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Results of medial patellofemoral ligament reconstruction compared with trochleoplasty plus individual extensor apparatus balancing in patellar instability caused by severe trochlear dysplasia: a systematic review and meta-analysis

Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Many studies have reported satisfactory clinical outcomes and low redislocation rates after reconstruction of the medial patellofemoral ligament (MPFL) for the treatment of lateral patellar instability. Despite uncorrected severe trochlear dysplasia (Dejour type B to D) being acknowledged as a major reason for less favourable clinical outcomes and a higher incidence of patellar redislocations after an isolated MPFL reconstruction, the evidence for a deepening trochleoplasty procedure remains scarce in the current literature. The hypothesis of this systematic review and meta-analysis was that a deepening trochleoplasty in combination with an a la carte extensor apparatus balancing procedure provides lower redislocation rates and superior clinical outcomes than isolated MPFL reconstruction in patients with lateral patellar instability caused by severe trochlear dysplasia.

Methods

A systematic review of the literature was conducted using specific inclusion and exclusion criteria for clinical studies reporting index operations (trochleoplasty and MPFL reconstruction) for the treatment of patellar instability caused by severe trochlear dysplasia. The Kujala score was analysed as the primary clinical outcome parameter in a random effects meta-analysis.

Results

Ten uncontrolled studies with a total of 407 knees (374 patients) were included in this analysis. The MPFL group comprised 4 studies with a total of 221 knees (210 patients), and the trochleoplasty group comprised 6 studies with a total of 186 knees (164 patients). The mean preoperative Kujala score ranged between 50.4 and 70.5 in the MPFL group and between 44.8 and 75.1 in the trochleoplasty group. The pooled Kujala score increased significantly by 26.4 (95% CI 21.4, 31.3; P < 0.00001) points in the MPFL group and by 26.2 (95% CI 19.8, 32.7; P < 0.00001) points in the trochleoplasty group. The post-operative patellar redislocation/subluxation rate was 7% in the MPFL group and 2.1% in the trochleoplasty group.

Conclusion

This analysis found significant post-operative improvements in patient-reported outcomes for patients undergoing both an MPFL reconstruction and in those undergoing a trochleoplasty plus an individual extensor apparatus balancing procedure when assessed using the Kujala score. The likelihood of preventing the patella from subsequent post-operative redislocation/subluxation was, however, greater in patients who underwent trochleoplasty plus extensor balancing.

Level of evidence

IV.

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References

  1. Balcarek P, Oberthür S, Hopfensitz S, Frosch S, Walde TA, Wachowski MM, Schüttrumpf JP, Stürmer KM (2014) Which patellae are likely to redislocate? Knee Surg Sports Traumatol Arthrosc 22:2308–2314

    Article  PubMed  Google Scholar 

  2. Banke IJ, Kohn LM, Meidinger G, Otto A, Hensler D, Beitzel K, Imhoff AB, Schöttle PB (2014) Combined trochleoplasty and MPFL reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study. Knee Surg Sports Traumatol Arthrosc 22:2591–2598

    Article  PubMed  Google Scholar 

  3. Bitar AC, Demange MK, D’Elia CO, Camanho GL (2012) Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med 40:114–122

    Article  PubMed  Google Scholar 

  4. Blønd L, Haugegaard M (2014) Combined arthroscopic deepening trochleoplasty and reconstruction of the medial patellofemoral ligament for patients with recurrent patella dislocation and trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc 22:2484–2490

    Article  PubMed  Google Scholar 

  5. Camathias C, Studer K, Kiapour A, Rutz E, Vavken P (2016) Trochleoplasty as a solitary treatment for recurrent patellar dislocation results in good clinical outcome in adolescents. Am J Sports Med. doi:10.1177/0363546516652894

    Google Scholar 

  6. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD, Victorian Institute of Sport Tendon Study Group (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Scand J Med Sci Sports 10:2–11

    Article  CAS  PubMed  Google Scholar 

  7. Dejour D, Byn P, Ntagiopoulos PG (2013) The Lyon’s sulcus-deepening trochleoplasty in previous unsuccessful patellofemoral surgery. Int Orthop 37:433–439

    Article  PubMed  Google Scholar 

  8. Dejour D, Le Coultre B (2007) Osteotomies in patello-femoral instabilities. Sports Med Arthrosc 15:39–46

    Article  PubMed  Google Scholar 

  9. Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26

    Article  CAS  PubMed  Google Scholar 

  10. Enderlein D, Nielsen T, Christiansen SE, Faunø P, Lind M (2014) Clinical outcome after reconstruction of the medial patellofemoral ligament in patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 22:2458–2464

    Article  PubMed  Google Scholar 

  11. Fitzpatrick CK, Steensen RN, Tumuluri A, Trinh T, Bentley J, Rullkoetter PJ (2016) Computational analysis of factors contributing to patellar dislocation. J Orthop Res 34:444–453

    Article  PubMed  Google Scholar 

  12. Hiemstra LA, Kerslake S, Lafave MR, Heard SM, Buchko GM, Mohtadi NG (2013) Initial validity and reliability of the Banff Patella Instability Instrument. Am J Sports Med 41:1629–1635

    Article  PubMed  Google Scholar 

  13. Howells NR, Barnett AJ, Ahearn N, Ansari A, Eldridge JD (2012) Medial patellofemoral ligament reconstruction: a prospective outcome assessment of a large single centre series. J Bone Jt Surg Br 94:1202–1208

    Article  CAS  Google Scholar 

  14. Jungmann PM, Tham SC, Liebl H, Nevitt MC, McCulloch CE, Lynch J, Link TM (2013) Association of trochlear dysplasia with degenerative abnormalities in the knee: data from the Osteoarthritis Initiative. Skelet Radiol 42:1383–1392

    Article  Google Scholar 

  15. Kita K, Tanaka Y, Toritsuka Y, Amano H, Uchida R, Takao R, Horibe S (2015) Factors affecting the outcomes of double-bundle medial patellofemoral ligament reconstruction for recurrent patellar dislocations evaluated by multivariate analysis. Am J Sports Med 43:2988–2996

    Article  PubMed  Google Scholar 

  16. Mackay ND, Smith NA, Parsons N, Spalding T, Thompson P, Sprowson AP (2014) Medial patellofemoral ligament reconstruction for patellar dislocation: a systematic review. Orthop J Sports Med. doi:10.1177/2325967114544021

    PubMed  PubMed Central  Google Scholar 

  17. Mulliez A, Lambrecht D, Verbruggen D, Van Der Straeten C, Verdonk P, Victor J (2015) Clinical outcome in MPFL reconstruction with and without tuberositas transposition. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3654-0

    PubMed  Google Scholar 

  18. Nelitz M, Dreyhaupt J, Lippacher S (2013) Combined trochleoplasty and medial patellofemoral ligament reconstruction for recurrent patellar dislocations in severe trochlear dysplasia: a minimum 2-year follow-up study. Am J Sports Med 41:1005–1012

    Article  PubMed  Google Scholar 

  19. Nelitz M, Williams RS, Lippacher S, Reichel H, Dornacher D (2014) Analysis of failure and clinical outcome after unsuccessful medial patellofemoral ligament reconstruction in young patients. Int Orthop 38:2265–2272

    Article  PubMed  Google Scholar 

  20. Ntagiopoulos PG, Byn P, Dejour D (2013) Midterm results of comprehensive surgical reconstruction including sulcus-deepening trochleoplasty in recurrent patellar dislocations with high-grade trochlear dysplasia. Am J Sports Med 41:998–1004

    Article  PubMed  Google Scholar 

  21. Senavongse W, Amis AA (2005) The effects of articular, retinacular, or muscular deficiencies on patellofemoral joint stability: a biomechanical study in vitro. J Bone Jt Surg Br 87:577–582

    Article  CAS  Google Scholar 

  22. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C (2012) A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 40:1916–1923

    Article  PubMed  PubMed Central  Google Scholar 

  23. Smith TO, Donell ST, Clark A, Chester R, Cross J, Kader DF, Arendt EA (2014) The development, validation and internal consistency of the Norwich Patellar Instability (NPI) score. Knee Surg Sports Traumatol Arthrosc 22:324–335

    Article  PubMed  Google Scholar 

  24. Song GY, Hong L, Zhang H, Zhang J, Li X, Li Y, Feng H (2014) Trochleoplasty versus nontrochleoplasty procedures in treating patellar instability caused by severe trochlear dysplasia. Arthroscopy 30:523–532

    Article  PubMed  Google Scholar 

  25. Steensen RN, Bentley JC, Trinh TQ, Backes JR, Wiltfong RE (2015) The prevalence and combined prevalences of anatomic factors associated with recurrent patellar dislocation: a magnetic resonance imaging study. Am J Sports Med 43:921–927

    Article  PubMed  Google Scholar 

  26. Stupay KL, Swart E, Shubin Stein BE (2015) Widespread implementation of medial patellofemoral ligament reconstruction for recurrent patellar instability maintains functional outcomes at midterm to long-term follow-up while decreasing complication rates: a systematic review. Arthroscopy 31:1372–1380

    Article  PubMed  Google Scholar 

  27. Testa EA, Camathias C, Amsler F, Henle P, Friederich NF, Hirschmann MT (2015) Surgical treatment of patellofemoral instability using trochleoplasty or MPFL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3698-1

    PubMed  Google Scholar 

  28. Tompkins MA, Arendt EA (2015) Patellar instability factors in isolated medial patellofemoral ligament reconstructions—what does the literature tell us? A systematic review. Am J Sports Med 43:2318–2327

    Article  PubMed  Google Scholar 

  29. Van Haver A, De Roo K, De Beule M, Labey L, De Baets P, Dejour D, Claessens T, Verdonk P (2015) The effect of trochlear dysplasia on patellofemoral biomechanics: a cadaveric study with simulated trochlear deformities. Am J Sports Med 43:1354–1361

    Article  PubMed  Google Scholar 

  30. Von Knoch F, Böhm T, Bürgi ML, von Knoch M, Bereiter H (2006) Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia: a 4–14-year follow-up study. J Bone Jt Surg Br 88:1331–1335

    Article  Google Scholar 

  31. Wagner D, Pfalzer F, Hingelbaum S, Huth J, Mauch F, Bauer G (2013) The influence of risk factors on clinical outcomes following anatomical medial patellofemoral ligament (MPFL) reconstruction using the gracilis tendon. Knee Surg Sports Traumatol Arthrosc 21:318–324

    Article  PubMed  Google Scholar 

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Acknowledgements

This study was performed at the University Medical Center Göttingen, Göttingen, Germany.

Authors contributions

PB contributed to conception and design, analysis and interpretation of data, drafting the manuscript, and final approval; SR helped in acquisition of data, analysis and interpretation of data, and final approval; NH contributed to acquisition and interpretation of data and final approval; JDE contributed to acquisition and interpretation of data and final approval; KK helped in acquisition and interpretation of data and final approval; DD contributed to acquisition and interpretation of data and final approval; MN contributed to acquisition and interpretation of data and final approval; IJB helped in acquisition and interpretation of data and final approval; DL helped in acquisition and interpretation of data and final approval; MH contributed to acquisition of data, analysis and interpretation of data, and final approval; and TF helped in analysis and interpretation of data and final approval.

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Correspondence to Peter Balcarek.

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For this type of study (systematic review and meta-analysis) formal consent is not required.

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This article does not contain any studies with human participants performed by any of the authors.

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Balcarek, P., Rehn, S., Howells, N.R. et al. Results of medial patellofemoral ligament reconstruction compared with trochleoplasty plus individual extensor apparatus balancing in patellar instability caused by severe trochlear dysplasia: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 25, 3869–3877 (2017). https://doi.org/10.1007/s00167-016-4365-x

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