In the JournalsPerspective

Age, gender did not impact patient-reported outcomes after MPFL reconstruction

According to recently published results, age at first dislocation and patient gender did not influence patient-reported quality of life outcomes after medial patellofemoral ligament reconstruction when adjusted for risky pathoanatomy.

“By stratifying for pathoanatomic risk factors, this study has clarified that females do not have poorer outcomes following [medial patellofemoral ligament] MPFL reconstruction based on their sex,” Laurie Hiemstra, MD, told Healio.com/Orthopedics. “Previous research has correlated female sex with poorer outcomes after patellar stabilization surgery, however females demonstrate a greater number of pathoanatomic risk factors, which adversely influence outcomes. Likewise, individuals who dislocate at a young age are likely to have a greater number of pathoanatomic risk factors.”

She added, “In this large cohort in which concomitant surgeries corrected for significant pathoanatomy, age at the time of surgical stabilization was the only factor that correlated with patient-reported outcome, with older patients demonstrating inferior scores compared with younger patients.”

Researchers identified 328 patients who underwent primary patellofemoral stabilization with MPFL reconstruction. At the preoperative and postoperative visits, patients completed the Banff Patellofemoral Instability Instrument (BPII). Of the 328 patients, 298 patients had complete data and minimum 12-month BPII scores. At 12 and 24 months, patients were assessed clinically. Multiple linear regression models were fit to predict BPII at 12 and 24 months to evaluate the impact of age at surgery and patient gender on BPII. Age at the time of surgery and sex were used as predictors for an unadjusted regression model, and a second regression model was used and adjusted for age at first dislocation, grade of trochlear dysplasia, knee hyperextension and the weak, atraumatic, risky anatomy, pain, and subluxation/strong, traumatic, anatomy normal, instability and dislocation (WARPS/STAID) score.

Results showed 11 redislocations and all were seen in women. Baseline characteristics, when stratified by sex ,were not significantly different apart from older age at first dislocation and higher WARPS/STAID scores for men. For each postoperative follow-up, age at the time of surgery was statistically significant, with lower BPII scores seen with a 10-year increase in age at the time of surgery. The WARPS/STAID score significantly correlated with the preoperative BPII score in the adjusted model. Age at the time surgery and preoperative WARPS/STAID score were significant for 24-month BPII postoperative scores. Lower BPII scores were seen for each 10-year increase in age at time of surgery, with lower scores for WARPS/STAID. – by Monica Jaramillo

Disclosure s : Hiemstra reports consulting fees from ConMed Linvatec and Smith & Nephew; research funds from ConMed Canada and Tribe Medical; project-specific funding from Sanofi-Genzyme, Pendopharm, Covenant Health and EFX; speaking and education fees from ConMed Linvatec, Smith & Nephew, Sanofi-Genzyme and Concession Medical; and reimbursement for attending a symposium from ConMed Linvatec, Smith & Nephew, Sanofi-Genzyme and Pendopharm. Please see the full study for a list of all other authors’ relevant financial disclosures.

According to recently published results, age at first dislocation and patient gender did not influence patient-reported quality of life outcomes after medial patellofemoral ligament reconstruction when adjusted for risky pathoanatomy.

“By stratifying for pathoanatomic risk factors, this study has clarified that females do not have poorer outcomes following [medial patellofemoral ligament] MPFL reconstruction based on their sex,” Laurie Hiemstra, MD, told Healio.com/Orthopedics. “Previous research has correlated female sex with poorer outcomes after patellar stabilization surgery, however females demonstrate a greater number of pathoanatomic risk factors, which adversely influence outcomes. Likewise, individuals who dislocate at a young age are likely to have a greater number of pathoanatomic risk factors.”

She added, “In this large cohort in which concomitant surgeries corrected for significant pathoanatomy, age at the time of surgical stabilization was the only factor that correlated with patient-reported outcome, with older patients demonstrating inferior scores compared with younger patients.”

Researchers identified 328 patients who underwent primary patellofemoral stabilization with MPFL reconstruction. At the preoperative and postoperative visits, patients completed the Banff Patellofemoral Instability Instrument (BPII). Of the 328 patients, 298 patients had complete data and minimum 12-month BPII scores. At 12 and 24 months, patients were assessed clinically. Multiple linear regression models were fit to predict BPII at 12 and 24 months to evaluate the impact of age at surgery and patient gender on BPII. Age at the time of surgery and sex were used as predictors for an unadjusted regression model, and a second regression model was used and adjusted for age at first dislocation, grade of trochlear dysplasia, knee hyperextension and the weak, atraumatic, risky anatomy, pain, and subluxation/strong, traumatic, anatomy normal, instability and dislocation (WARPS/STAID) score.

Results showed 11 redislocations and all were seen in women. Baseline characteristics, when stratified by sex ,were not significantly different apart from older age at first dislocation and higher WARPS/STAID scores for men. For each postoperative follow-up, age at the time of surgery was statistically significant, with lower BPII scores seen with a 10-year increase in age at the time of surgery. The WARPS/STAID score significantly correlated with the preoperative BPII score in the adjusted model. Age at the time surgery and preoperative WARPS/STAID score were significant for 24-month BPII postoperative scores. Lower BPII scores were seen for each 10-year increase in age at time of surgery, with lower scores for WARPS/STAID. – by Monica Jaramillo

Disclosure s : Hiemstra reports consulting fees from ConMed Linvatec and Smith & Nephew; research funds from ConMed Canada and Tribe Medical; project-specific funding from Sanofi-Genzyme, Pendopharm, Covenant Health and EFX; speaking and education fees from ConMed Linvatec, Smith & Nephew, Sanofi-Genzyme and Concession Medical; and reimbursement for attending a symposium from ConMed Linvatec, Smith & Nephew, Sanofi-Genzyme and Pendopharm. Please see the full study for a list of all other authors’ relevant financial disclosures.

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    Perspective
    Miho J. Tanaka

    Miho J. Tanaka

    In their study, Hiemstra and colleagues compared clinical outcomes and reported quality of life after medial patellofemoral (MPFL) reconstruction based on age at the time of surgery and sex. The cohort consisted of 298 patients who underwent primary patellar stabilization procedures. Redislocations occurred in 11 patients (3.4%), all of whom were female, at a mean of 16.9 months. The authors reported lower postoperative Banff Patellofemoral Instability Instrument (BPII) scores for each 10-year increase in age at the time of surgery, as well as with lower WARPS/STAID classification scores, which indicate tendency toward the descriptors “Weak”, “Atraumatic”, “Risky anatomy”, “Pain”, and “Subluxation”.

    While age at the time of first dislocation has been shown to be a risk factor for recurrence, this is the first study to assess the role of age at the time of surgical intervention as it relates to outcomes. The lower postoperative BPII scores in patients with greater age at stabilization highlights the consideration of early intervention in the treatment of patellar instability. Further studies to include corresponding examination and imaging findings may help elucidate the mechanism that influences such outcomes. While time from first dislocation to surgery was not assessed in this study, the authors have taken a step in the direction of ultimately identifying the optimal timing between first dislocation and surgical intervention.

    The authors noted that while all cases of recurrent dislocations in this cohort occurred in females, sex alone did not correlate with postoperative outcomes; they described a trend toward poorer quality of life scores in female patients, but after adjusting for WARPS/STAID score, they found no relationship between sex and postoperative BPII scores. The authors have provided an increased understanding of the confounding relationship between various risk factors and sex, which is an important concept that can help us to assess patient-related factors with greater granularity.  Further evaluation of the multifactorial risk factors that may be more prevalent in female patients may help better predict outcomes and target treatments for at-risk populations in the treatment of patellar instability.

     

    • Miho J. Tanaka, MD
    • Director, Women’s Sports Medicine Program, Massachusetts General Hospital
      Assistant Professor of Orthopaedic Surgery, Harvard Medical School
      Boston

    Disclosures: Tanaka reports no relevant financial disclosures.

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