Top

Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

10-04-2023 | KNEE

Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index

Authors: N. Sharma, L. Al-Mouazzen, J. H. Kuiper, P. Gallacher, A. Barnett

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 8/2023

Abstract

Purpose

Medial patellofemoral ligament reconstruction (MPFL-R) is a recognised surgical procedure for the treatment of recurrent patellofemoral instability with excellent outcomes reported. The aim of this study is to determine if body mass index can influence these outcomes.

Methods

This is a single-centre retrospective analysis of a longitudinal patellofemoral database. Patients with recurrent patellar instability, without patellar alta or severe trochlear dysplasia were treated using a MPFL-R between 2015 and 2019 at The Robert Jones & Agnes Hunt Orthopaedic Hospital. The clinical efficacy following surgery was assessed by Kujula, International Knee Documentation Committee Score (IKDC), and EuroQol-5 score (EQ-5D) at baseline and up to 26 months post-operatively; their safety assessed by complication rate and requirement for further surgery. The effect of Body Mass Index (BMI) on clinical outcome was analysed using linear, curvilinear, and segmented models following propensity score weighting.

Results

A total of 97 patients (97 Knees, mean age 25y) were analysed. Of these, 61 patients had a BMI < 30 kg/m² (mean age 23y, mean BMI 24) of which 7 patients (12.3%) required additional surgery. A further 36 patients had a BMI > 30 kg/m² (mean age 27y, mean BMI 36) of which 2 patients (5.6%) required additional surgery. The re-dislocation rate was 0% in each BMI group. Both groups had a significantly improved mean outcome following surgery, with improvements in mean IKDC above the minimum clinical important differences (MCID) of 20.5. BMI had an inverted J-shaped association with functional outcome, showing peak outcomes at BMI of 20.5 (95% CI 18.5 to 22.4; IKDC and Kujala) or BMI of 28 (EQ-5D index). No evidence for an association between BMI and complication risk was found.

Conclusion

BMI influences the functional outcomes in MPFL-R with an inverted J-shaped relation, without evidence it affected the complication or re-dislocation rate. In the absence of patella alta and severe trochlear dysplasia, an isolated MPFL reconstruction is a safe and effective procedure to treat patellar instability, with the best functional outcome in patients with a BMI around 20 to 21.

Level of evidence

Level III.

Austin PC, Stuart EA (2015) Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med 34:3661–3679. https://doi.org/10.1002/sim.6607CrossRefPubMedPubMedCentral

Bailey MEA, Metcalfe A, Hing CB, Eldridge J, BASK Patellofemoral Working Group (2021) Consensus guidelines for management of patellofemoral instability. Knee 29:305–312CrossRefPubMed

Baum G, Jacobs H, Lazovic D, Maus U, Hoffmann F, Seeber GH (2022) The influence of obesity on functional outcomes and patient satisfaction 8 weeks after total knee arthroplasty: results of the prospective FInGK study. BMC Musculoskelet Disord 23:949. https://doi.org/10.1186/s12891-022-05874-wCrossRefPubMedPubMedCentral

Bhaskaran K, dos Santos-Silva I, Leon DA, Douglas IJ, Smeeth L (2018) Association of BMI with overall and cause-specific mortality: a population-based cohort study of 3·6 million adults in the UK. Lancet Diabetes Endocrinol 6:944–953CrossRefPubMedPubMedCentral

Bouras T, Kuiper JH, Barnett A (2019) Isolated medial patellofemoral ligament reconstruction significantly improved quality of life in patients with recurrent patella dislocation: a response to Hiemstra et al’.s letter to the editor. Knee Surg Sports Traumatol Arthrosc 27:3735–3737CrossRefPubMed

D’Agostino RB, Rubin DB (2000) Estimating and using propensity scores with partially missing data. J Am Stat Assoc 95:749–759CrossRef

van Duijvenbode DC, van Dam MJJ, de Beer L, Stavenuiter MHJ, Hofstee DJ, van Dijke CF, Sjer AEB, Steen MW (2021) The reliability of the patellotrochlear index on magnetic resonance imaging for measuring patellofemoral height. Knee 32:56–63CrossRefPubMed

Enderlein D, Nielsen T, Christiansen SE, Faunø P, Lind M (2014) Clinical outcome after reconstruction of the medial patellofemoral ligament in patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 22:2458–2464CrossRefPubMed

Ferrua P, Compagnoni R, Calanna F, Randelli PS, Dejour D (2022) Good patient satisfaction with low complications rate after trochleoplasty in patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 30:3444–3450CrossRefPubMed

10.

Fong C, Hazlett C, Imai K (2018) Covariate balancing propensity score for a continuous treatment: application to the efficacy of political advertisements. Ann Appl Stat 12:156–177. https://doi.org/10.1214/17-AOAS1101CrossRef

11.

Fransen M, Edmonds J (1999) Reliability and validity of the EuroQol in patients with osteoarthritis of the knee. Rheumatology 38:807–813CrossRefPubMed

12.

Geraghty L, Humphries D, Fitzpatrick J (2022) Assessment of the reliability and validity of imaging measurements for patellofemoral instability: an updated systematic review. Skeletal Radiol 51:2245–2256CrossRefPubMed

13.

Huntington LS, Webster KE, Devitt BM, Scanlon JP, Feller JA (2020) Factors associated with an increased risk of recurrence after a first-time patellar dislocation: a systematic review and meta-analysis. Am J Sports Med 48:2552–256214CrossRefPubMed

14.

Irrgang JJ, Anderson AF, Boland AL, Harner CD, Neyret P, Richmond JC, Shelbourne KD (2006) Responsiveness of the international knee documentation committee subjective knee form. Am J Sports Med 34:1567–1573CrossRefPubMed

15.

Jenkins DG, Quintana-Ascencio PF (2020) A solution to minimum sample size for regressions. PLoS ONE 15:e0229345. https://doi.org/10.1371/journal.pone.0229345CrossRefPubMedPubMedCentral

16.

Kim HK, Parikh S (2022) Patellofemoral instability in children: imaging findings and therapeutic approaches. Korean J Radiol 23:674–687CrossRefPubMedPubMedCentral

17.

Kleiber C, Zeileis A (2008) Applied econometrics with R. Springer, New YorkCrossRef

18.

Kwon HM, Han CD, Yang I-H, Lee W-S, Kim CW, Park KK (2020) Being underweight is associated with worse surgical outcomes of total knee arthroplasty compared to normal body mass index in elderly patients. Orthop Res Rev 12:53–60PubMedPubMedCentral

19.

Laperche J, Feinn R, Myrick K, Halawi MJ (2022) Obesity and total joint arthroplasty: does weight loss in the preoperative period improve perioperative outcomes? Arthroplasty 4(1):47. https://doi.org/10.1186/s42836-022-00149-0CrossRefPubMedPubMedCentral

20.

Laxy M, Teuner C, Holle R, Kurz C (2018) The association between BMI and health-related quality of life in the US population: sex, age and ethnicity matters. Int J Obes 42:318–326CrossRef

21.

Mahajan R, Stokes M, Elliott A, Munawar DA, Khokhar KB, Thiyagarajah A, Hendriks J, Linz D, Gallagher C, Kaye D, Lau D, Sanders P (2020) Complex interaction of obesity, intentional weight loss and heart failure: a systematic review and meta-analysis. Heart 106:58–68CrossRefPubMed

22.

Migliorini F, Maffulli N, Bell A, Betsch M (2022) Outcomes, return to sport, and failures of MPFL reconstruction using autografts in children and adolescents with recurrent patellofemoral instability: a systematic review. Children (Basel). https://doi.org/10.3390/children9121892CrossRefPubMed

23.

Migliorini F, Trivellas A, Eschweiler J, Knobe M, Tingart M, Maffulli N (2022) Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 30:1282–1291CrossRefPubMed

24.

Muggeo VMR (2003) Estimating regression models with unknown break-points. Stat Med 22:3055–3071. https://doi.org/10.1002/sim.1545CrossRefPubMed

25.

Muthusamy N, Singh V, Sicat CS, Rozell JC, Lajam CM, Schwarzkopf R (2022) Trends of obesity rates between patients undergoing primary total knee arthroplasty and the general population from 2013 to 2020. J Bone Joint Surg Am 104:537–543CrossRefPubMed

26.

Nedunchezhiyan U, Varughese I, Sun AR, Wu X, Crawford R, Prasadam I (2022) Obesity, inflammation, and immune system in osteoarthritis. Front Immunol 13:907750CrossRefPubMedPubMedCentral

27.

Pauyo T, Park JP, Bozzo I, Bernstein M (2022) Patellofemoral instability part i: evaluation and nonsurgical treatment. J Am Acad Orthop Surg 30:e1431–e1442CrossRefPubMed

28.

Schöttle PB, Hensler D, Imhoff AB (2010) Anatomical double-bundle MPFL reconstruction with an aperture fixation. Knee Surg Sports Traumatol Arthrosc 18:147–151CrossRefPubMed

29.

Sharma N, Brown A, Bouras T, Kuiper JH, Eldridge J, Barnett A (2020) The Oswestry-Bristol classification. Bone Joint J 102-B:102–107CrossRefPubMed

30.

Sharma N, Rehmatullah N, Kuiper JH, Gallacher P, Barnett AJ (2021) Clinical validation of the Oswestry-Bristol classification as part of a decision algorithm for trochlear dysplasia surgery. Bone Joint J 103-B:1586–1594CrossRefPubMed

31.

Tan SHS, Lim BY, Chng KSJ, Doshi C, Wong FKL, Lim AKS, Hui JH (2020) The difference between computed tomography and magnetic resonance imaging measurements of Tibial Tubercle-Trochlear Groove distance for patients with or without patellofemoral instability: a systematic review and meta-analysis. J Knee Surg 33:768–776CrossRefPubMed

32.

Xu Z, Song Y, Deng R, Ye J, Wang X, Wang H, Yu J-K (2022) CT and MRI measurements of tibial tubercle lateralization in patients with patellar dislocation were not equivalent but could be interchangeable. Knee Surg Sports Traumatol Arthrosc 31(1):349–357. https://doi.org/10.1007/s00167-022-07119-8CrossRefPubMed

Title: Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index
Authors: N. Sharma
L. Al-Mouazzen
J. H. Kuiper
P. Gallacher
A. Barnett
Publication date: 10-04-2023
Publisher: Springer Berlin Heidelberg
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 8/2023
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-023-07391-2

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Please log in to get access to this content

Other articles of this Issue 8/2023

Mismatch between trochlear coronal alignment of arthritic knees and currently available prosthesis: a morphological analysis of 4116 knees and 45 implant designs

Preoperative factors associated with failure to reach the patient acceptable symptom state after anterior cruciate ligament reconstruction in patients aged 40 and older

Favourable clinical, arthroscopic and radiographic outcomes after autologous osteoperiosteal transplantation for massive medial cystic osteochondral defects of the talus

Quadriceps and hamstring anterior cruciate ligament reconstruction differ only marginally in function after the rehabilitation: a propensity score-matched case–control study

Development of a machine learning model to predict lateral hinge fractures by analyzing patient factors before open wedge high tibial osteotomy

A shallow morphology of the intertubercular groove is associated with medial and bilateral but not lateral pulley lesions