Background:An anterior cruciate ligament (ACL) injury accompanied by patellar instability (PI) is a topic that has gained orthopaedic surgeons’ attention recently. Untreated PI is reportedly associated with worse clinical outcomes after isolated ACL reconstruction (ACLR) in patients after an ACL injury with PI. Nevertheless, the appropriate surgical approach and its long-term therapeutic effects in these patients remain unclear.Purpose:(1) To compare the clinical and radiological outcomes between isolated ACLR (iACLR) and combined ACLR and medial patellofemoral ligament reconstruction (cAMR) in patients after an ACL injury with PI and (2) to explore the correlations between these 2 procedures and clinical and radiological outcomes.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 106 patients diagnosed with an ACL injury accompanied by PI between January 2016 and April 2021 were analyzed in this study. There were 34 patients excluded because of missing postoperative radiological data. Among the remaining 72 patients, 34 patients underwent iACLR, while 38 patients underwent cAMR. Demographic characteristics, intraoperative findings, and patient-reported outcomes (Lysholm score, subjective International Knee Documentation Committee score, and Tegner activity score) were prospectively collected. Patellar alignment parameters and worsening patellofemoral osteoarthritis (PFOA) features (evaluated with the modified Whole-Organ Magnetic Resonance Imaging Score) were analyzed longitudinally on magnetic resonance imaging. The Kujala score was used to evaluate the functional recovery of the patellofemoral joint, and redislocations of the patella were prospectively recorded. Finally, multivariate logistic regression analysis was used to explore the correlations between these 2 procedures and clinical (not achieving the minimal detectable change [MDC] for the Lysholm score) and radiological (worsening PFOA features) outcomes.Results:The mean follow-up duration was 28.9 ± 6.2 and 27.1 ± 6.8 months for the iACLR and cAMR groups, respectively ( P = .231). Significantly higher Lysholm scores (88.3 ± 9.9 vs 82.1 ± 11.1, respectively; P = .016) and subjective International Knee Documentation Committee scores (83.6 ± 11.9 vs 78.3 ± 10.2, respectively; P = .046) were detected in the cAMR group compared with the iACLR group postoperatively. The rates of return to preinjury sports were 20.6% and 44.7% in the iACLR and cAMR groups, respectively (difference, 24.1% [95% CI, 3.3%-45.0%]; P = .030). Moreover, the rates of worsening PFOA features were 44.1% and 18.4% in the iACLR and cAMR groups, respectively (difference, 25.7% [95% CI, 4.9%-46.4%]; P = .018). In addition, significantly higher Kujala scores (87.9 ± 11.3 vs 80.1 ± 12.0, respectively; P = .006), lower redislocation rates (0.0% vs 11.8%, respectively; difference, 11.8% [95% CI, 0.9%-22.6%]; P = .045), and significantly better patellar alignment were detected in the cAMR group compared with the iACLR group postoperatively. Furthermore, multivariate logistic regression analysis determined that iACLR and partial lateral meniscectomy were significantly correlated with not achieving the MDC for the Lysholm score and worsening PFOA features in our study population.Conclusion:In patients after an ACL injury with PI, cAMR yielded better clinical and radiological outcomes compared with iACLR, with better patellar stability and a lower proportion of worsening PFOA features. Furthermore, not achieving the MDC for the Lysholm score and worsening PFOA features were significantly correlated with iACLR and partial lateral meniscectomy. Our study suggests that cAMR may be a more appropriate procedure for patients after an ACL injury with PI, which warrants further high-level clinical evidence.

中文翻译：

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ACL 和 MPFL 联合重建与单独 ACL 重建治疗伴有髌骨不稳定的 ACL 损伤后的临床和放射学结果

背景：前交叉韧带（ACL）损伤伴有髌骨不稳定（PI）是最近引起骨科医生关注的一个话题。据报道，未经治疗的 PI 与 PI 导致 ACL 损伤的患者进行孤立 ACL 重建 (ACLR) 后临床结果较差有关。然而，对于这些患者合适的手术方式及其长期治疗效果仍不清楚。目的：（1）比较单纯ACLR（iACLR）与联合ACLR和内侧髌股韧带重建（cAMR）患者的临床和影像学结果ACL 损伤并伴有 PI 后，(2) 探讨这两种手术与临床和放射学结果之间的相关性。研究设计：队列研究；证据级别，3。方法：本研究分析了2016年1月至2021年4月期间诊断为ACL损伤并伴有PI的106例患者。有 34 名患者因术后放射学数据缺失而被排除。其余 72 名患者中，34 名患者接受了 iACLR，38 名患者接受了 cAMR。前瞻性收集人口统计学特征、术中发现和患者报告的结果（Lysholm 评分、国际膝关节文献委员会主观评分和 Tegner 活动评分）。在磁共振成像上纵向分析髌骨排列参数和恶化的髌股骨关节炎（PFOA）特征（使用改良的全器官磁共振成像评分进行评估）。采用Kujala评分评价髌股关节功能恢复情况，前瞻性记录髌骨再脱位情况。最后，使用多变量逻辑回归分析来探讨这 2 种手术与临床（Lysholm 评分未达到最小可检测变化 [MDC]）和放射学（PFOA 特征恶化）结果之间的相关性。 结果：平均随访时间iACLR 组和 cAMR 组的时间分别为 28.9 ± 6.2 和 27.1 ± 6.8 个月 ( P = .231)。与 cAMR 组相比，cAMR 组的 Lysholm 评分（分别为 88.3 ± 9.9 vs 82.1 ± 11.1；P = .016）和主观国际膝关节文献委员会评分（分别为 83.6 ± 11.9 vs 78.3 ± 10.2；P = .046）显着更高术后与iACLR组进行比较。iACLR 组和 cAMR 组恢复损伤前运动的比率分别为 20.6% 和 44.7%（差异为 24.1% [95% CI, 3.3%-45.0%]；P = .030）。此外，iACLR 组和 cAMR 组中 PFOA 特征恶化的比率分别为 44.1% 和 18.4%（差异为 25.7% [95% CI, 4.9%-46.4%]；P = .018）。此外，Kujala 评分显着较高（分别为 87.9 ± 11.3 vs 80.1 ± 12.0；P = .006），再脱位率较低（分别为 0.0% vs 11.8%；差异，11.8% [95% CI, 0.9%-22.6%] ]；P = .045), 术后，与 iACLR 组相比，cAMR 组的髌骨排列明显更好。此外，多变量逻辑回归分析确定 iACLR 和部分外侧半月板切除术与我们研究人群中 Lysholm 评分未达到 MDC 以及 PFOA 特征恶化显着相关。结论：在 ACL 损伤合并 PI 后的患者中，cAMR 产生了更好的临床和治疗效果。与 iACLR 相比，放射学结果具有更好的髌骨稳定性和较低的 PFOA 特征恶化比例。此外，未达到 Lysholm 评分的 MDC 和恶化的 PFOA 特征与 iACLR 和部分外侧半月板切除术显着相关。我们的研究表明，cAMR 可能是 ACL 损伤合并 PI 后患者更合适的手术，这需要进一步的高水平临床证据。