Which Technique Is Better for Treating Patellar Dislocation? A Systematic Review and Meta-analysis

doi:10.1016/j.arthro.2018.06.052

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 34, Issue 11, November 2018, Pages 3082-3093.e1

https://doi.org/10.1016/j.arthro.2018.06.052 Get rights and content

Purpose

To clarify the discrepancy in surgical options and present evidence to treat patellar dislocation by evaluating which of the techniques yields better improvement in stability and functional recovery for patellar dislocation.

Methods

The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus electronic databases were searched for relevant articles comparing the outcomes of medial patellofemoral ligament (MPFL) treatment published up until August 2017. Data searching, extraction, analysis, and quality assessment were performed based on The Cochrane Collaboration guidelines. Clinical outcomes were evaluated using various outcome values in various techniques. For results with high heterogeneity, 95% prediction intervals (PIs) were also investigated.

Results

Eleven clinical studies were investigated. In patients with primary patellar dislocation, there were no significant differences in all evaluated outcomes between the conservative and surgical treatment groups. For patients with recurrent patellar dislocation, MPFL reconstruction was associated with a favorable Kujala score (mean difference, −8.91; 95% confidence interval, −14.05 to −3.77; I² = 94%; 95% PI, −9.64 to −8.1) and Lysholm score (mean difference, –13.51; 95% confidence interval, −21.35 to –5.68; I² = 96%; 95% PI, −14.86 to −12.16) when compared with soft tissue realignment surgery.

Conclusions

Although surgical treatment of the MPFL for primary patellar dislocation is not superior to conservative treatment in restoring knee function and clinical outcomes, MPFL reconstruction is associated with more favorable clinical outcomes compared with medial soft tissue realignment surgery in patients with recurrent patellar dislocation. Double-bundle MPFL reconstruction seems to provide more favorable outcomes than single-bundle MPFL reconstruction, but this finding should be interpreted with caution because the evidence levels were low and were from only a few studies.

Level of Evidence

Level III, meta-analysis.

Section snippets

Study Selection

This study was based on the Cochrane Review methods, and reporting was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. To identify relevant studies, we used the controlled vocabulary and free text words described in Appendix 1 (available at www.arthroscopyjournal.org) to search the MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases. We identified all relevant studies regardless

Identification of Studies

A total of 2,151 relevant articles were initially identified. Of these, 155 were duplicated in the databases. After screening the remaining 1,996 articles using titles and abstracts, all but 25 were excluded because they were not relevant to the purpose of this study. A full-text review of the 25 articles resulted in exclusion of 14 articles because they lacked vital data, such as experimental outcomes. Among the 11 remaining studies, 4 focused on conservative versus surgical treatment for

Discussion

The most important finding of this study was that surgical treatment for primary patellar dislocation is not superior to conservative treatment in terms of clinical outcomes including the Kujala score, redislocation, and Tegner score. In addition, MPFL reconstruction yielded a higher Kujala score and Lysholm score compared with medial soft tissue realignment surgery in patients with recurrent patellar dislocation. Although quantitative analysis was not conducted, 2 included studies reported

Conclusions

Although surgical treatment of the MPFL for primary patellar dislocation is not superior to conservative treatment in restoring knee function and clinical outcomes, MPFL reconstruction is associated with more favorable clinical outcomes compared with medial soft tissue realignment surgery in patients with recurrent patellar dislocation. DB MPFL reconstruction seems to provide more favorable outcomes than SB MPFL reconstruction, but this finding should be interpreted with caution because the

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Cited by (42)

Minimally Invasive Medial Patellofemoral Ligament Reconstruction With Patellar-Sided Tensioning Using All-Suture Anchors
2024, Arthroscopy Techniques
Medial patellofemoral ligament (MPFL) reconstruction is a commonly performed procedure to reestablish the checkrein to the lateral patellar translation in patients with recurrent patellofemoral instability. Graft tensioning is one of the most critical aspects of the procedure. Most surgical methods for MPFL reconstruction involve tensioning and securing the graft on the femoral side. In this article, we describe a technique for patellar-sided tensioning of the graft using all-suture anchors, which provides the surgeon with the ability to finely control graft tension with two independent graft limbs, while preserving patellar bone stock.
Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient-Reported Outcomes but Less Donor-Site Morbidity Compared With Gracilis Tendon Autograft
2024, Arthroscopy - Journal of Arthroscopic and Related Surgery
To compare clinical and patient-reported outcome measures (PROMs) in patients with recurrent patellar dislocation after medial patellofemoral ligament (MPFL) reconstruction using either a gracilis tendon (GT) or quadriceps tendon autograft (QT).
All MPFL reconstruction performed between 2017 and 2019 were reviewed retrospectively. Only patients with isolated MPFL reconstruction, without any major patellofemoral risk factors and a minimum follow-up of 24 months, were included in the study. Patients were matched with respect to sex, age, and body mass index. All patients were evaluated clinically and using PROMs.
A total of 64 patients with an average follow up of 28.7 ± 7.5 months were included in this study. The mean Kujala score (GT: 84.8 ± 12.9, QT: 88.9 ± 10.1), Lysholm score (GT: 89.4 ± 10.2, QT: 88.4 ± 5.0), and visual analog scale score for pain (GT: 1.9 ± 1.8, QT: 1.1 ± 1.3) did not significantly differ between both groups. Tegner activity level was significantly greater (P = .027) in the QT group (5.5 ± 1.9) compared with the GT group (4.6 ± 1.8), but within the minimal clinically important differences. Occasional patellar instability events, but no recurrent dislocation, were reported in 12.5% in the GT group and 6.3% in the QT group (P = .39). Of all patients, 90.6% in the QT and 68.8% in the HT group exceeded the PASS for the Kujala score (P = .06). Significantly more patients (59.4%) treated with GT reported donor-site morbidity in the form of sensitivity deficit at the lower leg compared with those treated with QT (3.1%, P = .001).
GT and QT MPFL reconstruction have comparable PROMs and patellar redislocation rates 2 years’ postoperatively. Significantly more patients treated with GT reported lower-leg sensitivity deficit compared with those treated with QT.
Level III, retrospective case–control study.
Medial patellofemoral ligament reconstruction in skeletally immature patients without correction of bony risk factors leads to acceptable outcomes but higher failure rates
2023, Journal of ISAKOS
To report outcomes and re-dislocation rates of medial patellar stabilizers reconstruction without bone procedures for correction of anatomical risk factors for patellar instability in skeletally immature patients; to compare isolated medial patellofemoral ligament (MPFL) reconstruction to combined MPFL and medial patellotibial ligament (MPTL) reconstruction in this population.
Patients with open physis and bone abnormalities including patella alta and/or increased tibial tubercle-trochlear groove (TT-TG) distance and/or trochlear dysplasia underwent MPFL reconstruction, either isolated or associated with MPTL reconstruction. Preoperative, 1-year follow-up and the latest follow-up (5 years minimum) data were collected. Radiological and clinical evaluations were conducted, with special attention to failure rate. Comparison of results from isolated MPFL and combined MPFL/MPTL reconstructions was performed.
Twenty-nine patients were included, 19 in the isolated MPFL group (median 14 years old; follow-up 5.8 ± 1.7 years) and 10 in the combined MPFL/MPTL group (median 13.5 years old; follow-up 5.2 ± 1.4 years). Kujala and Tegner scores increased over time, although without statistically significant differences between the two groups at the latest follow-up (p = 0.840 and p > 0.999, respectively). During follow-up, 5 of 19 (26.3%) isolated MPFL and 2 of 10 (20%) MPFL/MPTL reconstructions experienced recurrence of patellar dislocation (p > 0.999). Trochlear dysplasia type D (p = 0.028), knee rotation (p = 0.009) and lateral patellar tilt angle (p = 0.003) were associated with patellar instability recurrence. The isolated MPFL group showed increased laxity on physical exam at the latest follow-up compared to the 1-year follow-up (patellar glide test (p = 0.002), patellar tilt test (p = 0.042) and subluxation in extension (p = 0.019). This increased laxity was not observed in the MPFL/MPTL group (p > 0.999). Comparing both groups, the glide test was significantly better in the combined MPFL/MPTL group in comparison to the isolated MPFL reconstruction group at the latest follow-up (p = 0.021).
MPFL reconstruction in isolation or combined with MPTL reconstruction in skeletally immature patients with additional uncorrected anatomical patellofemoral abnormalities leads to acceptable clinical outcomes within a minimum of 5 years follow-up, although has a high failure rate of 24.1%. Addition of a MPTL reconstruction to the MPFL may result in decreased patellar laxity on physical exams, as demonstrated by better patellar glide test, patellar tilt test and subluxation in extension.
Level III; retrospective cohort study.
A Simple Technique for Reconstruction of the Medial Patellofemoral Ligament With Patellar Soft-Tissue Fixation Using Synthetic Suture Tape Internal Bracing
2023, Arthroscopy Techniques
Recurrent patellar dislocation is most commonly treated with an isolated medial patellofemoral ligament reconstruction using autograft tissue. Harvest and fixation of these grafts have some theoretical disadvantages. With this Technical Note, we aim to describe a simple reconstruction of the medial patellofemoral ligament using high-strength suture tape with a soft-tissue fixation on the patellar side and an interference screw fixation on the femoral side, avoiding some of these possible disadvantages.
Editorial Commentary: From Lateral Release and Medial Plication to Complex Medial Patellofemoral Ligament Reconstruction Techniques: Medial Quadriceps Tendon Femoral Ligament Reconstruction Is the Most Anatomic Repair
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
Patella instability and dislocation are common in younger patients, and 1 in 5 patients are at risk of recurrent dislocations. Conservative treatment should be considered for first dislocations unless other concomitant injuries are present. Historically, lateral patella release and medial plication techniques were used for repair but have been superseded by medial patellofemoral ligament reconstruction. Overconstraint is a potential problem and often related to nonanatomic femoral tunnel position and graft tension, which could result in increased patellar contact pressures and graft failure. The medial quadriceps tendon–femoral ligament reconstruction technique (MQTFL) avoids patellar tunnels without the risk of patella fracture. When comparing medial patellofemoral ligament, MQTFL, and the combination of both techniques in a cadaver model, MQTFL resulted in less constraint with no differences for patellar contact pressures. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair.
The Tibial Tubercle-Trochlear Groove Distance/Trochlear Dysplasia Index Quotient Is the Most Accurate Indicator for Determining Patellofemoral Instability Risk
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
The primary aim of our study was to evaluate diagnostic accuracy of the tibial tubercle-trochlear groove (TT-TG) distance relative to associated quotients produced from trochlear width (TT-TG distance/TW) and trochlear dysplasia index (TT-TG distance/TDI) for detecting patellofemoral instability. Secondary aims included identifying thresholds for risk and comparing differences between cases and controls.
Consecutive sampling of electronic medical records produced 48 (21 males, 27 females) patellofemoral instability cases (19 ± 7 years old) and 79 (61 males, 18 females) controls (23 ± 4 years old) who had a history of isolated meniscal lesion, as evaluated by magnetic resonance imaging. Standardized methods were employed with measurements executed in a blinded and randomized manner. A receiver operating characteristic curve assessed accuracy by area under the curve (AUC). The index of union (IU) was employed to identify a threshold for risk. Two-sample t-tests examined group differences. P < .05 denoted statistical significance.
The AUC values were .69 (.60, .79) for TT-TG distance, .81 (.73, .88) for TT-TG distance/TW, and .85 (.78, .91) for TT-TG distance/TDI. Thresholds were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. Cases demonstrated statistically significant (P < .001) greater values for each measure compared with controls: TT-TG distance (15.8 ± 4.2 mm vs 12.9 ± 3.6 mm, [1.4, 4.3]); TT-TG distance/TW (.51 ± .24 vs .31 ± .09, [.13, .27]); TT-TG distance/TDI (3.07 ± 1.55 vs 1.7 ± .7, [.9, 1.84]).
The TT-TG distance, TT-TG distance/TW, and TT-TG distance/TDI measures were 69%, 81%, and 85%, respectively, accurate for determining patellofemoral instability risk. Thresholds for risk were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. The thresholds reported in this study may help in advancing clinical decision-making.
Level III, diagnostic retrospective comparative observatory trial

View all citing articles on Scopus

: See commentary on page 3094

: The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

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Meta-analysisWhich Technique Is Better for Treating Patellar Dislocation? A Systematic Review and Meta-analysis

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Study Selection

Identification of Studies

Discussion

Conclusions

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

High incidence of acute and recurrent patellar dislocations: A retrospective nationwide epidemiological study involving 24.154 primary dislocations

Knee Surg Sports Traumatol Arthrosc

Incidence of acute traumatic patellar dislocation among active-duty United States military service members

Am J Sports Med

Acute patellar dislocation. What to do?

Knee Surg Sports Traumatol Arthrosc

Predictors of recurrent instability after acute patellofemoral dislocation in pediatric and adolescent patients

Am J Sports Med

Patellar dislocation. The long-term results of nonoperative management in 100 patients

Am J Sports Med

An algorithm guiding the evaluation and treatment of acute primary patellar dislocations

Sports Med Arthrosc

Techniques of medial retinacular repair and reconstruction

Clin Orthop Relat Res

Surgical versus nonsurgical treatments of acute primary patellar dislocation with special emphasis on the MPFL injury patterns

J Knee Surg

A medium-term follow-up outcome of medial retinaculum plasty versus double-bundle anatomical medial patellofemoral ligament reconstruction for recurrent patellar dislocation in adults

Int J Clin Exp Med

Medial patellofemoral ligament repair versus reconstruction for recurrent patellar instability: Two-year results of an algorithm-based approach

Orthop J Sports Med

Traumatic patellar dislocation: Nonoperative treatment compared with MPFL reconstruction using patellar tendon

Am J Sports Med

Is surgical treatment better than conservative treatment for primary patellar dislocations? A meta-analysis of randomized controlled trials

Arch Orthop Trauma Surg

Meta-analysis
Which Technique Is Better for Treating Patellar Dislocation? A Systematic Review and Meta-analysis