Focal task-specific dystonias are unusual disorders of motor control, often affecting individuals who perform complex repetitive movements. Musicians are especially prone to develop these disorders because of their training regimens and intense practice schedules. Task-specific dystonia occurring in keyboard or string instrumentalists usually affects the hand. In contrast, there have been few descriptions of musicians with task-specific dystonia affecting the muscles of the face and jaw. We report detailed clinical observations of 26 professional brass and woodwind players afflicted with focal task-specific dystonia of the embouchure (the pattern of lip, jaw, and tongue muscles used to control the flow of air into a mouthpiece). This is the largest and most comprehensively studied series of such patients. Patients developed embouchure dystonia in the fourth decade, and initial symptoms were usually limited to one range of notes or style of playing. Once present, dystonia progressed without remission and responded poorly to oral medications and botulinum toxin injection. Patients with embouchure dystonia could be separated by the pattern of their abnormal movements into several groups, including embouchure tremor, involuntary lip movements, and jaw closure. Dystonia not infrequently spread to other oral tasks, often producing significant disability. Effective treatments are needed for this challenging and unusual disorder.

Background: The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint against lateral patellar displacement. Surgery to address MPFL incompetence is the current gold standard for recurrent patellofemoral instability. In the young patient, controversy remains regarding the role of MPFL repair in the setting of recurrent patella instability. Hypothesis/Purpose: Our purpose was to investigate subjective outcomes and complication profile of consecutive cohorts under age 18 undergoing MPFL repair or MPFL reconstruction. Our hypothesis was that the MPFL reconstruction group would have higher subjective outcome scores and a lower complication profile. Methods: Following IRB approval, a retrospective review of prospectively collected data identified a consecutive cohort of patients undergoing soft tissue stabilization for recurrent patella instability. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. MPFL repair was performed on patients prior to November 2015 and MPFL reconstruction with allograft from December 2015 to present. Patients undergoing concomitant bony realignment procedures were included. Patient reported outcomes (PROs) were collected including PROMIS, KOOS, IKDC, Marx, Tegner, and SANE scores. Complications requiring re-operation (i.e., infection, stiffness, recurrent instability) were recorded. Results were analyzed statistically. Results: The cohort was comprised of 43 patients (53 knees), with 15 males (34.9%), and 28 females (65.1%). The MPFL-Repair cohort had 22 patients (24 knees) and the MPFL-Reconstruction had 25 patients (29 knees). The average age of the MPFL-Repair cohort was 14.82 (range 10.5-17.8) and the average age of the MPFL-Reconstruction group was 15.59 (13.0-17.7). At final follow-up (minimum 6 months), there were no statistically significant differences between cohorts for KOOS Pain (p=0.4126), KOOS symptoms (p=0.7990), KOOS ADL (p=0.4398), KOOS Sport Rec (p=0.3357), KOOS QOL (p=0.8707), Global Physical Health (p=0.9736), Global Mental Health (p=0.1724), Physical Function (p=0.8077), Pain Interference (p=0.9740), Mobility T-Score (p=0.0634), Marx activity score (p=0.0844), Tegner Score (p=0.0752), IKDC (p=0.2646), and SANE score (p=0.0811). Regarding complications requiring re-operation, there was 1 knee in the MPFL-Reconstruction group (3.4%) that required further surgery (1 for fracture) and 9 knees in the MPFL-Iso cohort (37.5%) that required re-operation (1 for fracture, 8 for recurrent instability). The difference in complication rate was statistically significant (p=0.0012). Conclusion: In patients under 18 years old undergoing surgery for refractory patella instability, both MPFL allograft reconstruction and MPFL primary repair demonstrated no difference in subjective outcome scores at midterm follow-up. MPFL primary repair had significantly increased rate of complication requiring re-operation, particularly recurrent patella instability requiring revision to MPFL reconstruction. Tables/Figures: [Table: see text][Table: see text][Table: see text]

Objectives: The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint against lateral patellar displacement. Surgery to address MPFL incompetence is the current gold standard for recurrent patellofemoral instability. The role of tibial tubercle osteotomy (TTO) as an adjunct to MPFL reconstruction remains controversial. Our purpose was to evaluate a cohort of patella instability patients undergoing surgical soft tissue stabilization with or without concomitant TTO. Our hypothesis was that there would be no difference between cohorts in baseline values, subjective outcome scores at final follow-up, or complication profile. Methods: Following IRB approval, retrospective review of prospectively collected data identified a consecutive cohort of patients undergoing soft tissue stabilization for recurrent patella instability, with or without concomitant TTO. Indications for TTO were at the surgeon’s discretion, including elevated TT-TG, Caton-Deschamps ratio, and/or unloading chondral lesion(s). Surgery was performed by a single sports fellowship trained surgeon. Pre-surgical and post-surgical patient reported outcomes were collected including KOOS domains, PROMIS (global health, mental health, physical function, pain interference), IKDC, SANE, and Marx scores. Complications requiring re-operation (infection, stiffness, recurrent instability) were recorded. Results were analyzed statistically. Results: The cohort was comprised of 87 patients (95 knees), with 25 males (28.7%) and 62 females (71.3%). The MPFL-TTO cohort had 32 patients (38 knees) and the MPFL-Iso had 55 patients (57 knees). The average age of the MPFL-TTO cohort was 28.3 (range 19.5-44.6) and the average age of the MPFL-Iso group was 29.8 (18.7-55.3). There was no significant difference in pre-operation outcome scores between groups (p>.05). Significant improvements were seen for all KOOS domains in both patient cohorts with no significant differences detected between groups. SANE, IKDC, and PROMIS scores improved significantly with no differences detected between groups. Marx activity score at 6 months post-operatively was significantly different between the groups favoring the isolate MPFL reconstruction cohort. (MPFL-TTO 0.79 +/- 2.15 vs. 4.61 +/- 5.44 in the MPFL-Iso group (p=0.01)). In terms of complications, 4 knees in the MPFL-TTO group required further surgery (2 for stiffness, 1 for infection, and 1 for fracture) and 6 knees in the MPFL-Iso cohort required surgery (4 for stiffness, 1 for infection, and 1 for recurrent instability). Neither the overall complication rate of 4 vs. 6 (p=1) nor the recurrent instability rate of 0 vs. 1 (p=0.41) was significant. Conclusion: In a cohort of patients undergoing MPFL reconstruction, the addition of an appropriately indicated TTO appears to be both safe and effective. Both MPFL-TTO and MPFL-Iso groups demonstrated significant improvement in the majority of subjective outcome scores without major difference between groups. Marx activity scores were higher for the isolated MPFL reconstruction cohort at relatively short term follow-up. The surgical complication profile was similar between groups. Further work is needed to clearly define the role of TTO as an adjunct procedure to MPFL reconstruction.

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