Less than 25% of pediatric MPFL, osteochondral fracture procedures needed second surgery
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In pediatric patients undergoing medial patellofemoral ligament reconstruction and osteochondral fracture fixation procedures, the rate of follow-up surgery was less than 25%, according to findings.
Daniel W. Green, MD, MS, FACS, and colleagues sought to determine the incidence of recurrent instability and second surgery following osteochondral fracture fixation with concomitant medial patellofemoral ligament reconstruction.
“We know that approximately 10% of cases with acute patella dislocation and a relatively significant osteochondral fracture that early surgical stabilization is often necessary,” Green, of the division of pediatric orthopedic surgery at Hospital for Special Surgery in New York, said in his presentation for the American Orthopaedic Society for Sports Medicine Annual Meeting. The meeting was held virtually. “For the past many years, we’ve done this simultaneously with an MPFL reconstruction with an attempt to try and preserve cartilage going forward.”
The researchers analyzed data from a retrospective review of 321 MPFL reconstructions performed by a single surgeon between 2011 and 2019. Of the surgeries performed, 38 knees underwent MPFL reconstruction with osteochondral fixation.
Green and colleagues found patients had an average age of 14.8 years at surgery and average follow-up of 2.1 years. The surgeon used an average of 4.4 biodegradable fixation nails.
The researchers identified that 27 fractures were fixed to the patella, while 10 fractures were fixed to the lateral femoral condyle or trochlea.
Ten patients required a second surgery on the ipsilateral knee, while eight underwent chondroplasty, Green and colleagues wrote. Four patients had removal of biodegradable fixation nails. Two patients had removal of hemi-epiphysiodesis or tibial tubercle osteotomy (TTO) hardware and one patient each had revision MPFL with TTO or lateral meniscus repair.
The one patient who had revision MPFL reconstruction was diagnosed with juvenile idiopathic arthritis and had three additional surgeries, the researchers wrote. Eight patients had a second surgery performed to address cartilage damage or nail removal.
“I think this is a reasonable approach for treating these patients with osteochondral fractures and patella instability,” Green said.
Perspective
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Seth L. Sherman, MD
There is a paucity of high-quality information regarding surgical fixation of osteochondral fractures associated with patella dislocation. In their e-poster at the AOSSM 2020 Virtual Meeting, Green and colleagues retrospectively reviewed 41 pediatric cases of osteochondral fracture fixation using biodegradable nails. This cohort represented 11% of their patients undergoing MPFL reconstruction for patella instability during a 10-year period. The vast majority of cases involved the patella (76%) and lateral femoral condyle (17%).
At 2-year follow-up, 2.1% of patients had failure of surgical fixation requiring cartilage restoration. Ninety-seven percent of knees with postoperative MRI demonstrated good incorporation. However, there was a 24% reoperation rate, with most of these patients requiring chondroplasty for small unhealed portion of their fracture.
The strengths of the study include a large single-surgeon experience, standardized technique and midterm follow-up. Relative weakness includes lack of subjective/objective data, information on return to pre-injury activity or multivariate analysis (ie, by lesion size and location, malalignment parameters). Additionally, a comparison with a matched cohort of patients without osteochondral fracture undergoing isolated MPFL reconstruction would be interesting.
Overall, this study provides useful information for preoperative planning and patient counseling. Surgeons should have a high index of suspicion to evaluate for osteochondral fracture of the patella and lateral femoral condyle following patella dislocation. The presence of a fixable osteochondral fracture is a clear surgical indication. Open reduction internal fixation with bioabsorbable nails can lead to favorable outcomes.
Concomitant soft tissue stabilization (MPFL reconstruction) is strongly recommended to protect the osteochondral site and the joint from further instability. While reoperation rates remain high, this combined procedure led to successful fracture healing and patella stabilization in most patients.
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Green DW, et al. ePoster 211. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 8-9, 2020 (virtual meeting).
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