteriorly, and 6.2 +/- 0.6 mm posteriorly to the native insertion point when the attachment was marked with 5 degrees of divergence from the true-lateral view (all P < .05). Conclusion: The results of this study indicate the high sensitivity of femoral tunnel placement using lateral fluoroscopic guidance to minor degrees of deviation from the true-lateral view. Clinical Relevance: The study highlights the importance of an exact lateral view when fluoroscopic guidance is used for femoral tunnel positioning in the daily practice of MPFL reconstruction, and a possible explanation for the high incidence of nonanatomic tunnel placement is suggested
Outcomes After Deepening Trochleoplasty and Concomitant Realignment in Patients With Severe Trochlear Dysplasia With Chronic Patellofemoral Pain: Results at 2-Year Follow-up
No full textBackground: Abnormal patellofemoral joint stress appears to have major relevance in a subgroup of patients with patellofemoral pain (PFP). Purpose: To evaluate whether patients with chronic PFP and trochlear dysplasia–induced patellofemoral joint malalignment benefit from a deepening trochleoplasty procedure with the aim of improving patellotrochlear congruence. Study Design: Case series; Level of evidence, 4. Methods: Included were 15 patients (male/female, 1/14; mean age, 30.3 years [range, 19-51 years]) with 8.8 years (range, 1-20 years) of chronic PFP and severe trochlear dysplasia. All patients underwent correction of patellotrochlear malalignment with deepening trochleoplasty and concomitant realignment procedures. The Kujala score and a numerical analog scale (0-10) for intensity of pain were used to assess symptoms preoperatively and at 12 and 24 months postoperatively. Pre- and postoperative magnetic resonance imaging (MRI) scans from the patients were compared with the MRI scans of age- and sex-matched controls regarding the patellotrochlear contact area and contact ratio, patellar tilt, patellotrochlear index, and lateral trochlear inclination (LTI) angle. Results: The Kujala score increased from a mean of 55 (range, 15-81) preoperatively to 82.5 (range, 53-98) after 12 months (95% CI, –42.56 to –12.37; P < .001) and to 84.2 (range, 59-99) after 24 months (95% CI, –44.29 to –14.11; P < .001). The intensity of PFP decreased from 5.7 (range, 3-10) preoperatively to 1.4 (range, 0-4) after 12 months (95% CI, 2.57 to 5.96; P < .001) and had a mean of 1.6 (range, 0-6) after 24 months (95% CI, 2.44 to 5.75; P < .001). Preoperatively, parameters in the study group indicated significant patellotrochlear malalignment, which improved and normalized (except for the LTI angle) postoperatively compared with the values of the control group ( P > .05). Conclusion: In a subgroup of patients with chronic PFP due to severe trochlear dysplasia, deepening trochleoplasty and concomitant realignment procedures significantly reduced pain and improved knee joint function while normalizing patellotrochlear congruence
Implications for Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction Considering the Sagittal Trochlear Groove Curvature in Severe Trochlear Dysplasia Before and After Deepening Trochleoplasty
No full textBackground: Medial patellofemoral ligament reconstruction (MPFL-R) aims to restore proper ligament function with minimal changes in length during range of motion, yet the ideal area for femoral fixation of the graft remains controversial. Purpose: To determine the region where the isometric circular path of a simulated MPFL graft (best-fit circle) follows the sagittal radius curvature of the trochlea in normal (nontrochlear dysplastic) knees and to evaluate the best-fit circle coverage of different femoral fixation points in knees with severe trochlear dysplasia (TD) and after deepening trochleoplasty. Study Design: Controlled laboratory study. Methods: Twelve patients (4 male, 8 female; mean age, 24 ± 8 years) who underwent surgical treatment for recurrent lateral patellar instability due to severe TD were prospectively enrolled in this study. Four previously defined reference points for the femoral MPFL-R (Schöttle, Fujino, Stephen, and Oka) were identified, and the best-fit circle was drawn along the sagittal trochlear groove curvature. The divergence between each best-fit circle and the trochlear groove was calculated, with negative values indicating relative slackening and positive values indicating relative tightening of the simulated MPFL graft. Measurements were made on true-lateral fluoroscopic images before and after deepening trochleoplasty and compared with those of a sex-matched control group. Results: The best-fit circle of the Schöttle point followed the sagittal curvature of the trochlea most closely in both the control and trochlear dysplastic knees, followed by the Fujino, Stephen, and Oka points. As the radius of the trochlear groove curvature increased, the divergence of all best-fit circles to the trochlear groove became negative (all P < .05). This effect was most pronounced at the Stephen and Oka points, followed by the Fujino and Schöttle points (all P < .05). After deepening trochleoplasty, the divergence of the Schöttle point changed toward positive values (11.6% at 40°; P < .001). Concurrently, the best-fit circle divergence of all other reference points improved toward baseline (all P < .05). Conclusion: The isometric circle of the Schöttle point provides the best congruence with the sagittal trochlear groove curvature in both the normal trochlea and the dysplastic trochlea. After trochleoplasty, the best-fit circles of more distal femoral fixation points resulted in better congruence with the deepened trochlear groove, whereas the best-fit circle of Schöttle indicated graft tension during flexion. Clinical Relevance: According to the present study, different femoral fixation points should be considered depending on whether the TD is corrected
Mental and physical health-related quality of life in patients with recurrent patellar dislocations—a generic and disease-specific quality of life questionnaire assessment
No full textPURPOSE: There is a paucity of quality of life (QoL) assessments in studies evaluating patients treated for recurrent lateral patellar dislocation (LPD). The primary aim of this study was to investigate whether mental well-being is impaired in patients with chronic (recurrent) LPD and, if so, to assess whether the mental health-related QoL dimension improves equivalently to the physical-related QoL dimension after successful surgical treatment. METHODS: Thirty-eight patients with recurrent LPD over a mean course of the disease of 4.7 ± 3.9 years (1—18 years) prior to surgery were included. Generic health-related QoL (HRQoL) (Short Form 36; SF-36) and disease-specific QoL (Banff Patella Instability Instrument 2.0; BPII 2.0) were assessed preoperatively and after a mean follow-up of 3.5 ± 0.8 years (2 – 5 years) postoperatively. RESULTS: Untreated LPD significantly impacted the physical dimension of patients’ generic HRQoL and their disease-specific QoL. When compared to age-equivalent normative data sets, the mental HRQoL dimension was not reduced prior to operative treatment but increased during the follow-up period. Surgical treatment normalized the physical dimension of patients’ generic HRQoL and significantly improved their disease-specific QoL. However, BPII 2.0 values remained reduced, albeit patellae were successfully stabilized. CONCLUSION: The results of this study indicate that patients with recurrent LPD are generally in good mental health, although physical impairment is striking. Notwithstanding that surgery prevented further dislocations and normalized the generic HRQoL, the disease-specific QoL remained reduced as far as this can be interpreted without population-based data. LEVEL OF EVIDENCE: Level IV; Retrospective case series
A Modified Posterolateral Approach for the Treatment of Tibial Plateau Fractures
No full textOpen reduction and internal fixation of posterolateral tibial plateau fractures. Tibial plateau fractures involving the posterolateral quadrant. Critical soft-tissue conditions. Tibial plateau fractures which do not involve the posterolateral quadrant. 90A degrees side positioning on the contralateral side, skin incision along the fibular head, exposure of the peroneal nerve, lateral arthrotomy and exposure of the joint, dissection of the popliteal cavity between the lateral head of the gastrocnemius muscle and soleus muscle. Blunt preparation between popliteus muscle and soleus muscle under preservation of the popliteal artery and vein. Sharp dissection of the soleus muscle from the dorsal parts of fibula and tibia until the peroneal nerve at the fibular neck enters into the muscle. Exposure of the posterolateral tibial head. The dorsal joint capsule and the popliteal corner are prevented from any soft-tissue damage. Visual control of fracture reduction by viewing in the joint gap through lateral arthrotomy. Reduction of the fracture from dorsal with pointed reduction forceps. A conventional or locking radius T-plate can be pinched off with lateral cutters and anatomically bent for fracture fixation and is dorsally fixed at the tibial plateau. 10 kg partial weight bearing for 6-8 weeks. Limited range of motion 0-0-90A degrees for 6 weeks. In a period of 2 years, seven patients with posterolateral tibial plateau fractures received open reduction and internal fixation by using the modified posterolateral approach. The patients were examined at follow-up between 12 and 24 months after surgery. Six patients were free of pain with full range of motion and stable knee joints. Radiologically, a good fracture reduction was achieved in six cases. In one patient with a posterolateral comminuted dislocation fracture, a small fracture step and a gap could be observed. No approach-related complications were found
When Should Bony Correction Be Considered in Addition to Medial Patellofemoral Ligament Reconstruction? Results of a Clinically Derived 2-Group Classification of Lateral Patellar Instability Based on 122 Patients at 2- to 5-Year Follow-up
No full textBACKGROUND: The need for concomitant bony procedures to realign pathoanatomic risk factors in addition to medial patellofemoral ligament reconstruction (MPFL-R) remains unclear. PURPOSE: To evaluate a clinically derived 2-part classification of lateral patellar instability aimed at identifying patients indicated for a concomitant bony procedure. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study included 122 patients (42 male, 80 female; mean ± SD age, 22 ± 6 years) who were assigned to a mild instability group (mIG) and a complex instability group (cIG) based on the reversed dynamic patellar apprehension test (ReDPAT) and J-sign. The mIG had a positive ReDPAT result 40° of knee flexion and/or a high-grade J-sign (grade 2 or 3). The mIG underwent isolated MPFL-R, and the cIG underwent MPFL-R and concomitant bony procedures depending on the established risk factor assessment. For evaluation, the BANFF Patellar Instability Instrument 2.0 (BPII 2.0) and numeric analog scale (0-10) for patellofemoral pain and subjective knee function were used. The minimal clinically important difference for the BPII 2.0 was ascertained by calculating half the standard deviation of baseline scores. RESULTS: Radiographic analysis confirmed a significantly more pronounced pathoanatomic risk factor constellation in the cIG regarding severity of trochlear dysplasia, distal malalignment, and patellar height (all P < .05). At final follow-up, no patellar redislocation occurred in either group; 2 patients in the cIG reported patellar subluxation. Within both groups, all outcome scores improved significantly pre- to postoperatively (all P < .0001); no between-group difference was found regarding BPII 2.0 score and numeric analog scale for function. The minimal clinically important difference for the BPII 2.0 was met by 84% (32/38) of the mIG and 90% (76/84) of the cIG (P = .36), but the cIG experienced more patellofemoral pain than the mIG (1.3 ± 1.6 vs 2.1 ± 2.1; P = .036). CONCLUSION: Patients with a high-grade J-sign and/or a positive ReDPAT finding beyond 40° to 50° of knee flexion exhibited a significantly more pronounced pathoanatomic risk factor constellation; however, the correction of modifiable risk factors led to similarly good outcomes to patients who underwent isolated MPFL-R. A slightly higher level of patellofemoral pain after bony procedures was evident in these patients
Revision surgery for failed medial patellofemoral ligament reconstruction results in better disease-specific outcome scores when performed for recurrent instability than for patellofemoral pain or limited range of motion
No full textGeometry of Torsional Malalignment Syndrome: Trochlear Dysplasia but Not Torsion Predicts Lateral Patellar Instability
No full textThe J-sign and the body mass index determine the disease-specific quality of life in patients with lateral patellar instability
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