Napovedni dejavniki izida kirurškega zdravljenja nestabilnosti pogačice

Žlak, Nik (author), Drobnič, Matej (mentor), Kacin, Alan (co-mentor)

Namen: Proučiti vpliv specifičnih predoperativnih in intraoperativnih napovednih dejavnikov na subjektivni izid kirurškega zdravljenja nestabilnosti pogačice. Metode: V prospektivno raziskavo je bila vključena kohorta 116 bolnikov (138 kolen), ki so bili operirani zaradi nestabilnosti pogačice med letoma 2012 in 2019 na Ortopedski kliniki UKC Ljubljana: 34 primerov izolirane rekonstrukcije medialnega pogačičnega ligamenta (MPFL), 92 primerov rekonstrukcije MPFL in prestavitev tibije ter 12 primerov rekonstrukcije MPFL in trohleoplastike. Uspešnost operativnega zdravljenja smo vrednotili s standarniziranimi subjektivnimi vprašalniki: za specifično funkcijo kolena – vprašalnik KOOS, za splošno kakovost življenja – vprašalnik EQ-5D in za stopnjo aktivnosti – Tegnerjeva lestvica. Beležili smo pooperativne zaplete, revizijske operacije ter spremljali višino pogačice v zgodnjem in poznem pooperativnem obdobju. S parnimi statističnimi testi smo primerjali vrednosti subjektivnih vprašalnikov med pred- in pooperativnimi vrednostmi. Kot potencialne napovedne dejavnike za izid zdravljenja smo z multivariatnimi linearnimi regresijskimi modeli preverjali naslednje parametre: a) demografske (spol, starost, indeks telesne mase), b) radiološke (predoperativni: višina in nagib pogačice, razdalja med tuberositasom tibije in trohlearnim žlebom, stopnja trohlearne displazije, stopnja osteoartroze kolena; pooperativni: mesto fiksacije presadka MPFL), c) intraoperativne: izolirani ali kombinirani postopki stabilizacije pogačice, makroskopski hrustančni status kolena (angl. Chondropenia Severity Score – CSS). Rezultati: Mediani čas spremljanja bolnikov je bil 4,4 (1,0–8,9) leta. Subjektivni rezultati zdravljenja so se pooperativno statistično pomembno povečali pri vseh treh vprašalnikih: KOOS kumulativno z 71 (15) na 78 (16), EQ-5D-3L-TTO z 0,68 (0,20) na 0,78 (0,21), aktivnost na Tegnerjevi lestvici s 3 (0–10) na 4 (0–10). Nihče od preiskovancev ni potreboval revizijske operacije zaradi nestabilnosti pogačice. Preiskovanci, ki so potrebovali pooperativno manipulacijo kolena v anesteziji ali artroskopski debridement mehkih tkiv in hrustanca, so pooperativno manj napredovali pri vrednostih kumulativnega KOOS in EQ-5D-3L-TTO. Ugotavljali smo statistično značilne negativne povezave z določenimi deli pooperativne lestvice KOOS, pooperativnimi vrednostmi EQ-5D-3L-TTO in pooperativnimi vrednostmi Tegnerjeve lestvice aktivnosti. Mesto fiksacije presadka MPFL na stegnenico, medializacija in/ali distalizacija TT ter trohleopastika niso vplivali na izid zdravljenja. Razlik v višini pogačice pred operacijo, takoj po operaciji in ob zadnji kontroli nismo ugotavljali. Sklepi: Operativna stabilizacija pogačice z rekonstrukcijo MPFL, izolirana ali kot kombiniran poseg s prestavitvijo tuberositas tibije ali trohleoplastiko, je bila varna in je bistveno izboljšala funkcijo kolena, kakovost življenja ter stopnjo aktivnosti bolnikov. Starost, višji indeks telesne mase, slabše stanje patelofemoralnega hrustanca pred operacijo in ženski spol so negativno vplivali na izid operativnega zdravljenja. Bolniki, ki so po operaciji potrebovali manipulacijo kolena ali artroskopski debridement, so imeli slabše subjektivne kazalnike uspešnosti zdravljenja. Mesto fiksacije presadka MPFL na stegnenico ni vplivalo na subjektivno funkcijo kolena po operaciji. Resni neželeni dogodki so bili redki, ponovnih izpahov in sprememb v višini pogačice nismo beležili.

• Language: Slovenian
• Keywords: Koleno, Pogačica, Nestabilnost, Izpah, Medialni pogačični ligament, Transpozicija tuberositas tibije, Trohleoplastika, Kirurgija
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2023
• PID: 20.500.12556/RUL-145332
• COBISS.SI-ID: 151821571
• Publication date in RUL: 18.04.2023

Secondary language

• Language: English
• Title: Factors predicting outcome of patellar surgical treatment

Abstract

Purpose: To investigate factors predicting patient-reported outcomes and revision interventions after surgical treatment of patients with patellofemoral instability. Methods: From a prospective database of a university orthopaedic department, 138 knees of 116 patients who had undergone surgery for patellofemoral instability between 2012 and 2019 were included in the analysis: 34 cases of isolated MPFL reconstruction, 92 cases of MPFL reconstruction plus tibial tuberosity transfer, and 12 cases of MPFL reconstruction plus trochleoplasty. Patient-reported outcome measures (PROMs) were recorded for knee-specific function (KOOS), general quality of life (EQ-5D) and activity level (Tegner scale). Postoperative revision procedures were also recorded. Preoperative and postoperative PROMs values were compared using paired statistical tests. Potential predictive factors included patient demographics (sex, age, BMI), radiological data (preoperative: patella height and inclination, tuberosity-trochlear groove distance, trochlear dysplasia, knee osteoarthritis; postoperative: MPFL insertion point) and intraoperative parameters (isolated vs. combined procedures, macroscopic cartilage condition of the knee using Chondropenia Severity Score - CSS) were analysed using multivariate linear regression models. Results: After a median follow-up of 4.4 (1.0-8.9) years, all patient-reported outcome measures had significantly increased from preoperative to postoperative values: KOOS cumulative, from 71 (15) to 78 (16); EQ -5D-3L-TTO, from 0.68 (0.20) to 0.78 (0.21); and Tegner activity scale, from 3 (0-10) to 4 (0-10). No revision surgery was performed for patellofemoral instability. Patients who required postoperative knee manipulation under anaesthesia or arthroscopic debridement showed lower postoperative improvement in KOOS cumulative and EQ -5D-3L-TTO. Age, BMI, patellofemoral knee osteoarthritis and shorter follow-up time showed significant negative correlations with some of the postoperative KOOS subscales. Age was negatively correlated with postoperative EQ-5D-3L-TTO, while postoperative Tegner activity scale was negatively correlated with female sex and patellofemoral CSS. The femoral MPFL insertion point, tibial tuberosity transfer or trochleoplasty showed no association with any outcome measures. There were no differences in patellar height before surgery, immediately after surgery, and at last follow-up, except in patients who underwent intentional TT distalisation. Conclusion: Surgical treatment of patellofemoral instability using isolated or combined (with tibial tuberosity transfer or trochleoplasty) MPFL reconstruction was safe and significantly improved patients' subjective knee function, overall quality of life and activity level. Older age, higher BMI, poorer preoperative patellofemoral cartilage status and female gender had negative effects on outcome. Patients who required postoperative knee manipulation or arthroscopic debridement had less postoperative improvement in subjective measures, whereas the femoral MPFL insertion point was not associated with any of these factors. Serious adverse events were rare, with no recurrence of patellofemoral dislocation or changes in patellar height.

• Keywords: Knee, Patella, Instability, Dislocation, Medial patellofemoral ligament, Tibia tuberosity transfer, Trochleoplasty, Surgery