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An algorithm guiding the evaluation and treatment of acute primary patellar
dislocations. Sports Med Arthrosc 15: 78-81, 2007 Mehta VM, Inoue M, Nomura E, Fithian DC. Fox Valley Orthopaedic Institute, 2525 Kaneville Road, Geneva, IL 60134, USA. vishal@mehtas.com Primary patellar dislocation continues to be a common problem facing clinicians today. These injuries are associated with significant morbidity and a substantial recurrence rate. A myriad of operative and nonoperative options have been described to treat these injuries though the evidence-based literature is sparse. As a result, much controversy exists regarding the ideal management of the primary patellar dislocation. This article reviews the literature on this topic, from the initial examination and management to definitive treatment. Furthermore, an algorithm is presented to help the clinician approach and treat these patients. |
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Long-term Follow-up and Knee Osteoarthritis Change After Medial Patellofemoral
Ligament Reconstruction for Recurrent Patellar Dislocation. Am J Sports Med 35: 1851-1858, 2007 Nomura E, Inoue M, Kobayashi S BACKGROUND: Proximal or distal realignment procedures have long been selected as treatment for recurrent patellar dislocation, but associated knee osteoarthritis has been a substantial problem that leads to poor results. A new approach, medial patellofemoral ligament reconstruction, has recently started, but there have been no reports on the long-term follow-up. HYPOTHESIS: Anatomical medial patellofemoral ligament reconstruction can lead to satisfactory long-term outcome and a low association rate of knee osteoarthritis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-four knees from 22 patients who underwent medial patellofemoral ligament reconstruction for recurrent patellar dislocation were reviewed at a mean follow-up of 11.9 years (range, 8.5-17.2 years). A lateral release was done on 14 of 24 knees. The clinical/physical outcome and the association of knee osteoarthritis were investigated. Patellofemoral and femorotibial osteoarthritis on the radiographs was evaluated using the Crosby/Insall and the Kellgren/Lawrence grading systems. RESULTS: According to the Crosby/Insall criteria, 11 knees (46%) were classified as excellent, 10 (42%) as good, 3 (12%) as fair/poor, and none as worse at follow-up. Further lateral subluxation or dislocation occurred in only 2 knees. The mean Kujala score improved significantly from 63.2 points preoperatively to 94.2 points at follow-up (P < .0001). According to the Crosby/Insall grading system, patellofemoral osteoarthritis was none to mild in 23 of the 24 knees and moderate in 1 knee, preoperatively. At the final follow-up, 21 knees were none to mild, and 3 knees were moderate. There were only 2 knees that had definite progression from none to mild to a moderate grade. CONCLUSION: The association of definite knee osteoarthritis in medial patellofemoral ligament reconstruction with or without lateral release was small in the long-term follow-up. The conclusion is that medial patellofemoral ligament reconstruction not only prevents further patellar dislocation but also shows no or only slight progression of knee osteoarthritis. Classification of lesions of the medial patello-femoral ligament in patellar dislocation. Int Orthop 23:：260-263, 1999 (SICOT-SIROT AWARD) Nomura E The remnants of the medial patello-femoral ligament (MPFL) of 67 knees, 18 with acute patellar dislocation and 49 with chronic patellar dislocation, were studied. The MPFL injuries of the acute cases were categorised into 2 groups: an avulsion tear type and a substantial tear type. The chronic cases were put into 3 groups: those with loose femoral attachment (9 knees), those with scar tissue formation or abnormal scar branch formation (29 knees), and those with no evidence or continuity of the ligament (absent type) (11 knees). It is concluded that incompetence of the medial patello-femoral ligament is a major factor in the occurrence of recurrent patellar dislocation and/or an unstable patella following an acute patellar dislocation. Cartilage lesions of the patella in recurrent patellar dislocation. Am J Sports Med 32：498-502, 2004. Nomura E, Inoue M, Kobayashi S BACKGROUND: The etiology of patellar cartilage lesions in recurrent patellar dislocation has been poorly understood. HYPOTHESIS: The pathology of cartilage lesions of the patella accompanied by recurrent patellar dislocation can be analyzed. STUDY DESIGN: Series of case reports. METHODS: In 70 knees from 57 patients with recurrent patellar dislocation, the cartilage lesions of the patella were examined using arthroscopy and/or macroscopic observation. The average age of the patients was 22 years (range, 13 to 40 years). Lesions that involved only softening were not included. RESULTS: Sixty-seven knees (96%) had articular cartilage lesions of the patella, and only 3 knees had no change. Fissuring was observed in 53 knees (76%). The most common site of fissuring was on the central dome. There were basically two types of fissuring: multiple longitudinal fissuring and marginal/radial fissuring. Fibrillation and/or erosion were observed in 54 knees (77%). Of these, 40 knees had fissuring and 14 did not have fissuring. The main site of fibrillation and/or erosion was the medial facet. CONCLUSIONS: Cartilage lesions of the patella in recurrent patellar dislocation cases were very common. Fissuring was observed mainly on the central dome, and fibrillation and/or erosion were observed mainly on the medial facet. Hybrid medial patellofemoral ligament reconstruction using the semitendinous tendon for recurrent patellar dislocation: minimum 3 years' follow-up Arthrscopy 22: 787-793, 2006 Nomura E, Inoue M PURPOSE: The purpose of this study was to evaluate the results of a new hybrid medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation. METHODS: Hybrid MPFL reconstruction by use of the semitendinous tendon was performed in 12 knees with recurrent patellar dislocation. The results were evaluated at a minimum follow-up of 3 years (mean, 4.2 years). RESULTS: According to the grading system of Insall et al., the results were classified as excellent in 8 knees (66%), good in 2 (17%), and fair in 2 (17%), with none being classified as poor. The mean Kujala score was 56.3 points (range, 29 to 82) preoperatively and 96.0 points (range, 84 to 100) at follow-up. There were no patients with recurrent dislocation and subluxation. No knees had a positive apprehension sign, and there were no postoperative complications. CONCLUSIONS: At a midterm follow-up, hybrid MPFL reconstruction by use of the semitendinous tendon for recurrent patellar dislocation should be considered as an effective operation for cases without severe predisposing factors. LEVEL OF EVIDENCE: Level IV, therapeutic case series, no or historical control group. Surgical technique and rationale for medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Arthroscopy 19:E47, 2003 Nomura E, Inoue M This article describes a medial patellofemoral ligament (MPFL)
reconstruction procedure using an artificial ligament for recurrent patellar
dislocation. The MPFL has been shown biomechanically to be the primary restraint
among the medial patellar stabilizers. Although various predisposing factors are
involved in lateral patellar dislocation, we believe that the MPFL, as a primary
restraint, should undergo primary reconstruction for patellar dislocation. The
results of MPFL reconstruction using a mesh-type artificial ligament and medial
retinaculum slip coverage for recurrent patellar dislocation were as good as we
had expected. In this article, we describe the detailed surgical technique and
its rationale. We believe technique has also wide applications in MPFL
reconstruction using autogenous tendons. |