Complex Patellofemoral Reconstruction for Recurrent Instability

Background: Patellofemoral instability is due to a combination of bony and soft tissue factors. While recurrent patellar dislocations are rare, evaluation and treatment of these conditions require addressing patellar height and lateralization of the tibial tubercle (TT), restraint to lateral patellar subluxation, and trochlear dysplasia. Other factors to consider are coronal limb-length alignment outside of the physiologic 5 to 8° of valgus, which may significantly alter the Q angle and contribute to lateral instability. Other ligaments around the patella contribute to soft-tissue restraint, including the medial and lateral patellotibial ligaments, patellomeniscal ligaments, and the medial quadriceps tendon femoral ligament. Patellar tilt is assessed with and without quadriceps contraction to further evaluate the patella’s relationship to the trochlear groove. The Caton-Deschamps Index, as well as patellar trochlear index (PTI), are used to measure patellar height for patella alta or baja. Technique Description: The technique is to surgically manage a patient in neutral mechanical alignment on standing limb radiographs, with moderate-to-severe DeJour type B trochlear dysplasia and a trochlear sulcus angle of around 145°, patella alta with a Caton-Deschamps Index of 1.6 and PTI of 0.22, a TT to trochlear groove (TT-TG) distance of 8 mm, and a deficient medial patellofemoral ligament (MPFL). The MPFL reconstruction is done first, with harvesting of the ipsilateral quadriceps tendon and maintenance of its distal attachment on the superior patellar pole. The quadriceps tendon graft is folded medially upon its distal attachment and fixed in this position with suture anchors. Tibial tubercle osteotomy is accomplished by spacing drill holes 2 mm apart, medially and laterally, on the TT and connecting the drill holes with an osteotome and reciprocating saw. A distalized location to secure the TT is selected and superficial bone is excised. A medial parapatellar arthrotomy is performed, and bur attachments are used to drill into the subchondral bone beneath the femoral articular surface to create a V-shaped flap of trochlear cartilage. An arthroscope is inserted under the trochlear flap during this process to visualize the appropriate depth. The trochlear flap is then secured with screws passed over guide pins to secure the flap to the desired location. Cannulated screws and washers are then used to secure the TT to its distalized and/or medialized position, with fluoroscopic verification of screw depth and location. The arthrotomy is then closed with the knee at 45°. The quadriceps graft is passed through a subretinacular channel and secured with suture anchors, adjacent to the adductor tubercle, to complete the MPFL reconstruction. Before closure, appropriate tracking and translation of the patella is verified. Results: Sulcus-deepening trochleoplasty, with or without MPFL reconstruction, has been reported to obtain satisfactory outcomes at 2 years, with close to 85% return to sport and 100% return to work, with improvements in International Knee Documentation Committee (IKDC) scores from 50.8 to 79.1 in some studies. MPFL reconstruction with tibial tubercle osteotomy (TTO) has yielded a 94.5% patient satisfaction rate in the literature. Discussion/Conclusion: In patients with recurrent patellar instability and DeJour types B-D trochlear dysplasia, MPFL reconstruction with TTO and sulcus-deepening trochleoplasty provides excellent subjective outcomes and restores patellar tracking with elimination of recurrent subluxation.

Minimum 10-Year Clinical Outcomes After Arthroscopic 270° Labral Repair in Traumatic Shoulder Instability Involving Anterior, Inferior, and Posterior Labral Injury

Background: Current literature reports highly satisfactory short- and midterm clinical outcomes in patients with arthroscopic 270° labral tear repairs. However, data remain limited on long-term clinical outcomes and complication and redislocation rates in patients with traumatic shoulder instability involving anterior, inferior, and posterior labral injury. Purpose: To investigate, at a minimum follow-up of 10 years, the clinical outcomes, complications, and recurrent instability in patients with 270° labral tears involving the anterior, inferior, and posterior labrum treated with arthroscopic stabilization using suture anchors. Study Design: Case series; Level of evidence, 4. Methods: A retrospective outcomes study was completed for all patients with a minimum 10-year follow-up who underwent arthroscopic 270° labral tear repairs with suture anchors by a single surgeon. Outcome measures included pre- and postoperative Rowe score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test, visual analog scale for pain, and Single Assessment Numeric Evaluation (SANE). Western Ontario Shoulder Instability Index (WOSI) scores were collected postoperatively. Complication data were collected, including continued instability, subluxation or dislocation events, and revision surgery. Failure was defined as any cause of revision surgery. Results: In total, 21 patients (mean ± SD age, 27.1 ± 9.6 years) with 270° labral repairs were contacted at a minimum 10-year follow-up. All outcome measures showed statistically significant improvements as compared with those preoperatively: Rowe (53.9 ± 11.4 to 88.7 ± 8.9; P = .005), ASES (72.9 ± 18.4 to 91.8 ± 10.8; P = .004), Simple Shoulder Test (8.7 ± 2.4 to 11.2 ± 1.0; P = .013), visual analog scale (2.5 ± 2.6 to 0.5 ± 1.1; P = .037), and SANE (24.0 ± 15.2 to 91.5 ± 8.3; P = .043). The mean postoperative WOSI score at minimum follow-up was 256.3 ± 220.6. Three patients had postoperative complications, including a traumatic subluxation, continued instability, and a traumatic dislocation, 2 of which required revision surgery (14.2% failure rate). Conclusion: Arthroscopic repairs of 270° labral tears involving the anterior, inferior, and posterior labrum have highly satisfactory clinical outcomes at 10 years, with complication and redislocation rates similar to those reported at 2 years. This suggests that repairs of extensile labral tears are effective in restoring and maintaining mechanical stability of the glenohumeral joint in the long term.

Failure Rates in Contact versus Non-Contact Athletes Following Arthroscopic Inferior Capsular Shift at 10-Year Follow-Up (237)

Objectives: Arthroscopic Bankart repair has become the surgical procedure of choice for many in the United States, over the Latarjet in Europe, for first time anterior shoulder instability with minimal bone loss, less than 20%. However, high recurrence rates in contact athletes have led many to proceed with open type procedures. Our purpose was to compare failure rates and functional outcomes of the arthroscopic inferior capsular shift in contact and non-contact athletes. We hypothesized that contact and non-contact athletes would exhibit excellent functional outcomes and return to sport with low recurrence rates. Methods: A consecutive series of 69 shoulders in 61 contact and non-contact athletes underwent an arthroscopic inferior capsular shift with ≥3 suture anchors by a single surgeon (1999-2018). Thirty shoulders in 26 contact athletes (6 women; 25.3±8.1 years) and 39 shoulders in 35 non-contact athletes (7 women; 34.8±10.0 years) were included. Inclusion criteria were complete anterior inferior labral detachment (6 unit hours) and ≥2-year follow-up. Exclusion criteria included multidirectional instability, engaging Hill Sachs lesion or glenoid bone loss >30%. A modified 3-portal technique utilizing the outside-in method was employed. A conservative rehabilitation program was followed with return to sport no sooner than 3 months in non-contact, 4-5 months in contact, and 9 months in throwing athletes. Functional outcomes were measured using Constant Scores, American Shoulder and Elbow Surgeons (ASES) Score, Western Ontario Shoulder Instability Index (WOSI), Melbourne Instability Shoulder Scale (MISS), and Rowe. Forward elevation, external rotation at side and 90° abduction and internal rotation range of motion (ROM) were measured. Independent samples t-tests were used to assess differences in outcomes between contact and non-contact athletes (Bonferroni correction: p<0.006). Results: Follow-up was 11.0±3.5 years (range 2-16 years) in contact athletes and 12.2±4.3 years (range 2-21 years) in non-contact athletes (p=0.264). Contact athletes were significantly younger than non-contact athletes (p<0.0001). An average of 3.9±1.7 and 3.1±1.0 suture anchors were used in contact and non-contact groups, respectively (p=0.348). There were no significant differences in post-operative functional scores (all p>0.053) or shoulder ROM (all p>0.034) between groups. Forward flexion was 163.75±16.8° pre-operatively and 168.89±13.0° post-operatively in contact athletes (p=0.212) and 162.5±13.7° preoperatively and 170±7.7° post-operatively in non-contact athletes (p=0.005). External rotation at the side was 59.04±19.4° pre-operatively and 67.9±18.6° value post-operatively in contact athletes (p=0.094) and 52.94±25.1° pre-operatively and 62.83±14.3° post-operatively in non-contact athletes (p=0.062). External rotation at 90° abduction was 92.61±20.1° pre-operatively and 93.39±12.9° post-operatively in contact athletes (p=0.867) and 88.33±21.1° pre-operatively and 87.5±8.1° post-operatively in non-contact athletes (p=0.842).Internal rotation behind the back was to an average of T11 pre-operatively and T9 post-operatively in contact athletes (p=0.004) and L1 pre-operatively and T9 post-operatively in non-contact athletes (p=0.001).In contact and non-contact athletes, respectively, Rowe scores were 65.35±17.6 and 51.25±13.2 preoperatively and 89.22±17.6 and 96.25±12.4 post-operatively (p=0.002 and p<0.001); Constant Scores were 75.69±12.6 and 61.67±11.3 pre-operatively 85.79±19.6 and 89.71±13.6 post-operatively; ASES scores were 80.40±15.3 and 62.14±22.2 pre-operatively and 93.91±9.9 and 86.06±20.7 post-operatively (p<0.001 and p<0.001); MISS scores were 59.36±12.4 and 48.39±15.5 preoperatively and 88.20±13.5 and 75.75±19.7 post-operatively (p<0.001 and p<0.001); WOSI was 3.50±1.3 and 4.55±1.4 pre-operatively and 1.70±3.0 and 2.94±2.7 post-operatively (p=0.101 and p=0.066). Overall recurrence rate was 4.3% (3/69). Two contact athletes (2/30; 6.7%) and one non-contact athlete (1/39; 2.6%) experienced a traumatic recurrent instability event requiring revision surgery (p=0.439). These three patients underwent a revision arthroscopic inferior capsular shift with an additional 3-4 plication sutures and returned to pre-injury sports including hockey, football, skiing, and tennis without recurrence of instability at greater than 7 years following the revision surgery. Conclusions: Modified arthroscopic inferior capsular shift utilizing ≥3 suture anchors with plication sutures returns contact and non-contact athletes to sports with excellent functional outcomes, low recurrence rates (3/69), and full unrestricted ROM. While loss of ROM is a concern, particularly in overhead athletes, ROM was successfully restored in all patients, most notably in external rotation at 90° abduction. We recommend a modified arthroscopic inferior capsular shift with plication sutures as the primary procedure in all athletes with anterior instability with less than 30% bone loss excluding those with high Beighton scores rather than a Latarjet.