Age, body mass index, female gender, and patellofemoral cartilage degeneration predict worse patient outcome after patellofemoral instability surgery

Abstract

Purpose: To evaluate predicting factors for patient-reported outcomes and revision interventions following surgical treatment of patients with patellofemoral instability.

Methods: From a prospective database at the university Orthopedic Department, 138 knees from 116 patients who underwent patellofemoral instability surgery (2012-2019) were enrolled in a retrospective analysis: 34 cases of isolated MPFLrec; 92 cases of MPFLrec plus tibial tuberosity transfer; and 12 cases of MPFLrec plus trochleoplasty. Patient-reported outcome measures were recorded for knee-specific function (KOOS), general quality of life (EQ-5D), and activity level (Tegner scale). Post-operative revision interventions were also actively recorded. As potential predicting factors, patient demographic (gender, age, BMI) and radiographic (pre-operative: patellar height and tilt, tibial tuberosity-trochlear groove distance, trochlear dysplasia, knee osteoarthritis; post-operative: MPFL insertion point; intra-operative: isolated vs. combined procedures, chondropenia severity score) parameters were analyzed using multivariate linear regression models.

Results: With median follow-up of 4.4 (1.0-8.9) years, all patient-reported outcome measures had significantly improved from pre-operative levels: KOOS cumulative, from 71 (15) to 78 (16); EQ-5D, from 0.68 (0.20) to 0.78 (0.21); and Tegner activity scale, from 3 (0-10) to 4 (0-10). No patellofemoral instability revision procedures were performed. One-fifth (27/138) of the operated knees required second surgical interventions, predominately due to hardware or arthrofibrosis. Patients who required post-operative knee manipulation under anesthesia or arthroscopic debridement showed lower post-operative improvement for KOOS cumulative and EQ-5D. Age, BMI, patellofemoral knee osteoarthritis, and shorter follow-up time revealed significant negative correlations to some of the post-operative KOOS subscales. Age was negatively correlated to post-operative EQ-5D, while post-operative Tegner activity scale was negatively correlated to female gender and patellofemoral chondropenia severity score. Femoral MPFL insertion point revealed no association with any outcome measures.

Conclusion: Patellofemoral instability surgery for isolated or combined MPFLrec is safe and substantially improves knee function and patient quality of life and activity levels. Serious adverse events are rare, with no recurrent patellofemoral instability. Patients who required post-operative knee manipulation or arthroscopic debridement showed less improvement in subjective measures of treatment outcomes. Older age, higher BMI, worse pre-operative patellofemoral cartilage status, and female gender had negative effects on outcome.

Level of evidence: III.

Keywords: Dislocation; Instability; Knee; Medial patellofemoral ligament; Patella; Surgery; Tibia tuberosity transfer; Trochleoplasty.