Acute patellar dislocation · 2015-03-25 · RUPTURE OF THE VMO ALL CASES SURGICAL TREATMENT IN ALL...
Transcript of Acute patellar dislocation · 2015-03-25 · RUPTURE OF THE VMO ALL CASES SURGICAL TREATMENT IN ALL...
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ACUTE PATELLAR DISLOCATION
MARCO ANTONIO PERCOPE DE ANDRADE
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POINTS TO BE CONSIDERED
1- ACUTE TRAUMA (FIRST EPISODE)
2- PRESENCE OF PREDISPONENT FACTORS
3- PRESENCE OF OSTEOCHONDRAL FRACTURES
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POINTS TO BE CONSIDERED
1- ACUTE TRAUMA (FIRST EPISODE)
2- PRESENCE OF PREDISPONENT FACTORS
3- PRESENCE OF OSTEOCHONDRAL FRACTURES
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POINTS TO BE CONSIDERED
1- ACUTE TRAUMA (FIRST EPISODE)
2- PRESENCE OF PREDISPONENT FACTORS
3- PRESENCE OF OSTEOCHONDRAL FRACTURES
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HYPOTHESIS ACUTE DISLOCATION OF THE PATELLA
1- SURGICAL TREATMENT IN THE PRESENCE OF AN OSTEOCHONDRAL FRACTURE
2- NON-SURGICAL TREATMENT WITH BRACE FOLLOWED FOR PHYSIOTHERAPY FOR ALL OTHER PATIENTS
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LITERATURE
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Ahmad et al Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation A review of eight cases AJSM 28, 2000, pp 804-810
8 PATIENTS 4 MALES - 4 FEMALES
MEDIUM AGE - 32 YEARS
DISTAL RUPTURE OF THE MPFL RUPTURE OF THE VMO
ALL CASES
SURGICAL TREATMENT IN ALL CASES
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Ahmad et al Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation A review of eight cases AJSM 28, 2000, pp 804-810
8 PATIENTS 4 MALES - 4 FEMALES
MEDIUM AGE - 32 YEARS
DISTAL RUPTURE OF THE MPFL RUPTURE OF THE VMO
ALL CASES
NO DISLOCATIONS LIMITATION OF FLEXION IN 4 CASES
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Ahmad et al Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation A review of eight cases AJSM 28, 2000, pp 804-810
8 PATIENTS 4 MALES - 4 FEMALES
MEDIUM AGE - 32 YEARS
DISTAL RUPTURE OF THE MPFL MEDIAL RUPTURE
ALL CASES
CONCLUSION VMO AND LFPM REPAIR SHOULD BE DONE
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Fithian, DC Epidemiology and Natural History of Acute Patellar Dislocation AJSM 32, 2004, pp 1114-1121
2 GROUPS MINIMUM FOLLOW UP - 2 YEARS
1- FIRST DISLOCATION - 125 PATIENTS MEDIUM AGE 16 YEARS (9-67) 52% FEMALE GENDER 61% WITH SPORTS ACTIVITY
2- PREVIOUS DISLOCATION OR SUBLUXATION - 64 PATIENTS MEDIUM AGE 21 YEARS (8-65) 70% FEMALE GENDER 47% WITH SPORTS ACTIVITY
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Fithian, DC Epidemiology and Natural History of Acute Patellar Dislocation AJSM 32, 2004, pp 1114-1121
2 GROUPS MINIMUM FOLLOW UP - 2 YEARS
1- FIRST DISLOCATION - 125 PATIENTS 17% NEW EPISODES OF DISLOCATION
2- PREVIOUS DISLOCATION OR SUBLUXATION -64 PATIENTS 49% NEW EPISODES OF DISLOCATION
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Fithian, DC Epidemiology and Natural History of Acute Patellar Dislocation AJSM 32, 2004, pp 1114-1121
2 GROUPS MINIMUM FOLLOW UP - 2 YEARS
1- FIRST DISLOCATION - 125 PATIENTS 17% NEW EPISODES OF DISLOCATION
2- PREVIOUS DISLOCATION OR SUBLUXATION -64 PATIENTS 49% NEW EPISODES OF DISLOCATION
MRI NO CORRELATION BETWEEN MEDIAL RETINACULUM RUPTURE
AND NEW EPISODES OF DISLOCATION
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Fithian, DC Epidemiology and Natural History of Acute Patellar Dislocation AJSM 32, 2004, pp 1114-1121
2 GROUPS MINIMUM FOLLOW UP - 2 YEARS
1- FIRST DISLOCATION - 125 PATIENTS 17% NEW EPISODES OF DISLOCATION
2- PREVIOUS DISLOCATION OR SUBLUXATION - 64 PACIENTES 49% NEW EPISODES OF DISLOCATION
MRI TREND TOWARD LOWER RISK OF SUBSEQUENT DISLOCATION
WHEN THERE WAS MEDIAL RETINACULUM OR MPFL RUPTURE
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Sillanpaa et al 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 AJSM 36, 2008, pp 2301-2309
76 PATIENTS MEDIUM FOLLOW UP - 7 YEARS
30 PATIENTS ARTHROSCOPIC REPAIR
46 PATIENTS WITHOUT REPAIR
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Sillanpaa et al 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 AJSM 36, 2008, pp 2301-2309
76 PATIENTS MEDIUM FOLLOW UP - 7 YEARS
30 PATIENTS ARTHROSCOPIC REPAIR
46 PATIENTS WITHOUT REPAIR
RESULTS 23% RE-DISLOCATION RATE IN THE GROUP WITHOUT REPAIR
19% RE-DISLOCATION RATE IN THE GROUP WITH REPAIR p=0,84
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Sillanpaa et al 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 AJSM 36, 2008, pp 2301-2309
76 PATIENTS MEDIUM FOLLOW UP - 7 YEARS
30 PATIENTS ARTHROSCOPIC REPAIR
46 PATIENTS WITHOUT REPAIR
CONCLUSION
ARTHROSCOPIC REPAIR OF THE MEDIAL RETINACULUM DOES NOT IMPROVE
PATELLAR STABILITY NOR DECREASES THE RE-DISLOCATION RATE
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Buchner, M et al Acute traumatic primary patellar dislocation Long-term results comparing conservative and surgical treatment Clin J Sport Med 15 2005 pp 62-66
126 PATIENTS MEDIUM FOLLOW UP – 8.1 YEARS
63 PATIENTS CONSERVATIVE TREATMENT
20 PATIENTS DIAGNOSTIC ARTHROSCOPY
37 PATIENTS MEDIAL RECONSTRUCTION
6 PATIENTS OSTEOCHONDRAL FIXATION
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Buchner, M et al Acute traumatic primary patellar dislocation Long-term results comparing conservative and surgical treatment Clin J Sport Med 15 2005 pp 62-66
126 PATIENTS MEDIUM FOLLOW UP – 8.1 YEARS
RESULTS 26% RE-DISLOCATION RATE
85% EXCELLENT / GOOD RESULTS (LYSHOLM) 71% SUBJECTIVE GOOD RESULTS
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Buchner, M et al Acute traumatic primary patellar dislocation Long-term results comparing conservative and surgical treatment Clin J Sport Med 15 2005 pp 62-66
126 PATIENTS MEDIUM FOLLOW UP – 8.1 YEARS
RESULTS NO DIFFERENCES AMONG GROUPS RELATED TO
- RE-DISLOCATION RATE - RE-OPERATION - LEVEL OF ACTIVITY - CLINICAL OR FONCTIONAL RESULTS
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Buchner, M et al Acute traumatic primary patellar dislocation Long-term results comparing conservative and surgical treatment Clin J Sport Med 15 2005 pp 62-66
126 PATIENTS MEDIUM FOLLOW UP – 8.1 YEARS
26% RE-DISLOCATION RATE
85% EXCELLENT / GOOD RESULTS 71% SUBJECTIVE GOOD RESULTS
CONCLUSION
CONSERVATIVE TREATMENT SEEMS TO BE THE CHOICE FOR ACUTE
PATELLAR DISLOCATION
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Stefancin, JJ & Parker, RD First-time Traumatic Patellar Dislocation A Systematic Review CORR 455, 2007 pp 93-101
SYSTEMATIC REVIEW OF 70 PAPERS LEVELS I-IV
HOW TO TREAT AND DIAGNOSE ACUTE PATELLAR DISLOCATION ACCORDING TO EVIDENCE BASED MEDICINE
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Stefancin, JJ & Parker, RD First-time Traumatic Patellar Dislocation A Systematic Review CORR 455, 2007 pp 93-101
SYSTEMATIC REVIEW OF 70 PAPERS LEVELS I-IV
HOW TO TREAT AND DIAGNOSE ACUTE PATELLAR DISLOCATION ACCORDING TO EVIDENCE BASED MEDICINE
OSTEOCHONDRAL FRACTURE RATE 24.3%
MEDIUM RE-DISLOCATION RATE 48%
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Stefancin, JJ & Parker, RD First-time Traumatic Patellar Dislocation A Systematic Review CORR 455, 2007 pp 93-101
SYSTEMATIC REVIEW OF 70 PAPERS LEVELS I-IV
HOW TO TREAT AND DIAGNOSE ACUTE PATELLAR DISLOCATION ACCORDING TO EVIDENCE BASED MEDICINE
KNEE JOINT ASPIRATION 1- INCREASES COMFORT
2- HELPS IN DIAGNOSIS
3- LARGE VOLUME OF HEMARTROSIS SUGGESTS LESION OF THE MEDIAL STABILIZERS OR OSTEOCHONDRAL FRACTURE
4- PRESENCE OF FAT INDICATES OSTEOCHONDRAL FRACTURE
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Stefancin, JJ & Parker, RD First-time Traumatic Patellar Dislocation A Systematic Review CORR 455, 2007 pp 93-101
SYSTEMATIC REVIEW OF 70 PAPERS
5 PAPERS COMPARE CONSERVATIVE TO SURGICAL TREATMENT
ALL OF THEM RECOMMEND INICIAL CONSERVATIVE TREATMENT
ARTHROSCOPY INDICATED WHEN THERE IS OSTEOCHONDRAL FRACTURE ( ARTHROSCOPIC OR OPEN REPAIR INDICATED)
CONSERVATIVE AND SURGICAL TREATMENT HAVE SIMILAR RESULTS AFTER 2 YEARS OF FOLLOW UP
MAJOR COMPLICATION ONLY AFTER SURGICAL TREATMENT
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Sillanpaa et al Treatment with and without initial stabilzing surgery for primary traumatic patellar dislocation A prospective randomized study JBJS 91A, 2009, pp 263-273
40 PATIENTS MEDIUM AGE - 20 YEARS
MEDIUM FOLLOW UP - 7 YEARS
22 PATIENTS TREATMENT WITH BRACE
18 PATIENTS SURGICAL STABILIZATION
MRI SHOWING HEMARTROSIS, MEDIAL RETINACULUM AND MPFL RUPTURE IN ALL PATIENTS
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Sillanpaa et al Treatment with and without initial stabilzing surgery for primary traumatic patellar dislocation A prospective randomized study JBJS 91A, 2009, pp 263-273
40 PATIENTS MEDIUM AGE - 20 YEARS
MEDIUM FOLLOW UP - 7 YEARS
6 IN THE NON-OPERATED GROUP
0 IN THE OPERATED GROUP
RESULTS RE-DISLOCATION
PAINFUL SUBLUXATION 4 IN THE NON-OPERATED GROUP 2 IN THE OPERATED GROUP
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Sillanpaa et al Treatment with and without initial stabilzing surgery for primary traumatic patellar dislocation A prospective randomized study JBJS 91A, 2009, pp 263-273
40 PATIENTS MEDIUM AGE - 20 YEARS
MEDIUM FOLLOW UP - 7 YEARS
RESULTS MEDIUM KUJALA SCORE
90 POINTS IN THE NON-OPERATED GROUP 91 POINTS IN THE OPERATED GROUP
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Sillanpaa et al Treatment with and without initial stabilzing surgery for primary traumatic patellar dislocation A prospective randomized study JBJS 91A, 2009, pp 263-273
40 PATIENTS MEDIUM AGE - 20 YEARS
MEDIUM FOLLOW UP - 7 YEARS
CONCLUSION LOWER RE-DISLOCATION RATE IN THE OPERATED GROUP
CLINICAL AND FONCTIONAL RESULTS QUITE SIMILAR IN BOTH GROUPS
NO BENEFITS WERE SEEN IN SURGICAL TREATMENT IN A LONG PERIOD OF FOLLOW UP
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Camanho et al Conseervative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella Arthroscopy 25, 2009, pp 620-635
33 PATIENTS GROUP I - 16 PATIENTS CONSERVATIVE TREATMENT GROUP II - 17 PATIENTS SURGICAL TREATMENT
RE-DISLOCATION RATE
8 PATIENTS GROUP I 0 PATIENTS IN GROUP II
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Camanho et al Conseervative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella Arthroscopy 25, 2009, pp 620-635
33 PATIENTS GROUP I - 16 PATIENTS CONSERVATIVE TREATMENT GROUP II - 17 PATIENTS SURGICAL TREATMENT
KUJALA SCORE
GROUP I 69 POINTS
GROUP II 92 POINTS
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Camanho et al Conseervative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella Arthroscopy 25, 2009, pp 620-635
33 PATIENTS GROUP I - 16 PATIENTS CONSERVATIVE TREATMENT GROUP II - 17 PATIENTS SURGICAL TREATMENT
CONCLUSION
SURGICAL TREATMENT GAVE BETTER RESULTS
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Sillanpää et al. Femoral Avulsion of the Medial Patellofemoral Ligament After Primary Traumatic Patellar Dislocation Predicts Subsequent Instability in Men A Mean 7-Year Nonoperative Follow-Up Study AJSM 37: 1513-1521, 2009
53 MALE PATIENTS TREATED NON-SURGICALLY WITH THE SAME METHOD
INICIAL LOCATION OF MPFL TEAR EVALUATED BY MRI
FEMORAL AVULSION - 35 PATIENTS
PATELLAR AVULSION - 7 PATIENTS
MIDSUBSTANCE TEAR - 11 PATIENTS
COHORT STUDY – LEVEL OF EVIDENCE III
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Sillanpää et al. Femoral Avulsion of the Medial Patellofemoral Ligament After Primary Traumatic Patellar Dislocation Predicts Subsequent Instability in Men A Mean 7-Year Nonoperative Follow-Up Study AJSM 37: 1513-1521, 2009
42 PATIENTS SEEN AT MEAN 7-YEAR FOLLOW UP
PATELLAR INSTABILITY - 15 PATIENTS
13 PATIENTS - FEMORAL AVULSION
1 PATIENT - MIDSUBSTANCE TEAR
1 PATIENT - PATELLAR AVULSION p=0,01
COHORT STUDY- LEVEL OF EVIDENCE III
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Sillanpää et al. Femoral Avulsion of the Medial Patellofemoral Ligament After Primary Traumatic Patellar Dislocation Predicts Subsequent Instability in Men A Mean 7-Year Nonoperative Follow-Up Study AJSM 37: 1513-1521, 2009
42 PATIENTS SEEN AT MEAN 7-YEAR FOLLOW UP
PATELLAR REDISLOCATION - 9 PACIENTES
8 PATIENTS - FEMORAL AVULSION
1 PATIENT - MIDSUBSTANCE TEAR p=0,05
COHORT STUDY- LEVEL OF EVIDENCE III
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Sillanpää et al. Femoral Avulsion of the Medial Patellofemoral Ligament After Primary Traumatic Patellar Dislocation Predicts Subsequent Instability in Men A Mean 7-Year Nonoperative Follow-Up Study AJSM 37: 1513-1521, 2009
KUJALA SCORE
FEMORAL AVULSION 90 POINTS
PATELAR AVULSION 91 POINTS
MIDSUBSTANCE TEAR 96 POINTS p=0 .76
PROPORTION OF PATIENTS WHO REGAINED THEIR PREINJURY ACTIVITY LEVEL WAS SMALLER AMONG THOSE WITH FEMORAL AVULSION
COHORT STUDY – LEVEL OF EVIDENCE III
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Sillanpää et al. Femoral Avulsion of the Medial Patellofemoral Ligament After Primary Traumatic Patellar Dislocation Predicts Subsequent Instability in Men A Mean 7-Year Nonoperative Follow-Up Study AJSM 37: 1513-1521, 2009
CONCLUSION
MPFL AVULSION AT FEMORAL INSERTION INDICATES SUBSEQUENT PATELLAR INSTABILITY
LOCATION MUST BE TAKEN IN ACCOUNT WHEN PLANNING TREATMENT
COHORT STUDY – LEVEL OF EVIDENCE III
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SUMMARY
1- SURGICAL TREAMENT SHOULD BE CONSIDERED:
- WHEN THERE IS AN OSTEOCHONDRAL FRACTURE
- WITH FEMORAL AVULSION???
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SUMMARY
2- RECENT PAPERS SHOWING LESSER RECURRENT RATE WITH SURGICAL TREATMENT
- 1 OF THEM WITH SIMILAR CLINICAL RESULTS
- 1 OF THEM WITH BETTER CLINICAL RESULTS WITH SURGICAL TREATMENT
Sillanppaa et al
Camanho et al
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SUMMARY
3- RECURRENCE RATE SUPPOSED TO BE HIGHER IN FEMORAL AVULSIONS
Sillanppaa et al
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SUMMARY
THERE IS NO CLEAR EVIDENCE IN LITERATURE
THAT SURGICAL TREATMENT IS SUPERIOR TO
NON SURGICAL TREATMENT, EVEN THOUGH
RECURRENCE RATE IS LOWER IN SURGICAL
TREATMENT