A modified Delphi consensus statement on patellar instability: part II

Eoghan T Hurley^{1

2}, Seth L Sherman³, Jorge Chahla⁴, Safa Gursoy⁴, Michael J Alaia¹, Miho J Tanaka⁵, J L Pace⁶, Laith M Jazrawi¹; Patellar Instability International Consensus Group; Andrew J Hughes⁷, Elizabeth A Arendt⁸, Olufemi R Ayeni⁹, Ashley J Bassett¹⁰, Kevin F Bonner¹¹, Christopher L Camp¹², Kirk A Campbell⁷, Cordelia W Carter⁷, Michael G Ciccotti¹³, Andrew J Cosgarea¹⁴, David Dejour¹⁵, Cory M Edgar¹⁶, Brandon J Erickson¹⁷, João Espregueira-Mendes¹⁸, Jack Farr¹⁹, Lutul D Farrow²⁰, Rachel M Frank²¹, Kevin B Freedman¹³, John P Fulkerson²², Alan Getgood²³, Andreas H Gomoll²⁴, John A Grant²⁵, F W Gwathmey²⁶, Fares S Haddad²⁷, Laurie A Hiemstra²⁸, Betina B Hinckel²⁹, Ian Savage-Elliott⁷, Jason L Koh³⁰, Aaron J Krych¹², Robert F LaPrade³¹, Zachary I Li⁷, Catherine A Logan³², Guillem Gonzalez-Lomas⁷, Brian J Mannino⁷, Martin Lind³³, Bogdan A Matache³⁴, Elizabeth Matzkin³⁵, Bert Mandelbaum³⁶, Thomas F McCarthy³⁷, Mary Mulcahey³⁸, Volker Musahl³⁹, Philippe Neyret⁴⁰, Clayton W Nuelle⁴¹, Sam Oussedik⁴², Peter Verdonk⁴³, Scott A Rodeo²⁴, Fiachra E Rowan⁴⁴, Matthew J Salzler⁴⁵, Patrick C Schottel⁴⁶, Fintan J Shannon⁴⁷, Andrew J Sheean⁴⁸, Sabrina M Strickland²⁴, Brian R Waterman⁴⁹, Jocelyn R Wittstein², Michael Zacchilli⁵⁰, Stefano Zaffagnini⁵¹

Affiliations

¹ Department of Orthopedic Surgery, New York University Langone Health, New York, USA.
² Department of Orthopaedic Surgery, Duke University Hospital, Durham, North Carolina, USA.
³ Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.
⁴ Ankara Yildirim Beyazit University, Ankara, Turkey.
⁵ Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁶ Children's Health Andrews Institute for Orthopaedics and Sports Medicine, Plano, Texas, USA.
⁷ Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA.
⁸ Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA.
⁹ Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada.
¹⁰ The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA.
¹¹ Jordan-Young Institute, Virginia Beach, Virginia, USA.
¹² Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹³ Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA.
¹⁴ Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA.
¹⁵ Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France.
¹⁶ Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut, USA.
¹⁷ Rothman Orthopaedic Institute, New York, USA.
¹⁸ Dom Research Center, Clinica Espregueira Mendes, FIFA Medical Centre of Excellence, Porto, Portugal.
¹⁹ OrthoIndy Knee Preservation and Cartilage Restoration Center, Indianapolis, Indiana, USA.
²⁰ Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA.
²¹ Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.
²² Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA.
²³ Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada.
²⁴ Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA.
²⁵ Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.
²⁶ Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
²⁷ Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK.
²⁸ Department of Surgery, University of Calgary, Calgary, Canada.
²⁹ Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA.
³⁰ NorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, Illinois, USA.
³¹ Twin Cities Orthopedics, Edina-Crosstown, Edina, Minnesota, USA.
³² Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA.
³³ Department of Sports Traumatology, Aarhus University Hospital, Aarhus, Denmark.
³⁴ Division of Orthopaedic Surgery, Department of Surgery, Laval University, Quebec, Canada.
³⁵ Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
³⁶ Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA.
³⁷ Stryker Orthopaedics, Mahwah, New Jersey, USA.
³⁸ Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA.
³⁹ Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
⁴⁰ Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France.
⁴¹ Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA.
⁴² University College London Hospitals NHS Foundation Trust, London, UK.
⁴³ Antwerp Orthopaedic Center, AZ Monica Hospitals, Antwerp, Belgium.
⁴⁴ Department of Trauma & Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland.
⁴⁵ Department of Orthopedics, Tufts University School of Medicine, Boston, Massachusetts, USA.
⁴⁶ Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA.
⁴⁷ Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland.
⁴⁸ San Antonio Military Medical Center, San Antonio, Texas, USA.
⁴⁹ Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA.
⁵⁰ Hofstra Northwell School of Medicine, Hempstead, New York, USA.
⁵¹ IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.

PMID: 38035602
DOI: 10.1302/0301-620X.105B12.BJJ-2023-0110.R1

A modified Delphi consensus statement on patellar instability: part II

Eoghan T Hurley et al. Bone Joint J. 2023.

. 2023 Dec 1;105-B(12):1265-1270.

doi: 10.1302/0301-620X.105B12.BJJ-2023-0110.R1.

Authors

Affiliations

¹ Department of Orthopedic Surgery, New York University Langone Health, New York, USA.
² Department of Orthopaedic Surgery, Duke University Hospital, Durham, North Carolina, USA.
³ Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.
⁴ Ankara Yildirim Beyazit University, Ankara, Turkey.
⁵ Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁶ Children's Health Andrews Institute for Orthopaedics and Sports Medicine, Plano, Texas, USA.
⁷ Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA.
⁸ Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA.
⁹ Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada.
¹⁰ The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA.
¹¹ Jordan-Young Institute, Virginia Beach, Virginia, USA.
¹² Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹³ Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA.
¹⁴ Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA.
¹⁵ Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France.
¹⁶ Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut, USA.
¹⁷ Rothman Orthopaedic Institute, New York, USA.
¹⁸ Dom Research Center, Clinica Espregueira Mendes, FIFA Medical Centre of Excellence, Porto, Portugal.
¹⁹ OrthoIndy Knee Preservation and Cartilage Restoration Center, Indianapolis, Indiana, USA.
²⁰ Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA.
²¹ Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.
²² Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA.
²³ Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada.
²⁴ Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA.
²⁵ Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.
²⁶ Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
²⁷ Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK.
²⁸ Department of Surgery, University of Calgary, Calgary, Canada.
²⁹ Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA.
³⁰ NorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, Illinois, USA.
³¹ Twin Cities Orthopedics, Edina-Crosstown, Edina, Minnesota, USA.
³² Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA.
³³ Department of Sports Traumatology, Aarhus University Hospital, Aarhus, Denmark.
³⁴ Division of Orthopaedic Surgery, Department of Surgery, Laval University, Quebec, Canada.
³⁵ Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
³⁶ Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA.
³⁷ Stryker Orthopaedics, Mahwah, New Jersey, USA.
³⁸ Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA.
³⁹ Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
⁴⁰ Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France.
⁴¹ Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA.
⁴² University College London Hospitals NHS Foundation Trust, London, UK.
⁴³ Antwerp Orthopaedic Center, AZ Monica Hospitals, Antwerp, Belgium.
⁴⁴ Department of Trauma & Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland.
⁴⁵ Department of Orthopedics, Tufts University School of Medicine, Boston, Massachusetts, USA.
⁴⁶ Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA.
⁴⁷ Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland.
⁴⁸ San Antonio Military Medical Center, San Antonio, Texas, USA.
⁴⁹ Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA.
⁵⁰ Hofstra Northwell School of Medicine, Hempstead, New York, USA.
⁵¹ IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.

PMID: 38035602
DOI: 10.1302/0301-620X.105B12.BJJ-2023-0110.R1

Abstract

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous.

Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus.

Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

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Conflict of interest statement

S. L. Sherman reports royalties or licenses from CONMED Linvatec, consulting fees from Arthrex, BioVentus, JRF Ortho, Kinamed, Smith & Nephew, Vericel, CONMED Linvatec, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthex, Joint Restoration Foundation, Kinamed, Smith & Nephew, and Vericel, and stock or stock options from Epic Bio, Reparel, Sarcio, and Vivorte, all of which are unrelated to this study. J. Chahla reports consulting fees from Arthrex, CONMED Linvatec, Ossur, and Smith & Nephew, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Smith & Nephew, all of which are unrelated to this study. M. J. Alaia reports consulting fees from BodyCad, JRF Ortho, and Mitek, institutional grants from Orcosa, and royalties from Springer, all of which are unrelated to this study. M. J. Tanaka reports grants or contracts from FujiFilm, royalties or licenses from Verywell, and consulting fees from Depuy Synthes, all of which are unrelated to this study. J. L. Pace reports consulting fees from Arthrex and JRF Ortho, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthrex, and stock or stock options from OutcomeMD, all of which are unrelated to this study. L. M. Jazwari reports grants or contracts from Arthrex, Mitek, Smith & Nephew, and Wolters Kluwer Health, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Wolters Kluwer Health, and stock or stock options from Lazurite, all of which are unrelated to this study.

References

1. Tanaka MJ , Chahla J , Farr J , et al. Correction to: Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction . Knee Surg Sports Traumatol Arthrosc . 2019 ; 27 ( 8 ): 2551 . 10.1007/s00167-018-5304-9 30470849
1. McNeilan RJ , Everhart JS , Mescher PK , Abouljoud M , Magnussen RA , Flanigan DC . Graft choice in isolated medial patellofemoral ligament reconstruction: a systematic review with meta-analysis of rates of recurrent instability and patient-reported outcomes for autograft, allograft, and synthetic options . Arthroscopy . 2018 ; 34 ( 4 ): 1340 – 1354 . 10.1016/j.arthro.2017.11.027 29366741
1. Desai VS , Tagliero AJ , Parkes CW , et al. Systematic review of medial patellofemoral ligament reconstruction techniques: comparison of patellar bone socket and cortical surface fixation techniques . Arthroscopy . 2019 ; 35 ( 5 ): 1618 – 1628 . 10.1016/j.arthro.2018.10.150 31000392
1. Constant M , Trofa DP , Saltzman BM , Ahmad CS , Li X , Parisien RL . The fragility of statistical significance in patellofemoral instability research: a systematic review . Am J Sports Med . 2022 ; 50 ( 13 ): 3714 – 3718 . 10.1177/03635465211039202 34633219
1. Rosso F , Rossi R , Cottino U , Bonasia DE . Tibial tubercle osteotomy for patellofemoral malalignment and chondral disease provided good outcomes: a systematic review . J ISAKOS . 2022 ; 7 ( 2 ): 78 – 86 . 10.1016/j.jisako.2021.10.002 35546438

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A modified Delphi consensus statement on patellar instability: part II

Affiliations

A modified Delphi consensus statement on patellar instability: part II

Authors

Affiliations

Abstract

Conflict of interest statement

References

MeSH terms

LinkOut - more resources

Full Text Sources

Research Materials