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7/23/2019 Patellar Instability in Pediatric Patients
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Treating Patella Instability in
Skeletally Immature PatientsPatrick Vavken, MD., M.Sc., et al
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INTRODUCTION
• Conservative vs Surgical Treatment
• Damage to physes and subseuent gro!thdisturbance.
• "cute dislocations are typically treated !ithconservative treatment, unless there is evidence
o# osteochondral damage.• "cute dislocation $ anatomic de#iciencies
considered euivalent to osteochondraldamagesurgical treatment.
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• %b&ectives' (evie! current orthopaedic treatments o#
skeletally immature patient !ith patellarinstability )acute and recurrent*.
' "sses current evidence #or di##erent types o#surgical treatments that are clinically available.
' Provide summation and evidence needed in themanagement o# pediatric patellar instability
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METHODS
• "#ter statement o# P(+SM" )Pre#erred (eporting+tems #or Systemic revie!s and Meta"nalyses*and -%(%M )-uality o# (eporting o# Metaanalyses* in previous article in Arthroscopy.
• Studies !ere included report on surgical or
conservative treatment )or both* o# patellarinstability in skeletally immature individuals oradolescents, !ith at least / months o# #ollo!up.
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METHODS+nclusion Criteria 0
• +mmature 0 (adiologic proo# o# open physes or
Tanner stage )stage 1 or lo!er*.• +# neither physeal status nor tanner stage !as
reported, age 23 !as considered the cuto##threshold bet!een adolescent and adulthood.
4this age re#ers to the age at surgery, not atdislocation
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56clusion Criteria
• Patellar instability in association !ith syndrome)e.g., Turner syndrome*' Turner syndrome is one o# the most common
chromosomal abnormalities. That caused by the
absence o# the one set o# genes #rom short arm o#one 7 chromosome. )187*
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• Search #rom online database PubMed, C+9":;,5M<"S5, Cochrane Central (egister o#Controlled Trials, and Cochrane Database o#Systemic (evie!s.
• "ll searches !ere unlimited, i.e., publication in
all language and at all dates !ere considered.The last search !as per#ormed on %ctober 2,=>2=.
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RESULT• Twenty articles
reporting on a totalo# 18/ knees in 1=8
patients )2?2 male,=38 #emales*#ollo!edup #or 8/.@A 1=.= months onaverage.
• The average ageacross all studies !as 2=.3 A ?.2 years
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Acute Patellar Dislcatin
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Three studies #ocused on acute dislocations. T!o studies presented data on adirect comparison o# conservative and surgical treatments o# patellar instabilitya#ter acute patellar dislocation in pediatric and adolescent patients.
• Apostolovic et al #ound no di##erence in outcome bet!een surgical and
conservative treatment. they did not report on a #ormal po!er analysis inthe #ace o# P B .>32 #or #unctional outcome. "ssessment o# patello#emoralanatomy !as not reported.
• Palmu et al published a study o# @2 patients !ith patellar dislocation treated !ith medial restraint repair or conservatively and #ollo!ed #or 21 years. "ll patients had slight trochlear dysplasia )28> average sulcus angle*and some level o# patella alta )average +nsallSalvati ratio o# 2.?*, but no data !ere reported on - angles or the tibial tuberositytrochlear groove distance.
:o!ever, at @ and 21 years o# #ollo!up, there !as no di##erence in outcome.
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• Recurrence rates #or dislocations !ere #airlyhigh, ranging #rom 4% to 20% )Table ?*. Thehighest rates !ere seen in the oldest patients and !ith the oldest arthroscopic techniues.
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Recurrent Patellar Instability
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Three studies presented data on 1 groups o# patients !ithrecurrent instability treated !ith pro6imal realignment,
such as a medial retinacular or VM% plasty.• Ji et al . #ound high clinical scores a#ter medial
retinacular plication, but there !as no controlgroup.
• Zhao et al . compared medial retinacular plication !ith VM% plasty and #ound better stability and clinicalscores in the stronger repair !ith the VMO plasty .
• Ma et al . compared medial capsular reefing !ith
M!" repair and #ound better results !ith the latter.
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• Camp et al . and Kwon et al . presented data on open andarthroscopic M!" repair )to the patella* and #ound them to
be #easible and e##ective techniues to treat recurrent instabilitydespite recurrence rates as high as =E.
• Five studies reported on classic M!" reconstruction with ahamstring graft. Drez et al . and Deie et al. sutured
autologous semitendinosus to the patella.
• Kumahashi et al ., Yercan et al ., and Nelitz et al . usedintraosseous fi#ation of semitendinosis or gracilis grafts !ith good clinical results and no reported gro!th disturbances or
#ractures.
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DISCUSSION
• MPF; provides more than 8>E o# medial restrainGin most o# dislocations, MPF; undergoes some
level o# in&uries.• Current best evidence suggest conservative
treatment in first acute patellardislocation.
• T!o studies included sho!ed no signi#icantdi##erence in clinical score and recurrence bet!een conservative and surgical treatment.
)"postolovic et al. and Palmu et al .*
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• <racers have sho!n to stabiliHe the patellasuccess#ully but lead to sti##ness in the long
term. );arsen et al .*4
• VM% strengthening and proprioeptive trainingGclose chain more e##ective than open chain but
do more stress to cartilage. )+rish et al .*4• "bnormal e6tensor alignment cause abnormalpatellar tracking thus inter#ere !ithhealingconsider surgical approach
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Surgical A!!rac"
• Pro6imal (ealignment' (elease o# lateral retinaculum
' Medial procedures PlicationIimbrication o# capsule or retinaculum
VM% plasty
(econstruction o# MFP;
• Distal (ealignment' Tenodesis based on semitendinous
' Trans#ering patellar tendon medially
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Pr#imal Realignment
• Ma et al . #ound better sub&ective score andpostoperative stability on medial MPF; repair
compared to ree#ing o# the medial capsule• Jhao et al . #ound that simple medial capsule
plication a##ords less improvement than VM%
plasty• 8>>E o# medial restrain in&uries occur atMPF; attachment.
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Ptensial Prblems
• "llogra#t or autogra#t #rom hamstring is muchmore sti##er than natural MPF; )Colvin, =>>* minimal malposition induce stress patello#emoral degeneration )5lias, =>>/ and<eck et al ., =>>@*.
• Strategies0' MPF; anchored to adductor magnus )Kercan etal .,=>22*Iuse MC; as pulley )Deie et al .,=>22*
' Tensioning in /> to 3> degrees o# #le6ion rather
than conventional ?> degrees)Colvin, =>>*
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• (isk o# MPF; reconstruction on skeletal gro!th0' Leppler et al. sho!ed in an M(+ studies0 MPF;
insertion is on average 8 mm distal to the physis.' 9eliH et al. and Schottle et al. put MPF; insertion
/.1 and /.8 mm distal to physes .
provide secure and sa#e placement o# anchorsuture or tunnel !ithout &eopardiHing gro!th.
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LIMITATIONS
• Depended on uality o# included primarystudies.
• ;evel o# evidence o# the included studies !erelimited.
• nclear terminology
• " number o# studies mi6ed adolescent and adultpatiens.
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CONCLUSIONS• Current best evidence does not support the
superiority o# surgical intervention over
conservative treatment in acute patellardislocation.
• "natomic variations and their e##ect on healingshould be considered in decision making.
• +n recurrent patellar instability in pediatric andadolescent patients, reconstruction o# MPF; is themost e##ective options together !ith e6tensor
realignment as needed.
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T"ank $u
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