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Knee Surgery, Sports Traumatology, Arthroscopy
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 12/2017

01-12-2017 | Knee

Assessment of demographic and pathoanatomic risk factors in recurrent patellofemoral instability

Authors: Laurie Anne Hiemstra, Sarah Kerslake, Mark Lafave

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 12/2017

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Abstract

Purpose

The WARPS/STAID classification employs clinical assessment of presenting features and anatomic characteristics to identify two distinct subsets of patients within the patellofemoral instability population. The purpose of this study was to further define the specific demographics and the prevalence of risky pathoanatomies in patients classified as either WARPS or STAID presenting with recurrent patellofemoral instability. A secondary purpose was to further validate the WARPS/STAID classification with the Banff Patella Instability Instrument (BPII), the Marx activity scale and the Patellar Instability Severity Score (ISS).

Methods

A convenience sample of 50 patients with recurrent patellofemoral instability, including 25 WARPS and 25 STAID subtype patients, were assessed. Clinical data were collected including assessment of demographic risk factors (sex, BMI, bilaterality of symptoms, affected limb side and age at first dislocation) and pathoanatomic risk factors (TT-TG distance, patella height, patellar tilt, grade of trochlear dysplasia, Beighton score and rotational abnormalities of the tibia or femur). Patients completed the BPII and the Marx activity scale. The ISS was calculated from the clinical assessment data. Patients were stratified into the WARPS or STAID subtypes for comparative analysis. An independent t test was used to compare demographics, the pathoanatomic risk factors and subjective measures between the groups. Convergent validity was tested with a Pearson r correlation coefficient between the WARPS/STAID and ISS scores.

Results

Demographic risk factors statistically associated with a WARPS subtype included female sex, age at first dislocation and bilaterality. Pathoanatomic risk factors statistically associated with a WARPS subtype included trochlear dysplasia, TT-TG distance, generalized ligamentous laxity, patellar tilt and rotational abnormalities. The independent t test revealed a significant difference between the ISS scores: WARPS subtype (M = 4.4, SD = 1.1) and STAID subtype (M = 2.5, SD = 1.5); t(48) = 5.2, p < 0.001. The relationship between the WARPS/STAID and the ISS scores, measured using a Pearson r correlation coefficient, demonstrated a strong relationship: r = −0.61, n = 50, p < 0.001.

Conclusions

This study has demonstrated statistically significant evidence that certain demographics and pathoanatomies are more prevalent in each of the WARPS and STAID patellofemoral instability subtypes. There was no difference in quality-of-life or activity level between the subtypes. The WARPS/STAID score demonstrated convergent validity to the ISS and divergent validity to the BPII score and the Marx activity scale. This study has further validated both the WARPS/STAID classification and the ISS of patients that present with recurrent patellofemoral instability.

Level of evidence

III.
Literature
1.
Ali SA, Helmer R, Terk MR (2010) Analysis of the patellofemoral region on MRI: association of abnormal trochlear morphology with severe cartilage defects. AJR Am J Roentgenol 194(3):721–727.CrossRefPubMed
2.
Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C (2000) Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med 28(4):472–479CrossRefPubMed
3.
Balcarek P, Jung K, Ammon J, Walde TA, Frosch S, Schuttrumpf JP, Sturmer KM, Frosch KH (2010) Anatomy of lateral patellar instability: trochlear dysplasia and tibial tubercle-trochlear groove distance is more pronounced in women who dislocate the patella. Am J Sports Med 38(11):2320–2327.CrossRefPubMed
4.
Balcarek P, Oberthur S, Hopfensitz S, Frosch S, Walde TA, Wachowski MM, Schuttrumpf JP, Sturmer KM (2014) Which patellae are likely to redislocate? Knee Surg Sports Traumatol Arthrosc 22(10):2308–2314.CrossRefPubMed
5.
Balcarek P, Terwey A, Jung K, Walde TA, Frosch S, Schuttrumpf JP, Wachowski MM, Dathe H, Sturmer KM (2013) Influence of tibial slope asymmetry on femoral rotation in patients with lateral patellar instability. Knee Surg Sports Traumatol Arthrosc 21(9):2155–2163.CrossRefPubMed
6.
Bollier M, Fulkerson JP (2011) The role of trochlear dysplasia in patellofemoral instability. J Am Acad Orthop Surg 19(1):8–16CrossRefPubMed
7.
Brattstroem H (1964) Shape of the Intercondylar Groove Normally and in Recurrent Dislocation of Patella. A Clinical and X-Ray-Anatomical Investigation. Acta Orthop Scand Suppl 68(SUPPL 68):61–148
8.
Carter C, Sweetnam R (1958) Familial joint laxity and recurrent dislocation of the patella. J Bone Joint Surg Br 40(B(4)):664–667PubMed
9.
Cootjans K, Dujardin J, Vandenneucker H, Bellemans J (2013) A surgical algorithm for the treatment of recurrent patellar dislocation. Results at 5 year follow-up. Acta Orthop Belg 79(3):318–325PubMed
10.
Dejour D, Le Coultre B (2007) Osteotomies in patello-femoral instabilities. Sports Med Arthrosc 15(1):39–46.CrossRefPubMed
11.
Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2(1):19–26CrossRefPubMed
12.
Diederichs G, Issever AS, Scheffler S (2010) MR imaging of patellar instability: injury patterns and assessment of risk factors. Radiographics 30(4):961–981.CrossRefPubMed
13.
Escala JS, Mellado JM, Olona M, Gine J, Sauri A, Neyret P (2006) Objective patellar instability: MR-based quantitative assessment of potentially associated anatomical features. Knee Surg Sports Traumatol Arthrosc 14(3):264–272.CrossRefPubMed
14.
Fithian DC, Paxton EW, Cohen AB (2004) Indications in the treatment of patellar instability. J Knee Surg 17(1):47–56CrossRefPubMed
15.
Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, White LM (2004) Epidemiology and natural history of acute patellar dislocation. Am J Sports Med 32(5):1114–1121.CrossRefPubMed
16.
17.
Fucentese SF, von Roll A, Koch PP, Epari DR, Fuchs B, Schottle PB (2006) The patella morphology in trochlear dysplasia–a comparative MRI study. Knee 13(2):145–150.CrossRefPubMed
18.
Gausden EF, Fabricant PD, Taylor SA, McCarthy MM, Weeks KD, Potter H, Shubin Stein B, Green DW (2015) medial patellofemoral ligament reconstruction in children and adolescents. J Bone Joint Surg. doi:10.​2106/​JBJS.​RVW.​N.​00091
19.
Gillespie D, Mandziak D, Howie C (2015) Influence of posterior lateral femoral condyle geometry on patellar dislocation. Arch Orthop Trauma Surg 135(11):1503–1509.CrossRefPubMed
20.
Grelsamer RP, Bazos AN, Proctor CS (1993) Radiographic analysis of patellar tilt. J Bone Joint Surg Br 75(5):822–824PubMed
21.
Hiemstra LA, Kerslake S, Lafave M, Heard SM, Buchko GM (2014) Introduction of a classification system for patients with patellofemoral instability (WARPS and STAID). Knee Surg Sports Traumatol Arthrosc 22(11):2776–2782.CrossRefPubMed
22.
Hiemstra LA, Kerslake S, Lafave MR, Heard SM, Buchko GM, Mohtadi NG (2013) Initial validity and reliability of the Banff Patella Instability Instrument. Am J Sports Med 41(7):1629–1635.CrossRefPubMed
23.
Hiemstra LK, Kerslake S, Lafave MR (2016) Effect of Trochlear Dysplasia on outcomes after isolated soft-tissue stabilization for patellar instability. Am J Sports Med 44(6):1515–1523.CrossRefPubMed
24.
Hinton RY, Sharma KM (2003) Acute and recurrent patellar instability in the young athlete. Orthop Clin North Am 34(3):385–396CrossRefPubMed
25.
26.
27.
28.
29.
Kohlitz T, Scheffler S, Jung T, Hoburg A, Vollnberg B, Wiener E, Diederichs G (2013) Prevalence and patterns of anatomical risk factors in patients after patellar dislocation: a case control study using MRI. Eur Radiol 23(4):1067–1074.CrossRefPubMed
30.
Larsen E, Lauridsen F (1982) Conservative treatment of patellar dislocations. Influence of evident factors on the tendency to redislocation and the therapeutic result. Clin Orthop Relat Res 171:131–136
31.
Lewallen L, McIntosh A, Dahm D (2015) First-time patellofemoral dislocation: risk factors for recurrent instability. J Knee Surg 28(4):303–309.CrossRefPubMed
32.
Lewallen LW, McIntosh AL, Dahm DL (2013) Predictors of recurrent instability after acute patellofemoral dislocation in pediatric and adolescent patients. Am J Sports Med 41(3):575–581.CrossRefPubMed
33.
Lippacher S, Dejour D, Elsharkawi M, Dornacher D, Ring C, Dreyhaupt J, Reichel H, Nelitz M (2012) Observer agreement on the Dejour trochlear dysplasia classification: a comparison of true lateral radiographs and axial magnetic resonance images. Am J Sports Med 40(4):837–843.CrossRefPubMed
34.
Maenpaa H, Lehto MU (1996) Patellar dislocation has predisposing factors. A roentgenographic study on lateral and tangential views in patients and healthy controls. Knee Surg Sports Traumatol Arthrosc 4(4):212–216CrossRefPubMed
35.
Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF (2001) Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med 29(2):213–218CrossRefPubMed
36.
Mehta VM, Inoue M, Nomura E, Fithian DC (2007) An algorithm guiding the evaluation and treatment of acute primary patellar dislocations. Sports Med Arthrosc 15(2):78–81.CrossRefPubMed
37.
Nomura E, Inoue M (2005) Second-look arthroscopy of cartilage changes of the patellofemoral joint, especially the patella, following acute and recurrent patellar dislocation. Osteoarthr Cartilage 13(11):1029–1036.CrossRef
38.
39.
Nove-Josserand L, Dejour D (1995) Quadriceps dysplasia and patellar tilt in objective patellar instability. Rev Chir Orthop Reparatrice Appar Mot 81(6):497–504PubMed
40.
41.
Runow A (1983) The dislocating patella. Etiology and prognosis in relation to generalized joint laxity and anatomy of the patellar articulation. Acta Orthop Scand Suppl 201:1–53CrossRefPubMed
42.
Senavongse W, Amis AA (2005) The effects of articular, retinacular, or muscular deficiencies on patellofemoral joint stability: a biomechanical study in vitro. J Bone Joint Surg Br 87(4):577–582.CrossRefPubMed
43.
Sillanpaa P, Mattila VM, Iivonen T, Visuri T, Pihlajamaki H (2008) Incidence and risk factors of acute traumatic primary patellar dislocation. Med Sci Sports Exerc 40(4):606–611.CrossRefPubMed
44.
Song GY, Hong L, Zhang H, Zhang J, Li X, Li Y, Feng H (2014) Trochleoplasty versus nontrochleoplasty procedures in treating patellar instability caused by severe trochlear dysplasia. Arthroscopy 30(4):523–532.CrossRefPubMed
45.
Stanitski CL (1995) Articular hypermobility and chondral injury in patients with acute patellar dislocation. Am J Sports Med 23(2):146–150CrossRefPubMed
46.
Stanitski CL, Paletta GA Jr (1998) Articular cartilage injury with acute patellar dislocation in adolescents. Arthroscopic and radiographic correlation. Am J Sports Med 26(1):52–55CrossRefPubMed
47.
Steensen RN, Bentley JC, Trinh TQ, Backes JR, Wiltfong RE (2015) The prevalence and combined prevalences of anatomic factors associated with recurrent patellar dislocation: a magnetic resonance imaging study. Am J Sports Med 43(4):921–927.CrossRefPubMed
48.
Stefancin JJ, Parker RD (2007) First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat Res 455:93–101.CrossRefPubMed
49.
Stephen JM, Lumpaopong P, Dodds AL, Williams A, Amis AA (2015) The effect of tibial tuberosity medialization and lateralization on patellofemoral joint kinematics, contact mechanics, and stability. Am J Sports Med 43(1):186–194.CrossRefPubMed
50.
Van Haver A, De Roo K, De Beule M, Labey L, De Baets P, Dejour D, Claessens T, Verdonk P (2015) The effect of trochlear dysplasia on patellofemoral biomechanics: a cadaveric study with simulated trochlear deformities. Am J Sports Med 43(6):1354–1361.CrossRefPubMed
51.
van Huyssteen AL, Hendrix MR, Barnett AJ, Wakeley CJ, Eldridge JD (2006) Cartilage-bone mismatch in the dysplastic trochlea. An MRI study. J Bone Joint Surg Br 88(5):688–691.CrossRefPubMed
52.
Waterman BR, Belmont PJ Jr, Owens BD (2012) Patellar dislocation in the United States: role of sex, age, race, and athletic participation. J Knee Surg 25(1):51–57CrossRefPubMed
53.
Yeung M, Leblanc MC, Ayeni OR, Khan M, Hiemstra LA, Kerslake S, Peterson D (2015) Indications for medial patellofemoral ligament reconstruction: a Systematic Review. J Knee Surg. doi:10.​1055/​s-0035-1564730 PubMed
Metadata
Title
Assessment of demographic and pathoanatomic risk factors in recurrent patellofemoral instability
Authors
Laurie Anne Hiemstra
Sarah Kerslake
Mark Lafave
Publication date
01-12-2017
Publisher
Springer Berlin Heidelberg
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 12/2017
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-016-4346-0

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