Patellar Instability in Pediatric Patients

7/23/2019 Patellar Instability in Pediatric Patients

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Treating Patella Instability in

Skeletally Immature PatientsPatrick Vavken, MD., M.Sc., et al



INTRODUCTION

• Conservative vs Surgical Treatment

• Damage to physes and subseuent gro!thdisturbance.

• "cute dislocations are typically treated !ithconservative treatment, unless there is evidence

o# osteochondral damage.• "cute dislocation $ anatomic de#iciencies

considered euivalent to osteochondraldamagesurgical treatment.



• %b&ectives' (evie! current orthopaedic treatments o#

skeletally immature patient !ith patellarinstability )acute and recurrent*.

' "sses current evidence #or di##erent types o#surgical treatments that are clinically available.

' Provide summation and evidence needed in themanagement o# pediatric patellar instability



METHODS

• "#ter statement o# P(+SM" )Pre#erred (eporting+tems #or Systemic revie!s and Meta"nalyses*and -%(%M )-uality o# (eporting o# Metaanalyses* in previous article in Arthroscopy.

• Studies !ere included report on surgical or

conservative treatment )or both* o# patellarinstability in skeletally immature individuals oradolescents, !ith at least / months o# #ollo!up.



METHODS+nclusion Criteria 0

• +mmature 0 (adiologic proo# o# open physes or

Tanner stage )stage 1 or lo!er*.• +# neither physeal status nor tanner stage !as

reported, age 23 !as considered the cuto##threshold bet!een adolescent and adulthood.

4this age re#ers to the age at surgery, not atdislocation





56clusion Criteria

• Patellar instability in association !ith syndrome)e.g., Turner syndrome*' Turner syndrome is one o# the most common

chromosomal abnormalities. That caused by the

absence o# the one set o# genes #rom short arm o#one 7 chromosome. )187*



• Search #rom online database PubMed, C+9":;,5M<"S5, Cochrane Central (egister o#Controlled Trials, and Cochrane Database o#Systemic (evie!s.

• "ll searches !ere unlimited, i.e., publication in

all language and at all dates !ere considered.The last search !as per#ormed on %ctober 2,=>2=.



RESULT• Twenty articles

reporting on a totalo# 18/ knees in 1=8

patients )2?2 male,=38 #emales*#ollo!edup #or 8/.@A 1=.= months onaverage.

• The average ageacross all studies !as 2=.3 A ?.2 years



Acute Patellar Dislcatin



Three studies #ocused on acute dislocations. T!o studies presented data on adirect comparison o# conservative and surgical treatments o# patellar instabilitya#ter acute patellar dislocation in pediatric and adolescent patients.

• Apostolovic et al #ound no di##erence in outcome bet!een surgical and

conservative treatment. they did not report on a #ormal po!er analysis inthe #ace o# P B .>32 #or #unctional outcome. "ssessment o# patello#emoralanatomy !as not reported.

• Palmu et al published a study o# @2 patients !ith patellar dislocation treated !ith medial restraint repair or conservatively and #ollo!ed #or 21 years. "ll patients had slight trochlear dysplasia )28> average sulcus angle*and some level o# patella alta )average +nsallSalvati ratio o# 2.?*, but no data !ere reported on - angles or the tibial tuberositytrochlear groove distance.

:o!ever, at @ and 21 years o# #ollo!up, there !as no di##erence in outcome.



• Recurrence rates #or dislocations !ere #airlyhigh, ranging #rom 4% to 20% )Table ?*. Thehighest rates !ere seen in the oldest patients and !ith the oldest arthroscopic techniues.



Recurrent Patellar Instability







Three studies presented data on 1 groups o# patients !ithrecurrent instability treated !ith pro6imal realignment,

such as a medial retinacular or VM% plasty.• Ji et al . #ound high clinical scores a#ter medial

retinacular plication, but there !as no controlgroup.

• Zhao et al . compared medial retinacular plication !ith VM% plasty and #ound better stability and clinicalscores in the stronger repair !ith the VMO plasty .

• Ma et al . compared medial capsular reefing !ith

M!" repair and #ound better results !ith the latter.



• Camp et al . and Kwon et al . presented data on open andarthroscopic M!" repair )to the patella* and #ound them to

be #easible and e##ective techniues to treat recurrent instabilitydespite recurrence rates as high as =E.

• Five studies reported on classic M!" reconstruction with ahamstring graft. Drez et al . and Deie et al. sutured

autologous semitendinosus to the patella.

• Kumahashi et al ., Yercan et al ., and Nelitz et al . usedintraosseous fi#ation of semitendinosis or gracilis grafts !ith good clinical results and no reported gro!th disturbances or

#ractures.



DISCUSSION

• MPF; provides more than 8>E o# medial restrainGin most o# dislocations, MPF; undergoes some

level o# in&uries.• Current best evidence suggest conservative

treatment in first acute patellardislocation.

• T!o studies included sho!ed no signi#icantdi##erence in clinical score and recurrence bet!een conservative and surgical treatment.

)"postolovic et al. and Palmu et al .*



• <racers have sho!n to stabiliHe the patellasuccess#ully but lead to sti##ness in the long

term. );arsen et al .*4

• VM% strengthening and proprioeptive trainingGclose chain more e##ective than open chain but

do more stress to cartilage. )+rish et al .*4• "bnormal e6tensor alignment cause abnormalpatellar tracking thus inter#ere !ithhealingconsider surgical approach



Surgical A!!rac"

• Pro6imal (ealignment' (elease o# lateral retinaculum

' Medial procedures PlicationIimbrication o# capsule or retinaculum

VM% plasty

(econstruction o# MFP;

• Distal (ealignment' Tenodesis based on semitendinous

' Trans#ering patellar tendon medially



Pr#imal Realignment

• Ma et al . #ound better sub&ective score andpostoperative stability on medial MPF; repair

compared to ree#ing o# the medial capsule• Jhao et al . #ound that simple medial capsule

plication a##ords less improvement than VM%

plasty• 8>>E o# medial restrain in&uries occur atMPF; attachment.



Ptensial Prblems

• "llogra#t or autogra#t #rom hamstring is muchmore sti##er than natural MPF; )Colvin, =>>* minimal malposition induce stress patello#emoral degeneration )5lias, =>>/ and<eck et al ., =>>@*.

• Strategies0' MPF; anchored to adductor magnus )Kercan etal .,=>22*Iuse MC; as pulley )Deie et al .,=>22*

' Tensioning in /> to 3> degrees o# #le6ion rather

than conventional ?> degrees)Colvin, =>>*



• (isk o# MPF; reconstruction on skeletal gro!th0' Leppler et al. sho!ed in an M(+ studies0 MPF;

insertion is on average 8 mm distal to the physis.' 9eliH et al. and Schottle et al. put MPF; insertion

/.1 and /.8 mm distal to physes .

provide secure and sa#e placement o# anchorsuture or tunnel !ithout &eopardiHing gro!th.



LIMITATIONS

• Depended on uality o# included primarystudies.

• ;evel o# evidence o# the included studies !erelimited.

• nclear terminology

• " number o# studies mi6ed adolescent and adultpatiens.



CONCLUSIONS• Current best evidence does not support the

superiority o# surgical intervention over

conservative treatment in acute patellardislocation.

• "natomic variations and their e##ect on healingshould be considered in decision making.

• +n recurrent patellar instability in pediatric andadolescent patients, reconstruction o# MPF; is themost e##ective options together !ith e6tensor

realignment as needed.



T"ank $u





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Patellar Instability in Pediatric Patients