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INTRODUCTION: This study aimed to evaluate the effectiveness and safety of a combined surgical approach for treating complex patellofemoral instability. This approach combines four procedures: medial patellofemoral ligament (MPFL) reconstruction with the quasi-anatomic technique, lateral retinaculum release, anteromedialization and distalization of tibial tuberosity and patellar/femoral mosaicplasty. MATERIAL AND METHODS: Between August and November 2021, we enrolled 27 patients in the study (21 females, 6 males, average age 28.6 years). All with patella alta, recurrent patellar instability, severe cartilage focal damage, and increased tibial tubercle-trochlear groove distance. All underwent the combined procedure during this period. We assessed their pain and functional scores before surgery and at 6, 12, and 24 months after surgery using standardized scoring systems. RESULTS: Patients initially reported significant pain and functional limitations. However, at 24 months, their pain scores significantly reduced, averaging 1.5 compared to 8.2 pre-surgery. Similarly, their functional scores substantially improved, with Lysholm, Tegner, Kujala, BPII scores reaching 87.44, 8.44, 90.03, 86.07 compared to 56.4, 3.7, 42.48, 23 pre-surgery, respectively. Importantly, no cases of recurrent instability occurred, and 96.3% of patients reported complete satisfaction. CONCLUSIONS: This combined surgical approach has a high rate of success for patients with patella alta, recurrent lateral patellar instability, severe focal chondral lesions, and increased TT-TG distance. Moreover, 26 out of 27 patients (96.3%) reported total satisfaction. Therefore, we conclude that although this procedure combination is not simple, it is a safe, reproducible, and alleviates pain at 24 months postoperatively, and significantly improves functional scores.

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INTRODUCTION: Medial Patellofemoral ligament (MPFL) reconstruction, the primary procedure for restoring patellar stability and preventing further dislocation, has seen numerous methods and grafts. However, a consensus on the technique and graft remains elusive. This study introduces a novel approach to MPFL reconstruction, utilizing a unique combination of minimal invasiveness, de novo method, and arthroscopic guidance to harvest a quadriceps tendon (QT) graft without the need for a harvesting tool. CASE ILLUSTRATION: A 37-year-old female presented to the emergency room with the chief complaints of left knee pain and swelling following the third spontaneous dislocation of the patella. The patient had a few episodes of locking sensation and instability of the left knee while walking, especially while climbing stairs. A knee MRI revealed MPFL tear in the left knee. A modified minimal invasive MPFL reconstruction technique was performed. The IKDC, Lysholm, and Modified Cincinnati scores improved significantly from preoperatively 48.3 %, 49 %, and 51 % to 89.7 %, 90 %, and 95 % consecutively. No recurrent patellar dislocations or swelling were reported during follow-up. DISCUSSION: While quadriceps graft harvesting for MPFL reconstruction is typically highly invasive, using quadriceps tendons has consistently shown excellent outcomes. This study, however, takes it a step further by demonstrating that a minimally invasive procedure for harvesting quadriceps tendons, even without specialized instrumentation, can also yield excellent results. CONCLUSION: MPFL reconstruction using superficial quadriceps tendon autograft can be achieved using a minimally invasive technique without the use of specialized instrumentation and has shown excellent knee functional improvement.

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BACKGROUND: It remains unclear which subset of patients with recurrent patellofemoral instability would benefit from a concomitant bony realignment procedure in addition to a medial patellofemoral ligament (MPFL) reconstruction. PURPOSE: To provide midterm results for patients who underwent an isolated MPFL reconstruction as part of an ongoing prospective trial. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with recurrent patellar instability were prospectively enrolled in an institutional registry beginning in March 2014. Exclusion criteria included history of a previous surgery for patellar instability, an off-loadable (inferior/lateral) chondral defect, anterior knee pain ≥50% of their chief complaint, and a "jumping J" sign. All patients underwent primary, unilateral, isolated MPFL reconstruction regardless of their bony anatomic characteristics. Patient-reported outcome measures (PROMs), episodes of recurrent instability, and ability to return to sport were obtained annually. Radiographic measurements of baseline radiographs and MRI were obtained at baseline. RESULTS: A total of 138 patients underwent isolated MPFL reconstruction between March 2014 and December 2019. The mean radiographic measurements were tibial tubercle-trochlear groove, 15.1 ± 4.9 mm; Caton-Deschamps index, 1.14 ± 0.16; patellar trochlear index, 46.9% ± 15.1%; trochlear depth index, 2.5 ± 1.2 mm; tibial tubercle to lateral trochlear ridge, -8.4 ± 5.7 mm; and patellar tendon to lateral trochlear ridge, 5.7 ± 6.2 mm. Trochlear dysplasia, defined as a trochlear depth index <3 mm, was present in 79/125 (63%) patients. A total of 50 patients reached ≥5 years, of whom 40 (80%) completed follow-up PROMs. A total of 119 patients reached ≥2 years, of whom 89 (75%) completed follow-up PROMs. Six patients (5%) reported recurrent instability with a mean time of 2.97 years after surgery. All PROMs improved over time except for the Pediatric Functional Activity Brief Scale (Pedi-FABS), which had no change. At 2 years, the mean changes from baseline for Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life subscale (QOL), Pedi-FABS, International Knee Documentation Committee (IKDC) score, KOOS Physical Function Short Form (PS), and Kujala score were 42.1, 0.6, 35.1, -23.5, and 32.3, respectively. All changes had P values <.001 except for Pedi-FABS, which showed no change and had P > .999. At 5 years, the mean changes from baseline for KOOS-QOL, Pedi-FABS, IKDC, KOOS-PS, and Kujala score were 42.6, -2.8, 32.6, -21.5, and 31.6, respectively. All changes had P values <.001 except for Pedi-FABS, which showed no change and had P > .453. In total, 89% of patients returned to sport with a mean of 9.1 months. CONCLUSION: Midterm outcomes for patients who underwent isolated MPFL reconstruction were favorable and were maintained at 5 years. Outcomes for the expanded cohort of patients with a minimum 2-year follow-up support previously published results.

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BACKGROUND: Assessment of readability and reliability of online resources for orthopedic patients is an area of growing interest, but there is currently limited reporting on this topic for patellar instability (PI) and medial patellofemoral ligament reconstruction (MPFLR). METHODS: Utilizing the Searchresponse.io dataset, we analyzed inquiries related to PI and MPFLR. Readability and reliability were assessed using the Automated Reading Index, Flesch Reading Ease, and the JAMA benchmark criteria. RESULTS: Analysis of 363 frequently asked questions from 130 unique websites revealed a predominant interest in fact-based information. Readability assessments indicated that the average grade level of the resources was significantly higher than the 6th grade level and reliability varied between resources. CONCLUSION: Although the internet is an easily accessible resource, we demonstrate that PI and MPFLR resources are written at a significantly higher reading level than is recommended, and there is inconsistent reliability amongst resources with medical practice websites demonstrating the lowest reliability.

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Patellofemoral instability is a common and clinically relevant disorder of multifactorial causes. Several concomitant problems such as genua valga, hyperlaxity, injuries or sports-related overuse may contribute to the development of instability and recurrent patellar dislocations. A thorough diagnosis is of paramount importance to delineate every contributing factor. This includes radiographic modalities and advanced imaging such as magnetic resonance imaging or torsional analyses. The authors recommend non-operative management (including physiotherapy, gait and proprioceptive training, orthoses) and, whenever non-operative measures fail, surgical patellar stabilization using, e.g. MPFL reconstruction.

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PURPOSE: This study investigated the effect of different fluoroscopy settings on the accuracy of locating Schottle's point during medial patellofemoral ligament (MPFL) reconstruction. METHODS: The centre of the MPFL femoral footprint was identified and marked on 44 dry femurs. Two standard true lateral knee fluoroscopic images were obtained: (1) medial to lateral (ML) and (2) lateral to medial (LM). The deviation between the anatomically determined MPFL femoral footprint and the fluoroscopically identified point was measured on both fluoroscopic images. An 'acceptable tunnel location' was defined as within a 5- or 7-mm margin of error from the anatomic MPFL footprint. Distal femoral morphometric dimensions were also measured using digital calipers. Statistical analysis determined discrepancies between techniques and their relation to femoral morphometry. RESULTS: The LM view yielded a significantly smaller distance between the anatomical MPFL footprint and Schottle's point compared to the ML view (3.2 ± 1.5 vs. 4.5 ± 2.1 mm, p < 0.001). The LM view achieved acceptable tunnel locations, meeting the 5-mm error criterion in 90.9% of cases, while the ML view achieved 65.9% (p < 0.001). Both views yielded acceptable tunnel locations at similar rates using the 7-mm error criterion (n.s.). The anatomic MPFL footprint was displaced towards the anterior and proximal location in the ML view in reference to the Schottle point. No correlation was observed between any of the morphometric measurements and the deviations. CONCLUSIONS: This study demonstrated that using the LM fluoroscopic view improves the accuracy of femoral tunnel placement when identifying the MPFL footprint via the Schottle technique. Adopting the LM view in surgical practice will help surgeons locate the anatomical femoral footprint accurately, replicating the native MPFL and enhancing clinical outcomes. LEVEL OF EVIDENCE: Level 4, cadaveric study.

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BACKGROUND: This study aimed to investigate the potential relationship between kinesiophobia and functional outcomes in patients following medial patellofemoral ligament reconstruction (MPFLr). METHODS: Twenty-one patients (six males, 15 females) who underwent MPFLr between 2016 and 2020, (23.57 ± 9.49 years old) with a mean follow up period of 52.33 ± 24.82 months were included in the study. Following an assessment of patellar stability and alignment, kinesiophobia levels, function and balance were measured. The kinesiophobia was measured using the Tampa Scale of Kinesiophobia, while functional outcomes were assessed with the single-leg hop test, Y-Balance test and single-leg sway index. The self-reported function was measured by Kujala patellofemoral score and Lysholm knee score. RESULTS: The patients exhibited kinesiophobia scores of 43.10 ± 6.90. A negative correlation existed between kinesiophobia and both the Kujala scores (r = -0.75, P < 0.001) and the Lysholm scores (r = -0.79, P < 0.001). Moderate negative correlations were observed between kinesiophobia and the single-leg hop distance (r = -0.64, P < 0.01), as well as in Y-Balance test anterior reach distance (r = -0.51, P < 0.01) and posterolateral reach distance (r = -0.55, P < 0.01). Additionally, a low negative correlation was noted between kinesiophobia and Y-Balance test posteromedial reach distances (r = -0.43, P = 0.05), as well as the total sway index (r = -0.46, P = 0.04). CONCLUSIONS: A high level of kinesiophobia was strongly correlated with self-reported functional scores and moderately correlated with measured functional outcomes. The findings underscore a notable prevalence of kinesiophobia following biomechanically successful MPFLr. Investigating the impact of kinesiophobia on outcomes after MPFLr may provide a better understanding of patient recovery.

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Purpose: Patellofemoral joint instability (PFJI) can surgically be treated with a multitude of approaches, depending on the underlying pathology. In the presence of increased femoral anteversion, some authors have reported good results with a derotational distal femoral osteotomy (DeDFO). The purpose of the study was to investigate the indications, outcomes and complication rate of DeDFO for PFJI. Methods: A systematic review was performed according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) by searching Medline, Embase, Web of Science and Cochrane Library databases through 1 December 2023. Included were levels 1-4 clinical studies of skeletally mature patients undergoing a DeDFO for PFJI irrespective of concomitant procedures. Study characteristics, indications, radiological and clinical outcomes, surgical technique and concomitant procedures, re-dislocation and complication rate were all analysed, as was methodological quality. Results: A total of 12 studies including 310 patients (325 knees) were included. Three studies were cohort studies, all others were case series. The mean patient age across the studies was 22 years, and the mean follow-up was 29.4 months. Femoral anteversion cut-off was between 20° and 30°. Every study included at least one concurrent soft tissue, bony or combined procedure. Across all studies, one case of re-dislocation was reported (0.3%) and four implant or osteotomy-related complications (1.2%) were reported. All studies reported a statistically significant increase in clinical scores. Conclusion: This systematic review of DeDFO for patellofemoral instability in the presence of increased femoral anteversion demonstrates promising clinical results and an extremely low dislocation and complication rate. The heterogeneity of the cut-off in anteversion and concomitant procedures, especially tibial tubercle osteotomy with seemingly identical results, indicates the need for high-quality evidence for treating patellofemoral instability. Based upon this systematic review, we strongly recommend that DeDFO be added to the 'menu à la carte' of PFJI. Level of Evidence: Level III Systematic Review.

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BACKGROUND: patellar instability is a relatively frequent musculoskeletal disorder in children with Down syndrome (DS). However, such a condition has seldom been studied in the literature, even less its surgical treatment. Different techniques have been offered for this condition; the evidence for surgical options is scarce and primarily based on case reports or case series with few patients and heterogeneous techniques. Given this background, we aimed to evaluate the outcomes of a uniform kind of surgical procedure for such a condition that combined lateral soft tissue release, medial patellofemoral ligament (MPFL) reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty (if needed). MATERIALS AND METHODS: This retrospective study involved 11 skeletally immature patients (12 knees; 9 males and 2 females), 5.5 to 14.1 years of age, with DS who had patellofemoral instability (PFI) and were managed by this technique between October 2018 and March 2020. Preoperative radiography, CT scan, and MRI were performed to evaluate the physis status, lower limb alignment, patellar height, trochlear morphology, and any associated knee pathology. A functional knee assessment was done by using the Kujala score and the modified Lysholm score. RESULTS: The mean time of follow-up (± SD) was 47.7 ± 5.8 months (range: 39-56). Pre-operatively, the Kujala score (± SD) was 52.6 ± 14.3 (range: (31-74), and at final follow-up, it was 92.2 ± 4.4 (range: (88-98), showing a significant improvement (P < 0.001). The preoperative modified Lysholm score (± SD) was 54.3 ± 8.1 (range: 39-62), and at final follow-up it was 92.4 ± 5.3 (range: 82-96), showing a significant improvement (P < 0.001). All patients had a stable patella without a recurrence of instability and regained full ROM. There was no incidence of a patellar fracture or femoral physis injury. CONCLUSIONS: Our proposed technique of combined soft tissue procedures, including lateral soft tissue release, MPFL reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty, was an effective method for treating patellar instability in children with DS while avoiding physeal injury and patellar fracture. Functional scores and radiological outcomes were improved. LEVEL OF EVIDENCE: IV; retrospective case series.

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INTRODUCTION AND OBJECTIVE: Patella dislocation represents 3.3% of all knee injuries often leading to persistent instability. Medial patello-femoral ligament(MPFL) reconstruction is the standard method of treatment in the patellar instability. Rehabilitation after MPFL-R is a long and demanding procedure. The hypothesis presented reflects the idea that despite relatively good access to hospital care and surgical options, the post-operative rehabilitation care system is still inferior in rural areas versus the one offered in major cities and towns. MATERIAL AND METHODS: Between January 2015 - January 2018, 47 patients met the study inclusion criteria, diagnosed and operated on due to patellar instability. 8 patients were lost for full follow-up. Finally, 39 patients were included, divided into two groups - group A (19 from cities), group B (20 from rural area). Prospective KOOS and Kujala scales assessments were conducted: preoperative, 6 and 12 months after surgery. Knee isokinetic muscle strength was measured at 3 stages; prior to surgery, 6 and 12 months after reconstruction. RESULTS: All patients showed significant improvement measured in the KOOS and Kujala scales after the procedure, compared to the pre-operational results. Despite equal clinical improvement, patients from Group A(city) achieved better functional outcomes as presented in the results of knee extensor functional tests using a Biodex dynamometer. CONCLUSIONS: Rehabilitation after MPFL reconstruction improves muscle strength and clinical outcome. Patients from rural areas had inferior functional results in comparison to the patients from major cities, even 12 months after surgical patella stabilization. Despite the development of roads and transport according to the EU cohesion policy, there are still differences in rehabilitation results between rural and city areas.

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OBJECTIVES: The purpose of this study was to evaluate the validity and reliability of two techniques, palpation and fluoroscopy, for assessing medial patellofemoral ligament (MPFL) reconstruction femoral tunnel position accuracy. METHODS: Twenty-one fresh frozen cadaveric knees had an MPFL femoral tunnel drilled and filled with a metal screw. Tunnels were created in a nonstandard fashion to ensure the sample included a range of tunnel positions from poor to ideal. Six experienced sport medicine and arthroscopy surgeons evaluated the placement of the femoral tunnel by palpating the screw in relation to anatomic landmarks and by fluoroscopy related to Schöttle's Point. They evaluated 1) the accuracy of femoral tunnel placement, 2) the direction of tunnel error, and 3) the clinical acceptability of the tunnel position. Validity measures included sensitivity, specificity, and correlation to clinical acceptability, which were calculated for the palpation and fluoroscopic assessments. Reliability measures included interrater reliability (ICC 2,k) for femoral tunnel accuracy and percent agreement of the raters' tunnel direction assessment. RESULTS: The palpation method demonstrated a sensitivity of 0.79 and specificity of 0.84 for assessing the accuracy of femoral tunnel placement, while the fluoroscopic method showed a sensitivity of 0.83 and specificity of 0.92. Pearson correlation coefficients for clinical acceptability of tunnel position were high, with both techniques ranging from .589 to .854. Interrater reliability for the palpation and fluoroscopic techniques for assessment of tunnel accuracy were 0.31 and 0.55 (ICC 2,k), respectively. Assessment of the direction of tunnel error was good with the fluoroscopic technique slightly more accurate than palpation. CONCLUSION: This study demonstrated that both palpation and fluoroscopy are valid techniques for assessing femoral tunnel position after MPFL reconstruction. Despite demonstrating good validity, the accuracy of assessing tunnel position was unreliable in a group of six experienced knee surgeons. Further research into MPFL reconstruction femoral tunnel assessment techniques, including patient-specific reference standards, is warranted. LEVEL OF EVIDENCE: Level 2.

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BACKGROUND: There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction. PURPOSE: To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed. RESULTS: A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement. CONCLUSION: IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.

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(1) Background: Acute patella dislocation (APD) is a prevalent knee injury, with rates between 5.8-77.8 per 100,000. APD often results in repeat lateral patella dislocations due to the instability of the medial patellofemoral ligament (MPFL). Non-operative treatments have a 50% recurrence rate. While autologous grafting for MPFL has been favored, surgeons are now exploring synthetic grafts. We aimed to assess the effectiveness of synthetic grafts in MPFL reconstruction surgeries for repeated patellar dislocations; (2) Methods: Our research was based on a thorough search from the National Institute of Health and Clinical Excellence Healthcare Databases, using the Modified Coleman Methodology Score for quality assessment; (3) Results: Six studies met the inclusion criteria. A total of 284 patients and 230 knees were included. Seventy-five percent of patients were graded to have excellent-good clinical outcomes using the Crosby and Insall Grading System. International Knee Documentation Committee score and Knee injury and Osteoarthritis Outcome Score scores showed 59% and 60% post-operative improvement, respectively; (4) Conclusions: All studies showed improvement in post-operative functional outcomes and report no serious adverse events. The 6 mm, LARS (Orthomedic Ltd., Dollard-des-Ormeaux, QC, Canada) proved to have the most improvement in post-operative outcomes when used as a double bundle graft.

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BACKGROUND: Recurrent patella instability is a common and debilitating condition which affects mainly adolescents and young adults. Medial patellofemoral ligament (MPFL) reconstruction is the most popular surgical treatment for recurrent patella instability. The most common graft choice in the literature is ipsilateral hamstring tendon (gracilis or semitendinosis) but the complication rate remains high (11-26%). Conversely, there are very few papers on the use of modern, synthetic grafts. METHODS: A total of 85 patients who underwent MPFL reconstruction using a modern, synthetic graft (Xiros, UK) from 2014 to 2022 were retrospectively reviewed. Exclusion criteria were patella alta, malalignment, trochlea dysplasia and significant pain between episodes of instability. The author has developed an operative technique which is anatomic, minimally invasive and reproducible. Pre- and post-operative Kujala and Oxford knee scores were collected and analysed. RESULTS: The male to female ratio was 27:58, the average age was 28 years, and the follow up range was 1-9 years (mean follow up 4.84 years). We found a statistically significant improvement in mean Kujala and Oxford knee scores (P < 0.001) postoperatively. No major complications such as knee stiffness, soft tissue reaction, re-dislocation, patella fracture were identified in the series. There were nine minor complications (10.6%): five cases of medial knee pain, two cases of residual instability and two of superficial infection. CONCLUSION: This study demonstrates that modern, synthetic graft is a viable option for MPFL reconstruction. The technique described, achieves good clinical outcomes with low complication rates when compared with the published literature.

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OBJECTIVES: To analyze the effect of patellofemoral anatomical variations (patella alta, increased tibial tubercle-trochlear groove [TT-TG] distance, and trochlear dysplasia) on clinical outcomes after isolated medial patellofemoral ligament (MPFL) reconstruction. METHODS: A comprehensive search from PubMed, Embase, and the Cochrane Library databases was conducted to identify studies that compared outcomes based on the presence or absence of patella alta, elevated tibial tubercle-trochlear groove (TT-TG) distance, and/or trochlear dysplasia. Exclusion criteria included reviews and meta-analyses, studies that included patients who underwent associated bony procedures, and those reporting outcomes after isolated MPFL reconstruction with no comparison between varying anatomical groups. RESULTS: After application of selection criteria, 19 studies were included. Patella alta was not predictive of failure or poorer outcomes among 13 studies; however, 2 studies demonstrated poorer patient-reported outcome scores and/or higher failure rates with increasing patellar height. Increasing TT-TG distance demonstrated a statistically significant correlation with poorer outcomes in only one study, whereas 12 other studies showed no association. Trochlear dysplasia resulted in worse outcomes and greater failure rates in 6 studies, while 10 studies showed no statistically significant correlation between trochlear dysplasia and postoperative outcomes. CONCLUSION: Patella alta and increased TT-TG distance did not adversely affect outcomes following isolated MPFL reconstruction in the preponderance of reviewed studies. Data are mixed regarding the impact of trochlear dysplasia on the outcomes of isolated MPFL reconstruction. LEVEL OF EVIDENCE: IV.

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BACKGROUND: The extent to which recurrent patellar instability (RPI) affects wrestlers has not been thoroughly examined. PURPOSE: To assess return to wrestling (RTW), patient-reported outcomes, and reoperation rates after patellofemoral stabilization surgery (PFSS) for RPI in a cohort of competitive wrestlers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All competitive wrestlers with a history of RPI and subsequent PFSS performed at a single institution between 2000 and 2020 were identified. Primary PFSS procedures included medial patellofemoral (MPFL) reconstruction (n = 31; 50%); MPFL repair (n = 22; 35.5%); or other PFSS (n = 9; 14.5%), such as tibial tubercle osteotomy, lateral retinacular release, and/or medial retinacular reefing. Exclusion criteria included revision PFSS or concomitant anterior cruciate ligament reconstruction or multiligament knee injury. Surgical failure was defined as subsequent patellar dislocation despite operative management or need for secondary PFSS. RESULTS: Ultimately, 62 knees in 56 wrestlers with a mean age of 17.0 years (range, 14.0-22.8 years) were included at a mean follow-up of 6.6 years (range, 2.0-18.8 years). RTW occurred in 55.3% of wrestlers at a mean ± SD 8.8 ± 6.7 months. Among PFSS types, no differences were observed in rates of RTW (P = .676), postoperative pain (P = .176), Tegner activity level (P = .801), International Knee Documentation Committee (P = .378), Lysholm (P = .402), or Kujala scores (P = .370). RPI was the most common postoperative complication (n = 13; 21.0%). MPFL reconstruction had the lowest rate of RPI (6.5% vs 27.3% [repair] vs 55.6% [other]; P = .005) and surgical failure (9.7% vs 31.8% [repair] vs 55.6% [other]; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared with MPFL repair and other PFSS up to 10 years after the index surgery (90.3% vs 64.1% vs 27.8%; P = .048). CONCLUSION: RPI remains a concern for competitive wrestlers after PFSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared with other PFSS procedures at up to 10 years after surgery.

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Background: Sparse objective data are available documenting changes of trochlear shape after trochleoplasty. Purpose/Hypothesis: The purpose was to investigate whether standardized magnetic resonance imaging (MRI) measurements that characterize trochlear dysplasia (TD) change significantly after arthroscopic deepening trochleoplasty (ADT) combined with medial patellofemoral ligament (MPFL) reconstruction. It was hypothesized that MRI measurements would approximate normal values. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent ADT between October 2014 and December 2017 were considered for this study. The preoperative inclusion criteria for ADT surgery were patellar instability, a dynamic patellar apprehension sign at 45° of flexion, a lateral trochlear inclination (LTI) angle of <11°, and failed physical therapy. MRI was performed pre- and postoperatively, and standardized MRI measurements were calculated: LTI angle, trochlear depth, trochlear facet asymmetry, cartilage thickness, and trochlear height. The Banff Patella Instability Instrument 2.0 (BPII) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Kujala score were obtained pre- and postoperatively. Results: A total of 16 knees in 15 patients (12 female and 3 male; median age, 20.9 years; range, 14.1-51.3 years) were evaluated. The mean follow-up time was 63.6 months (range, 23-97 months). The median LTI angle improved from 1.25° (range, -25.1° to 10.6°) preoperatively to 10.7° (range, -17.7° to 25.8°) postoperatively (P < .001), trochlear depth increased from 0.0 mm (range, -4.2 to 1.8 mm) to 3.23 mm (range, 0.25-5.3 mm) (P < .001), and trochlear facet asymmetry improved from 4.55% (range, 0.0%-28.6%) to 17.8% (range, 0.0%-55.6%) (P < .003). Cartilage thickness was unchanged: 4.5 mm (range, 1.9-7.4 mm) preoperatively and 4.9 mm (range, 0.6-8.3 mm) postoperatively (P = .796). BPII, KOOS, and Kujala scores improved significantly (P < .0034 for all). Conclusion: Combined ADT and MPFL reconstruction led to statistically significant and clinically relevant improvements in patient-reported outcomes and standardized MRI measurements that characterize TD. The improvements corresponded to those obtained by open trochleoplasty. No significant reduction in cartilage thickness was seen.

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PURPOSE: Lateral patellar instability is a debilitating condition not only to athletes, but also to a wide range of highly active individuals. Many of these patients experience symptoms bilaterally, though it is unknown how these patients fair with return to sports following a second medial patellofemoral ligament reconstruction (MPFLR). The purpose of this study is to evaluate the rate of return to sport following bilateral MPFLR compared to a unilateral comparison group. METHODS: Patients who underwent primary MPFLR with minimum 2-year follow-up were identified from 2014 to 2020 at an academic center. Those who underwent primary MPFLR of bilateral knees were identified. Pre-injury sport participation and Tegner score, Kujala score, Visual Analog Score (VAS) for pain, satisfaction, and MPFL-Return to Sport after Injury (MPFL-RSI) scale were collected. Bilateral and unilateral MPFLRs were matched in a 1:2 ratio based on age, sex, body mass index, and concomitant tibial tubercle osteotomy (TTO). A sub-analysis was performed regarding concomitant TTO. RESULTS: The final cohort consisted of 63 patients, including 21 patients who underwent bilateral MPFLR, matched to 42 unilateral patients at mean follow-up of 47 ± 27 months. Patients who underwent bilateral MPFLR returned to sport at a rate of 62% at a mean of 6.0 ± 2.3 months, compared to a unilateral rate of 72% at 8.1 ± 4.2 months (n.s.). The rate of return to pre-injury level was 43% among bilateral patients and 38% in the unilateral cohort. There were no significant differences in VAS pain, Kujala, current Tegner, satisfaction, and MPFL-RSI scores between cohorts. Approximately half of those (47%) who failed to return to sport cited psychological factors and had significantly lower MPFL-RSI scores (36.6 vs 74.2, p = 0.001). CONCLUSION: Patients who underwent bilateral MPFLR returned to sports at a similar rate and level compared to a unilateral comparison group. MPFL-RSI was found to be significantly associated with return to sport. LEVEL OF EVIDENCE: III.

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Background: Medial patellofemoral ligament (MPFL) reconstruction is a well-established procedure for the treatment of patients with patellofemoral instability (PFI) at low flexion angles (0°-30°). Little is known about the effect of MPFL surgery on patellofemoral cartilage contact area (CCA) during the first 30° of knee flexion. Purpose/Hypothesis: The purpose of this study was to investigate the effect of MPFL reconstruction on CCA using magnetic resonance imaging (MRI). We hypothesized that patients with PFI would have a lower CCA than patients with healthy knees and that CCA would increase after MPFL reconstruction over the course of low knee flexion. Study Design: Cohort study; Level of evidence, 2. Methods: In a prospective matched-paired cohort study, the CCA of 13 patients with low-flexion PFI was determined before and after MPFL reconstruction, and the data were compared with those of 13 healthy volunteers (controls). MRI was performed with the knee at 0°, 15°, and 30° of flexion in a custom-designed knee-positioning device. To suppress motion artifacts, motion correction was performed using a Moiré Phase Tracking system via a tracking marker attached to the patella. The CCA was calculated on the basis of semiautomatic cartilage and bone segmentation and registration. Results: The CCA (mean ± SD) at 0°, 15°, and 30° of flexion for the control participants was 1.38 ± 0.62, 1.91 ± 0.98, and 3.68 ± 0.92 cm2, respectively. In patients with PFI, the CCA at 0°, 15°, and 30° of flexion was 0.77 ± 0.49, 1.26 ± 0.60, and 2.89 ± 0.89 cm2 preoperatively and 1.65 ± 0.55, 1.97 ± 0.68, and 3.52 ± 0.57 cm2 postoperatively. Patients with PFI exhibited a significantly reduced preoperative CCA at all 3 flexion angles when compared with controls (P ≤ .045 for all). Postoperatively, there was a significant increase in CCA at 0° of flexion (P = .001), 15° of flexion (P = .019) and 30° of flexion (P = .026). There were no significant postoperative differences in CCA between patients with PFI and controls at any flexion angle. Conclusion: Patients with low-flexion patellar instability showed a significant reduction in patellofemoral CCA at 0°, 15°, and 30° of flexion. MPFL reconstruction increased the contact area significantly at all angles.

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Purpose: The purpose of this systematic review aimed to investigate the clinical outcome of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair and medial reefing for patients with first-time patellar dislocation. Methods: Databases of PubMed, EMBASE, Cochrane Library and Web of Science were searched up to May 8, 2022. Only articles treating first-time patellar dislocation with MPFL reconstruction, MPFL repair and medial reefing were included in the analysis. Eligible identification, data extraction, quality assessment and statistical analysis were performed by two independent reviewers. The primary outcome measures were the incidences of postoperatively redislocation and reoperation. The second outcomes were the Kujala functional score and complications (including infection, osteoarthritis, and loss of range of motion). Results: Twenty-two studies involving 668 patients met the inclusion criteria. Of which, four studies involving 126 patients were in MPFL reconstruction group, ten studies involving 220 patients in MPFL repair group and 9 studies involving 322 patients in medial reefing group. Our results showed that the MPFL reconstruction (1.8%, 95% CI - 0.5 to 4.0%) had a significantly lower rate of postoperative redislocation and reoperation rate than the MPFL repair (15.4%, 95% CI 5.2-25.7%) and medial reefing (18.0%, 95% CI 9.3-26.7%). Besides, no significant differences were found in the Kujala score and complication rate among the three treatments. Conclusion: The available evidence demonstrated that MPFL reconstruction could achieve significantly lower redislocation rate and reoperation rate than MPFL repair and medial reefing after first-time patella dislocation. Furthermore, there was not enough evidence to reveal that MPFL reconstruction provided better functional outcome compared with MPFL repair and medial reefing. MPFL reconstruction is a preferred surgical treatment for patients with first-time patellar dislocation. Level of Evidence: Level IV, systematic review of Level I-IV.