Summary

A multidisciplinary qualitative study to determine which findings are key indicators in a patient self-administered virtual clinical examination for patellofemoral instability.

Abstract

Background

The use of virtual clinics in orthopaedic practice has seen exponential growth in recent years. This evolution bears benefits towards improved reach, healthcare cost, as well as the potential to expedite delivery of tertiary services by streamlining access to specialists. The COVID-19 pandemic has inadvertently led to a more rapid uptake of virtual clinics. However, there is still paucity in the evidence base pertaining to orthopaedic virtual clinical assessment. The objective of this study was to determine which patient-reported features and clinical examination findings could be used to reliably assess patellofemoral instability during a virtual examination.

Method

A multidisciplinary focus group of surgeons, physiotherapists and advanced nurse practitioners involved in caring for patients with patellofemoral instability was created. All members had prior expertise in qualitative research. Members of the group met at three-week intervals over a period of four months. Focussed discussions developed into a series of clinically relevant virtual clinical assessment indicators.

Results

The focus group attained an agreement in identifying the most appropriate features and clinical indicators that can be implemented into patient self-administered virtual examination for patellofemoral instability. The focus group agreed on the following approach. To facilitate orientation, patients should be asked to draw a circle around the patella and around the tibial tuberosity using a non-permanent marker. The use of a couch and a chair is sufficient to carry out a video-linked self-administered examination. The virtual examination consisted of three parts: an examination of the patient whilst seated, lying down supine, and standing. Each part examined five key domains.

In the seated position: 1. look for blunting of the knee and vastus medialis obliquus (VMO) contour; 2. ask to localise sites of pain using a single finger; 3. palpate tenderness along the medial patella and patellofemoral ligament; 4. ask to flex and extend the knee to elicit J-sign tracking or fixed lateral tracking; 5. ask to report sensation of crepitus around the patella during movement.

In the supine position: 1. assess ability to achieve extension and/or hyperextension; 2. assess symmetry and ease of straight-leg raise; 3. assess the span and symmetry of active range of motion. With a cushion placed under the knee: 4. check for subjective apprehension sensation with lateral displacement of the patella; 5. check for excessive lateral patella glide

In the standing position: 1. forward facing: standing alignment, patella position, quadriceps muscle bulk and symmetry. 2. side facing: knee hyperextension, pelvic tilt, and hyper-lordosis. 3. Rear facing: leg alignment, foot and ankle alignment and foot hyper-pronation. 4. Front facing activity assess ease/symmetry/compensation during: walking few steps, changing direction, single-leg stance, mini squat. 5. Assessment of generalised joint hyperlaxity.

Discussion/Conclusion:
The present qualitative multidisciplinary study has determined which findings are key indicators in a patient self-administered virtual clinical examination for patellofemoral instability. The results have informed the development of a virtual examination framework and launched a Delphi study aimed at multi-disciplinary experts on the subject. The subsequent study is underway in order to generate a wider consensus.