SLIDE 1
First Time Patellar Dislocation in a 21 Year Old Female with - - PowerPoint PPT Presentation
First Time Patellar Dislocation in a 21 Year Old Female with - - PowerPoint PPT Presentation
First Time Patellar Dislocation in a 21 Year Old Female with Ligamentous Laxity: Who needs Surgery, Why & How O RTHOPAEDIC SUMMIT 2017 EVOLVING TECHNIQUES Beth E. Shubin Stein, MD Associate Professor Weill Cornell Medical College Sports
SLIDE 2
SLIDE 3
1st Patella Dislocation
- 21 y.o Female
- MOI- Lacrosse
- No previous injuries
- No famiy hx
SLIDE 4
Physical Exam
- + 3/5 Beighton Index
- Mild valgus standing alignment
- + Effusion
- + J sign
- - Crepitus
- + TTP Medial patella
- + Apprehension
SLIDE 5
SLIDE 6
- Lateral Xray
demonstrates crossing sign and slight bump
SLIDE 7
- Caton-Deschamps
ratio = 1.2
SLIDE 8
Merchant view
- Avulsion fx
- Tilt
- Subluxation
SLIDE 9
- Axial MRI
with MPFL torn off patella
- Dysplasia
SLIDE 10
TT-TG = 15.3
SLIDE 11
First Time Dislocator
- Alta 1.2
- TT-TG 15.3
- Trochlear dysplasia
- Torn MPFL off Patella with bony fragment
SLIDE 12
- If surgery
– MPFL repair vs. reconstruction – Bony realignment
Operative vs. Non Op Tx?
SLIDE 13
Post Op
SLIDE 14
SLIDE 15
Who Needs Surgery?
SLIDE 16
Associated Injuries
- MPFL/complex
– Askenberger AJSM 2015:
99%
- Chondral/osteochondral
injuries
– Stanitski and Paletta AJSM 1998: 71%!
SLIDE 17
SLIDE 18
Risk Factors
- Balcarek et al KSSTA 2013: 66%
– Age ≤ 16 years – Contralateral instability – Trochlear dysplasia – Patella alta > 1.2 – TT-TG ≥ 16 mm – Patellar tilt > 20° – 4 or more points: OR 4.88 compared with ≤ 3 points
SLIDE 19
Risk Factors
- Jaquith and Parikh JPO 2015 (pediatric):
35%
– Age < 14 years – History of contralateral dislocation – Trochlear dysplasia – Patella alta (C-D > 1.45) – 4 factors = 88% risk of recurrence – 3 factors = 75% – 2 factors = 55%
SLIDE 20
J Knee Surg 2015
- 312 pts (326 knees) with acute, 1st time
dislocation
- 47% female, 53% male
- Mean age: 20 yrs (9-60)
SLIDE 21
Significant risk factors
- Trochlear dysplasia
- Immature physes
- Younger age
- Sports related injuries
- Patella alta
SLIDE 22
Risk factors
- Trochlear dysplasia =
strongest risk factor for recurrent instability
- Trochlear dysplasia (any age):
– > 3x increased risk of recurrence
- Trochlear dysplasia + patella
alta:
4
SLIDE 23
Risk factors
- 2nd strongest risk factor was age
- Age (yrs)
Recurrent PF instability ≥ 40 0% ≥ 25 16% < 25 47%
SLIDE 24
Algorithm
Lewallen et al
SLIDE 25
Surgical Intervention
- Acute MPFL repair does NOT reduce
recurrence
– Christiansen Arthroscopy 2009 – Sillanpaa AJSM 2008 – Hing Cochrane Data Rev 2011
SLIDE 26
MPFL Repair vs. Non Op
- Camanho ‘09 Arthroscopy
Acute MPFL repair
- Better PRO’s
- Sig lower risk of redislocation
– Zone of injury localized to femur
- r patella (avulsion)
SLIDE 27
- Bitar AJSM 2012:
MPFL reconstruction reduces recurrence (35% vs 0%)
MPFL Reconstruction vs. Non Op Tx
SLIDE 28
Conclusions
- Instability is multifactorial.
- SOC is non operative---- BUT
– Growing body of literature identifying ‘at risk’ group – Multi Center Studies Underway
- ***Consider surgery for patients at high risk
- f recurrence
SLIDE 29