To determine in skeletally mature patients with a traumatic, first-time, patellar dislocation, the effect of early MPFL reconstruction versus rehabilitation on the rate of recurrent patellar dislocations and functional outcomes. Three online databases MEDLINE, EMBASE and PubMed were searched from database inception (1946, 1974, 1966 respectively), to August 20th, 2021, for literature addressing the management of patients sustaining acute first-time patellar dislocations. Data on redislocation rates, functional outcomes using the Kujala score, and complication rates were recorded. A meta-analysis was used to pool the mean postoperative kujala score as well as calculate the proportion of patients sustaining redislocation episodes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS and Detsky scores. Overall, there were a total of 22 studies and 1705 patients included in this review. The pooled mean redislocation rate in 18 studies comprising 1409 patients in the rehabilitation group was 31% (95% CI 25%-36%, I2 = 65%). Moreover, the pooled mean redislocation rate in five studies comprising 318 patients undergoing early MPFL reconstruction was 7% (95% CI 2%-17%, I2 = 70%). The pooled mean postoperative Kujala anterior knee pain score in three studies comprising 67 patients in the reconstructive group was 91 (95% CI 84-97, I2 = 86%), compared to a score of 81 (95% CI 78-85, I2 = 78%) in 7 studies comprising 332 patients in the rehabilitation group. The reoperation rate was 9.0% in 936 patients in the rehabilitation group and 2.2% in 322 patients in the reconstruction group. Management of acute first-time patellar dislocations with MPFL reconstruction resulted in a lower rate of redislocation and a higher Kujala score, as well as noninferiority with respect to complication rates compared to nonoperative treatment. The paucity of high-level evidence warrants further investigation in this topic in the form of well-designed and high-powered RCTs to determine the optimal management option in these patients

INTRODUCTION. It has been reported that the rate of complications around the patella after Total Knee Arthroplasty(TKA) is 1–12%, and the patella dislocation is the most common one. PURPOSE. We will report a case that had the patella dislocation after TKA caused by malrotation of the components. CASE. 67 years old, Female. The chief complaint was an instability of the right patella. She had undergone TKA due to osteoarthritis at another hospital. After 2 months, she felt a subluxation of the patella. And after 4 months, she had a reoperation of medial reefing and revision of the patella at the same hospital, and the doctor allowed her to flex her right knee within 70 degrees. However, after 3 months, she started experiencing pain with a feeling of dislocation and got it corrected and immobilized with a knee brace. 2 weeks later, she visited our hospital for the first time. STATUS. 148cm, 65kg. She could gait with an extension knee brace. Tenderness was seen around the right patella. She could bend her right knee from 0 degrees to 60 degrees. Extension lag and instability of varus and valgus were not existent. An X-ray showed the FTA was 172 degrees on the right side. The right knee had a TKA(Stryker Scorpion Energy®/fixed surface), and the measurements of component after TKA were almost good. However, the patella had lateral subluxation. A CT image showed the femoral component inserted in internal rotation of 8 degrees from CEA and tibia component inserted in internal rotation of 23 degrees from the left Akagi line. We diagnosed right knee dislocation because of rotation failure of the components. COURSE OF TREATMENT. We replaced implants which were produced by the same company. We replaced the tibial component externally referring to the Akagi's line. On the femur side, we augumented the femur component at the posterolateral and replaced it referring to the CEA. We made a lateral release and used a CCK surface. We did not replace the patella because the surviving patella bone was thin and patella tracking was satisfactory.2 weeks after the operation, she could bend her knee from 0 degrees to 120 degrees and walk with a cane. An X-ray showed the patella was reduced and a CT scan showed the appropriate rotation angle. DISCUSSION. Regarding the treatment of patella dislocation after TKA, when there is malrotation of components, revision is recommended. The definition and the degree of malrotation are still controversial. It was reported that when total internal rotation angle was more than 7 degrees, Revision is recommended. This patient obtained the stability of patella due to the proper rotation angle of components

Optimal management of acute patellar dislocation is still a topic of debate. Although, conventionally it has been managed by non-operative measures, recent literature recommends operative treatment to prevent re-dislocations. Our study recommends that results of non-operative measures comparable to that of operative management. Our study is the retrospective with 46 consecutive patients (47 knees) of first time patellar dislocation managed between 2012 and 2014. The study methodology highlighted upon the etiology, mechanism of injury and other characteristics of first time dislocations and also analysed outcomes of conservative management including re-dislocation rates. The duration of follow up ranged from 1 to 4 years. Average age at first-time dislocation was 23 years (Range 10–62 years). Male:Female ratio was 30:17. Twisting injury was the commonest cause. 1 patient required open reduction but all others relocated spontaneously or had successful closed reduction. Medial Patello-Femoral Ligament injury was frequent associated feature. 11 knees (24%) re-dislocated during follow up. Age was the significant risk factor for re-dislocations. All patients with re-dislocation were less than 30 years old. Maximum redislocations happened between 6 months to 1 year after index dislocation. Skeletal abnormality was the commonest pathology in re-dislocators. Only 4 patients (8.6%) finally required surgical intervention. One patient had persistent knee pain as a complication. Conservative management of primary patellar dislocation is successful in majority of patients. Surgery should be reserved for the carefully selected patients with specific indications

Purpose of Study:

Various techniques have been described and are still used for treating recurrent dislocation of the patella when conservative measures fail. Among them are distal, proximal and combined realignment techniques and lateral releases. Since being shown proof of the biomechanical importance of the medial patellofemoral ligament (MPFL) in patellofemoral instability, the reconstruction of the MPFL has gained in popularity. The objective of this paper is to present a case series with preliminary clinical results using the gracilis tendon to reconstruct the MPFL.

Recurrent patellar instability is a common problem and there are multiple demographic and pathoanatomic risk factors that predispose patients to dislocating their patella. The most common of these is trochlear dysplasia. In cases of severe trochlear dysplasia associated with patellar instability, a sulcus deepening trochleoplasty combined with a medial patellofemoral ligament reconstruction (MPFLR) may be indicated. Unaddressed trochlear pathology has been associated with failure and poor post-operative outcomes after stabilization. The purpose of this study is to report the clinical outcome of patients having undergone a trochleoplasty and MPFLR for recurrent lateral patellofemoral instability in the setting of high-grade trochlear dysplasia at a mean of 2 years follow-up. A prospectively collected database was used to identify 46 patients (14 bilateral) who underwent a combined primary MPFLR and trochleoplasty for recurrent patellar instability with high-grade trochlear dysplasia between August 2013 and July 2021. A single surgeon performed a thin flap trochleoplasty using a lateral para-patellar approach with lateral retinaculum lengthening in all 60 cases. A tibial tubercle osteotomy (TTO) was performed concomitantly in seven knees (11.7%) and the MPFLR was performed with a gracilis tendon autograft in 22%, an allograft tendon in 27% and a quadriceps tendon autograft in 57% of cases. Patients were assessed post-operatively at three weeks and three, six, 12 and 24 months. The primary outcome was the Banff Patellar Instability Instrument 2.0 (BPII 2.0) and secondary outcomes were incidence of recurrent instability, complications and reoperations. The mean age was 22.2 years (range, 13 to 45), 76.7% of patients were female, the mean BMI was 25.03 and the prevalence of a positive Beighton score (>4/9) was 40%. The mean follow-up was 24.3 (range, 6 to 67.7) months and only one patient was lost to follow-up before one year post-operatively. The BPII 2.0 improved significantly from a mean of 27.3 pre-operatively to 61.1 at six months (p < 0 .01) and further slight improvement to a mean of 62.1 at 12 months and 65.6 at 24 months post-operatively. Only one patient (1.6%) experienced a single event of subluxation without frank dislocation at nine months. There were three reoperations (5%): one for removal of the TTO screws and prominent chondral nail, one for second-look arthroscopy for persistent J-sign and one for mechanical symptoms associated with overgrowth of a lateral condyle cartilage repair with a bioscaffold. There were no other complications. In this patient cohort, combined MPFLR and trochleoplasty for recurrent patellar instability with severe trochlear dysplasia led to significant improvement of patient reported outcome scores and no recurrence of patellar dislocation at a mean of 2 years. Furthermore, in this series the procedure demonstrated a low rate (5%) of complications and reoperations

Introduction. Epidemiologic studies indicate that isolated patellofemoral (PF) arthritis affects nearly 10% of the population over 40 years of age, with a predilection for females. A small percentage of patients with PF arthritis may require surgical intervention. Surgical options include non-arthroplasty procedures (arthroscopic debridement, tibial tubercle unloading procedures, cartilage restoration, and patellectomy), and patellofemoral or total knee arthroplasty (PFA or TKA). Historically, non-arthroplasty surgical treatment has provided inconsistent results, with short-term success rates of 60–70%, especially in patients with advanced arthritis. Although TKA provides reproducible results in patients with isolated PF arthritis, it may be undesirable for those interested in a more conservative, kinematic-preserving approach, particularly in younger patients, who may account for nearly 50% of patients undergoing surgery for PF arthritis. Due to these limitations, patellofemoral arthroplasty (PFA) has become utilised more frequently over the past two decades. Indications for PFA. The ideal candidate for PFA has isolated, non-inflammatory PF arthritis resulting in “anterior” pain and functional limitations. Pain should be retro- and/or peri-patellar and exacerbated by descending stairs/hills, sitting with the knee flexed, kneeling and standing from a seated position. There should be less pain when walking on level ground. Symptoms should be reproducible during physical examination with squatting and patellar inhibition testing. An abnormal Q-angle or J-sign indicate significant maltracking and/or dysplasia, particularly with a previous history of patellar dislocations. The presence of these findings may necessitate concomitant realignment surgery with PFA. Often, patients with PF arthritis will have significant quadriceps weakness, which should be treated with preoperative physical therapy to prevent prolonged postoperative pain and functional limitations. Tibiofemoral joint pain suggests additional pathology, which may not be amenable to PFA alone. Conclusion. PFA is effective for the treatment of arthritis localised to the PF compartment. Outcomes can be optimised with proper patient selection, meticulous surgical technique, and selection of an onlay-style implant that can be positioned perpendicular to the AP axis of the femur. Minimizing the risk of patellar instability by using onlay-design PFAs has enhanced mid- and long-term results, and leaves progressive tibiofemoral arthritis as the primary failure mechanism beyond 10–15 years

The Femoro Patella Vialli (FPV) is indicated for isolated patello-femoral joint replacement (PFJR). It is now the second most commonly used PFJR in the UK, however there are limited studies evaluating its outcome. Key differences include a larger component sulcus angle of 140 degrees which more closely mimics the normal knee. Between 2006 and 2012, we performed 53 consecutive FPV patellofemoral arthroplasties in 41 patients with isolated patellofemoral joint osteoarthritis. Mean age was 62.2years (39–86) and mean follow-up was 3.5 years. Mean Oxford Knee scores improved from 19.7 to 37.7 at latest follow-up. Ninety four percent of patients were happy or very happy with their knees. Progression of tibiofemoral osteoarthritis was seen 12% of knees. 2 knees required revision to TKR at 7 months post-operatively, which we attribute to poor patient selection. There were no cases of maltracking patella or patella dislocations at final follow-up, which we attribute to the larger sulcus angle. There were no cases of radiological loosening. Our findings suggest the FPV patellofemoral prosthesis has good mid-term functional outcomes

Recurrent patella dislocation is a well-recognized complication after primary dislocation of the patellofemoral joint. We propose that acute surgical management of the injury minimizes this risk. Between February 2006 and August 2010 47 patients (49 knees) with a mean age of 17.9 (range 12–31) at the time of surgery who sustained a patellofemoral joint dislocation for the first time were treated with an acute repair of the medial patellofemoral ligament. Patients presenting to our fracture clinic following a primary lateral dislocation of the patella were investigated with an MRI scan and with consent, proceeded to have an examination under anaesthesia and arthroscopy of the injured knee. An easily dislocatable patella in the presence of a confirmed medial patellofemoral ligament rupture was the indication for open repair. All patients treated surgically were followed up for a period of 24–72 months where the primary outcome measure was further dislocation. An evaluation of symptoms, functional recovery, restoration of range of movement and patient satisfaction was made supported by the Lysholm knee score. Our results confirm that acute repair of the medial patella femoral ligament in selected patients reduces the risk of further dislocations and results in a overall good functional outcome and patient satisfaction with minimal complications

Tibiofemoral joint dislocations are uncommon. Four cases of paediatric knee dislocation are described, none in British journals. We report two paediatric patients who presented with a 3-ligament knee injury following in-field or spontaneous reduction. One case was initially diagnosed as patella dislocation. One patient, age 12 years, had associated nerve and vessel injury so underwent fixation, vascular grafting and fasciotomy emergently. The second, age 15 years, underwent acute reconstruction following MRI evidence of both cruciates and medial-collateral ligament ruptures, with tears to both menisci. History is essential to diagnosis as the knee is often relocated at the scene. Tibiofemoral dislocation can be confused with patellofemoral dislocation. There are important differences on examination, which should be performed carefully, and must include neurovascular status. Knee AP and lateral radiographs can exhibit subtle signs, posterior subluxation of the tibia is pathognomonic of PCL rupture and should raise suspicion of dislocation. These cases show that traumatic dislocation is an important differential diagnosis in a child that presents with a painful knee. Although an uncommon injury, particularly in the skeletally immature, it is essential to recognise the possibility of knee dislocation in children so that prompt diagnosis and treatment of this limb threatening injury can occur

Aim. To correlate the surgical and MRI findings in acute lateral patellar dislocation and to determine the accuracy of MRI in identifying location of MFPL injury. Methods. it's a retrospective study. Patients with first time dislocation of patella were admitted after reviewing in fracture clinic and MRI was arranged. Surgical repair of MFPL was performed within 2 weeks of injury. Arthroscopy was performed at the same time to remove osteochondral fragments and to confirm the diagnosis by viewing the area of haemorrhage deep to medial retinaculum. MRI was reported by consultant radiologist with a special interest in musculoskeletal system. MRI and surgical finding were compared. Results. There were forty two patients with a mean age of 18.9. MRI was assessed to ascertain the site of MFPL disruption to allow focused surgical approach. On correlating MRI and surgical findings, MRI was 90% sensitive and 82.2% accurate in detecting site of MFPL disruption. Conclusion. This study assesses the accuracy of MRI to confirm the site of disruption of MFPL and associated findings, allowing a focussed surgical approach

Hinges were used early in total knee replacement history. The stems were too short, the trochlear groove was absent or inadequate and the mechanism lacked strength. Hinges, therefore, acquired a very bad reputation. As the only stems in early knees were on hinges, I used them when necessary, i.e. a completely missing medial collateral ligament, a flexion gap of more than three centimeters with a normal extension gap and missing bone. I used a Guepar II and my results were good up to 20 years when the plastic wore out and the spindle was damaged. By that time, new spindles were not available and the cases had to be revised. Revision of a cemented bowed stem is a nightmare. One would wish, therefore, to have a design, where the bearings could be detached from the stems and a new bearing inserted. The main problem with hinges nowadays is that they all rotate, or at any rate, all the hinges which I can get, rotate. The commonest indication for a hinge is the multiply revised knee due to missed tibial torsion. A rotating hinge used in a situation like this results in the patient externally rotating the tibia and subluxating or dislocating the patella. They, therefore, cannot use this knee as the leading leg on any activity and they may have instability or falls as a result of the patellar dislocation. It is not difficult to block rotation but, so far as I know, no one has done it. Is there a role for hinge? Very seldom and not with the existing designs

This study is a prospective analysis of clinical outcome in 201 consecutive patients treated with medial patellofemoral ligament reconstruction using an autologous semitendinosus graft between October 2005 and January 2011. Patients received pre and post-operative clinical evaluation, radiological assessment and outcome scoring systems. 193 patients (92 male, 119 female) underwent 211 procedures, with mean age 26 (16–49) and follow-up 16 months (6–42 months). Indications were atraumatic recurrent patella dislocation (68%), traumatic recurrent dislocation (22.8%), instability (5%), single dislocation (2.7%) and anterior knee pain (1.4%). Trochlea dysplasia was moderate in 57% and mild in 35%. There have been no recurrent dislocations/ subluxations. 10 patients have required further surgery. The mean pre-op Kujala Scores were 55 (SE 5.21) and post-op scores improved to mean 82 (31–100) (SE 1.18)(p < 0.001). This improvement and significance is mirrored with Oxford (27 to 41), WOMAC (76 to 93), Fulkerson (53 to 83), IKDC (46 to 75), Tegner (4.1 to 5.3) and SF12 (38 to 51) scores (p < 0.005). 93% of patients were satisfied with their operation. History of prior realignment surgery was associated with significantly worse outcomes compared to patients where MPFL reconstruction was their first realignment procedure (p < 0.05). This series is the largest reported in the literature for any technique of MPFL surgery. This technique allows for objective intra-operative evaluation of the required graft tension to optimise patella tracking

Trochlear dysplasia is a developmental condition characterised by an abnormally flat or dome shaped trochlea and is an important contributing factor to patellofemoral instability and recurrent patellar dislocation. We prospectively studied a cohort of 54 consecutive patients (59 knees) with patellofemoral instability secondary to trochlear dysplasia, treated with a trochleoplasty by a single surgeon over a 5 year period. Patients were recruited from the senior author's specialist knee clinic and pre-operatively, multiple patient-centred scores were recorded. After the trochleoplasty, these were repeated along with a patient satisfaction questionnaire. Of the 54 patients and 59 knees operated, 39 of the patients (44 knees) were female and 15 (15 knees) male and 40 patients (42 knees) had follow-up of 12 months or more. Their mean age at surgery was 21 years and 6 months and mean length of follow up 2 years. One patient was unable to attend for follow up due to the development of a pelvic Ewings sarcoma. A statistically significant improvement in outcomes was demonstrated when the pre and post-operative scores were compared (mean scores of Oxford 26 to 19, WOMAC 23 to 17, IKDC 54 to 72, Kujala 62 to 76, Lysholm 57 to 78, p values <0.001 for all scores). 93% (50 patients) were satisfied with the outcome of their procedure. We conclude that in the short and medium term, the results of trochleoplasty are encouraging in this challenging group of patients

Introduction. Osteochondral defects of the knee may occur following patella dislocation or following direct trauma or twisting injuries to the knee in adolescents. Often a diagnostic and therapeutic challenge, if these lesions are left, posttraumatic osteoarthritis may occur. This retrospective single centre study presents the short-term results following operative fixation of osteochondral fragments of the knee using Omnitech ® screws. Method. All skeletally immature patients presenting with an osteochondral fracture of their femur or patella confirmed on xray and MRI were identified. Arthroscopic evaluation of the osteochondral defect was performed followed by open reduction and internal fixation of the osteochondral fragment using Omnitech ® screws. A standard postoperative rehabilitation protocol was followed. Patients were evaluated at follow-up using a Knee Injury and Osteoarthritis Outcome Score (KOOS). Results. Eight patients were identified. The mean age at time of injury was 15 years (range 14–16) for two girls and 14.4 years (range 13–16) for six boys. The lateral femoral condyle was involved in six cases and patella in two cases. At mean follow up of 14 months (range 1–38) there was no revision for failure and no postoperative complications. The KOOS score (out of 100) at final follow up was subdivided as follows; Pain, 93 (range 81–100), other symptoms, 77 (range 36–100), function in daily living (ADL), 97 (range 84–100), function in sport and recreation, 84 (range 55–100) and knee related quality of life, 79 (range 44–100). Discussion. The short-term results of using Omnitech® screws are promising. Subchondral screw placement with adequate compression of the osteochondral fragment is achievable with Omnitech ® screws. Seven patients are back to their pre-injury sporting activity and one patient is currently undergoing postoperative rehabilitation, one month following surgery

Chronic patello-femoral joint instability leads to recurrent subluxation and dislocation affecting knee function and preventing participation at sport. Traumatic dislocation of the patella results in rupture of the medial patello-femoral ligament (MPFL) in the majority of cases with a high incidence of chronic instability after a second dislocation. MPFL reconstruction can prevent recurrent dislocation and improve knee function. We report on our experience in MPFL reconstruction using hamstring tendons and its effect on the knee function in patients with chronic patello-femoral joint instability. In this prospective study from 2005 to 2008, 68 patients (69 knees) with chronic patello-femoral instability were treated with MPFL reconstruction through a minimally invasive and arthroscopically assisted approach. In this procedure the semintendonosis with or without the gracilis tendon is routed from the pes anserinus to the most distal portion of the medial intramuscular septum before being secured to the superomedial border of the patella. All patients were evaluated pre-operatively and then post-operatively for a mean of 25 months (range 12-48 months). Knee function was assessed by the Tegner, Kujala and Lysholm scores. There were 44 (65%) women and 24 (35%) men. Average age was 27 years. There were 2.7 mean pre-operative patellar dislocations (range 2-7). Mean follow-up was 19.6 months (range 12 to 56 months). IKDC score improved from 48.2 to 74.2, Kujala scores improved from 55.4 to 85.3. Lysholm scores improved from 52.4 to 77.3. Tegner activity scores improved from 2.5 to 5.4. There were overall 87% good to excellent results. No recurrent dislocations or wound related complications. Medial patello-femoral reconstruction can provides excellent results in the treatment of patello-femoral joint instability with poor knee function

While short stem designs are not a new concept, interest has surged with increasing popularity of less invasive techniques. If the goal of the tapered stem is to load preferentially proximally, why do we need a stem at all? Perhaps the only reason to use a tapered, long stem is to prevent varus; however, studies have shown that varus malalignment of a tapered stem does not affect results. Short stems are easier to insert, especially when using an anterior approach such as the anterior supine intermuscular in which the proximal femur is elevated anteriorly from the wound during stem insertion. Femoral preparation can be accomplished with straightforward broaching of the canal, without use of reamers. Short stems are bone conserving. They violate less femoral bone stock, providing more favorable conditions should a revision be required. However, ease of insertion and bone conservation matter little if not supported by clinical results. Thus, we reviewed our early experience with 2094 patients undergoing 2457 primary THA using short, tapered titanium, porous plasma spray-coated femoral components since January 2006 at our center. The TaperLoc Microplasty stem (Biomet, Warsaw, IN) has been used in 1881 THA, and the TaperLoc Complete Microplasty stem (Biomet) in 576. Patient age averaged 63.6 years. Increased offset was used in 1990 hips (81%). The surgical approach was less invasive direct lateral (LIDL) in 1194 THA (49%), anterior supine intermuscular (ASI) in 1117 (46%), and standard direct lateral (Std) in 146 (6%). Follow-up averaged 20 months. Thirty-five stems (1.4%) have been revised: 15 for infection (12 LIDL, 3 ASI), 1 same day revision for intraoperative femoral shaft perforation (Std), 1 at 3 days for patellar dislocation (LIDL), 2 for early subsidence (1 LIDL, 1 ASI), 13 for periprosthetic femoral fracture (1 Std, 12 ASI), 2 for aseptic loosening (1 LIDL, 1 ASI), and 1 stem well fixed (ASI) removed for loose cup and unable to disarticulate trunnion. What lessons have we learned? First, we usually require one or two diameter sizes larger with short porous tapered stem versus the standard length version of the same design. The surgeon should be aggressive with sizing, pushing to the largest size possible. Use the broach like a rasp. Drive the component in valgus during insertion. Upon seating the component, do a trial reduction using the shortest available neck length. The component will generally sit slightly prouder than the broach and may require additional effort to seat completely. Conservation of existing bone stock, compatibility with soft-tissue sparing surgery, more physiologic loading of the proximal femur, and versatility with varying femoral anatomy make the short taper an attractive implant option. The tapered wedge short stem represents the natural evolution of joint arthroplasty to a smaller, less-invasive, and more efficient implant

Introduction

Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics.