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      Patella re-alignment in children with a modified Grammont technique : Outcome in 65 knees after mean 8 years

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          Abstract

          Background and purpose

          In skeletally immature patients, surgical options due to recurrent patella dislocation are limited, because bony procedures bear the risk of growth disturbances. In this retrospective study, we report the long-term functional and radiographic outcome in skeletally immature patients using the modified Grammont surgical technique.

          Patients

          Between 1999 and 2004, 65 skeletally immature knees (49 children) were treated with a modified Grammont procedure: an open lateral release and a shift of the patella tendon insertion below the growth plate on the tuberositas tibia, allowing the tendon to medialize. At mean 8 (5.6–11) years after surgery, 58 knees in 43 patients were evaluated by clinical examination, from functional scores (Lysholm, Tegner), and from radiographs of the knees.

          Results

          Mean Lysholm score was 82 postoperatively. Tegner score decreased from 6.2 to 5. Eight knees had a single dislocation within 3 months of surgery. 3 knees had repeated late dislocations, all with a high grade of trochlea dysplasia. 6 knees showed mild signs of osteoarthritis. No growth disturbances were observed.

          Interpretation

          The modified Grammont technique in skeletally immature patients allows restoration of the distal patella tendon alignment by dynamic positioning. Long-term results showed that there were no growth disturbances and that there was good functional outcome. However, patients with a high grade of trochlea dysplasia tended to re-dislocate.

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          Most cited references37

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          Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.

          We have designed a scoring scale for knee ligament surgery follow-up emphasizing evaluation of symptoms of instability. Instability is defined as "giving way" during activity. Our scoring scale was compared to a slightly modified Larson scale in patients with anteromedial and/or anterolateral instability, posterolateral and straight posterior instability, chondromalacia patellae, and meniscus lesion. The two scales gave basically the same results in patients with meniscus rupture. In patients with unstable knees, the new scale gave a significantly lower total score. Thus, the new scale evaluates functional impairment due to clinical instability better than the modified Larson scale. The total score, with the new scoring scale, corresponded to the patients' own opinion of function and to the presence or absence of signs of instability.
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            Factors of patellar instability: an anatomic radiographic study.

            We analyzed the radiographs and computed tomography (CT) scans of 143 knees operated on for symptomatic patellar instability and 67 contralateral asymptomatic knees, together with 190 control knee radiographs and 27 control knee scans, to determine the factors affecting patellar instability. Four factors were relevant in knees with symptomatic patellar instability: (1) Trochlear dysplasia (85%), as defined by the crossing sign (96%) and quantitatively expressed by the trochlear bump, pathological above 3 mm or more (66%), and the trochlear depth, pathologic at 4 mm or less. (2) Quadriceps dysplasia (83%), defined a present when the patellar tilt in extension is more than 20% on the CT scans. (3) Patella alta (Caton-Deschamps) index greater than or equal to 1.2 (24%). (4) Tibial tuberosity-trochlear groove, pathological when greater than or equal to 20 mm (56%). The factors appeared in only 3%-6.5% of the control knees. The etiology of patellar instability is multifactorial. Determination of the factors permits an effective elective therapeutic plan which aims at correcting the anomalies present.
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              Acute patellar dislocation in children and adolescents: a randomized clinical trial.

              The treatment of acute patellar dislocation in children is controversial. Some investigators have advocated early repair of the medial structures, whereas others have treated this injury nonoperatively. The present report describes the long-term subjective and functional results of a randomized controlled trial of nonoperative and operative treatment of primary acute patellar dislocation in children less than sixteen years of age. The data were gathered prospectively on a cohort of seventy-four acute patellar dislocations in seventy-one patients (fifty-one girls and twenty boys) younger than sixteen years of age. Sixty-two patients (sixty-four knees) without large (>15 mm) intra-articular fragments were randomized to nonoperative treatment (twenty-eight knees) or operative treatment (thirty-six knees). Operative treatment consisted of direct repair of the damaged medial structures if the patella was dislocatable with the patient under anesthesia (twenty-nine knees) or lateral release alone if the patella was not dislocatable with the patient under anesthesia (seven knees). All but four patients who underwent operative treatment had a concomitant lateral release. The rehabilitation protocol was the same for both groups. The patients were seen at two years, and a telephone interview was conducted at a mean of six years and again at a mean of fourteen years. Fifty-eight patients (sixty-four knees; 94%) were reviewed at the time of the most recent follow-up. At the time of the most recent follow-up, the subjective result was either good or excellent for 75% (twenty-one) of twenty-eight nonoperatively treated knees and 66% (twenty-one) of thirty-two operatively treated knees. The rates of recurrent dislocation in the two treatment groups were 71% (twenty of twenty-eight) and 67% (twenty-four of thirty-six), respectively. The first redislocation occurred within two years after the primary injury in twenty-three (52%) of the forty-four knees with recurrent dislocation. Instability of the contralateral patella was noted in thirty (48%) of the sixty-two patients. The only significant predictor for recurrence was a positive family history of patellar instability. The mode of treatment and the existence of osteochondral fractures had no clinical or significant influence on the subjective outcome, recurrent patellofemoral instability, function, or activity scores. The long-term subjective and functional results after acute patellar dislocation are satisfactory in most patients. Initial operative repair of the medial structures combined with lateral release did not improve the long-term outcome, despite the very high rate of recurrent instability. A positive family history is a risk factor for recurrence and for contralateral patellofemoral instability. Routine repair of the torn medial stabilizing soft tissues is not advocated for the treatment of acute patellar dislocation in children and adolescents.
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                Author and article information

                Journal
                Acta Orthop
                Acta Orthop
                ORT
                Acta Orthopaedica
                Informa Healthcare
                1745-3674
                1745-3682
                October 2012
                22 October 2012
                : 83
                : 5
                : 504-510
                Affiliations
                1Department of Paediatric Orthopaedics, Medical University of Graz , Graz, Austria
                2Department of Trauma and Orthopaedics, Eastbourne District General Hospital , East Sussex, UK
                3Department of Orthopaedic and Traumatology for Children and Adults, Faculty of Medicine, Charles University Prague , Prague, Czech Republic.
                Author notes
                Article
                ORT_A_736168_O
                10.3109/17453674.2012.736168
                3488178
                23039166
                718cb3bc-efaf-435a-bb44-93b88c5be598
                Copyright: © Nordic Orthopaedic Federation

                This is an open-access article distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.

                History
                : 14 December 2011
                : 14 July 2012
                Categories
                Knee

                Orthopedics
                Orthopedics

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