First-time patellar dislocation: surgery or conservative treatment?

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Abstract

[Indexed for MEDLINE] 16. Orthop Traumatol Surg Res. 2023 Dec;109(8):103515. doi: 10.1016/j.otsr.2022.103515. Epub 2022 Dec 14. Patellar dislocation recurrence after pediatric MPFL reconstruction: Bone tunnels and soft tissues versus suture anchors and interference screw. Zampieri A(1), Girardin C(2), Hocquet B(3), Coursier R(4), Fournier A(5), Martin C(6), Nectoux E(2), Canavese F(2). Author information: (1)Université de médecine de Lille, hôpital Jeanne-de-Flandre, CHU de Lille, Hauts de France, 59000 Lille, France; Service d'orthopédie pédiatrique, hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59000 Lille, France. Electronic address: adrienzampieri1@gmail.com. (2)Université de médecine de Lille, hôpital Jeanne-de-Flandre, CHU de Lille, Hauts de France, 59000 Lille, France; Service d'orthopédie pédiatrique, hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59000 Lille, France. (3)Service d'orthopédie pédiatrique, hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59000 Lille, France; Service de chirurgie pédiatrique, centre hospitalier de Lens, 99, route de la Bassée, 62300 Lens, France. (4)Service d'orthopédie pédiatrique, hôpitaux catholiques de Lille Saint-Vincent-de-Paul, boulevard de Belfort, 59000 Lille, France. (5)Service d'orthopédie pédiatrique, hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59000 Lille, France. (6)Département de biostatistiques, CHU de Lille, 59000 Lille, France. BACKGROUND: Several Medial Patellofemoral Ligament (MPFL) reconstruction techniques have been developed, and those with soft tissue fixation are often preferred in children because they allow the growth cartilage to be preserved. Nevertheless, the recurrence rate of patellar dislocation varies widely from one series to another, with no clear superiority of one technique in the pediatric setting. The objectives of this study were to compare the results of two tendon graft fixation techniques (tendon-tendon fixation and anchor-screw fixation) by analyzing: 1) the rate of patellar dislocation recurrence, 2) clinical outcomes, 3) tourniquet time and 4) complication rate. HYPOTHESIS: The two tendon graft fixation techniques used in MPFL reconstruction are equivalent in terms of the patellar dislocation recurrence rate. PATIENTS AND METHODS: This is a retrospective comparative study including 57 patients with a median age of 14 years (12-15 years) who underwent MPFL reconstruction between 2016 and 2020. The tendon graft was fixed upon itself, after passing through a patellar tunnel (Group A: tendon-tendon fixation; n=29) or by two anchors and an interference screw (Group B: anchor-screw fixation; n=28). The preoperative radiographic data were comparable in the two groups: patellar height [A: 1.3 (interquartile range (IQR): 1.2-1.4) / B: 1.2 (IQR: 1-1.4) (p=0.21)], tibial tuberosity to trochlear groove (TTTG) distance [A: 16 (IQR: 13-19) / B: 13.5 (IQR: 11.5-18.8) (p=0.12)], patellar tilt [A: 25 (IQR: 20-35) / B: 24.5 (IQR: 21-32) (p=0.93)]. For each technique, the rate of patellar dislocation recurrence, clinical and functional results (Kujala score, Marx activity score, Lille patellofemoral score), complications (pain, stiffness, revision) were analyzed. In addition to MPFL repair, 13 patients (2 in Group A, 11 in Group B) underwent additional orthopedic procedures to enhance patellar stability. RESULTS: no patients were lost to follow-up and the median follow-up was 30 months (IQR: 20-38). The dislocation recurrence rate was higher in Group A, 6.9% (2/29) compared to none in Group B. The clinical results were comparable for the two groups with a Kujala score [A: 94 (IQR: 89-100) / B: 92 (IQR: 87.5-94.5) (p=0.12)]; Marx score [A: 10 (IQR: 7-11) / B: 9.5 (IQR: 7.5-12) (p=0.89)] and Lille patellofemoral score [A: 97 (IQR: 91-100) / B: 94 (IQR: 90-98) (p=0.21)]. The tourniquet time was shorter in Group A than in Group B, 61minutes (IQR: 52-71) versus 85minutes (IQR: 55-115) (p=0.024) excluding additional orthopedic procedures. The complication rate was 17.2% (5/29) in Group A (dislocation n=2, stiffness n=2, ATT (anterior tibial tuberosity) revision with screw removal n=1) and 10.7% (3/28) in B (pain n=1, ATT revision with screw removal n=2) (p=0.35). CONCLUSION: Clinically, anchor-screw fixation appears to reduce the risk of patellar dislocation recurrence but this could not be statistically tested. On the other hand, the two techniques are comparable in terms of the functional results. LEVEL OF EVIDENCE: III; retrospective case-control study. Copyright © 2022 Elsevier Masson SAS. All rights reserved. DOI: 10.1016/j.otsr.2022.103515