When Should Bony Correction Be Considered in Addition to Medial Patellofemoral Ligament Reconstruction? Results of a Clinically Derived 2-Group Classification of Lateral Patellar Instability Based on 122 Patients at 2- to 5-Year Follow-up

Felix Zimmermann; Danko Dan Milinkovic; Alexander Zimmerer; Peter Balcarek

doi:10.1177/23259671221147572

When Should Bony Correction Be Considered in Addition to Medial Patellofemoral Ligament Reconstruction? Results of a Clinically Derived 2-Group Classification of Lateral Patellar Instability Based on 122 Patients at 2- to 5-Year Follow-up

Orthop J Sports Med. 2023 Jan 27;11(1):23259671221147572. doi: 10.1177/23259671221147572. eCollection 2023 Jan.

Authors

Felix Zimmermann¹, Danko Dan Milinkovic², Alexander Zimmerer³, Peter Balcarek^{3

4}

Affiliations

¹ BG Unfallklinik Ludwigshafen, Ludwigshafen am Rhein, Germany.
² Department of Orthopaedic Surgery, Charite Universitatsmedizin, Berlin, Germany.
³ Arcus Sportklinik, Pforzheim, Germany.
⁴ Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Göttingen, Germany.

Abstract

Background: The need for concomitant bony procedures to realign pathoanatomic risk factors in addition to medial patellofemoral ligament reconstruction (MPFL-R) remains unclear.

Purpose: To evaluate a clinically derived 2-part classification of lateral patellar instability aimed at identifying patients indicated for a concomitant bony procedure.

Study design: Cohort study; Level of evidence, 3.

Methods: The study included 122 patients (42 male, 80 female; mean ± SD age, 22 ± 6 years) who were assigned to a mild instability group (mIG) and a complex instability group (cIG) based on the reversed dynamic patellar apprehension test (ReDPAT) and J-sign. The mIG had a positive ReDPAT result <40° to 50° of knee flexion and an absent or low-grade J-sign (grade 1), and the cIG had a positive ReDPAT result >40° of knee flexion and/or a high-grade J-sign (grade 2 or 3). The mIG underwent isolated MPFL-R, and the cIG underwent MPFL-R and concomitant bony procedures depending on the established risk factor assessment. For evaluation, the BANFF Patellar Instability Instrument 2.0 (BPII 2.0) and numeric analog scale (0-10) for patellofemoral pain and subjective knee function were used. The minimal clinically important difference for the BPII 2.0 was ascertained by calculating half the standard deviation of baseline scores.

Results: Radiographic analysis confirmed a significantly more pronounced pathoanatomic risk factor constellation in the cIG regarding severity of trochlear dysplasia, distal malalignment, and patellar height (all P < .05). At final follow-up, no patellar redislocation occurred in either group; 2 patients in the cIG reported patellar subluxation. Within both groups, all outcome scores improved significantly pre- to postoperatively (all P < .0001); no between-group difference was found regarding BPII 2.0 score and numeric analog scale for function. The minimal clinically important difference for the BPII 2.0 was met by 84% (32/38) of the mIG and 90% (76/84) of the cIG (P = .36), but the cIG experienced more patellofemoral pain than the mIG (1.3 ± 1.6 vs 2.1 ± 2.1; P = .036).

Conclusion: Patients with a high-grade J-sign and/or a positive ReDPAT finding beyond 40° to 50° of knee flexion exhibited a significantly more pronounced pathoanatomic risk factor constellation; however, the correction of modifiable risk factors led to similarly good outcomes to patients who underwent isolated MPFL-R. A slightly higher level of patellofemoral pain after bony procedures was evident in these patients.

Keywords: BPII 2.0; MPFL-R; patellar instability; risk factor correction.