Concomitant Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Osteotomy Do Not Increase the Incidence of 30-Day Complications: An Analysis of the NSQIP Database

Avinesh Agarwalla, Anirudh K Gowd, Joseph N Liu, Richard N Puzzitiello, Adam B Yanke, Nikhil N Verma, Brian Forsythe, Avinesh Agarwalla, Anirudh K Gowd, Joseph N Liu, Richard N Puzzitiello, Adam B Yanke, Nikhil N Verma, Brian Forsythe

Abstract

Background: Lateral patellar dislocations account for 2% to 3% of total knee injuries, especially in adolescents. Depending on the anatomic abnormality contributing to lateral patellar instability, medial patellofemoral ligament reconstruction (MPFLR) and/or tibial tubercle osteotomy (TTO) may be indicated.

Purpose: To assess the risk of adverse events (AEs) after TTO, MPFLR, and concomitant MPFLR and TTO.

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

Methods: Patients who underwent MPFLR, TTO, and concomitant MPFLR and TTO between 2005 and 2016 were identified through the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Medical complications (eg, surgical site infection and deep vein thrombosis), readmission rates, and extended hospital stay within 30 days of the procedure were recorded. Outcomes were compared with bivariate and multivariate Poisson regression.

Results: Out of 882 patients, 617 (70.0%) underwent isolated MPFLR, 170 (19.3%) underwent TTO, and 95 (10.8%) underwent concomitant MPFLR and TTO. The operative time for concomitant MPFLR and TTO was significantly longer (122 ± 45 minutes) compared with isolated MPFLR (97 ± 55 minutes; P < .001) and isolated TTO (89 ± 51 minutes; P < .001). There were 32 AEs (3.6%), with 10 AEs in the isolated TTO group (5.9%), 18 AEs in the isolated MPFLR group (2.9%), and 4 AEs in the MPFLR + TTO group (4.2%). There was no significant difference in the rate of AEs between the isolated MPFLR and isolated TTO groups (P = .1), isolated MPFLR and MPFLR + TTO groups (P = .5), and isolated TTO and MPFLR + TTO groups (P = .8). Diabetes mellitus was associated with an increased risk of developing an AE (odds ratio, 4.0; P = .003), and hypertension resulted in an increased risk of an extended hospital stay (odds ratio, 4.0; P = .010).

Conclusion: While concomitant MPFLR and TTO significantly increased operative time, there was no difference in the rate of AEs, extended hospital stay, and readmissions within 30 days after isolated MPFLR, isolated TTO, and concomitant MPFLR and TTO.

Keywords: NSQIP; complications; medial patellofemoral ligament; patellar dislocation; patellar instability; tibial tubercle osteotomy.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: A.B.Y. has received research support from NuTech and Arthrex; educational support from Medwest, Arthrex, and Smith & Nephew; and consulting fees from Aastrom Biosciences and JRF Ortho. N.N.V. has received research support from Arthrex, Arthrosurface, DJ Orthopaedics, Ossur, Athletico, ConMed Linvatec, MioMed, and Mitek; educational support from Medwest; royalties from Arthroscopy, Smith & Nephew, and Vindico Medical Education–Orthopedics Hyperguide; consulting fees from Arthrex, Medacta, Minivasive, OrthoSpace, and Smith & Nephew; nonconsulting fees from Pacira Pharmaceuticals; and stock options from CyMedica, Minivasive, and Omeros. B.F. has received research support from Arthrex and Stryker; honoraria from Arthrosurface; educational support from Medwest, Smith & Nephew, and Ossur; consulting fees from Sonoma Orthopedics and Stryker; royalties from Elsevier; and stock options from Jace Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
The surgical management of patellar instability significantly increased over the study period. MPFLR, medial patellofemoral ligament reconstruction; TTO, tibial tubercle osteotomy.

References

    1. Arendt EA, Askenberger M, Agel J, Tompkins MA. Risk of redislocation after primary patellar dislocation: a clinical prediction model based on magnetic resonance imaging variables. Am J Sports Med. 2018;46(14):3385–3390.
    1. Arshi A, Cohen JR, Wang JC, Hame SL, McAllister DR, Jones KJ. Operative management of patellar instability in the United States: an evaluation of national practice patterns, surgical trends, and complications. Orthop J Sports Med. 2016;4(8):2325967116662873.
    1. Askenberger M, Ekstrom W, Finnbogason T, Janarv PM. Occult intra-articular knee injuries in children with hemarthrosis. Am J Sports Med. 2014;42(7):1600–1606.
    1. Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med. 2000;28(4):472–479.
    1. Baumann CA, Pratte EL, Sherman SL, Arendt EA, Hinckel BB. Reconstruction of the medial patellotibial ligament results in favorable clinical outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):2920–2933.
    1. Bicos J, Fulkerson JP, Amis A. Current concepts review: the medial patellofemoral ligament. Am J Sports Med. 2007;35(3):484–492.
    1. Brandao GM, Junqueira DR, Rollo HA, Sobreira ML. Pentasaccharides for the treatment of deep vein thrombosis. Cochrane Database Syst Rev. 2017;12:CD011782.
    1. Colvin AC, West RV. Patellar instability. J Bone Joint Surg Am. 2008;90(12):2751–2762.
    1. Conlan T, Garth WP, Jr, Lemons JE. Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am. 1993;75(5):682–693.
    1. Davis CL, Pierce JR, Henderson W, et al. Assessment of the reliability of data collected for the Department of Veterans Affairs National Surgical Quality Improvement Program. J Am Coll Surg. 2007;204(4):550–560.
    1. Demers C. ESSENCE trial results: breaking new ground. Efficacy and safety of subcutaneous enoxaparin in non-Q wave coronary events. Can J Cardiol. 1998;14(suppl E):15E–19E.
    1. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med. 1998;26(1):59–65.
    1. Ebied AM, El-Kholy W. Reconstruction of the medial patello-femoral and patello-tibial ligaments for treatment of patellar instability. Knee Surg Sports Traumatol Arthrosc. 2012;20(5):926–932.
    1. Eriksson BI, Dahl OE, Rosencher N, et al. Oral dabigatran etexilate versus enoxaparin for venous thromboembolism prevention after total hip arthroplasty: pooled analysis of two phase 3 randomized trials. Thromb J. 2015;13:36.
    1. Fulkerson JP. Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop Relat Res. 1983;177:176–181.
    1. Keller RA, Moutzouros V, Dines JS, Bush-Joseph CA, Limpisvasti O. Deep venous thrombosis prophylaxis in anterior cruciate ligament reconstructive surgery: what is the current state of practice? Sports Health. 2018;10(2):156–159.
    1. Khuri SF. The NSQIP: a new frontier in surgery. Surgery. 2005;138(5):837–843.
    1. Koh JL, Stewart C. Patellar instability. Orthop Clin North Am. 2015;46(1):147–157.
    1. Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S. Lateral release of the patella: indications and contraindications. Am J Sports Med. 1990;18(4):359–365.
    1. LaPrade MD, Kallenbach SL, Aman ZS, et al. Biomechanical evaluation of the medial stabilizers of the patella. Am J Sports Med. 2018;46(7):1575–1582.
    1. McGee TG, Cosgarea AJ, McLaughlin K, Tanaka M, Johnson K. Rehabilitation after medial patellofemoral ligament reconstruction. Sports Med Arthrosc Rev. 2017;25(2):105–113.
    1. Mehta VM, Inoue M, Nomura E, Fithian DC. An algorithm guiding the evaluation and treatment of acute primary patellar dislocations. Sports Med Arthrosc Rev. 2007;15(2):78–81.
    1. Merican AM, Kondo E, Amis AA. The effect on patellofemoral joint stability of selective cutting of lateral retinacular and capsular structures. J Biomech. 2009;42(3):291–296.
    1. Neri T, Parker DA, Beach A, et al. Medial patellofemoral ligament reconstruction with or without tibial tubercle transfer is an effective treatment for patellofemoral instability. Knee Surg Sports Traumatol Arthrosc. 2019;27(3):805–813.
    1. Nomura E, Inoue M, Kurimura M. Chondral and osteochondral injuries associated with acute patellar dislocation. Arthroscopy. 2003;19(7):717–721.
    1. Nonweiler DE, DeLee JC. The diagnosis and treatment of medial subluxation of the patella after lateral retinacular release. Am J Sports Med. 1994;22(5):680–686.
    1. Payne J, Rimmke N, Schmitt LC, Flanigan DC, Magnussen RA. The incidence of complications of tibial tubercle osteotomy: a systematic review. Arthroscopy. 2015;31(9):1819–1825.
    1. Philippot R, Boyer B, Testa R, Farizon F, Moyen B. The role of the medial ligamentous structures on patellar tracking during knee flexion. Knee Surg Sports Traumatol Arthrosc. 2012;20(2):331–336.
    1. Redziniak DE, Diduch DR, Mihalko WM, et al. Patellar instability. J Bone Joint Surg Am. 2009;91(9):2264–2275.
    1. Saltzman BM, Rao A, Erickson BJ, et al. A systematic review of 21 tibial tubercle osteotomy studies and more than 1000 knees: indications, clinical outcomes, complications, and reoperations. Am J Orthop (Belle Mead NJ). 2017;46(6):e396–e407.
    1. Sanchis-Alfonso V, Montesinos-Berry E, Monllau JC, Merchant AC. Results of isolated lateral retinacular reconstruction for iatrogenic medial patellar instability. Arthroscopy. 2015;31(3):422–427.
    1. Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J. The tibial tuberosity-trochlear groove distance: a comparative study between CT and MRI scanning. Knee. 2006;13(1):26–31.
    1. Schoettle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med. 2007;35(5):801–804.
    1. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med. 2012;40(8):1916–1923.
    1. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006–2017.
    1. Sobh AH, Koueiter DM, Mells A, Siljander MP, Karadsheh MS. The role of aspirin and unfractionated heparin combination therapy immediately after total hip and knee arthroplasty. Orthopedics. 2018;41(3):171–176.
    1. Steensen RN, Bentley JC, Trinh TQ, Backes JR, Wiltfong RE. The prevalence and combined prevalences of anatomic factors associated with recurrent patellar dislocation: a magnetic resonance imaging study. Am J Sports Med. 2015;43(4):921–927.
    1. Stupay KL, Swart E, Shubin Stein BE. Widespread implementation of medial patellofemoral ligament reconstruction for recurrent patellar instability maintains functional outcomes at midterm to long-term follow-up while decreasing complication rates: a systematic review. Arthroscopy. 2015;31(7):1372–1380.
    1. Swarup I, Elattar O, Rozbruch SR. Patellar instability treated with distal femoral osteotomy. Knee. 2017;24(3):608–614.
    1. Tanaka MJ, Munch JL, Slater AJ, Nguyen JT, Shubin Stein BE. Incidence of deep venous thrombosis after tibial tubercle osteotomy: a single case series study. Orthop J Sports Med. 2014;2(8):2325967114544457.
    1. Tjoumakaris FP, Forsythe B, Bradley JP. Patellofemoral instability in athletes: treatment via modified Fulkerson osteotomy and lateral release. Am J Sports Med. 2010;38(5):992–999.
    1. Trickey AW, Wright JM, Donovan J, et al. Interrater reliability of hospital readmission evaluations for surgical patients. Am J Med Qual. 2017;32(2):201–207.

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