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Prolonged rehabilitation may be needed in adolescents after medial patellofemoral ligament reconstruction
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Prolonged rehabilitation programs that go beyond 8 months may be needed for recovery of muscle strength to allow for safe return to sport in adolescent patients who undergo medial patellofemoral ligament reconstruction.
Michael G. Saper and colleagues performed a retrospective review of data for 28 adolescent patients who underwent medial patellofemoral ligament reconstruction and also underwent isometric and functional return-to-sport testing. Mean patient age was 14.9 years. Investigators compared data with findings for the other uninvolved limb. A limb symmetry index of 90% or greater was used to define the recovery of muscle strength.
Results showed 17 patients who underwent reconstruction with hamstring autograft and 10 patients who underwent concomitant tibial tubercle osteotomy. At a mean of 7.4 months, investigators performed testing.
The limb symmetry index for quadriceps strength was 85.3% and was 95.1% for hamstring strength. There was a statistically significant difference between isometric peak torque measured in the surgical and uninvolved limb with regard to knee extension.
There were 32% of patients who passed all four hop tests, and 63% of patients achieved anterior reach symmetry of less than 4 cm on the lower quarter Y-balance test.
No statistically significant difference was seen in isometric strength testing, hop tests or the lower quarter Y-balance test with regard to graft type or concomitant procedures. There was no association seen between isometric strength and performance on the lower quarter Y-balance test and hop tests. – by Monica Jaramillo
Disclosures: The researchers report no relevant financial disclosures.
Perspective
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Shital N. Parikh, MD
In a retrospective study, the authors evaluated isometric strength and dynamic functional tests in 28 adolescents at a mean of 7.4 months after patellar stabilization surgery, which involved medial patellofemoral ligament reconstruction with lateral retinacular surgery with or without tibial tubercle osteotomy. Only 44.4% of patients achieved greater than 90% quadriceps strength compared to contralateral limb and only 32% patients cleared all hop tests.
The strength of the study is the rigorous performance and analysis of return to sports (RTS) tests. The study concluded the RTS criteria cannot be based solely on the time from surgery and that prolonged rehabilitation programs may be required for safe RTS in this young population. The study raises two important and broader questions about the factors that contribute to postoperative limb asymmetry and validity of the RTS tests.
Preoperative limb asymmetry could be a predisposing factor for patellar instability, especially when the instability is recurrent; this information and indications for medial patellofemoral ligament reconstruction, LR surgery and concomitant surgery are lacking in the current study. Other factors including regional nerve blocks, knee position during graft tensioning, postoperative complications, compliance with physical therapy and sports-specific performance are confounding variables that may influence postoperative limb asymmetry and deficits, but were not investigated in the current study.
Although RTS tests have been widely used after ACL reconstruction, their validity to predict outcomes has been questioned. The current study did not correlate limb asymmetry with subjective (patient-reported outcomes, pain anxiety, fear) or objective (apprehension) outcomes. It is not known if limb asymmetry and residual deficits contribute to patellar redislocation, increased risk of knee injury, increased risk of contralateral knee injury, decreased performance or decreased subjective score. Further studies should validate the RTS tests and criteria to determine their true prognostic value before these test are used as benchmarks for patient counseling.
Cincinnati
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