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Individualizing the tibial tubercle to trochlear groove distance to patient specific anatomy improves sensitivity for recurrent instability

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

An initial episode of patellar instability poses a treatment challenge given the absence of a valid, reproducible, and universally applicable predictor of recurrence. Recently, a series of patellar instability ratios (PIRs) were described. Each ratio consisted of the traditional tibial tubercle to trochlear groove (TT-TG) distance normalized to patient-specific measures. The purpose of this study was to investigate the reliability and validity of these novel measures.

Methods

Eighty-seven patients experiencing a first-time lateral patellar dislocation were identified in a retrospective manner. Magnetic resonance imaging (MRI) studies obtained at the time of injury were reviewed. The TT-TG distance, patellar width (PW), trochlear width (TW), patellar length (PL), and trochlear length (TL) were obtained by two observers in a blinded, randomized fashion. Measurement reliability was assessed using intra-class correlation coefficients (ICCs). Patients were divided into those having a single dislocation (Group 1) and those experiencing recurrent instability (Group 2). The ability of the TT-TG distance and each PIR to predict recurrent instability was assessed by calculating odds ratios (ORs) with 95% confidence intervals (CIs). Sensitivity and specificity were also calculated for each measure.

Results

Excellent inter-rater agreement was observed with ICCs > 0.75 for all patellofemoral joint measurements obtained on MRI. The TT-TG distance alone was predictive of recurrent patellar instability with an OR of 8.9 (p < 0.001). However, the isolated TT-TG distance had the lowest sensitivity at 25.6%. Among ratios, a TT-TG/PL ≥ 0.5 was the most predictive of recurrent instability with an ORs of 6.1 (p = < 0.001). A TT-TG/TL ≥ 0.8 was also predictive of recurrence (OR 4.9, p = 0.027) and had the highest sensitivity of any measure at 94.9%.

Conclusion

The results of the current study support the reproducibility and predictive ability of PIRs. While a TT-TG ≥ 20 mm was the strongest predictor of recurrent patellar instability, it was a relatively insensitive measure. Sensitivity may be improved by normalizing the TT-TG distance to patient-specific axial and sagittal plane patellofemoral measurements on MRI. Ultimately, PIRs are reproducible measures that may serve as an additional tool when clinically assessing the unstable patellofemoral joint.

Level of evidence

III.

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Fig. 1

Reproduced with permission from Camp et al. [5], Springer Publishing

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Acknowledgements

The authors would like to thank members of the Rochester Epidemiology Project (REP) at Mayo Clinic Rochester and Olmsted Medical Center for their assistance with database access.

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Authors and Affiliations

  1. Department of Orthopedic Surgery and the Sports Medicine Center, Mayo Clinic and Mayo Foundation, Mayo Clinic 200 First St., SW, Rochester, MN, 55905, USA

    Mark J. Heidenreich, Thomas L. Sanders, Mario Hevesi, Nicholas R. Johnson, Isabella T. Wu, Christopher L. Camp, Diane L. Dahm & Aaron J. Krych

Authors
  1. Mark J. Heidenreich
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  2. Thomas L. Sanders
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  3. Mario Hevesi
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  4. Nicholas R. Johnson
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  5. Isabella T. Wu
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  6. Christopher L. Camp
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  7. Diane L. Dahm
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  8. Aaron J. Krych
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Corresponding author

Correspondence to Aaron J. Krych.

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Conflicts of interest

Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with this study.

Funding

This study was not funded by industry or by outside institutions. The authors did not received financial support for the research, nor publication of this work.

Ethical approval

This study was approved by the appropriate institutional review board(s) (IRBs), as outlined in the manuscript (IRB numbers: 15-009310 and 077-OMC-15).

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Heidenreich, M.J., Sanders, T.L., Hevesi, M. et al. Individualizing the tibial tubercle to trochlear groove distance to patient specific anatomy improves sensitivity for recurrent instability. Knee Surg Sports Traumatol Arthrosc 26, 2858–2864 (2018). https://doi.org/10.1007/s00167-017-4752-y

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