Tan Si Heng Sharon, Ngiam Erica Hian Kim, Lim Jia Ying, Lim Andrew Kean Seng, Hui James Hoipo
Department of Orthopaedic Surgery, National University Health System, Singapore.
Orthop J Sports Med. 2021 Apr 21;9(4):2325967121999642. doi: 10.1177/2325967121999642. eCollection 2021 Apr.
Proximal, distal, and combined proximal and distal procedures have been performed for patellofemoral instability in the presence of patella alta. No consensus exists regarding the accepted surgical management for this condition.
To pool the outcomes of surgical management for patellofemoral instability in the presence of patella alta and to determine whether the outcomes differ for different surgical techniques.
Systematic review; Level of evidence, 4.
This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported surgical outcomes for patellofemoral instability in the presence of patella alta were included. The random-effects model was used to analyze pooled estimates of preoperative and postoperative differences for outcomes that were reported in ≥3 studies. If heterogeneity existed among the studies, further analysis was performed using random-effects meta-regression analysis, which allowed for the identification of moderators.
A total of 11 studies with 546 knees were included. The pooled relative risk (RR) of having no patellofemoral dislocation and no patellofemoral apprehension or subjective instability postoperatively was 51.80 (95% CI, 20.75-129.31) and 48.70 (95% CI, 17.22-137.71), respectively. The pooled weighted mean improvement (WMI) for the Kujala and Lysholm scores postoperatively was 31.98 (95% CI, 28.66-35.30) and 35.93 (95% CI, 30.12-41.74), respectively. The pooled WMI for patellar tilt angles postoperatively was 10.94 (95% CI, 7.87-14.01). These outcomes were homogeneous across all studies. The pooled WMI for Insall-Salvati ratio, Caton-Deschamps index, and tibial tubercle-trochlear groove distance postoperatively was 0.31 (95% CI, 0.17-0.45), 0.24 (95% CI, 0.12-0.36), and 6.77 (95% CI, 1.96-11.58), respectively. These outcomes were heterogeneous across the studies, with the presence of distal procedures being a significant moderator. The presence of distal procedures had a significantly higher unweighted RR of 38.07 (95% CI, 2.37-613.09) for major complications compared with proximal procedures alone, although the incidence of minor complications was comparable (unweighted RR, 1.25; 95% CI, 0.35-4.48).
Surgical management for patellofemoral instability in the presence of patella alta consistently led to improvement in clinical and functional outcomes, regardless of the type of procedure performed. Distal procedures were better able to correct the patellar height and tibial tubercle-trochlear groove distance, although these procedures also posed a higher RR of subsequent surgery compared with proximal procedures alone.
对于高位髌骨合并髌股关节不稳定，已经开展了近端、远端以及近端和远端联合手术。对于这种情况，目前尚无公认的手术治疗方案。
汇总高位髌骨合并髌股关节不稳定的手术治疗结果，并确定不同手术技术的治疗结果是否存在差异。
系统评价；证据等级为4级。
本系统评价按照PRISMA（系统评价与Meta分析的首选报告项目）指南进行。纳入所有报告高位髌骨合并髌股关节不稳定手术结果的研究。对于≥3项研究所报告的结果，采用随机效应模型分析术前和术后差异的合并估计值。如果研究之间存在异质性，则使用随机效应Meta回归分析进行进一步分析，以确定调节因素。
共纳入11项研究，涉及546个膝关节。术后无髌股关节脱位、无髌股关节恐惧或主观不稳定的合并相对危险度（RR）分别为51.80（95%CI，20.75 - 129.31）和48.70（95%CI，17.22 - 137.71）。术后Kujala和Lysholm评分的合并加权平均改善（WMI）分别为31.98（95%CI，28.66 - 35.30）和35.93（95%CI，30.12 - 41.74）。术后髌骨倾斜角的合并WMI为10.94（95%CI，7.87 - 14.01）。所有研究中的这些结果均具有同质性。术后Insall-Salvati比值、Caton-Deschamps指数和胫骨结节-滑车沟距离的合并WMI分别为0.31（95%CI，0.17 - 0.45）、0.24（95%CI，0.12 - 0.36）和6.77（95%CI，1.96 - 11.58）。这些结果在各研究中存在异质性，远端手术的存在是一个显著的调节因素。与单纯近端手术相比，远端手术主要并发症的未加权RR显著更高，为38.07（95%CI，2.37 - 613.09），尽管轻微并发症的发生率相当（未加权RR，1.25；95%CI，0.35 - 4.48）。
对于高位髌骨合并髌股关节不稳定，无论采用何种手术方式，手术治疗均能持续改善临床和功能结果。远端手术更能纠正髌骨高度和胫骨结节-滑车沟距离，尽管与单纯近端手术相比，这些手术后续手术的RR也更高。
