Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3027-0
KNEE
Medial capsule reefing in patellar instability Simone Cerciello • Michele Vasso • Katia Corona Chiara Del Regno • Alfredo Schiavone Panni
•
Received: 3 December 2013 / Accepted: 19 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The efficacy of medial capsule reefing in the treatment of patellar instability is well documented. Aim of the present study was to prospectively evaluate the outcomes of an all-arthroscopic medial capsule reefing technique in young patients with painful patella syndrome and potential patellar instability. Methods Thirty patients with painful patellar syndrome and potential patellar instability having undergone a minimum of 6 months of intensive rehabilitation were enrolled in the present study. All subjects were evaluated with physical examination, clinical and functional outcomes and complete imaging study. Results All patients were reviewed at an intermediate follow-up of 72 months. Average Kujala score improved from 72.9 ± 15.0 to 88.4 ± 7.6 (p \ 0.0001), average Larsen score from 15.0 ± 2.5 to 17.2 ± 2.2 (p \ 0.002), average Lysholm from 63.8 ± 16.7 to 87.9 ± 11.7 (p \ 0.0001) and average Fulkerson score from 69.5 ± 21.5 to 90.8 ± 9.8 (p \ 0.0001). No intraoperative or postoperative complications were recorded. Ninety per cent of patients were very satisfied or satisfied with their functional result. Twenty-eight patients were reviewed at the final follow-up, 120 months after surgery. Average Kujala was 87.7 ± 8.8 (p \ 0.0001), average Larsen was 16.8 ± 2.7 (p \ 0.01), average Lysholm was 87.6 ± 14.3 (p \ 0.0001), and average Fulkerson was 87.2 ± 13.9 (p \ 0.0001). Almost 86 % of patients were very satisfied
S. Cerciello (&) M. Vasso K. Corona C. Del Regno A. S. Panni Department of Health Science, Molise University, Via De Sanctis 1, 86100 Campobasso, Italy e-mail: [email protected]
or satisfied with their result. However, slight deterioration of the outcomes over time was observed. Conclusion At the final follow-up, the outcomes of allarthroscopic technique were significantly improved from preoperative values; however, they were slightly inferior at the 72 months follow-up. This slight deterioration of the outcomes may be the consequence of the reduction in physical activities. Level of evidence Case series, Level IV. Keywords Medial capsule reefing Arthroscopy Patellar instability Medial retinaculum Rehabilitation
Introduction The efficacy of medial structures repair in the treatment of patellar instability was demonstrated by Insall in the last century [8]. Anatomic and biomechanics studies have demonstrated the role of medial structures in preventing lateral patellar displacement [1, 13, 15]. The medial patello-femoral ligament (MPFL) contributes to more than 50 % of the restraint, while the medial patello-meniscal ligament (MPML), the medial patello-tibial ligament (MPTL) and the medial retinaculum (MR) contribute to 24, 13 and 13 %, respectively [13]. These passive stabilizers play even more important role in case of patella alta or trochlear dysplasia. For these reasons, it seems reasonable to repair these structures once they are damaged. However, under the term of patellar instability, several spectrums of pathologies are usually included. According to the classification by H. Dejour, three major situations can be identified [4]. The painful patellar syndrome and the potential patellar instability have a common aspect: patients may refer
123
Knee Surg Sports Traumatol Arthrosc
history of anterior knee pain, subjective instability or popping with no evidence of previous patellar dislocation. In addition, patients with potential patellar instability may have one or more of the anatomic predisposing factors for dislocation (patella alta, trochlear dysplasia, increased tibial tuberosity–trochlear groove distance and increased patellar tilt). Anatomic risk factors for dislocation are present in patients with potential patellar instability. On the other hand, patients with objective patellar instability have both anatomic risk factors and previous episodes of patellar dislocation. This difference is crucial because one or more episodes of dislocations lead to severe damages of medial structures. Anatomic studies have demonstrated the incidence of MPFL rupture rate after first dislocation is up to 94 % and it increases in case of recurrence [1]. Conservative treatment (stretching exercises and vastus medialis obliquus strengthening) can be proposed after these episodes. Unfortunately, there is a recurrence rate of re-dislocations and chronic retropatellar pain following conservative treatment varying from 26 to 70 % [3, 7, 18, 19]. Young and active subjects seem more prone to recurrence while there is no evidence of factor that predisposes to develop chronic symptoms. Once surgery is proposed, it must address the laxity of the medial capsule in case of patellar subluxation or the rupture of the MPFL after patellar dislocation. Medial capsule reefing has been proposed in the treatment of patellar instability. However, in most series, it is associated with lateral retinacular release or tibial tuberosity transfer. Moreover, in all series with the exception of the one by Ma et al. [11], the indication for surgery is both patellar subluxation and dislocation. This is the first study to report the outcomes of an ‘‘all-arthroscopic’’ technique for medial capsule reefing in a homogenous group of patients with painful patellar syndrome and potential patellar instability.
Materials and methods From 2001 to 2007, 30 surgical procedures of medial capsule reefing were performed in 30 patients with painful patellar syndrome and potential patellar instability. Inclusion criteria were a history of anterior knee pain or sensation of instability or popping at the anterior aspect of the knee. Patients had normal anatomic risk factors for patellar dislocation [4]. All patients had to undergo a minimum of 6 months of intensive rehabilitation before surgery and had not to be operated on the index knee. Eleven patients were male, and 19 were female. Right side was involved in 17 cases. Mean age at the time of surgery was 26.6 ± 9.3 years. All patients were evaluated with physical examination and with complete imaging study (weight bearing AP and lateral views of the injured knee and
123
bilateral skyline views at 30° of flexion) [2]. Computer tomography (CT) scan was performed to assess the TT-TG distance and patellar tilt. Preoperative and postoperative patellar tilt was calculated as the angle between the tangent to the posterior femoral condyles and the major patellar axis. The clinical and functional evaluations were carried out using the Kujala score [9], Fulkerson score [5], Larsen score [10] and the modified Lysholm score [20]. Moreover, subjective evaluation was carried out answering the following question: are you very satisfied, satisfied or no satisfied with your functional result? Surgical technique The procedure is performed under loco-regional anaesthesia. With the patient under anaesthesia, accurate knee exam is performed: passive ROM, patellar tilt and medial/lateral patellar glide are recorded. Surgical procedure is then performed with the tourniquet inflated. First arthroscopic look is always performed. Patellar tracking is evaluated with repeated flexion–extension movements. The presence of chondral damages is investigated and addressed. The deep surface of the MR is inspected to confirm the absence of gross anatomic lesions. A gentle shaving of the deep surface is performed to enhance the healing process of the MR. Medial sutures are passed percutaneously through a spinal needle. First of all, the most distal needle is positioned at the distal third of the patella just adjacent to the patella. A No. 1 PDS suture is passed trough the needle and then is retrieved from a more posterior access. Two more sutures are then passed more proximally at 1.5 cm distance from each other (Fig. 1). The more tissue is included in the loop the greater is the re-centring effect of this reefing (Fig. 2). The two edges of each suture are finally retrieved from the posterior access, and the knot is tied at 60°–70° of flexion under arthroscopic control to avoid hypercorrection. Additional lateral release is never performed because it increases patellar hypermobility. The tourniquet is deflated, and washout is performed. No skin suture is
Fig. 1 Three vertical stitches allow achieving a good correction of the patellar tilt and subluxation. The distance between the stitches is usually 1.5 cm
Knee Surg Sports Traumatol Arthrosc
Fig. 2 The wider is the tissue included in each stich, the greater is the re-centring effect of the reefing
performed. Postoperative treatment consists in elastic compressive casting in extension for 3 weeks, immediate passive motion from 0°–50° and complete weight bearing after 4 weeks. At the end of this period, quadriceps and vastus medialis obliquus strengthening was encouraged. No perioperative or postoperative complications were recorded. Intermediate follow-up was performed at 72 months, while final follow-up was scheduled at 120 months. All the methods described in this article were approved by the local ethics committee (Health Director of the San Luca Clinic in Rome), and all patients gave informed consent to be included in the study. Statistical analysis Statistical analysis was performed using the Wilcoxon signed-rank test: XLSTAT 2009 (v. 3.01, AddinsoftTM software) setting the alpha value at 0.05. Comparison was performed between preoperative values of Kujala, Larsen, Lysholm and Fulkerson scores and postoperative corresponding values at 72 and 120 months.
12° ± 3.8° preoperatively to 9° ± 2.7° postoperatively. Additional clinical examination was carried out at 120 months (80–150 months); however, 2 patients were not available for this evaluation. All parameters had a slight decrease in their values. Average Kujala was 87.7 ± 8.8 (p \ 0.0001), average Larsen was 16.8 ± 2.7 (p \ 0.01), average Lysholm was 87.6 ± 14.3 (p \ 0.0001), and average Fulkerson was 87.2 ± 13.9 (p \ 0.0001). Seventeen patients out of 28 (60.7 %) were very satisfied with their functional result, 7 (25 %) were satisfied, while 4 patients (14.3 %) were not satisfied with their result. Moreover, 13 patients referred slight discomfort to mild pain in daily activities such as kneeling and climbing or descending stairs. Functional results are summarized in Table 1, while subjective results are reported in Table 2. This last follow-up examination was exclusively clinical, and no radiograph evaluation was performed.
Discussion The findings of the present study confirm the efficacy of this technique even at longer follow-up (120 months) in a homogenous population of non-dislocator patients. However, the superiority of this option over conservative treatment has criticized by Sillanpa¨a¨ et al. [17]. He compared the results of acute arthroscopic MR repair with conservative treatment after acute patellar dislocation. Twenty-six patients in group I and 35 of group II were prospectively evaluated at an average follow-up of 7.5 years. At final follow-up, Kujala score was 87 in group I and 90 in group II, while 81 and 56 % of patients Table 1 Functional results at intermediate (30 patients) and last FU (28 patients) Preop
Intermediate follow-up (72 months)
Results At intermediate follow-up of 72 months (44–114 months), 30 patients were reviewed for both clinical and imaging examinations by an independent observer. Average Kujala score improved from 72.9 ± 15.0 to 88.4 ± 7.6 (p \ 0.0001), average Larsen score from 15.0 ± 2.5 to 17.2 ± 2.2 (p \ 0.002), average Lysholm from 63.8 ± 16.7 to 87.9 ± 11.7 (p \ 0.0001) and average Fulkerson score from 69.5 ± 21.5 to 90.8 ± 9.8 (p \ 0.0001). No intraoperative or postoperative complications were recorded. Eighteen patients (60 %) were very satisfied with their functional result, 9 (30 %) were satisfied, while 3 patients (10 %) were not satisfied with their result. No differences in patellar height were seen comparing the preoperative and postoperative radiographs. Patellar tilt decreased from
Last follow-up (120 months)
Kujala score
72.9 ± 15.0
88.4 ± 7.6
87.7 ± 8.8
Larsen score
15.0 ± 2.5
17.2 ± 2.2
16.8 ± 2.7
Lysholm score
63.8 ± 16.7
87.9 ± 11.7
87.6 ± 14.3
Fulkerson score
69.5 ± 21.5
90.8 ± 9.8
87.2 ± 13.9
Table 2 Subjective results at intermediate (30 patients) and last FU (28 patients)
Very satisfied
Intermediate FU (72 months)
Last FU (120 months)
60 % (18)
60.7 % (17)
Satisfied
30 % (9)
25 % (7)
Not satisfied
10 % (3)
14.3 % (4)
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Knee Surg Sports Traumatol Arthrosc
regained their preinjury activity level, respectively. Redislocation and subluxation rates were 19 and 12 % in group I, and 23 and 23 % in group II, respectively. Despite these good outcomes, Sillanpa¨a¨ et al. concluded that medial retinacular repair was not followed by improved patellar stability nor reduced incidence of re-dislocations compared with non-operative treatment. Once this option has been chosen, some confusion still exists on the clinical indications for this type of surgery. The majority of the clinical studies are focused on patellar subluxation and dislocation. This is a crucial aspect, since anatomic investigations have clearly demonstrated an extremely high incidence of MPFL rupture after first patellar dislocation [1]. In the same way, the predominant role as principal passive stabilizer of this ligament has been clearly demonstrated in biomechanical studies [13]. According to these evidences, it seems reasonable to address this anatomic damage with a reconstruction of the MPFL. This concept has been demonstrated by Zhao et al. [22]. In a prospective study, he compared the results of arthroscopic MR plication and lateral release with those of medial patella-femoral ligament reconstruction in 88 adults with recurrent patellar instability. Tibial tubercle transfer was performed if indicated. At the 24-month follow-up, group I had an average IKDC score of 61.2, Lysholm score of 69.3, Kujala score of 73.8 and Tegner score of 4.0. Concerning group II, mean IKDC score was 79.4, Lysholm score was 86.9, Kujala score was 87.4, and Tegner score was 5.7. Concerning group I, 9.3 % of patients had episodes of re-dislocation and 16.3 % had multiple episodes of patellar instability, compared with 2.2 and 6.7 % of patients of group II, respectively [22]. He concluded that MPFL reconstruction achieved better static patellar position and functional outcomes than MR plication in the treatment of recurrent patellar dislocation in adults. Despite the conclusions of this interesting study, most of the papers in literature do not clearly differentiate the outcomes according to the indications. Some authors propose this surgery in case of subluxation [11], acute [6] and recurrent dislocation [21]. Our functional and subjective results are encouraging and in accordance with those of the literature [11, 16, 17, 22]. The indication was precise and homogeneous, with all patients having been conservatively treated for at least 6 months for a painful patella syndrome. To our knowledge, the present study is the first one to report the outcomes of an all-arthroscopic technique in patients with such precise and strict indication. In fact, Ma et al. performed a retrospective study on 78 cases of patellar subluxation. Forty patients were treated with medial capsule reefing (group I), while 38 had medial patellar retinaculum plasty (group 2). However, in both groups, almost one-third of patients had additional lateral release. At an average follow-up of 60 months, Kujala
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score improved significantly from 78.3 to 88.3 in group I and from 77.8 to 91.2 in Group I. Moreover, 32 patients of group I had either excellent or good results, while 38 cases had the same result in group II. He concluded that MR plasty was better than medial capsule reefing in improving the subjective effects and decreasing the patellar subluxation rate. The follow-up of the present study is long enough to allow some conclusions. The outcomes are stable along with time; however, a slight trend toward a decrease in the outcomes was observed at longer follow-up. This is less evident than what has been previously published concerning lateral retinacular release. Panni et al. [14] reported less favourable results in long-term follow-up evaluation in patients with patellar instability. The presence of highgrade joint surface injury is a poor prognostic indicator for lateral release. Even if risk factors are normal like it was in our series of patient, the pathogenesis of anterior knee pain and patellar hypermobility is multifactorial. The positive outcomes at medium-term follow-up may be the combined result of surgery (addressing the laxity of MR) and postoperative muscle strengthening. The importance of postoperative protocol has been in all series concerning medial reefing outcomes. Micheli demonstrated a strict correlation between trophism of the quadriceps and knee flexors and the quality of the results obtained after lateral retinacular release [12]. At longer follow-up, the relative contribute of muscle strengthening may have less relevance. This study has several strengths: the long-term follow-up, the homogeneous population, which has been enrolled following strict and precise indications, and the precise technique, which has been adopted in all cases. This operation is an all-arthroscopic procedure, which is minimally invasive, has low impact and morbidity and is easily reproducible. However, the study has some limitations. First, the number of subjects recruited is limited in consequence of the strict inclusion criteria. Finally, no radiograph evaluation was performed at the last follow-up.
Conclusion The outcomes of MR reefing are generally very satisfying in literature. However, the available literature compares different study populations, different techniques using different evaluation tools. In our series, the indications were strict and precise excluding patient with previous dislocations. This made our series extremely homogeneous. The arthroscopic procedure was always performed isolated. All patients attended the same rehabilitation protocol. At an intermediate follow-up of 72 months, functional results were significantly improved from preoperative values and 90 % of patients were very satisfied with their functional result. At a final follow-up 120 months after surgery, the
Knee Surg Sports Traumatol Arthrosc
outcomes were still very positive; however, a slight deterioration was observed.
References 1. Arendt EA, Fithian DC, Cohen E (2002) Current concepts of lateral patella dislocation. Clin Sports Med 21(3):499–519 2. Beaconsfield T, Pintore E, Maffulli N, Petri GJ (1994) Radiological measurements in patellofemoral disorders: a review. Clin Orthop Relat Res 308:18–28 3. Buchner M, Baudendistel B, Sabo D, Schmitt H (2005) Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment. Clin J Sport Med 15(2):62–66 4. Dejour H (1995) Instabilite´ et souffrance rotulienne 8e journe´es Lyonnaises du genou 49–52 5. Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA (1990) Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med 18:490–497 6. Haspl M, Cicak N, Klobucar H, Pecina M (2002) Fully arthroscopic stabilization of the patella. Arthroscopy 18(1):E2 7. Hing CB, Smith TO, Donell S, Song F (2011) Surgical versus nonsurgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 11:CD008106 8. Insall JN, Aglietti P, Tria AJ Jr (1983) Patellar pain and incongruence. II: clinical application. Clin Orthop Relat Res 176:225–232 9. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9(2):159–163 10. Larsen E, Lauridsen F (1992) Conservative treatment of patellar dislocations: influence of evident factors on the tendency to redislocation and therapeutic result. Clin Orthop Relat Res 171:131–136 11. Ma LF, Wang F, Chen BC, Wang CH, Zhou JW, Ji G, Dong JT (2012) Medial patellar retinaculum plasty versus medial capsule reefing for patellar subluxation in adult. Orthop Surg 4(2):83–88
12. Micheli LJ, Stanitsky CL (1981) Lateral retinacular release. Am J Sports Med 9:330 13. Panagiotopoulos E, Strzelczyk P, Herrmann M, Scuderi G (2006) Cadaveric study on static medial patellar stabilizers: the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 14(1):7–12 14. Panni AS, Tartarone M, Patricola A, Paxton EW, Fithian DC (2005) Long term results of lateral retinacular release. Arthroscopy 21(5):526–531 15. Senavongse W, Farahmand F, Jones J, Andersen H, Bull AM, Amis AA (2003) Quantitative measurement of patellofemoral joint stability: force-displacement behaviour of the human patella in vitro. J Orthop Res 21(5):780–786 16. Shelbourne KD, Urch SE, Gray T (2012) Results of medial retinacular imbrication in patients with unilateral patellar dislocation. J Knee Surg 25(5):391–396 17. Sillanpa¨a¨ PJ, Ma¨enpa¨a¨ HM, Mattila VM, Visuri T, Pihlajama¨ki H (2008) Arthroscopic surgery for primary traumatic patellar dislocation: a prospective, nonrandomized study comparing patients treated with and without acute arthroscopic stabilization with a median 7-year follow-up. Am J Sports Med 36(12):2301–2309 18. Smith TO, Song F, Donell ST, Hing CB (2011) Operative versus nonoperative management of patellar dislocation. A meta-analysis. Knee Surg Sports Traumatol Arthrosc 19:988–998 19. Stefancin JJ, Parker RD (2007) First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat Res 455:93–101 20. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49 21. Zhao J, Huangfu X, He Y, Liu W (2012) Recurrent patellar dislocation in adolescents: medial retinaculum plication versus vastus medialis plasty. Am J Sports Med 40(1):123–132 22. Zhao J, Huangfu X, He Y (2012) The role of medial retinaculum plication versus medial patellofemoral ligament reconstruction in combined procedures for recurrent patellar instability in adults. Am J Sports Med 40(6):1355–1364
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KNEE
Medial capsule reefing in patellar instability Simone Cerciello • Michele Vasso • Katia Corona Chiara Del Regno • Alfredo Schiavone Panni
•
Received: 3 December 2013 / Accepted: 19 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The efficacy of medial capsule reefing in the treatment of patellar instability is well documented. Aim of the present study was to prospectively evaluate the outcomes of an all-arthroscopic medial capsule reefing technique in young patients with painful patella syndrome and potential patellar instability. Methods Thirty patients with painful patellar syndrome and potential patellar instability having undergone a minimum of 6 months of intensive rehabilitation were enrolled in the present study. All subjects were evaluated with physical examination, clinical and functional outcomes and complete imaging study. Results All patients were reviewed at an intermediate follow-up of 72 months. Average Kujala score improved from 72.9 ± 15.0 to 88.4 ± 7.6 (p \ 0.0001), average Larsen score from 15.0 ± 2.5 to 17.2 ± 2.2 (p \ 0.002), average Lysholm from 63.8 ± 16.7 to 87.9 ± 11.7 (p \ 0.0001) and average Fulkerson score from 69.5 ± 21.5 to 90.8 ± 9.8 (p \ 0.0001). No intraoperative or postoperative complications were recorded. Ninety per cent of patients were very satisfied or satisfied with their functional result. Twenty-eight patients were reviewed at the final follow-up, 120 months after surgery. Average Kujala was 87.7 ± 8.8 (p \ 0.0001), average Larsen was 16.8 ± 2.7 (p \ 0.01), average Lysholm was 87.6 ± 14.3 (p \ 0.0001), and average Fulkerson was 87.2 ± 13.9 (p \ 0.0001). Almost 86 % of patients were very satisfied
S. Cerciello (&) M. Vasso K. Corona C. Del Regno A. S. Panni Department of Health Science, Molise University, Via De Sanctis 1, 86100 Campobasso, Italy e-mail: [email protected]
or satisfied with their result. However, slight deterioration of the outcomes over time was observed. Conclusion At the final follow-up, the outcomes of allarthroscopic technique were significantly improved from preoperative values; however, they were slightly inferior at the 72 months follow-up. This slight deterioration of the outcomes may be the consequence of the reduction in physical activities. Level of evidence Case series, Level IV. Keywords Medial capsule reefing Arthroscopy Patellar instability Medial retinaculum Rehabilitation
Introduction The efficacy of medial structures repair in the treatment of patellar instability was demonstrated by Insall in the last century [8]. Anatomic and biomechanics studies have demonstrated the role of medial structures in preventing lateral patellar displacement [1, 13, 15]. The medial patello-femoral ligament (MPFL) contributes to more than 50 % of the restraint, while the medial patello-meniscal ligament (MPML), the medial patello-tibial ligament (MPTL) and the medial retinaculum (MR) contribute to 24, 13 and 13 %, respectively [13]. These passive stabilizers play even more important role in case of patella alta or trochlear dysplasia. For these reasons, it seems reasonable to repair these structures once they are damaged. However, under the term of patellar instability, several spectrums of pathologies are usually included. According to the classification by H. Dejour, three major situations can be identified [4]. The painful patellar syndrome and the potential patellar instability have a common aspect: patients may refer
123
Knee Surg Sports Traumatol Arthrosc
history of anterior knee pain, subjective instability or popping with no evidence of previous patellar dislocation. In addition, patients with potential patellar instability may have one or more of the anatomic predisposing factors for dislocation (patella alta, trochlear dysplasia, increased tibial tuberosity–trochlear groove distance and increased patellar tilt). Anatomic risk factors for dislocation are present in patients with potential patellar instability. On the other hand, patients with objective patellar instability have both anatomic risk factors and previous episodes of patellar dislocation. This difference is crucial because one or more episodes of dislocations lead to severe damages of medial structures. Anatomic studies have demonstrated the incidence of MPFL rupture rate after first dislocation is up to 94 % and it increases in case of recurrence [1]. Conservative treatment (stretching exercises and vastus medialis obliquus strengthening) can be proposed after these episodes. Unfortunately, there is a recurrence rate of re-dislocations and chronic retropatellar pain following conservative treatment varying from 26 to 70 % [3, 7, 18, 19]. Young and active subjects seem more prone to recurrence while there is no evidence of factor that predisposes to develop chronic symptoms. Once surgery is proposed, it must address the laxity of the medial capsule in case of patellar subluxation or the rupture of the MPFL after patellar dislocation. Medial capsule reefing has been proposed in the treatment of patellar instability. However, in most series, it is associated with lateral retinacular release or tibial tuberosity transfer. Moreover, in all series with the exception of the one by Ma et al. [11], the indication for surgery is both patellar subluxation and dislocation. This is the first study to report the outcomes of an ‘‘all-arthroscopic’’ technique for medial capsule reefing in a homogenous group of patients with painful patellar syndrome and potential patellar instability.
Materials and methods From 2001 to 2007, 30 surgical procedures of medial capsule reefing were performed in 30 patients with painful patellar syndrome and potential patellar instability. Inclusion criteria were a history of anterior knee pain or sensation of instability or popping at the anterior aspect of the knee. Patients had normal anatomic risk factors for patellar dislocation [4]. All patients had to undergo a minimum of 6 months of intensive rehabilitation before surgery and had not to be operated on the index knee. Eleven patients were male, and 19 were female. Right side was involved in 17 cases. Mean age at the time of surgery was 26.6 ± 9.3 years. All patients were evaluated with physical examination and with complete imaging study (weight bearing AP and lateral views of the injured knee and
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bilateral skyline views at 30° of flexion) [2]. Computer tomography (CT) scan was performed to assess the TT-TG distance and patellar tilt. Preoperative and postoperative patellar tilt was calculated as the angle between the tangent to the posterior femoral condyles and the major patellar axis. The clinical and functional evaluations were carried out using the Kujala score [9], Fulkerson score [5], Larsen score [10] and the modified Lysholm score [20]. Moreover, subjective evaluation was carried out answering the following question: are you very satisfied, satisfied or no satisfied with your functional result? Surgical technique The procedure is performed under loco-regional anaesthesia. With the patient under anaesthesia, accurate knee exam is performed: passive ROM, patellar tilt and medial/lateral patellar glide are recorded. Surgical procedure is then performed with the tourniquet inflated. First arthroscopic look is always performed. Patellar tracking is evaluated with repeated flexion–extension movements. The presence of chondral damages is investigated and addressed. The deep surface of the MR is inspected to confirm the absence of gross anatomic lesions. A gentle shaving of the deep surface is performed to enhance the healing process of the MR. Medial sutures are passed percutaneously through a spinal needle. First of all, the most distal needle is positioned at the distal third of the patella just adjacent to the patella. A No. 1 PDS suture is passed trough the needle and then is retrieved from a more posterior access. Two more sutures are then passed more proximally at 1.5 cm distance from each other (Fig. 1). The more tissue is included in the loop the greater is the re-centring effect of this reefing (Fig. 2). The two edges of each suture are finally retrieved from the posterior access, and the knot is tied at 60°–70° of flexion under arthroscopic control to avoid hypercorrection. Additional lateral release is never performed because it increases patellar hypermobility. The tourniquet is deflated, and washout is performed. No skin suture is
Fig. 1 Three vertical stitches allow achieving a good correction of the patellar tilt and subluxation. The distance between the stitches is usually 1.5 cm
Knee Surg Sports Traumatol Arthrosc
Fig. 2 The wider is the tissue included in each stich, the greater is the re-centring effect of the reefing
performed. Postoperative treatment consists in elastic compressive casting in extension for 3 weeks, immediate passive motion from 0°–50° and complete weight bearing after 4 weeks. At the end of this period, quadriceps and vastus medialis obliquus strengthening was encouraged. No perioperative or postoperative complications were recorded. Intermediate follow-up was performed at 72 months, while final follow-up was scheduled at 120 months. All the methods described in this article were approved by the local ethics committee (Health Director of the San Luca Clinic in Rome), and all patients gave informed consent to be included in the study. Statistical analysis Statistical analysis was performed using the Wilcoxon signed-rank test: XLSTAT 2009 (v. 3.01, AddinsoftTM software) setting the alpha value at 0.05. Comparison was performed between preoperative values of Kujala, Larsen, Lysholm and Fulkerson scores and postoperative corresponding values at 72 and 120 months.
12° ± 3.8° preoperatively to 9° ± 2.7° postoperatively. Additional clinical examination was carried out at 120 months (80–150 months); however, 2 patients were not available for this evaluation. All parameters had a slight decrease in their values. Average Kujala was 87.7 ± 8.8 (p \ 0.0001), average Larsen was 16.8 ± 2.7 (p \ 0.01), average Lysholm was 87.6 ± 14.3 (p \ 0.0001), and average Fulkerson was 87.2 ± 13.9 (p \ 0.0001). Seventeen patients out of 28 (60.7 %) were very satisfied with their functional result, 7 (25 %) were satisfied, while 4 patients (14.3 %) were not satisfied with their result. Moreover, 13 patients referred slight discomfort to mild pain in daily activities such as kneeling and climbing or descending stairs. Functional results are summarized in Table 1, while subjective results are reported in Table 2. This last follow-up examination was exclusively clinical, and no radiograph evaluation was performed.
Discussion The findings of the present study confirm the efficacy of this technique even at longer follow-up (120 months) in a homogenous population of non-dislocator patients. However, the superiority of this option over conservative treatment has criticized by Sillanpa¨a¨ et al. [17]. He compared the results of acute arthroscopic MR repair with conservative treatment after acute patellar dislocation. Twenty-six patients in group I and 35 of group II were prospectively evaluated at an average follow-up of 7.5 years. At final follow-up, Kujala score was 87 in group I and 90 in group II, while 81 and 56 % of patients Table 1 Functional results at intermediate (30 patients) and last FU (28 patients) Preop
Intermediate follow-up (72 months)
Results At intermediate follow-up of 72 months (44–114 months), 30 patients were reviewed for both clinical and imaging examinations by an independent observer. Average Kujala score improved from 72.9 ± 15.0 to 88.4 ± 7.6 (p \ 0.0001), average Larsen score from 15.0 ± 2.5 to 17.2 ± 2.2 (p \ 0.002), average Lysholm from 63.8 ± 16.7 to 87.9 ± 11.7 (p \ 0.0001) and average Fulkerson score from 69.5 ± 21.5 to 90.8 ± 9.8 (p \ 0.0001). No intraoperative or postoperative complications were recorded. Eighteen patients (60 %) were very satisfied with their functional result, 9 (30 %) were satisfied, while 3 patients (10 %) were not satisfied with their result. No differences in patellar height were seen comparing the preoperative and postoperative radiographs. Patellar tilt decreased from
Last follow-up (120 months)
Kujala score
72.9 ± 15.0
88.4 ± 7.6
87.7 ± 8.8
Larsen score
15.0 ± 2.5
17.2 ± 2.2
16.8 ± 2.7
Lysholm score
63.8 ± 16.7
87.9 ± 11.7
87.6 ± 14.3
Fulkerson score
69.5 ± 21.5
90.8 ± 9.8
87.2 ± 13.9
Table 2 Subjective results at intermediate (30 patients) and last FU (28 patients)
Very satisfied
Intermediate FU (72 months)
Last FU (120 months)
60 % (18)
60.7 % (17)
Satisfied
30 % (9)
25 % (7)
Not satisfied
10 % (3)
14.3 % (4)
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regained their preinjury activity level, respectively. Redislocation and subluxation rates were 19 and 12 % in group I, and 23 and 23 % in group II, respectively. Despite these good outcomes, Sillanpa¨a¨ et al. concluded that medial retinacular repair was not followed by improved patellar stability nor reduced incidence of re-dislocations compared with non-operative treatment. Once this option has been chosen, some confusion still exists on the clinical indications for this type of surgery. The majority of the clinical studies are focused on patellar subluxation and dislocation. This is a crucial aspect, since anatomic investigations have clearly demonstrated an extremely high incidence of MPFL rupture after first patellar dislocation [1]. In the same way, the predominant role as principal passive stabilizer of this ligament has been clearly demonstrated in biomechanical studies [13]. According to these evidences, it seems reasonable to address this anatomic damage with a reconstruction of the MPFL. This concept has been demonstrated by Zhao et al. [22]. In a prospective study, he compared the results of arthroscopic MR plication and lateral release with those of medial patella-femoral ligament reconstruction in 88 adults with recurrent patellar instability. Tibial tubercle transfer was performed if indicated. At the 24-month follow-up, group I had an average IKDC score of 61.2, Lysholm score of 69.3, Kujala score of 73.8 and Tegner score of 4.0. Concerning group II, mean IKDC score was 79.4, Lysholm score was 86.9, Kujala score was 87.4, and Tegner score was 5.7. Concerning group I, 9.3 % of patients had episodes of re-dislocation and 16.3 % had multiple episodes of patellar instability, compared with 2.2 and 6.7 % of patients of group II, respectively [22]. He concluded that MPFL reconstruction achieved better static patellar position and functional outcomes than MR plication in the treatment of recurrent patellar dislocation in adults. Despite the conclusions of this interesting study, most of the papers in literature do not clearly differentiate the outcomes according to the indications. Some authors propose this surgery in case of subluxation [11], acute [6] and recurrent dislocation [21]. Our functional and subjective results are encouraging and in accordance with those of the literature [11, 16, 17, 22]. The indication was precise and homogeneous, with all patients having been conservatively treated for at least 6 months for a painful patella syndrome. To our knowledge, the present study is the first one to report the outcomes of an all-arthroscopic technique in patients with such precise and strict indication. In fact, Ma et al. performed a retrospective study on 78 cases of patellar subluxation. Forty patients were treated with medial capsule reefing (group I), while 38 had medial patellar retinaculum plasty (group 2). However, in both groups, almost one-third of patients had additional lateral release. At an average follow-up of 60 months, Kujala
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score improved significantly from 78.3 to 88.3 in group I and from 77.8 to 91.2 in Group I. Moreover, 32 patients of group I had either excellent or good results, while 38 cases had the same result in group II. He concluded that MR plasty was better than medial capsule reefing in improving the subjective effects and decreasing the patellar subluxation rate. The follow-up of the present study is long enough to allow some conclusions. The outcomes are stable along with time; however, a slight trend toward a decrease in the outcomes was observed at longer follow-up. This is less evident than what has been previously published concerning lateral retinacular release. Panni et al. [14] reported less favourable results in long-term follow-up evaluation in patients with patellar instability. The presence of highgrade joint surface injury is a poor prognostic indicator for lateral release. Even if risk factors are normal like it was in our series of patient, the pathogenesis of anterior knee pain and patellar hypermobility is multifactorial. The positive outcomes at medium-term follow-up may be the combined result of surgery (addressing the laxity of MR) and postoperative muscle strengthening. The importance of postoperative protocol has been in all series concerning medial reefing outcomes. Micheli demonstrated a strict correlation between trophism of the quadriceps and knee flexors and the quality of the results obtained after lateral retinacular release [12]. At longer follow-up, the relative contribute of muscle strengthening may have less relevance. This study has several strengths: the long-term follow-up, the homogeneous population, which has been enrolled following strict and precise indications, and the precise technique, which has been adopted in all cases. This operation is an all-arthroscopic procedure, which is minimally invasive, has low impact and morbidity and is easily reproducible. However, the study has some limitations. First, the number of subjects recruited is limited in consequence of the strict inclusion criteria. Finally, no radiograph evaluation was performed at the last follow-up.
Conclusion The outcomes of MR reefing are generally very satisfying in literature. However, the available literature compares different study populations, different techniques using different evaluation tools. In our series, the indications were strict and precise excluding patient with previous dislocations. This made our series extremely homogeneous. The arthroscopic procedure was always performed isolated. All patients attended the same rehabilitation protocol. At an intermediate follow-up of 72 months, functional results were significantly improved from preoperative values and 90 % of patients were very satisfied with their functional result. At a final follow-up 120 months after surgery, the
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outcomes were still very positive; however, a slight deterioration was observed.
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