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A pre-operative grade 3 J-sign adversely affects short-term clinical outcome and is more likely to yield MPFL residual graft laxity in recurrent patellar dislocation

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purposes of this study were to investigate the anatomical risk factors of grade 3 J-sign and analyse the influence of J-sign grades on the short-term clinical outcomes of patients with recurrent patellar dislocation.

Methods

From 2016 to 2018, a total of 168 patients with recurrent patellar dislocation (187 knees) underwent medial patellofemoral ligament reconstruction with or without tibial tuberosity medialization. Pre-operative J-sign severity was graded according to a previously described classification (grades 1–3). Potential anatomical risk factors of J-sign were explored. Comparisons were assessed between patients with different grades of J-sign using univariate and binary logistic regression analyses. The Kujala score was assessed and compared with pre-operative values, and stress fluoroscopy was performed to assess medial patellofemoral ligament residual graft laxity. Among the 130 included cases, 104 knees with at least 1-year follow-up were included in the clinical outcome analyses to explore the influence of several anatomical factors and J-sign grade on short-term clinical outcomes.

Results

A total of 118 patients (130 knees) were included in the present study. The median age at surgery was 21 years (range 13–38), and 111 affected knees belonged to female patients (85%). Univariate and multivariate logistic regressions between the grade 3 group and the grade 1–2 groups showed that increased femoral anteversion, excessive external tibial torsion, and patella alta were three independent risk factors of grade 3 J-sign in patients with recurrent patellar dislocation. A total of 104 knees with at least a 1-year follow-up were included in the clinical outcome analyses. The median Kujala score improved from 54 (range, 38–72) pre-operatively to 86 (range, 70–100) post-operatively. Although no re-dislocation was reported during the follow-up, 6 out of 32 patients in the grade 3 group demonstrated “MPFL residual graft laxity” based on post-operative stress radiography (18.8%), which was significantly higher than in the grade 1–2 groups (0%, p < 0.001). Subgroup analysis showed that patients with grade 3 J-sign had significantly lower post-operative Kujala scores than those with grade 1–2 J-sign (p < 0.001). Moreover, increased femoral anteversion (≥ 30°) was correlated with an inferior post-operative Kujala score (p = 0.023).

Conclusion

The three independent anatomic risk factors of grade 3 J-sign in patients with recurrent patellar dislocation were increased femoral anteversion, excessive external tibial torsion, and patella alta. A pre-operative grade 3 J-sign was correlated with a lower post-operative Kujala score and more “MPFL residual graft laxity” in patients with recurrent patellar dislocation treated with MPFL reconstruction with or without tibial tuberosity medialization at a minimum 1-year follow-up.

Level of evidence

III

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Funding

Funded by Beijing municipal administration of hospitals’ ascent plan (Grant No. DFL20180402).

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Authors and Affiliations

  1. Sports Medicine Service, Peking University Fourth School of Clinical Medicine, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China

    ZhiJun Zhang, Hui Zhang, GuanYang Song, Tong Zheng & Hua Feng

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  2. Hui Zhang
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Correspondence to Hua Feng.

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This study was approved by the ethics board of Beijing Jishuitan Hospital.

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Electronic supplementary material

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Supplementary file1 J-sign grade 1(.MP4). Female, 23, RPD for 5 years (right), J-sign (+), the lateral shift of patella during terminal knee extension was more than 1 quadrant of the patella (grade 1 J-sign) (MP4 555 kb)

Supplementary file2 J-sign grade 2(.MP4). Female, 18, RPD for 5 years (left), J-sign(+), the lateral shift of patella during terminal knee extension was more than 2 quadrants of patella (grade 2 J-sign) (MP4 416 kb)

Supplementary file3 J-sign grade 3 (grade 3 J-sign) (.MP4). Female, 32, RPD for 15 years (left), the patella dislocated completely in terminal knee extension and locked in subsequent flexion. The manual force was needed to unlock the patellofemoral joint. (MP4 1449 kb)

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Zhang, Z., Zhang, H., Song, G. et al. A pre-operative grade 3 J-sign adversely affects short-term clinical outcome and is more likely to yield MPFL residual graft laxity in recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 28, 2147–2156 (2020). https://doi.org/10.1007/s00167-019-05736-4

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