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Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability

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Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability Journal of Clinical Medicine Article Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability Robert C. Palmer 1, David A. Podeszwa 1,2, Philip L. Wilson 1,2 and Henry B. Ellis 1,2,* 1 Scottish Rite for Children, Dallas, TX 75219, USA; [email protected] (R.C.P.); [email protected] (D.A.P.); [email protected] (P.L.W.) 2 Department of Orthopeadics, University of Texas Southwestern Medical Center, Dallas, TX 75033, USA * Correspondence: [email protected] Abstract: Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Previous studies have estimated the incidence of acute patellar dislocation at 43 per 100,000 children younger than age 16 years. The medial patellofemoral ligament (MPFL) complex is a static soft tissue constraint that stabilizes the patellofemoral joint serving as a checkrein to prevent lateral displacement. The causes of PFI are multifactorial and not attributed solely to anatomic features within the knee joint proper. Specific anatomic features to consider include patella alta, increased tibial tubercle–trochlear groove distance, genu valgum, external tibial torsion, femoral anteversion, and ligamentous laxity. The purpose of this paper is to provide a review of the evaluation of PFI in the pediatric and adolescent patient with a specific focus on the contributions of coronal and transverse plane deformities. Moreover, a framework will be provided for the incorporation of bony procedures to address these issues. Keywords: pediatric patellar instability; coronal malalignment; genu valgum; rotational malalignment; Citation: Palmer, R.C.; Podeszwa, D.A.; femoral anteversion; tibial torsion Wilson, P.L.; Ellis, H.B. Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability. J. Clin. Med. 2021, 10, 3035. https://doi.org/ 1. Introduction 10.3390/jcm10143035 Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Dislocations are almost always to the lateral side of Academic Editor: the femoral trochlea. Patellar subluxation occurs when the patella partially dislocates but Vicente Sanchis-Alfonso does not fully dislocate out of the trochlear groove [1]. In order to standardize terminology, Received: 7 June 2021 Parikh and Lykissas provided a comprehensive 4-part classification for lateral PFI that Accepted: 2 July 2021 includes first-time dislocators (type I), recurrent patellar dislocation (type II), dislocatable Published: 8 July 2021 patella (type III), and dislocated patella (type IV) which have further sub-classifications for each type [2]. Frosch and Schmeling have published a classification scheme with similar Publisher’s Note: MDPI stays neutral considerations [3]. with regard to jurisdictional claims in The incidence of acute patellar dislocation has been estimated at 43 per 100,000 children published maps and institutional affil- younger than age 16 years [4]. In a pediatric population, greater than 60% of those with iations. a first-time dislocation may go on to recurrence, which is reported more commonly in females (~70%) than males [5,6]. A history of recurrent instability (two or more episodes) is predictive of future instability [7]. Younger children (<14 years of age) and those with trochlear dysplasia are more likely to experience recurrent dislocations [8,9]. Hevesi et al. Copyright: © 2021 by the authors. developed a scoring system known as the recurrent instability of the patella score that Licensee MDPI, Basel, Switzerland. focuses on four factors, including age <25 years (2 points), skeletal immaturity (1 pt), This article is an open access article trochlear dysplasia (1 pt), and the tibial tubercle–trochlear groove to patellar length ratio distributed under the terms and (TT–TG/PL) (1 pt). Patients were stratified into three groups of low- (0–1), intermediate- conditions of the Creative Commons (2–3), and high-risk (4–5) groups based on these factors. Instability-free survival was Attribution (CC BY) license (https:// provided at 1, 2, 5 and 10 years; for the high-risk group, this was 84.4% at 1 year, 62.5% at creativecommons.org/licenses/by/ 2 years, 34.4% at 5 years, and 20.8% at 10 years [10]. 4.0/). J. Clin. Med. 2021, 10, 3035. https://doi.org/10.3390/jcm10143035 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 3035 2 of 19 The medial patellofemoral ligament (MPFL) complex is a static soft tissue constraint that stabilizes the patellofemoral joint serving as a checkrein to prevent lateral displace- ment. Other static osseous constraints include trochlear and patellar morphology and skeletal alignment, which should be evaluated in both the coronal (angular) and transverse (rotational) planes with regard to PFI [11]. Specific anatomic features to consider include patella alta, increased tibial tubercle–trochlear groove distance, genu valgum, external tibial torsion, femoral anteversion, and ligamentous laxity [5,12,13]. The combination of excessive femoral anteversion, patella alta, an increased Q-angle, and excessive external tibial torsion is known as “miserable malignment” which has historically been associated with recurrent PFI [14,15]. As highlighted above, the causes of PFI are multifactorial and not attributed solely to anatomic features within the knee joint proper. Rarely, medial patellofemoral instability can occur and typically associated with an iatrogenic etiology (i.e., prior lateral release). Thus, the current manuscript will exclusively focus on lateral patellofemoral instability when referencing PFI. The purpose of this paper is to provide a review of the evaluation of PFI in the pediatric and adolescent patient with a specific focus on the contributions of coronal and transverse plane deformities. Moreover, a framework will be provided for the incorporation of bony procedures to address these issues. 1.1. Patient History Depending on the type of PFI, the patient may describe the symptoms in many different manners. Some may merely describe frequent falling, while many endorse fear of a ‘knee cap’ problem with no true dislocation. In the acute, traumatic patellar dislocation, the patient may describe hearing or feeling a pop at the time of injury with observation of a knee deformity and swelling when the patella dislocates laterally. Specific points of the patient’s history to elicit should include the patient’s level of activity, mechanism of the event, history of previous dislocations, total number of dislocations, how the dislocation reduced, and the timing and severity of effusion following the event. Dislocations commonly spontaneously reduce or reduce with extension of the knee, but a minority may require assisted reduction with sedation. Acutely following instability events, the physician should carefully assess the patient for mechanical symptoms which may suggest the presence of a loose body from an osteochondral injury. An understanding of the patient’s activity level can also be valuable at the onset as this can help guide treatment decision making. Emphasis is also placed on obtaining a thorough family history of PFI, as well as ligamentous laxity and associated conditions (e.g., generalized ligamentous laxity, Ehlers– Danlos syndrome, Marfan Syndome, Down syndrome, Ellis–van Creveld syndrome, nail- patella syndrome, Rubenstein–Taybi syndrome, Kabuki syndrome, hypotonic cerebral palsy, and hypoplastic patella syndromes), which is critical to evaluate [1]. 1.2. Physical Exam A standard physical examination of PFI should begin with evaluating the patient’s standing limb alignment including an assessment of genu valgum and varum. Subtle deformity may be difficult to grossly visualize if not suspected. Significant genu valgum deformity can be assessed during an evaluation of gait or by having the patient stand upright. Genu valgum can be quantified by the intermalleolar distance. If significant femoral anteversion is present, one will appreciate the “squinting/kissing patella” where the patient’s feet are facing forward and the patella is facing towards the midline as if to ‘kiss’ the contralateral patella (Figure1)[ 16]. With special attention to rotational profile, upon gait assessment the examiner must document the patient’s foot progression angle (mean 10◦ external; range 3◦ internal to 20◦ external) [17]. The amount of generalized hyperlaxity may be an important consideration in evaluation of a patient with PFI. The Beighton hypermobility score is helpful in assessing ligamentous laxity (Table1)[ 18,19]. A score of five or greater is indicative of a hypermobile condition and may warrant further evaluation and consideration in treatment. J. Clin. Med. 2021, 10, x FOR PEER REVIEW 3 of 20 J. Clin. Med. 2021, 10, 3035 five or greater is indicative of a hypermobile condition and may warrant further evalua- 3 of 19 tion and consideration in treatment. Figure 1. ((left) image) Clinical appearance of excessive femoral version in a girl. With the knees in Figure 1. ((left) image) Clinical appearance of excessive femoral version in a girl. With the knees in full extension and the feet aligned (pointing straight forward), the patellae face inward. ((right) image) full extension and the feet aligned (pointing straight forward), the patellae face inward. ((right) im- Anotherage) Another patient patient demonstrates demonstrates significant significantoutward outward tibial angulation angulation with with the the patella patella facing facing for- forward, indicatingward, indicating significant
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