Similar results seen in skeletally immature, mature patients after ligament reconstruction

ByMax R. Wursta

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Similar outcomes and recurrence rates were found in skeletally immature and mature patients who underwent medial patellofemoral ligament reconstruction for recurrent lateral patellar instability, according to presented results.

Perspective from Etan Sugarman, MD

“Adult-type reconstruction techniques have been avoided in young patients due to the proximity of the femoral insertion of the [medial patellofemoral ligament] MPFL to the distal femoral physis,” said Joseph Nguyen, MPH, a musculoskeletal health specialist at Hospital for Special Surgery, who presented findings on MPFL reconstruction at the American Orthopaedic Society for Sports Medicine Annual Meeting. The meeting was held virtually.

“It is currently unclear how outcomes of MPFL reconstruction in skeletally immature patients compare to those who are skeletally mature patients,” Nguyen said in the presentation. “Many have suggested waiting until the growth plate closes before operating; however, between the risk of cartilage injury with each subsequent dislocation and the long-term effects on the young knee, the risk of waiting maybe even the higher,” he said.

From March 2014 to July 2018, Nguyen and colleagues analyzed 107 patients (25 skeletally immature patients and 82 skeletally mature patients) who underwent isolated MPFL reconstruction. Researchers compared return-to-sport rates and re-dislocation episodes. They also compared outcomes between standard, adult graft placement and graft placement distal to the physis, which avoids the growth plate, in a strictly pediatric cohort.

“Over 90% of patients were able to return to sport in both groups, with a high percentage of patients in both groups returning at the same or an even higher level of activity,” Nguyen said. “In the sub-analysis of skeletally immature patients, no differences were found in any outcomes between patients with standard graft placement vs. those with distal graft placement,” he said.

Additionally, no patients reported postoperative dislocations.

“Successful outcomes can be achieved in skeletally immature patients following MPFL reconstruction, or over these outcomes are aligned with outcomes in the skeletally mature patients,” Nguyen concluded. “Future studies with larger populations are needed to further investigate if any morphological differences impact patient outcomes, and additional studies are needed to study the impact of graft placement on the younger population,” he added.

Perspective

Etan Sugarman, MD

I read with great interest the article by Joseph Nguyen, MD, and colleagues regarding outcomes of isolated MPFL reconstruction in skeletally immature vs. skeletally mature patients.

MPFL reconstruction has been one of the cornerstone procedures to restore patellar kinematics after primary or recurrent patellar dislocation and decrease the risk of re-dislocation. However, many treating physicians are hesitant to operate on the skeletally immature patient for fear of damaging the femoral physis, which is often adjacent to the femoral origin of the MPFL. Without stabilization, there exists a significant risk of re-dislocation with the possibility of damage to the patellofemoral joint cartilage and potential for long-term sequelae to these young patients.

This study compared outcomes of 25 skeletally immature patients who underwent isolated MPFL reconstruction for patellar instability to a matched cohort of 82 skeletally mature patients undergoing the same procedure. Clinical outcomes were tracked for 2 years following MPFL reconstruction and, in this cohort, the authors found no significant differences in KOOS QoL, IKDC, KOOS PS and Kujala surveys. Clinically, a low incidence of re-dislocation, a high return-to-sport rate and no evidence of damage to the physis were seen.

These outcomes help demonstrate that significantly improved outcomes can be achieved in skeletally immature patients that equal their adult counterparts. Given the high rates of re-dislocation in younger patients, as well as their increased sport participation rate, this study shows me that stabilization at an earlier age appears to be safe and may help to prevent a significant number of cartilage injuries that might otherwise occur. Additionally, stabilization of the skeletally immature patient may allow patients who might otherwise have curtailed their sport participation secondary to fear of recurrent dislocation an opportunity to continue to participate in sports during these formative years.

Etan Sugarman, MD

Sports medicine surgeon

Assistant professor of orthopedic surgery

Lenox Hill Hospital, Northwell Health

New York

Disclosures: Sugarman reports no relevant financial disclosures.

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Source:

Nguyen J, et al. ePaper 192. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 8-9, 2020 (virtual meeting).

Disclosures: Nguyen reports no relevant financial disclosures.