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 Medicine & Shoulder Surgery Hospital for Special Surgery

DISCLOSURE I, Beth E. Shubin Stein, have NO relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation as follows:

1 st Patella Dislocation • 21 y.o Female • MOI- Lacrosse • No previous injuries • No famiy hx

Physical Exam • + 3/5 Beighton Index • Mild valgus standing alignment • + Effusion • + J sign • - Crepitus • + TTP Medial patella • + Apprehension

• Lateral Xray demonstrates crossing sign and slight bump

• Caton-Deschamps ratio = 1.2

Merchant view • Avulsion fx • Tilt • Subluxation

• Axial MRI with MPFL torn off patella • Dysplasia

TT-TG = 15.3

First Time Dislocator • Alta 1.2 • TT-TG 15.3 • Trochlear dysplasia • Torn MPFL off Patella with bony fragment

Operative vs. Non Op Tx? • If surgery – MPFL repair vs. reconstruction – Bony realignment

Post Op

Who Needs Surgery?

Associated Injuries • MPFL/complex – Askenberger AJSM 2015: 99% • Chondral/osteochondral injuries – Stanitski and Paletta AJSM 1998: 71% !

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

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%

J Knee Surg 2015 • 312 pts (326 knees) with acute, 1 st time dislocation • 47% female, 53% male • Mean age: 20 yrs (9-60)

Significant risk factors • Trochlear dysplasia • Immature physes • Younger age • Sports related injuries • Patella alta

Risk factors • Trochlear dysplasia = strongest risk factor for recurrent instability • Trochlear dysplasia (any age): – > 3x increased risk of recurrence • Trochlear dysplasia + patella alta: 4

Risk factors • 2 nd strongest risk factor was age • Age (yrs) Recurrent PF instability ≥ 40 0% ≥ 25 16% < 25 47%

Algorithm Lewallen et al

Surgical Intervention • Acute MPFL repair does NOT reduce recurrence – Christiansen Arthroscopy 2009 – Sillanpaa AJSM 2008 – Hing Cochrane Data Rev 2011

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 or patella (avulsion)

MPFL Reconstruction vs. Non Op Tx • Bitar AJSM 2012: MPFL reconstruction reduces recurrence (35% vs 0%)

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 of recurrence

Thank You