THANK YOU 7/29/2016 DISCLOSURES PATELLOFEMORAL INSTABILITY INTO THE MYSTIC. Skeletally Immature Patients. Anthropology. Epidemiology.

Transcription

1 DETROIT REGIONAL SPORTS MEDICINE SYMPOSIUM THANK YOU Richard Hinton, MD, MPH, MEd, PT Medical and Fellowship Director MedStar Sports Medicine Baltimore / Washington richard.hinton@medstar.net, (410) , Union Memorial Hospital Baltimore, Maryland DISCLOSURES I have no personal disclosures related to today s talk MedStar Sports Medicine Fellowships receives institutional support for its sports medicine fellowship from Smith and Nephew DJO Global Depuy PATELLOFEMORAL INSTABILITY INTO THE MYSTIC Skeletally Immature Patients Anthropology Epidemiology Morphology 1

2 HOT TOPICS IN SPORTS KNEE SURGERY: MPFL Weber, AE JBJS, Am, 2016, 98, Arnoczky, S AJSM 1982, 10, MPFL SYSTEMATIC REVIEWS Am J Sports Med Feb 12. pii: [Epub ahead of print] Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for the Treatment of Recurrent Lateral Patellar Dislocations: A Systematic Review and Meta-analysis. Schneider DK 1, Grawe B 2, Magnussen RA 3, Ceasar A 4, Parikh SN 5, Wall EJ 5, Colosimo AJ 2, Kaeding CC 3, Myer GD 6 MPFL RECONSTRUCTION Pick the right patient Put the graft in the right place They do well. With reported outcomes is it time to rethink the relative surgical indications for first time dislocators based on a comprehensive view of host, agent, and environmental risk factors? 2

3 ACL RECONSTRUCTION IN COLLEGE ATHLETES 10 YEARS AGO Preselected, best subjects Physical characteristics Motivation Resources Outcomes Limited Defining success 5% Re tear rates Pat yourself on the back ACL RECONSTRUCTIONS IN 12 YEAR OLD FEMALES ACL injury on return to sports 15 to 20 % Humbling then Motivating Injury environment Imbalance Increasing exposure Constellation of risk factors Host: Mental and physical Environment: Physical and Social Agent: Energy Exchange PATELLOFEMROAL INSTABILITY Enumerating Orthopaedic Host Risk Factors RISK FACTORS Ligamentous laxity L/E misalignment Valgus Rotational Increased Q angle Increased TT TG distance Trochlear Dysplasia Patella Alta Quadriceps Dysfunction CONCERNS Isolated measurements in a constellations of risk factors Static measurements of active processes Limited reliability Lacking standardization Chondral versus osseous architecture Focus on host factors not the return environment 3

4 PATELLOFEMORAL INSTABILITY Searching for a better understanding. PATELLOFEMORAL INSTABILITY Understanding what it is to be human. WHAT IS IT TO BE HUMAN? Two Major Characteristics Large Brains ~1.8 Million Years Ago Bipedal, Upright, Alternating Gait ~ 3.5 Million 4

5 THEORIES ON BIPEDAL GAIT Traveling Efficiency Food Gathering at Heights Hands Free Carrying Model Thermoregulation Recognition of Danger / Resources Wading ASSOCIATES OF BIPEDAL GAIT LOWER EXTREMITY Longer leg bones Long, energy storing L/E muscles Wider pelvis Strong hip abductors Foot centered under body Full knee extension KNEE Bicondylar angle Lateral trochlear pillar Elongated, flattened condyles Shared patellofemoral and tibiofemoral joints FEMORAL BICONDYLAR ANGEL Phylogenic 5

6 FEMORAL BICONDYLAR ANGLE Ontogenic Shefelbine, S J: Bone 30, 5, May 2002, Pujol, A: J of Anatomy 10,225,3,5,2014 FEMORAL BICONDYLAR ANGLE Epigenetic and Genetic Javois, C: Orthopaedics and Traumatology, Surgery and Research 2009, 955, s49 s59 BICONDYLAR ANGLE Necessitates Lateral Trochlear Lip Lateral lip is phylogenetic Common labeler for hominid and bipedal gait Lovejoy, CO: Science Direct, gait and posture, 25, 2007, Fulkerson, JP: Disorders of the patellofemoral joint, 4 th edition 6

7 TROCHLEAR ARCHITECTURE Epiphysis genetically determined Rapid, integrated development Some maturation of PF in early childhood Most apparent differences dependent upon cartilage vs. bone phenotype Trochlear dysplasia is a complex malformation Constellation of malformations Trochlear formatioin also diaphyseal 7 weeks 8 weeks Guillen-Garcia, P in Gobbi, A the Patellofe,oral joint. ISAKOS 2014 Dejour, H: Knee Surg Sports Trauma, Arthro 1994, 2, TROCHLEAR ARCHITURE Diaphyseal vs. Epiphyseal Contribution Tardieu, C Am J of Phys Anthro 130, , 2006 EXTENSION VERSUS FLEXION Dominant Knee Great Apes Separate patellofemoral and tibiofemoral articulations Round rather than elliptical lateral condyles Flexed knee Flexed hip gait Lovejoy, CO: Science Direct, gait and posture, 25, 2007,

8 WHAT ARE WE BUILT FOR? ENERGY ABSORPTION AND RELEASE ENERGY ABSORPTION AND RELEASE The Root Cause of Sporting Injuries Not Prepared Neuromuscular Preparation Weakness Fatigue Attention Video Analysis Contact vs. Noncontact Noncontact vs. Avoidance 8

9 EPIDEMIOLOGIC / PUBLIC HEALTH APPROACH EPIDEMIOLOGY / ORGANIZATION Balancing Host, Agent, and Environmental Risk Factors Characteristics of Patients with Primary Acute Lateral Patellar Dislocation: Atkin, DM: AJSM 28, 4, 2000 Epidemiology and Natural History of Acute Patellar Dislocation: Fithian, DC et al: AJSM 32, 5, , 2004 The Dislocating Patella, Etiology and Prognosis: Runow, A: Acta Ortho Scand Supp 201, , 1983 Patella Instability in the Child and Adolescent: Hinton, R, Sharma, K: Surgery of the Knee, Insall and Kelly, 5th 2012, ELSEVIER Philadelphia. PA RISK FACTORS Characteristics of Patients with Primary Acute Lateral Patella Dislocation: Atkin, DM, AJSM 28, 4, 2000 METHOD Kaiser Permanente, San Diego, CA Captured, HMO Population Demographics on Patients and At Risk Population 367,335 Members 3 year Collection Period All Acute Patella Dislocations (Defined Diagnostic Criterion ) Data: Demographics, Questionnaire, History, Physical Exam, Diagnostic Imaging, Knee Scoring, Activity Rating RESULTS 74 Patients: 37 Men, 37 Women Avg. Age: 19.9 Avg. Annual Risk: 7 / 100,000 Highest Risk in Second Decade: 31 / 100,000 Women Second Decade: / 100,000 Men Second Decade : / 100,000 Women Third Decade: / 100,000 Men Third Decade: / 100,00 9

10 RISK FACTORS Primary, acute patella dislocation Atkin, DM, AJSM 28, 4, 2000 Mitchell, J: AJSM 2015,43,1676, 72 % In Sporting Activity April 21 66% In Level 1 Cutting Sports Scholastic athletes overall rate Second Decade Patients: 2.8 / 100,000 A/E s compared 7 Hours of Sports per Week to US population avg. of 2.3 / Similar to Primary ACL 100,000 person years Injury Each A /E same rate as annual Multiple studies * rate for general population Highest risk group yo Gymnastics in Initial dislocation associated competition vs practice with athletics or high demand physical activity Football 10.8 competition vs practice per 100,000 A/Es 51% in general population 95 % in military populations Hsiao, M: AJSM 2010, 38, , July 8, Sillanpaa, P: Med Sci Sports Exercise 2008, Waterman, BR: J Knee Surg, 2012, Mar, 25, 1, 51-7 RISK FACTORS AND CLASSIFICATION Epidemiology and Natural History of Acute Patella Dislocation: Fithian, DC, AJSM 32, 5, 2004 METHODS Kaiser Permanente, San Diego, CA 5 year collection period Acute Patella Dislocation Acute First Time Acute with a Previous History of Instability Hypothesis: These two groups of patients would represent distinct populations in terms of risk factors and outcomes. PREDICTORS OF RECURRENCE Fithian, DC, AJSM 32, 5, 2004 Age:.93 ( ) History of previous instability: 6.6 ( ) Family history: 3.7 ( ) Radiographic associated factors: Patella alta Jaquith, BP: J Peds Ortho 00, , 1-7 Radiographic predictors in adolescents 1) Age < 14 2) Contralateral dislocation 3) Trochlear dysplasia 4) Alta: Caton Deshamps >1.45 All 4 : 88% recurrence Any three 75 % Lewallen, L AJSM 2013, 41,575 Trochlear dysplasia B, C, B with skeletal immaturity 69 % recurrence 10

11 EPIDEMIOLOGY The Dislocating Patella: Etiology and Prognosis: Runow, A, Acta Ortho Scand 201, 54, METHODS Case Series of 104 Acute Dislocates Lund, Sweden Data: Historical, Physical Examination, Mechanism of Injury, Radiographs Pattern of Osteochondral and Avulsion Fractures Classification based on presence of patella alta ( as measured by Insall Method ) and hyper laxity CLASSIFICATION OF PATELLA DISLOCATION GRADE JOINT LAXITY INSALL > 1.3 % OF TOTAL AGE ONSET RECUR % BILAT % MOD TRAUMA % FXS % I NEG NEG II POS NEG III NEG POS IV POS POS * Runow, A Acata Ortho Scand 201, 54, 1 53, 1983 CONCURRENT INJURY The Dislocating Patella: Etiology and Prognosis: Runow, A, Acta Ortho Scand 201, 54,

12 RELATIVE IMBALANCE HIGH HOST LOWER ENVIRONMENT RISK FACTORS LOW HOST HIGH ENVIRONMENTAL RISK FACTORS RELATIVE CLASSIFICATION OF PATELLA DISLOCATION Traumatic, high energy, sports related Older at initial presentation and Osteochondral fxs Normal alignment, architecture and ligament function Equal sex distribution Single occurrence and Single leg involvement * Hinton, RY, Sharma, K: in the Child and Adolescent, Surgery of the Knee, Eds. Insall and Scott, Fifth Edition EPI RELATIVE CLASSIFICATION OF PATELLA DISLOCATION Lower age at onset and Laxity Atraumatic Abnormal alignment and architecture Chronic, Contralateral Sex dependent, with greater number of females * Hinton, RY, Sharma, K: in the Child and Adolescent, Surgery of the Knee, Eds. Insall and Scott, Fifth Edition

13 TONES VERSUS LACCS TONES Better rehabers op and non op If surgical, more likely just proximal Less surgical morbidity Higher surgical osteochondral lesions More often higher end athletes / high energy environment Possible surgery for return and scheduling needs for high end sports environment LAACS More likely surgery for recurrent instability More likely to require combined procedure for instability Higher surgical morbidity Try to modify risks Possible surgery required just for daily acuities ENVIRONMENTAL ( SOCIAL) RISKS American Youth Sports Culture Sports / Entertainment complex Over stressed entertainers and overweight spectators Sports specialization Increased game time Increased injury exposure No down time tolerance Demanding aggressive care like the pros Club SKELETALLY IMMATURE Knowledge Base for decision making: Normative Data Gausden, E: Medial patellofemoral ligament reconstruction in children and adolescents. JBJS Reviews2015, 3,10,

14 SKELETALLY IMMATURE Knowledge Base for decision making: Normative Data Walker, P: J Peds Ortho 18, 1, 1998, Redler, LH:AOSSM annual meeting 2016, abstract 105 SKELETALLY IMMATURE Knowledge Base for decision making: Normative Data Dickens, AJ: JBJS Am 2014, 96, TT TG DISTANCE Dickens et al: Pediatric /adolescent population Mean age 12.7 years Mean TT TG Norms 8.6 mm Patellar instability 12.1 Pennock, AT: AJSM42, , 2014 Mean age: 15.7 years Norms 11.7 mm Instability 16.3 mm Dickens, AJ: JBJS Am 2014, 96,

15 TT TG ISSUES Similar to Q Angle What degree of flexion Active or passive quads Weight bearing or non CT 2mm > MRI Most dependent on relative rotation of tibia on femur not true lateralization of the tubercule on the face of tibia. This changes with flexion and position Fairly wide range of normal values One piece of information TROCHLEAR DYSPLASIA Dejour, H: Knee Surg Sports Trauma, Arthro 1994, 2, SKELETALLY IMMATURE 15

16 FEMORAL PHYSIS Surgical Implications Kepler, CK: AJSM, July 2011, 39, 7, mm distal to the physis Cupping nature of the distal femoral physis Angle along, not through the growth plate Avoid tunnels ZONE OF INJURY Multiple Studies * Failure Patella greatest Different than adults Femur Midsubstance Combined *Kepler, CK: AJSM July 2011, 39, 7, *Felus, J: AJSM 2012, Oct, 40, *Zhang, G: Eur radiology, June 28, 2016, SURGICAL OPTIONS Comprehensive Assessment of Risk Factors Host, Agent, Environment Operative versus Non operative Proximal versus combined Growth plate sparing or traditional Other options Guided Growth Rotational Osteotomies Trochlearplasty 16

17 PRIMARY PATELLA DISLOCATION RELATIVE OPERATIVE NONOPERATIVE CARE INDICATIONS Still the majority of first time Other surgical co morbidities dislocators but evolving Osteochondral fracture Extensive, palpable deformity Failure of rehabilitation Early recurrent instability TONES going back to high energy environment with scheduling issues LAACS with high host risks, contra lateral recurrent or requiring surgery and non modifiable environment PROXIMAL vs. COMBINED PROCEDURE CONSTELLATION LLACS Multiple radiographic markers Ligamentous laxity Multiple misalignment RADIOGRAPHIC RANGES Trochlear dysplasia: B, C, D Alta: C.D > TT TG > MM PROXIMAL REALIGNEMENT PROCEDURES Weeks, KD: Sports Med Arthrosc Rev, 20, 3, Sept 2012, Gausden, E: Medial patellofemoral ligament reconstruction in children and adolescents. JBJS Reviews2015, 3,10,

18 DISTAL REALIGNEMTN PRODEDURES Weeks, KD: Sports Med Arthrosc Rev, 20, 3, Sept 2012, Gausden, E: Medial patellofemoral ligament reconstruction in children and adolescents. JBJS Reviews2015, 3,10, 1-11 REHAB AND RETURN TO PLAY Comprehensive Early quad activity / stim Avoid early valgus stress ACL like Core, Hips, Sporting core activity ACL type return to play RESOURCES FOR PATELLA INSTABILITY IN THE SKELETALLY IMMATURE Hinton, RY et al: Pediatric Knee, Patella Instability in Insall and Scott 5 th Edition, Surgery of the Knee, Elsevier, 2012, ( 6 th Edition due next several months ) Hennrikus, W et al: in the Skeletally Immature Athletes, JBJS Am 2013, 95, Gausden, E: Medial Patellofemoral Ligament reconstruction in children and adolescents. JBJS Reviews2015, 3,10, 1-11 Weeks, K: Surgical options for patella stabilization in the skeletally immature patient Weber, A: An algorithmic approach to the management of recurrent lateral patellar dislocation, JBJS Am, 2016,98, Cordasco, F: Patella Instability in the Skeletally immature patient: Vumedi, pediatric knee section 18

19 THANK YOU MPFL RECONSTRUCTION TECHNIQUE Hamstring Autograft Relative recreation of anatomy Femoral and patella origins Femoral and patella attachments Adequate graft Adequate fixation Decrease surgical trauma Appropriate graft tensioning Avoid physical injury Avoid patella fracture or other complications Adequate biomechanics for early rehabilitation MPFL RECONSTRUCTION Advance and repair native MPFL Patella fixation: two suture only anchors and perosteal sleeve Femoral fixation: 5.5 double loaded anchor and perosteal stitch Tension graft limbs separately Check relative isometricity 0 to 45 degrees with patella sutures and with graft limbs Tension at 30 degrees, lightly Evolution of technique; fixation, incision, etc 19

20 20

21 THANK YOU 21