Knee Surg Sports Traumatol Arthrosc (2014) 22:2505–2512 DOI 10.1007/s00167-014-3171-6

KNEE

Medial retinaculum reefing for the treatment for patellar instability Simone Cerciello · Sebastien Lustig · Giuseppe Costanzo · Philippe Neyret 

Received: 27 January 2014 / Accepted: 3 July 2014 / Published online: 25 July 2014 © Springer-Verlag Berlin Heidelberg 2014

Abstract  Purpose  Medial structures repair is a well-established approach in the treatment for patellar instability. However, the literature is confusing concerning the indications for surgery, the different surgical techniques and outcomes. The goal of this systematic review was to clarify the indications for medial structures repair and to analyse the results of both arthroscopic and open techniques. Methods  A comprehensive literature review was performed using the keywords ‘patellar instability’, ‘medial capsule reefing’ and ‘medial capsule plication’ with no limit regarding the year of publication. All the selected articles in Anglo-Saxon language were evaluated with the Coleman methodology score. Results  Seventeen full-text articles were evaluated. Initial cohort included 617 patients. About 569 patients were reviewed at an average FU of 54.6 months (range 2–165 months) after medial structures repair. Average age at the time of surgery was 21.2 years (range 9–65 years). The indications for surgery included both patellar subluxation and dislocation (acute or chronic). Average Kujala score increased from 55 to 84 at the last FU, and in the same way average Lysholm score increased from 41.2 to 80.5, whereas average Tegner score increased from 3 to 5.3 and IKDC score from 47.8 to 75.1. Re-dislocation rate among the series was 6.1 %. Average Coleman methodology score was 61.6 (range 17–92). S. Cerciello (*) · S. Lustig · P. Neyret  Albert Trillat Center, Lyon North University Hospital, 103 Grande Rue de la Croix‑Rousse, 69004 Lyon, France e-mail: [email protected] G. Costanzo  Università La Sapienza-Polo Pontino, Corso della Repubblica 79, 04100 Latina, Italy

Conclusion  From this review, it emerges that medial capsule reefing is a reliable option in the treatment for patellar instability. It can be proposed with good expectations, since the outcomes are positive and stable even at longer FU and complications rates are low. Re-dislocation rate is variable and can occur in up to one-third of patients. However, most of the available studies are case series, and comparison of the series is hard since they widely differ in inclusion criteria and indications, surgical technique and additional procedures, and outcome measures. Keywords  Patellar instability · Medial capsule reefing · Medial capsule plication · Re-dislocation · Arthroscopy

Introduction Patello-femoral instability occurs commonly in young and active patients. A spectrum of clinical entities can be identified according to the classification of Dejour [3]: objective patellar instability, potential patellar instability (PPI) and the painful patellar syndrome (PPS). Painful patellar syndrome is defined by the presence of an anterior knee pain, subjective instability without evidence of patellar dislocation and no major anatomical anomalies being identifiable in the patello-femoral joint. Episodic patellar instability (EPI) is defined by one or more confirmed patellar dislocations and the presence of anatomical anomalies of the patello-femoral joint. These anatomical abnormalities include trochlear dysplasia, patella alta, excessive tibial tuberosity–trochlear groove distance (TT– TG), and vastus medialis obliquus (VMO) dysplasia and are considered to be the main predisposing factors in EPI. Patients with PPI claim symptoms of the painful patellar syndrome group, have one or more of the anatomical

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anomalies, but have not yet experienced a confirmed patella dislocation. There is, however, the potential for them to develop EPI. In patients with patello-femoral instability, generally non-operative treatment should be proposed first and surgery is indicated when non-operative measures fail. Surgical options are aimed at addressing the anatomical pathology of the patello-femoral joint. These include trochleoplasty, distal bony realignment of the tibial tuberosity, and medial soft-tissue realignments and reconstructions. Insall was one of the first surgeons to describe medial proximal realignment with positive outcomes [10]. Recently, several authors have proposed arthroscopic or mini-open techniques for medial capsule plications or reefing. Despite over one hundred different surgical techniques for patello-femoral instability being described in the literature [5], the treatment of choice remains controversial, especially in regard to medial soft-tissue procedures. Although randomised controlled trials (RCTs) are the most reliable source for evaluating the efficacy of different therapeutic interventions, most of the existing studies on surgical management of patellar instability with medial structures reefing are level III or level IV studies. To our knowledge, the present systematic review is the first addressing medial soft-tissue surgery in patients treated for patello-femoral instability. The outcomes of the present study may be helpful providing some guidelines for its use.

Knee Surg Sports Traumatol Arthrosc (2014) 22:2505–2512

the publications in the literature, there were no set limitations on the type of study, follow-up duration and the number of patients enrolled. The selected papers were then evaluated according to the Coleman methodology score (CMS) [2]. This scoring system was initially introduced to assess the methodology of study on tendinopathy and consists of 10 criteria. Part A is divided into 7 subsections with a total score of 60, whereas part B is divided into 3 subsections with 42 a total score of 40. Although no cut-off for the definition of high- or lowquality studies has been previously set, a total score greater than 65 is usually accepted as the inferior limit for a highquality study.

Results An initial electronic search using the specified search terms returned 75 publications. Of these, 22 relevant full-text articles were identified. Four of these publications included articles on surgical technique [4, 6, 9, 25], and one publication was considered not to be entirely relevant [19] after further review. This left 17 publications to be included for final analysis. Nine studies were retrospective while eight were prospective. Demographic data are summarised in Table 1. The initial cohort included 617 patients. About 569 patients were reviewed at an average follow-up of 54.6 months (range 2–165 months) after medial softtissue surgery. The average age at the time of surgery was 21.2 years (range 9–65 years).

Materials and methods A comprehensive literature search using the keywords ‘patellar instability’, ‘medial capsule reefing’ and ‘medial capsule plication’ with no limit regarding the year of publication was performed. The term ‘reconstruction’ was not utilised to exclude all the literature concerning the reconstruction of the medial patello-femoral ligament (MPFL). The following databases were accessed on 9 September 2013: PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez/), Ovid (http://www.ovid.com), Cochrane Reviews (http:// www.cochrane.org/reviews/) and Google Scholar. Seventyfive publications were identified electronically. One author (SC) reviewed the abstract of each publication. In addition, the publication reference lists were searched manually to include articles not identified in the electronic search. Inclusion criteria included being published in a peerreviewed journal in English language and studies reporting clinical and radiographic outcomes in either a prospective or retrospective manner. Papers were excluded if an abstract was not available, published in a language other than English or if the paper related to a surgical technique without reporting clinical outcomes. Due to the nature of

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Diagnosis of patella dislocation and indication for medial soft‑tissue surgery The diagnosis of patella dislocation was confirmed by CT scan, or MRI or accurate X-ray study in most series. In some cases, however, medical imaging before surgery was either not performed or not reported in the study [1, 8, 12, 18, 23]. Only four studies report data on the precise number of patella dislocations [1, 13, 26, 27]. The indication for medial soft-tissue surgery is not precise in the literature. Most authors report performing this procedure both in the case of patella dislocation or subluxation. Ma et al. [14] report performing a medial soft-tissue procedure when there is patella subluxation alone. There was no clear use of the definitions relating to patello-femoral instability according to Dejour. Indications for surgery and preoperative imaging evaluation data are summarised in Table 2. Surgical technique Operations performed included arthroscopic, arthroscopically assisted [24] or open [11, 15, 18] medial soft-tissue

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Table 1  Study demographic data References

Journal

Mean patient age (years)

Type of study

Sex (M/F)

Initial cohort

Length of FU

Patients at FU

Ma et al. [16] Ma et al. [15]

28.4 13.5 (10–17)

Prospective Prospective

12/19 15/36

34 61

40 months (24–55) 50 months (25–75)

31 61

Ma et al. [14] Zhao et al. [27] Lee et al. [13]

Arthroscopy Arch Orthop Trauma Surg Orthop Surg Am J Sports Med KSSTA

28.5 (31–37) 14.7 (12–19) 23.2 (14–32)

Retrospective Prospective Retrospective

31/47 5/23 12/19

78 30 31

78 26 31

Ji et al. [11] Shelbourne et al. [22] Zhao et al. [26] Sillanpää [23] Jórász et al. [12] Ali et al. [1] Miller et al. [17] Schöttle et al. [21] Nam et al. [18] Haspl et al. [8] Halbrecht et al. [7]

Int Orthop J Knee surg Am J Sports Med Am J Sports Med Joint Dis Rel Surg Arthroscopy Am J Sports Med Arthroscopy Am J Sports Med Arthroscopy Arthroscopy

15 (12–18) 19.2 23.9 (17–43) 20.0 (19–22) 18 (13–32) 30.5 (15–46) 28.1 (13–54) 20.7 23 (12–65) 18.8 (14–27) 30 (17–50)

Retrospective Prospective Prospective Prospective Retrospective Retrospective Prospective Retrospective Retrospective Retrospective Retrospective

7/10 24/14 7/36 29/1 6/6 9/26 7/17 22/26 10/12 6/11 15/14

17 42 50 30 12 38 36 48 28 17 41

60 months (33–87) 56.8 months (24–92) 11.6 years (7–16.9 years) 20.7 months (12–36) 31.7 months (22–65) 60 months 7.5 years (6–11) 9.8 months (2–28) 51 months (12–74) 61 months (24–120) 12 months 4.4 years (1.4–14) 13.3 months (9–18) 20 months

16 38 43 26 10 35 34 48 22 17 29

Small et al. [24]

Arthroscopy

16.8 (9–32)

Prospective

10/14

24

19 months (18–27)

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repair of the capsule or retinaculum. In the different publications, the operation was either named reefing, plasty, repair, suture, imbrication or plication. In some studies, the medial soft-tissue repair was routinely performed with lateral retinacular release (LRR) [1, 7, 12, 13, 18, 26, 27]. In other series, however, an additional LRR was performed at the end of the operation if the medial repair was considered insufficient [7, 12–15, 24, 26, 27]. A tibial tuberosity transfer was performed with a LRR in the series by Zhao et al. [26]. The different reported techniques are summarised in Table 2. Patient‑reported outcome scores Patients were reviewed at an average follow-up of 54.6 months (range 2–165 months). Outcomes and complications are reported in Table 3. Patients were evaluated at the last follow-up with subjective and objective questionnaires including Kujala, Lysholm and Tegner in most cases. The average Kujala score increased from 55 to 84 at the last follow-up. Similarly, the average Lysholm score increased from 41.2 to 80.5, whereas the average Tegner score increased from 3 to 5.3. The IKDC score increased from 47.8 to 75.1. Patient satisfaction alone was reported by Small et al. [24], which was 92.5 %. Average re-dislocation rate was 6.1 % (range 0–31 %) with subjective instability symptoms reported in up to 16 % of patients [26]. No major complications were reported in any series.

Coleman methodology score All studies were evaluated according to the Coleman score criteria. Several studies had methodological limitations, with average score of 61.6 (range 17–92). Concerning section A of the scoring methodology, the average score for the study size was 3.8, the score for the mean follow-up was 3.8, for the number of different surgical procedures the score was 7.6, for the type of study it was 5.5, for diagnostic certainty it was 3.5, for the description of surgical procedures the score was 5.0, and for the description of post-operative rehabilitation it was 8.5. Concerning section B, the average score for the outcome criteria was 8.6, the score for the procedure for assessing outcomes was 6.2, while the score for the description of subject selection process was 9.1.

Discussion Two important aspects emerged from the present study. Firstly, the strength of the methodology of the available studies in the literature was low with an average Coleman score of 61.6. Most articles were written with a focus on the surgical technique and reported the outcomes of a retrospective series with short follow-up. Secondly, despite this limitation, all studies showed positive outcomes with extremely low complication rates. These outcomes remained positive

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Length of FU

40 months (24–55)

50 months (25–75)

60 months (33–87)

56.8 months (24–92)

11.6 years (7–16.9) 20.7 months (12–36) 31.7 months (22–65)

60 months

7.5 years (6–11)

9.8 months (2–28)

51 months (12–74) 61 months (24–120)

12 months

References

Ma et al. [16]

Ma et al. [15]

Ma et al. [14]

Zhao et al. [27]

Lee et al. [13] Ji et al. [11] Shelbourne et al. [22]

Zhao et al. [26]

Sillanpää [23]

Jórász et al. [12]

Ali et al. [1] Miller et al. [17]

Schöttle et al. [21]

Table 2  Inclusion criteria and surgical details

No X-ray

na

No

CT

X-ray MRI X-ray, MRI

X-ray, CT, MRI

X-ray, CT

X-ray, CT, MRI

CT, MRI

Imaging

Acute and chronic PD CT

RPD (>3) or sblx RPD or sblx

APD, RPD

Acute PD

RPD (1–7)

RPD (9.5) RPD PD

RPD (2.4)

P sblx

PD

RPD and instability

Inclusion criteria

Medial retinaculum repair (A)

Proximal realignment and LRR (A) Medial capsule reefing (A)

Medial retinaculum repair (A)

Medial retinaculum repair (A)

Medial plication and LRR (A) Medial retinaculum plasty (O) Medial capsule imbrication and LRR (O) Medial plication and LRR (A)

Medial retinaculum plication (A) and LRR

Medial capsule reefing (O) Medial retinaculum plasty (O)

Medial capsule reefing (O) Medial retinaculum plasty (O)

Medial retinaculum plasty (O)

Procedure

No

No No

LRR (some cases)

TTA transfer (n.41) LRR (n.47) No

No No

No

LRR (n.15) LRR (n.12)

LRR (n.12) LRR (n.13)

No

Additional procedures

Unique procedure No preoperative evaluation Small sample Multiple procedures No preoperative evaluation No Good sample and FU Unique procedure Short FU

Good sample and FU Multiple procedures Good sample and FU

Good sample and FU Unique procedure Good sample and FU No comparison between preoperative and post-operative values Good sample and FU No comparison between preoperative and post-operative values Good sample and FU Always in association with LRR Longest FU Small sample Good sample and FU

Observations

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Rsblx recurrent subluxation, APD acute patellar dislocation, RPD recurrent patellar dislocation, LRR lateral retinacular release, (A) arthroscopic, (O) open, TTA transfer anterior tibial tuberosity transfer

Short FU

No preoperative evaluation No

No Medial capsule reefing and LRR (A)

Proximal realignment (A assisted) na

X-ray RPD, Rsblx 20 months

19 months (18–27)

Halbrecht et al. [7]

Small et al. [24]

APD, RPD, Rsblx

13.3 months (9–18) Haspl et al. [8]

APD, RPD, Rsblx

na

Medial capsule plication and LRR (A)

No

Good sample and FU Unique procedure Small sample Short FU No evaluation No Medial capsule reefing and LRR (O) X-ray 4.4 years (1.4–14) Nam et al. [18]

RPD

Length of FU References

Table 2  continued

Inclusion criteria

Imaging

Procedure

Additional procedures

Observations

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even at longer follow-up [13] with no signs of deterioration. Medial soft-tissue procedures addressing patello-femoral instability were introduced several decades ago [10]. Recently, arthroscopic techniques and mini-open approaches have led to renewed interest in these procedures. Several technical variations have been documented, and many case series have been published in the literature. Most of them report retrospective outcomes of arthroscopic techniques in adult patients. Ali performed an arthroscopic technique in 35 patients (36 knees) affected by patellar dislocation or subluxation. At an average follow-up of 51 months, 28 had excellent or good results with two cases of recurrent dislocation [1]. Similarly, Halbrecht performed an allarthroscopic technique in 26 patients (29 knees) affected by patellar dislocation or subluxation. At an average follow-up of 20 months, 93 % of patients felt their symptoms significantly improved and none had experienced any further dislocation [7]. Jórász et al. performed an arthroscopic medial capsule suturing in 10 patients affected by patellar dislocation. The retrospective analysis at an average follow-up of 9.8 months revealed excellent results in nine cases and no re-dislocation [12]. Haspl et al. described a fully arthroscopic technique to achieve medial capsule plication. A group of 17 patients affected by patello-femoral dysplasia and either dislocation or subluxation were retrospectively re-evaluated at an average follow-up of 13.3 months. Good outcomes and no re-dislocation were reported [8]. The average follow-up of the study by Lee et al. is the longest in the literature. They reported the outcomes of medial capsule repair and lateral release in a series of 31 patients at 11.6 years follow-up. Excellent or good results were achieved in 90 % of cases; however, recurrence of dislocation was reported in three cases [13]. Schöttle et al. analysed the outcomes of an arthroscopic medial retinaculum repair according to the grade of trochlear dysplasia. Forty-eight patients were reviewed at an average followup of 12 months. Patients with type A trochlear dysplasia (26 patients) reached a significantly better post-operative outcomes than patients with type B, C and D dysplasia (22 patients). Four re-dislocations were observed in the last group [21]. Other retrospective series included open or mini-open medial capsule repair. Nam and Karzel reviewed the outcomes of 22 patients (23 knees) affected by patellar dislocation. At an average follow-up of 4.4 years, 91 % of patients were rated as excellent or good; however, 1 re-dislocation and 1 recurrent subluxation were observed [18]. Ma et al. compared the outcomes of open medial capsule reefing (group 1, 40 patients) to those of open medial patellar retinaculum plasty (group 2, 38 patients). In both groups, almost one-third of patients had an additional lateral release. At an average follow-up of 60 months, 32 patients of group 1 had either excellent or good results, while 38 cases had the same result in group 2 [14].

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40 months (24–55)

50 months (25–75)

60 months (33–87)

56.8 months (24–92)

11.6 years (7–16.9)

20.7 months (12–36)

31.7 months (22–65)

60 months

7.5 years (6–11)

9.8 months (2–28) 51 months (12–74)

61 months (24–120)

12 months

4.4 years (1.4–14)

13.3 months (9–18) 20 months

19 months (18–27)

Ma et al. [16]

Ma et al. [15]

Ma et al. [14]

Zhao et al. [27]

Lee et al. [13]

Ji et al. [11]

Shelbourne et al. [22]

Zhao et al. [26]

Sillanpää [23]

Jórász et al. [12] Ali et al. [1]

Miller et al. [17]

Schöttle et al. [21]

Nam et al. [18]

Haspl et al. [8] Halbrecht et al. [7]

Small et al. [24]

Proximal realignment (A assisted)

Medial capsule plication and LRR (A) Medial capsule reefing and LRR (A)

Medial capsule reefing and LRR (O)

Medial retinaculum repair (A)

Medial capsule reefing (A)

Medial retinaculum repair (A) Proximal realignment and LRR (A)

Medial retinaculum repair (A)

Medial plication and LRR (A)

Medial capsule imbrication and LRR (O)

Medial retinaculum plasty (O)

Medial plication and LRR (A)

Medial capsule reefing (O) Medial retinaculum plasty (O) Medial retinaculum plication (A) and LRR

Medial capsule reefing (O) Medial retinaculum plasty (O)

Medial retinaculum plasty (O)

Procedure

LRR lateral retinacular release, (A) arthroscopic, (O) open, Rsblx recurrent subluxation

Length of FU

References

Table 3  Outcomes and complications

2 Rsblx

0 % 0 %

1 (4 %)

4 (8.3 %)

0 %

0 % 2 (5.5 %)

Subjective

na Lysholm

na

na 41.5

na 3.7

44.0

Lysholm Kujala Tegner

1.5

54 Tegner

3.3 Lysholm

na na na 17 Tegner

Kujala Tegner Lysholm Lysholm

50.0

Lysholm 5 (19 %)

2.9

Tegner

Instability

66.6

Kujala

16.3 %

44.9

58.1 59.2 47.9

IKDC

Kujala Lysholm IKDC

3

52.6

Lysholm Tegner

3.1

Tegner 57.5

66.7

Kujala

Kujala

78.3 77.8 47.7

Kujala Kujala IKDC

52.3 53.5

3

Kujala Kujala

55

Tegner

Preoperative

Kujala

Outcome score

4 (9.3 %)

3 (7.9 %)

0

3 (9.7 %)

9/29 (31 %) 2/32 excessive lateral glide 0 % 0 % 5 (17.9 %)

6 (19 %) excessive lateral shift

Re-dislocation rate

92.5 % satisfied

na 79.3

88.2 6.9

62.8

4.8

91

6.2

87 4.5 97.6 70

69.3

4.0

73.8

61.2

93.4 92.3 87.8

7

89.2

70.7

3.9

76.6

88.3 91.2 62.5

78.1 82.2

5

84

Post-operative

na

Medial retinaculum reefing for the treatment for patellar instability.

Medial structures repair is a well-established approach in the treatment for patellar instability. However, the literature is confusing concerning the...
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