Marie Askenberger1,2, Eva Bengtsson Moström1,2, Wilhelmina Ekström3, Elizabeth A Arendt4, Anna Hellsten5, Christina Mikkelsen3,6, Per-Mats Janarv1,3,6. 1. Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden. 2. Section of Pediatric Orthopaedic Surgery, Karolinska University Hospital, Solna, Sweden. 3. Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden. 4. Department of Orthopaedic Surgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA. 5. Sport & Rehabkliniken, Stockholm, Sweden. 6. Capio Artro Clinic, Stockholm, Sweden.
Abstract
BACKGROUND: A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment. PURPOSE: (1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years. RESULTS: The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively ( P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth <3 mm) had the highest odds ratio for redislocations (2.35 [95% CI, 0.69-8.03]), with no significant association between APIFs and a redislocation. CONCLUSION: Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations. Registration: ISRCTN 39959729 (Current Controlled Trials).
RCT Entities:
BACKGROUND: A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment. PURPOSE: (1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years. RESULTS: The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively ( P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth <3 mm) had the highest odds ratio for redislocations (2.35 [95% CI, 0.69-8.03]), with no significant association between APIFs and a redislocation. CONCLUSION: Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations. Registration: ISRCTN 39959729 (Current Controlled Trials).
Authors: Reva Y Qiu; Daire W D Fitzpatrick; Dan Cohen; Jeffrey Kay; Mahmoud Almasri; Darren L de Sa Journal: Knee Surg Sports Traumatol Arthrosc Date: 2022-07-07 Impact factor: 4.342
Authors: Mikko M Uimonen; Jussi P Repo; Tuomas T Huttunen; Heikki Nurmi; Ville M Mattila; Juha Paloneva Journal: Knee Surg Sports Traumatol Arthrosc Date: 2020-09-18 Impact factor: 4.342
Authors: Ryan W Paul; Joseph M Brutico; Margaret L Wright; Brandon J Erickson; Fotios P Tjoumakaris; Kevin B Freedman; Meghan E Bishop Journal: Arthrosc Sports Med Rehabil Date: 2021-09-02
Authors: Jussi P Repo; Mikko M Uimonen; Mika T Nevalainen; Heikki Nurmi; Ville T Ponkilainen; Antti Tuominen; Juha Paloneva Journal: Knee Surg Relat Res Date: 2022-04-13
Authors: Juan Pablo Martinez-Cano; Julián Chica; Juan José Martinez-Arboleda; Erika Rincón-Escobar; Laura Zamudio-Castilla; Martin Renjifo; Alfredo Martinez-Rondanelli Journal: Orthop J Sports Med Date: 2021-01-28