Good long-term results seen with medial reefing for recurrent patellar instability

Researchers found 100% patient satisfaction and a 5% rate of recurrent patellar instability.

Issue: July 2012

ORLANDO — Patients who underwent arthroscopically assisted isolated medial reefing for recurrent patellar instability showed a low rate of recurrent instability and high satisfaction with the procedure, according to a study presented at the Arthroscopy Association of North America Annual Meeting.

Perspective from Vipool K. Goradia, MD

“We had good results with long-term follow-up, with 100% satisfaction, a low rate of recurrent instability, and all of the following outcomes improved at long-term: pain, instability, swelling, Lysholm and Tegner scores, apprehension, patellar quadrant glide and lateral patellofemoral angle,” Madhav R. Boddula, MD, MPH, said during his presentation. “Our good results were maintained from mid- to long-term. The presence of preoperative chondral lesions did show decreased Lysholm and Tegner scores and increased osteoarthritis, suggesting that with the medial reefing technique the risk of osteoarthritis is low, and can be associated with chondral injury.”

Boddula and colleagues conducted a long-term study of 24 patients (25 knees) with patellar instability or normal bony alignment. Follow-up data was available for 19 patients (20 knees) with a mean age of 40 years and 11.8 years mean follow-up.

“The arthroscopically assisted technique was as follows,” Boddula said. “Percutaneous placement of sutures with a King needle is performed followed by bisecting the medial capsule with electrocautery. A mini-transverse incision was made, suture ends retrieved, and the medial and lateral capsules grasped and tied in pants-over-vest fashion.”

Outcomes measures included Lysholm score, Tegner activity score, patient satisfaction scores and physical exam findings. The investigators examined radiographs for congruence angle, lateral patellofemoral angles, lateral patellar displacement and operative reports for preoperative chondral lesions.

The researchers found pain, instability and swelling improved. On the Visual Analogue Scale (VAS), pain decreased from 6.4 to 1.9, instability decreased from 7.9 to 0.6 and swelling deceased from 5.1 to 0.9, according to the study abstract. Lysholm scores improved significantly from 53.2 to 86.2. Tegner activity scores also improved significantly from 3.2 to 4.7. Patellar apprehension decreased from 100% to 15%, and patellar quadrant glide decreased from 4.9 quadrants to 2.4 quadrants. The investigators noted improvements in all angles, most notably the lateral patellofemoral angle, which improved significantly from 5.7· to 8.6·. Recurrent instability rate was 5%.

“All patients were both satisfied with the results of their surgery and would have the same surgery performed again for the same symptoms at long-term,” Boddula said.

On radiographic examination, the researchers found 50% of knees showed signs of osteoarthritis, 35% of knees had medial soft tissue ossicles, and 39% of knees showed preoperative chondral lesions predominantly on the medial patellar facet. They noted an association between chondral lesions and lower Lysholm and Tegner scores, and an increased rate of osteoarthritis (OA). However, presence of OA was not associated with Lysholm or Tegner scores, but was linked to chondral lesions, according to Boddula.

“Isolated medial reefing should be considered to obtain good long-term results for patients with patellar instability and normal bony alignment,” he said. – by Renee Blisard Buddle

Reference:

Boddula MR, Adamson G, Pink M. Long-term outcomes of medial reefing for recurrent patellar instability. Paper #SS-75. Presented at the Arthroscopy Association of North America 2012 Annual Meeting. May 17-19. Orlando.

For more information:

Madhav R. Boddula, MD, MPH, can be reached at Kaiser Permanente Downey, 9353 Imperial Hwy, Downey, CA. 90242; email: boddula22@gmail.com.

Disclosure:

Boddula has no relevant financial disclosures.

Perspective

Vipool K. Goradia, MD

The study by Dr. Boddula looks at the long-term outcomes of medial reefing. I congratulate the authors on a long-term study of 142-month follow-up in 19 patients. It is important to note that in this recurrent instability group, they did not perform any lateral releases, which is appropriate. They had a 5% recurrent subluxation rate and found that chondral lesions were associated with degenerative joint disease at long-term follow-up.

Vipool K. Goradia, MD

Go Orthopedics

Chester, Va.

Disclosures: Goradia receives royalties and is a paid consultant for Arthrex Inc., owns stock in Cool Systems Inc., is on the editorial board of Arthroscopy and is a board member of the Arthroscopy Association of North America.