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Selective bundle tensioning in double-bundle MPFL reconstruction to improve restoration of dynamic patellofemoral contact pressure. Knee Surg Sports Traumatol Arthrosc 2020; 28:1144-1153. [PMID: 31740983 DOI: 10.1007/s00167-019-05789-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the optimal graft tension angles in a medial patellofemoral ligament (MPFL) reconstruction with selective bundle tensioning in order to restore patellofemoral contact pressure distributions closest to the native state. METHODS Twelve human cadaveric knee specimens were mounted with the femur on a custom-made fixation device allowing free range of motion in the knee joint for testing. Using a sensitive pressure film (Tekscan) patellofemoral contact pressure was measured in 15° intervals during a dynamic flexion movement from 0°-90° in the native state, in cut MPFL and after MPFL-reconstruction with a gracilis tendon. The graft was separated in two bundles and was fixed independently on the patella using two knotless anchors. Two groups were made with either the proximal or distal bundle fixed at the femur at a knee flexion angle of 30° and the corresponding other bundle subsequently fixed at the femur at 15°, 45°, 60°, 75° and 90° of knee flexion using extra-cortical fixation and controlled tension of 2N in both groups. The sequence of the flexion angles at the graft fixation was alternated. Pressure measurements were repeated after every fixation of the graft. RESULTS Cutting the MPFL resulted in significantly reduced patellofemoral contact pressure at all flexion angles. After MPFL reconstruction the patellofemoral contact pressure remained significantly reduced during dynamic knee flexion in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°. Selective evaluation of lateral patellofemoral contact pressure, however, showed significant reduction in all tested double-bundle combinations (p < 0.05) from 15° to 90°. Evaluation of isolated medial patellofemoral pressure changes showed no significant difference in all tested combinations compared to the intact knee. Furthermore, evaluation of the isolated proximal and distal patellofemoral contact pressure also revealed a significantly reduced contact pressure in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°. CONCLUSION According to this study, selective bundle tensioning in anatomic MPFL-reconstruction should be considered as an easy and more anatomic alternative to current popular techniques to restore patella kinematics and give clear recommendation about knee flexion angle and tension during fixation. Although tensioning two bundles separately may further improve clinical results. If performed, fixation of the graft is recommended under low tension (2N) with the proximal bundle at 30° and the distal bundle at 75° of knee flexion.
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Validity of intraoperative observation of graft length change pattern for medial patellofemoral ligament reconstruction. J Orthop 2020; 21:131-136. [PMID: 32255994 DOI: 10.1016/j.jor.2020.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/23/2020] [Indexed: 01/23/2023] Open
Abstract
Background The clinical outcome of the medial patellofemoral ligament reconstruction (MPFLR) based on graft length change pattern (length pattern group) was compared with MPFLR based on visual examination combined with palpation (visual/palpation group). Methods Physical findings, patient-reported outcome, and radiographic demonstration were evaluated pre- and postoperatively. Results The length pattern group had significantly lower risk of a positive apprehension test (Odds ratio 0.12, p < 0.01), and higher scores in postoperative Lysholm score (p = 0.046) and patient satisfaction (p = 0.036) than The visual/palpation group. Conclusion MPFLR based on graft length change pattern improved on patient-reported outcomes and apprehension test. Level of evidence Level Ⅲ, Retrospective comparative study.
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Izadpanah K, Meine H, Kubosch J, Lang G, Fuchs A, Maier D, Ogon P, Südkamp NP, Feucht MJ. Fluoroscopic guided tunnel placement during medial patellofemoral ligament reconstruction is not accurate in patients with severe trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc 2020; 28:759-766. [PMID: 31055609 DOI: 10.1007/s00167-019-05413-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 02/13/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE Accurate femoral tunnel placement is of great importance during medial patellofemoral ligament (MPFL) reconstruction. Purpose of the present study was to investigate the influence of trochlear dysplasia on the accuracy of fluoroscopic guided femoral tunnel placement. METHODS CT-Scans of 30 knees (five with regular shaped trochlea, 10 with a Type A and five each with a Type B, C, or D trochlear dysplasia) were imported into the image analysis platform MeVisLab. A 3D Bone Volume Rendering (VR) and a virtual lateral radiograph was created. The anatomic femoral MPFL insertion was identified on the 3D VR. On virtual lateral radiographs, the MPFL insertion was identified based on landmarks described by Schöttle et al. using three different perspectives: Best possible overlap of the femoral condyles (BC) and a tangent along posterior border of the posterior femoral cortex (pBC); a tangent along the anterior border of the posterior cortex (aBC); and best possible overlap of the distal part of the posterior femoral cortex (BF). Distances between the anatomic attachment and radiographically obtained insertions were measured on the 3D VR and compared according to the type of trochlear dysplasia. RESULTS Significantly lower accuracy of fluoroscopy guided tunnel placement in MPFL reconstruction was found in knees with Type C and D dysplasia. This effect was observed irrespectively from the radiologic perspective (pBC, aBC, and FC). In the pBC view (highest accuracy), the mean distance from the centre of the anatomic MPFL attachment to the radiographically defined location was 4.3 mm in knees without trochlear dysplasia and increased to 4.8 mm in knees with Type A dysplasia, 3.8 mm in knees with Type B dysplasia, 6.7 mm (p < 0.001) in knees with Type C dysplasia, and 7.3 mm (p < 0.001) in knees with Type D dysplasia. CONCLUSION Radiographic landmark-based femoral tunnel placement in the pBC view provides highest accuracy in knees with a normal shaped trochlea or low grade trochlear dysplasia. In patients with severe dysplasia, fluoroscopy guided tunnel placement has a low accuracy, exceeding a critical threshold of 5 mm distance to the anatomic MPFL insertion irrespective of the radiographic perspective. In these patients, utilization of anatomic landmarks may be beneficial. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kaywan Izadpanah
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Hans Meine
- Medical Image Computing Group, Department of Informatics, University of Bremen, Enrique-Schmidt-Straße 5, 28359, Bremen, Germany.,Institute for Medical Image Computing, Fraunhofer MEVIS Bremen, Am Fallturm 1, 28359, Bremen, Germany
| | - Johanna Kubosch
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Gernot Lang
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Andreas Fuchs
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Dirk Maier
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Peter Ogon
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.,Center of Orthopedic Sports Medicine Freiburg, Breisacher Strasse 84, 79110, Freiburg, Germany
| | - Norbert P Südkamp
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Matthias J Feucht
- Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.,Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, TU Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Luceri F, Roger J, Randelli PS, Lustig S, Servien E. How Does Isolated Medial Patellofemoral Ligament Reconstruction Influence Patellar Height? Am J Sports Med 2020; 48:895-900. [PMID: 32058795 DOI: 10.1177/0363546520902132] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reconstruction of the medial patellofemoral ligament (MPFL) is the gold standard treatment for recurrent patellar dislocation. Patella alta has been reported in about half of patients with recurrent patellofemoral instability. HYPOTHESIS MPFL reconstruction (MPFLr) has a beneficial role in the correction of patellar height in patients with mild patella alta (Caton-Deschamps index [CDI] between 1.20 and 1.40). STUDY DESIGN Case series; Level of evidence, 4. METHODS Skeletally mature patients, with no history of previous or concomitant knee surgical procedures, who underwent isolated MPFLr using hamstring autograft for recurrent patellar instability between 2005 and 2018, were included in this study. The authors calculated CDI, modified Insall-Salvati index (MISI), and Blackburne-Peel index (BPI) ratios. Measurements done by 2 independent observers were calculated and used to compare pre- and postoperative patellar height (patella alta: CDI >1.20). RESULTS A total of 89 patients (95 knees) were included in the study, with a mean age of 25.0 years (range, 15.0-45.0 years). There were 70% women and 30% men. We found patella alta in 35.8% of cases preoperatively. Among them, 79.4% had reduced patellar height indices, within normal limits, postoperatively (mean follow-up, 18.4 ± 12.0 months). All the ratios showed a significant reduction in patellar height after surgery (CDI: 0.19 [range, -0.05, 0.60]; MISI: 0.22 [-0.14, 0.76]; BPI: 0.18 [-0.08, 0.59]; P < .00001). The CDI of 79.4% of the study knees was reduced to within normal limits postoperatively. The CDI was maintained within normal limits postoperatively in 93.4% of the knees with normal patellar height and reduced to normal in 50% of the knees with severe patella alta before surgery . No patient reported patella infera before surgery, whereas this condition was found in 8.2% of study patients postoperatively. A moderate correlation was reported between preoperative radiographic indices and their reduction after surgery (CDI: P < .001, ρ = 0.39; MISI: P < .001, ρ = 0.39; BPI: P < .001, ρ = 0.48). CONCLUSION The higher the preoperative patellar height, the more important is the lowering effect of MPFLr using the hamstring for patellar instability. Bony procedures should not be indicated in patients with patellar instability and a CDI between 1.20 and 1.40.
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Affiliation(s)
- Francesco Luceri
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France.,Università degli Studi di Milano, Milan, Italy
| | - Julien Roger
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France
| | - Pietro Simone Randelli
- UOC 1a Divisione, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy.,Laboratorio di Biomeccanica Applicata, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Sébastien Lustig
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France.,LBMC UMR T 9406, Laboratory of Chock Mechanics and Biomechanics, Claude Bernard Lyon 1 University, Lyon, France
| | - Elvire Servien
- FIFA Medical Center of Excellence, Orthopaedics Surgery and Sports Medicine Department, Croix Rousse Hospital, Civil Hospices of Lyon, Lyon, France.,LIBM, EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France
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Huber C, Zhang Q, Taylor WR, Amis AA, Smith C, Hosseini Nasab SH. Properties and Function of the Medial Patellofemoral Ligament: A Systematic Review. Am J Sports Med 2020; 48:754-766. [PMID: 31091114 DOI: 10.1177/0363546519841304] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND As the main passive structure preventing patellar lateral subluxation, accurate knowledge of the anatomy, material properties, and functional behavior of the medial patellofemoral ligament (MPFL) is critical for improving its reconstruction. PURPOSE To provide a state-of-the-art understanding of the properties and function of the MPFL by undertaking a systematic review and statistical analysis of the literature. STUDY DESIGN Systematic review. METHODS On June 26, 2018, data for this systematic review were obtained by searching PubMed and Scopus. Articles containing numerical information regarding the anatomy, mechanical properties, and/or functional behavior of the MPFL that met the inclusion criteria were reviewed, recorded, and statistically evaluated. RESULTS A total of 55 articles met the inclusion criteria for this review. The MPFL presented as a fanlike structure spanning from the medial femoral epicondyle to the medial border of the patella. The reported data indicated ultimate failure loads from 72 N to 208 N, ultimate failure elongation from 8.4 mm to 26 mm, and stiffness values from 8.0 N/mm to 42.5 N/mm. In both cadaveric and in vivo studies, the average elongation pattern demonstrated close to isometric behavior of the ligament in the first 50° to 60° of knee flexion, followed by progressive shortening into deep flexion. Kinematic data suggested clear lateralization of the patella in the MPFL-deficient knee during early knee flexion under simulated muscle forces. CONCLUSION A lack of knowledge regarding the morphology and attachment sites of the MPFL remains. The reported mechanical properties also lack consistency, thus requiring further investigations. However, the results regarding patellar tracking confirm that the lack of an MPFL leads to lateralization of the patella, followed by delayed engagement of the trochlear groove, plausibly leading to an increased risk of patellar dislocations. The observed isometric behavior up to 60° of knee flexion plausibly suggests that reconstruction of the ligament can occur at flexion angles below 60°, including the 30° and 60° range as recommended in previous studies.
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Affiliation(s)
| | - Qiang Zhang
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | | | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - Colin Smith
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
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Mehl J, Otto A, Comer B, Kia C, Liska F, Obopilwe E, Beitzel K, Imhoff AB, Fulkerson JP, Imhoff FB. Repair of the medial patellofemoral ligament with suture tape augmentation leads to similar primary contact pressures and joint kinematics like reconstruction with a tendon graft: a biomechanical comparison. Knee Surg Sports Traumatol Arthrosc 2020; 28:478-488. [PMID: 31410528 DOI: 10.1007/s00167-019-05668-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare suture tape-augmented MPFL repair with allograft MPFL reconstruction using patellofemoral contact pressure and joint kinematics to assess the risk of patellofemoral over-constrainment at point zero. METHODS A total of ten fresh frozen cadaveric knee specimens were tested in four different conditions of the MPFL: (1) native, (2) cut, (3) reconstructed with tendon graft, and (4) augmented with suture tape. The patellofemoral mean pressure (MP), peak pressure (PP) and contact area (CA) were measured independently for the medial and lateral compartments using pressure-sensitive films. Patellar tilt (PT) and shift (PS) were measured using an optical 3D motion tracking system. Measurements were recorded at 0°, 10°, 20°, 30°, 60° and 90° of flexion. Both the tendon graft and the internal brace were preloaded with 2 N, 5 N, and 10 N. RESULTS There was no significant differences found between surgical methods for medial MP, medial PP, medial CA, lateral MP and PS at any preload or flexion angle. Significant differences were seen for lateral PP at 20° knee flexion and 10 N preload (suture tape vs. reconstruction: 1045.9 ± 168.7 kPa vs. 1003.0 ± 151.9 kPa; p = 0.016), for lateral CA at 10° knee flexion and 10 N preload (101.4 ± 39.5 mm2 vs. 108.7 ± 36.6 mm2; p = 0.040), for PT at 10° knee flexion and 2 N preload (- 1.9 ± 2.5° vs. - 2.5 ± 2.3°; p = 0.033) and for PT at 0° knee flexion and 10 N preload (- 0.8 ± 2.5° vs. - 1.8 ± 3.1°; p = 0.040). A preload of 2 N on the suture tape was the closest in restoring the native joint kinematics. CONCLUSIONS Suture tape augmentation of the MPFL resulted in similar primary contact pressures and joint kinematics in comparison with MPFL reconstruction using a tendon graft. A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics.
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Affiliation(s)
- Julian Mehl
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA.,Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Alexander Otto
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Augsburg, Germany
| | - Brendan Comer
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Cameron Kia
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Franz Liska
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Knut Beitzel
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - John P Fulkerson
- Orthopaedic Associates of Hartford, 499 Farmington Avenue, Farmington, CT, 06032, USA
| | - Florian B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
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Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery. Knee Surg Sports Traumatol Arthrosc 2020; 28:3720-3732. [PMID: 32483671 PMCID: PMC7669796 DOI: 10.1007/s00167-020-06050-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/30/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To define the length-change patterns of the superficial medial collateral ligament (sMCL), deep MCL (dMCL), and posterior oblique ligament (POL) across knee flexion and with applied anterior and rotational loads, and to relate these findings to their functions in knee stability and to surgical repair or reconstruction. METHODS Ten cadaveric knees were mounted in a kinematics rig with loaded quadriceps, ITB, and hamstrings. Length changes of the anterior and posterior fibres of the sMCL, dMCL, and POL were recorded from 0° to 100° flexion by use of a linear displacement transducer and normalised to lengths at 0° flexion. Measurements were repeated with no external load, 90 N anterior draw force, and 5 Nm internal and 5 Nm external rotation torque applied. RESULTS The anterior sMCL lengthened with flexion (p < 0.01) and further lengthened by external rotation (p < 0.001). The posterior sMCL slackened with flexion (p < 0.001), but was lengthened by internal rotation (p < 0.05). External rotation lengthened the anterior dMCL fibres by 10% throughout flexion (p < 0.001). sMCL release allowed the dMCL to become taut with valgus rotation (p < 0.001). The anterior and posterior POL fibres slackened with flexion (p < 0.001), but were elongated by internal rotation (p < 0.001). CONCLUSION The structures of the medial ligament complex react differently to knee flexion and applied loads. Structures attaching posterior to the medial epicondyle are taut in extension, whereas the anterior sMCL, attaching anterior to the epicondyle, is tensioned during flexion. The anterior dMCL is elongated by external rotation. These data offer the basis for MCL repair and reconstruction techniques regarding graft positioning and tensioning.
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Sanchis-Alfonso V, Monllau JC. Medial Patellofemoral Ligament Reconstruction. OPER TECHN SPORT MED 2019. [DOI: 10.1016/j.otsm.2019.150688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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The Ribbon-shaped Femoral Footprint of the Medial Patellofemoral Ligament: Implications for Reconstruction. Sports Med Arthrosc Rev 2019; 27:150-153. [PMID: 31688533 DOI: 10.1097/jsa.0000000000000238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The medial patellofemoral ligament (MPFL) is the primary static stabilizer to lateral translation of the patella and serves as part of the medial patellar soft tissue restraints. Because of the sensitivity of MPFL graft function after reconstruction to the position of the femoral tunnel, many studies have aimed to identify the exact point of the femoral origin, as well as defining techniques to confirm this position intraoperatively. We describe the ribbon-shaped footprint of the MPFL on the medial femur and the associated difficulty in identifying the origin as a single "point." Varying isometry and biomechanical functions have been shown to exist within the most proximal and most distal fibers, suggesting the function of the MPFL may not be fully recreated with a tubular graft in a round tunnel. We review the anatomical descriptions of the elongated femoral footprint of the MPFL and describe our surgical technique to recreate this.
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Jaecker V, Neumann L, Shafizadeh S, Koenen P, Kanakamedala AC, Tjardes T. Radiographic images are inapplicable for a precise evaluation of the femoral tunnel position following MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:3432-3440. [PMID: 30715593 DOI: 10.1007/s00167-019-05378-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 01/24/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE In medial patellofemoral ligament (MPFL) reconstruction, it remains controversial whether more accurate femoral tunnel positioning is correlated with improved clinical outcomes. The purpose was to verify the accuracy of methods for evaluating tunnel positioning, one of which is the use of postoperative radiographs, in determining the femoral tunnel position following MPFL reconstruction and to compare the variability of tunnel positions to the intraoperatively documented positions on a true-lateral view. METHODS Seventy-three consecutive MPFL reconstructions were prospectively enrolled. Femoral tunnel positions were intraoperatively determined using fluoroscopy to obtain true-lateral radiographs. Postoperatively, lateral radiographic images were taken. Seven independent radiologists and seven independent orthopaedic knee surgeons evaluated the femoral tunnel position and amount of malrotation for each radiograph. Deviations from the Schoettle's point were measured and repeated after 4 weeks. Intraobserver and interobserver analyses of variance were calculated to determine the reliability of measurements on both intraoperative and postoperative radiographs. RESULTS Fifty-six patients were included in the final analysis. Tunnel positions were unable to be identified on postoperative radiographs in 14% of cases on average, independent of the degree of radiograph rotation. Intraoperative images showed mean deviations from the tunnel position to the centre of Schoettle's point of 1.9 ± 1.4 mm and 1.6 ± 1.0 mm in anterior-posterior and proximal-distal direction, respectively. Postoperative radiographs showed mean anterior-posterior and deviations of 7.4 ± 4.4 mm and 8.9 ± 5.8 mm assessed by orthopaedic surgeons and 10.6 ± 6.3 mm and 11.6 ± 7.1 mm assessed by radiologists at first and repeated measurement, respectively. The mean proximal-distal deviations were 4.8 ± 4.4 mm and 6.5 ± 6.0 mm and 7.2 ± 6.3 mm and 8.1 ± 7.1 mm, respectively. Measurement of tunnel position on intraoperative fluoroscopic images was significantly different compared to postoperative radiographs for each of the 14 observers (p < 0.05). Significant intraobserver and interobserver differences between the first and repeat measurements for both orthopaedic surgeons and radiologists were observed (p < 0.05). CONCLUSION Measurement of the femoral tunnel position on postoperative lateral radiographs is not an accurate or reliable method for evaluating tunnel position after MPFL reconstruction due to exposure, contrast, and malrotation of the radiograph from a true-lateral image. In contrast, intraoperative fluoroscopic control allows for a precise lateral view and correct tunnel positioning. Thus, postoperative radiographic images may be unnecessary for the evaluation of femoral tunnel positions, particularly when intraoperative fluoroscopy has been used. STUDY DESIGN Level II, prospective cohort study.
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Affiliation(s)
- Vera Jaecker
- Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne Merheim Medical Centre, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Lars Neumann
- Department of Radiology, Cologne Merheim Medical Centre, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Sven Shafizadeh
- Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne Merheim Medical Centre, Ostmerheimer Strasse 200, 51109, Cologne, Germany. .,Department of Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Sana Medical Centre Cologne, Aachener Str. 445-449, 50933, Cologne, Germany.
| | - Paola Koenen
- Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne Merheim Medical Centre, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Ajay C Kanakamedala
- Department of Orthopaedic Surgery, NYU Langone Health, 301 East 17th St, New York, NY, 10003, USA
| | - Thorsten Tjardes
- Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne Merheim Medical Centre, Ostmerheimer Strasse 200, 51109, Cologne, Germany
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Lösungen für häufige Komplikationen bei Patella-Stabilisierungseingriffen. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-00309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:2537-2550. [PMID: 30370440 DOI: 10.1007/s00167-018-5266-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/23/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE The scientific literature concerning the anatomy of medial soft-tissue stabilizers of the patella is growing exponentially. Much of the surgical literature has focused on the role of the medial patellofemoral ligament (MPFL) and techniques to reconstruct it, yet our understanding of its anatomy has evolved during the past several years. Given this, we report on the current understanding of medial patellofemoral anatomy and implications for reconstruction. METHODS Current and historical studies of medial patellar anatomy were reviewed, which include the MPFL and medial quadriceps tendon femoral ligament (MQTFL), as well as that of the distal medial patellar restraints, the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML). In addition to the reported findings, the authors' anatomic descriptions of each ligament during their dissections were identified and recorded. RESULTS Despite the name of the MPFL, which implies that the ligament courses between the femur and patella, recent studies have highlighted the proximal MPFL fibers that attach to the quadriceps tendon, known as the MQTFL. The MPFL and MQTFL have also been referred to as the medial patellofemoral complex, reflecting the variability in anatomical attachment sites. The MPFL accounts for only half of the total restraint to lateral patellar displacement, and the remaining contributions to patellar stability are derived from the combination of the MPTL and MPML, which function primarily in greater degrees of knee flexion. CONCLUSION The understanding of the complexity of the medial patellar stabilizers continues to evolve. Although MPFL reconstruction is gaining wide acceptance as a procedure to treat patellar instability, it is important to recognize the complex and changing understanding of the anatomy of the medial soft-tissue stabilizers and the implications for reconstruction. LEVEL OF EVIDENCE V.
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Kizher Shajahan MB, Choh CTA, Yew KSA, Chan HY, Howe TS, Lie TTD, Koh SBJ, Chang CCP. Strain behavior of native and reconstructed medial patellofemoral ligaments during dynamic knee flexion - a cadaveric study. J Exp Orthop 2019; 6:31. [PMID: 31270628 PMCID: PMC6609927 DOI: 10.1186/s40634-019-0195-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Surgical reconstruction of the Medial Patello-Femoral Ligament (MPFL) has been recognized as an effective treatment for patients with instability despite conservative treatment. The purpose of this cadaveric study is to compare the strain patterns within the native and reconstructed single and double-bundle MPFL. This will help ascertain if the native biomechanics are restored with the reconstructions. Methods Twelve cadaveric knees were dissected and the native MPFL of each specimen was identified. The knees were subjected to dynamic flexion using a customized jig. Continuous strain measurements were taken for each knee from 0 to 120 degrees flexion and then back to full extension using differential variable reluctance transducers (DVRTs). The MPFL was then cut. Six single bundle and six double bundle MPFL reconstructions were performed using hamstring tendon grafts. The DVRTs were reattached to the grafts and strain measurements were retaken. Statistical analysis was performed using a paired t-test. Results Strain patterns of the native and reconstructed MPFL showed an increase in strain from 0 to 120 degrees of flexion except for the inferior bundle of the double bundle reconstruction. The strain patterns in the intact specimens were higher than the reconstructed MPFL through different degrees of knee flexion. In the double-bundle group, the superior graft had statistically significantly lower strains compared to the native MPFL with p-value <.05 at all flexion angles. The reconstructed inferior band showed loss of tension as the knee flexed. Higher strain with statistical significance (p-value <.05) was found in the single-bundle compared to the superior band of the double-bundle reconstruction at flexion angles less than 90 degrees. Conclusion The strain variation at progressive angles of knee flexion is dissimilar between the native and reconstructed MPFL. The reconstructed MPFL exhibited non-physiological biomechanics with the inferior band losing tension. Although the single-bundle reconstruction shows a better strain profile compared to double-bundle reconstruction, the grafts are significantly stiffer than the native MPFL.
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Affiliation(s)
| | - Chaw Tat Alex Choh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Khye Soon Andy Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Hiok Yang Chan
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Tet Sen Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Tjiauw Tjoen Denny Lie
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Suang Bee Joyce Koh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Chee Cheng Paul Chang
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
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Kernkamp WA, Wang C, Li C, Hu H, van Arkel ERA, Nelissen RGHH, LaPrade RF, van de Velde SK, Tsai TY. The Medial Patellofemoral Ligament Is a Dynamic and Anisometric Structure: An In Vivo Study on Length Changes and Isometry. Am J Sports Med 2019; 47:1645-1653. [PMID: 31070936 DOI: 10.1177/0363546519840278] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is associated with a high rate of complications, including recurrent instability and persistent knee pain. Technical errors are among the primary causes of these complications. Understanding the effect of adjusting patellofemoral attachments on length change patterns may help surgeons to optimize graft placement during MPFL reconstruction and to reduce graft failure rates. PURPOSE To determine the in vivo length changes of the MPFL during dynamic, weightbearing motion and to map the isometry of the 3-dimensional wrapping paths from various attachments on the medial femoral epicondyle to the patella. STUDY DESIGN Descriptive laboratory study. METHODS Fifteen healthy participants were studied with a combined computed tomography and biplane fluoroscopic imaging technique during a lunge motion (full extension to ~110° of flexion). On the medial femoral epicondyle, 185 attachments were projected, including the anatomic MPFL footprint, which was divided into 5 attachments (central, proximal, distal, posterior, and anterior). The patellar MPFL area was divided into 3 possible attachments (proximal, central, and distal). The length changes of the shortest 3-dimensional wrapping paths of the various patellofemoral combinations were subsequently measured and mapped. RESULTS For the 3 patellar attachments, the most isometric attachment, with an approximate 4% length change, was located posterior and proximal to the anatomic femoral MPFL attachment, close to the adductor tubercle. Attachments proximal and anterior to the isometric area resulted in increasing lengths with increasing knee flexion, whereas distal and posterior attachments caused decreasing lengths with increasing knee flexion. The anatomic MPFL was tightest in extension, decreased in length until approximately 30° of flexion, and then stayed near isometric for the remainder of the motion. Changing both the femoral and patellar attachments significantly affected the length changes of the anatomic MPFL ( P < .001 for both). CONCLUSION The most isometric location for MPFL reconstruction was posterior and proximal to the anatomic femoral MPFL attachment. The anatomic MPFL is a dynamic, anisometric structure that was tight in extension and early flexion and near isometric beyond 30° of flexion. CLINICAL RELEVANCE Proximal and anterior MPFL tunnel positioning should be avoided, and the importance of anatomic MPFL reconstruction is underscored with the results found in this study.
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Affiliation(s)
- Willem A Kernkamp
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.,Leiden University Medical Center, Leiden, the Netherlands
| | - Cong Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Changzou Li
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Hai Hu
- Department of Orthopaedic Surgery and Orthopaedic Biomechanical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | | | | | | | | | - Tsung-Yuan Tsai
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Clinical Translational Digital Medicine, Ministry of Education of P.R. China, Shanghai, China
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Mochizuki Y, Kaneko T, Kawahara K, Toyoda S, Ikegami H, Musha Y. A 2-year follow-up of isolated Medial Patellofemoral Ligament Reconstruction by using soft suture anchor and adjustable cortical fixation system. J Orthop 2019; 16:356-360. [PMID: 31015756 DOI: 10.1016/j.jor.2019.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/25/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Numerous surgical techniques and fixation methods have been described in medial patellofemoral ligament (MPFL) reconstruction such as choice of graft, graft fixation method of patella/femur and initial tension. We describe short term clinical results of MPFL reconstruction by using soft suture anchor and adjustable cortical fixation system. Methods Twenty-four patients who underwent isolated MPFL reconstruction by using soft suture anchor and adjustable cortical fixation system were included in this study. All patients were followed up for at least 2 years, and pre-operative and 2 years post-operative Kujala score, IKDC score and Knee Injury and Osteoarthritis Outcome Score were used to assess clinical outcome. Radiographic evaluation included the Q angle, congruence angle and patellar tilt angle. Pre- and post-operative changes were evaluated by Mann-Whitney U test. Results There were no complications including re-dislocation, patella fracture, infection, and joint contracture. The apprehension test was positive in 4.2% post-operatively. A statistically significant improvement in clinical scores and radiographic evaluation were evident after surgery. Conclusions Isolated MPFL Reconstruction using soft suture anchor and adjustable cortical fixation system led good restoration of patellar stability and significant improvement of knee function in short-term results. This surgical technique can reduce complications such as patella fractures, and can be done safely. Clinical relevance This technique may be a treatment option with little associated complications in the treatment for patellar instability. Level of Evidence Case series, Level IV.
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Affiliation(s)
- Yuta Mochizuki
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Takao Kaneko
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Keisuke Kawahara
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Shinya Toyoda
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Hiroyasu Ikegami
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Yoshiro Musha
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
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Descriptive and dynamic study of the medial patellofemoral ligament (MPFL). Surg Radiol Anat 2019; 41:763-774. [PMID: 30944976 DOI: 10.1007/s00276-019-02234-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/28/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The goal of this study was to evaluate the anatomy of the medial patellar retinaculum and the medial patellofemoral ligament (MPFL) to provide an anatomical validation of a pediatric reconstruction technique. METHODS Fifteen knees were dissected to study the MPFL and its relationship with the medial patellar retinaculum and the femoral insertion of the medial collateral ligament (MCL). The distances between the insertions of the MPFL of eight knees, and the patellar insertion of the MPFL and the femoral insertion of the MCL of four knees, were measured during the flexion to evaluate the isometricity of the native and reconstructed MPFL. RESULTS The medial patellar retinaculum includes four structures: the fascia, fibrous expansions of the vastus muscles, the MPFL and the medial patellomeniscal ligament. The femoral insertion of the MPFL was located just behind the femoral insertion of the MCL in 12 knees. During flexion, the distance between the insertion on the upper patella and the femoral insertion of the MPFL increased while the distance between the insertion on the lower patella and the femoral insertion of the MPFL decreased. The variation in the distances measured during the flexion was greater between the MPFL insertions (nsup = 6.5 mm, ninf = 6.5 mm) than between the patellar insertion of the MPFL and the femoral insertion of the MCL (n'sup = 2.5 mm, n'inf = 5.75 mm). CONCLUSION The MPFL is not isometric. Even though the results were obtained from knees of elderly specimens, this study demonstrates reconstruction of the MPFL should take into account its anatomy and biomechanical role in the knee.
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Editorial Commentary: Medial Patellofemoral Complex: Driving a Better Understanding of Medial Knee Anatomy. Arthroscopy 2019; 35:1147-1151. [PMID: 30954108 DOI: 10.1016/j.arthro.2019.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 02/02/2023]
Abstract
Although its importance as the prime restraint to lateral patellar instability is undoubted, the anatomy of the medial patellofemoral ligament has never been agreed on. Since it was first described by Warren and Marshall in 1979, most of the anatomic studies confirmed its presence in 90% of the cases, but they usually provide inconsistent descriptions of its femoral and patellar attachments. It is proven that length changes in the reconstructed medial patellofemoral ligament depend principally on the femoral attachment site. Moreover, the femoral attachment site affects the patellar tilt, translation, and joint reaction force. Because of the early inconsistent descriptions of the medial patellofemoral ligament attachment sites, some authors have suggested that its anatomy is not fixed or may be patient specific.
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No Difference in Outcome Between Femoral Soft-Tissue and Screw Graft Fixation for Reconstruction of the Medial Patellofemoral Ligament: A Randomized Controlled Trial. Arthroscopy 2019; 35:1130-1137. [PMID: 30871907 DOI: 10.1016/j.arthro.2018.11.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/14/2018] [Accepted: 11/20/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of the present randomized controlled trial was to compare 2 different medial patellofemoral ligament reconstruction (MPFL-R) techniques that utilize different femoral fixation principles, which could affect subjective clinical outcomes and surgical morbidity. METHODS Sixty patients were randomly assigned to 2 MPFL-R techniques: bone or soft-tissue fixation of the graft at the femoral condyle. Patients had operations performed between 2010 and 2015 at a single center. Indication for surgery was 2 or more patellar dislocations. When the bone fixation technique was used, the gracilis tendon was fixed with the use of an interference screw. When the soft-tissue fixation technique was used, the gracilis tendon was looped around the adductor magnus tendon. Both techniques used patella-graft fixation with drill holes in the medial patellar edge. Clinical outcomes were evaluated by means of Kujala, knee injury and osteoarthritis outcome, and pain scores before the operation and at 1- and 2-year follow-up examinations. Surgical morbidity was evaluated by pain on palpation along the reconstruction site. RESULTS Kujala scores were 88 and 89 for bone and soft-tissue fixation groups, respectively, with no difference between groups (P = .73). No significant differences in knee injury osteoarthritis outcome or pain scores were found. Analysis of surgical morbidity, defined as femoral-based tenderness overlying the fixation site, demonstrated that 13% and 12% of patients had significant tenderness at the reconstruction site after bone and soft-tissue MPFL-R, respectively. No patellar re-dislocations were observed in either group. CONCLUSIONS MPFL-R with soft-tissue graft fixation at the femoral condyles resulted in findings for subjective clinical outcome, patellar stability, and pain level similar to those associated with MPFL-R with bone fixation. Surgical morbidity was also similar between patients who had soft-tissue and those who had bone fixation MPFL-R. Soft-tissue femoral graft fixation does not result in inferior clinical outcomes compared with screw fixation, and it can be used safely for MPFL-R.
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Ferrua P, Kruckeberg BM, Pasqualotto S, Berruto M, Randelli P, Arendt EA. Proximal medial patellar restraints and their surgical reconstruction. J Orthop Traumatol 2019; 20:17. [PMID: 30915690 PMCID: PMC6435766 DOI: 10.1186/s10195-019-0525-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/08/2019] [Indexed: 01/27/2023] Open
Abstract
Reconstruction of the medial patellofemoral ligament (MPFL) has been increasing as a surgical solution for treatment of recurrent lateral patellofemoral dislocation. Recent attention has been given to fibers extending from the femur to the quadriceps tendon, proximal to the MPFL, termed the medial quadriceps tendon-femoral ligament. This article briefly reviews the proximal medial patellar restraints and surgical procedures for their reconstruction.
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Affiliation(s)
- Paolo Ferrua
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Bradley M Kruckeberg
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Stefano Pasqualotto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Massimo Berruto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Pietro Randelli
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
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Comparation and evaluation of the accuracy of the sulcus localization method to establish the medial patellofemoral ligament femoral tunnel: a cadaveric and clinical study. BMC Musculoskelet Disord 2019; 20:53. [PMID: 30732597 PMCID: PMC6367746 DOI: 10.1186/s12891-019-2439-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 01/29/2019] [Indexed: 12/23/2022] Open
Abstract
Background In anatomic medial patellofemoral ligament (MPFL) reconstruction, malpositioning of the MPFL femoral tunnel is common. A palpable sulcus reportedly exists at the anatomic femoral attachment of the MPFL. The present study aimed to investigate the accuracy of the sulcus localization method to establish the MPFL femoral tunnel. Methods A cadaveric study was first done on 12 knees to evaluate the accuracy of the sulcus localization method to establish the entry points of the MPFL femoral tunnel in comparison with the midpoint and fluoroscopic localization methods. The center of the native MPFL femoral attachment was served as the reference in the cadaveric study. A clinical study was then performed to further evaluate the accuracy of the sulcus localization method in 53 patients (60 knees). Schöttle’s point was served as the reference in the clinical study. Femoral tunnel placement was defined as accurate when it was less than 5 mm from Schöttle’s point. In both the cadaveric and clinical studies, MPFL femoral tunnel placement was assessed on postoperative reconstructed three-dimensional computed tomography images. In the cadaveric study, the accuracy of different localization methods was compared using analysis of variance. Results In the cadaveric study, the mean distances from the native MPFL attachment to the femoral tunnel entry point were 4.2 ± 1.0 mm (range 2.4–5.6 mm), 4.4 ± 1.4 mm (range 1.8–6.6 mm) and 2.9 ± 0.8 mm (range 1.9–4.4 mm) using the midpoint, fluoroscopic, and sulcus localization methods, respectively; this distance significantly differed between the midpoint and sulcus localization methods, and between the fluoroscopic and sulcus localization methods (p ≤ .05). While there were no significant differences between the midpoint and fluoroscopic localization methods (n.s.). In the clinical study, the mean distance between the femoral tunnel and Schöttle’s point was 3.5 ± 1.5 mm (range 0.4–6.1 mm), with accurate tunnel placement achieved in 49 of 60 cases (82%). Conclusion The sulcus localization method can accurately guide MPFL femoral tunnel placement. This method might be useful for orthopedic surgeons. Level of evidence IV
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Combined Reconstruction of the Medial Patellofemoral Ligament (MPFL) and Medial Quadriceps Tendon-Femoral Ligament (MQTFL) for Patellar Instability in Children and Adolescents: Surgical Technique and Outcomes. J Pediatr Orthop 2019; 39:e54-e61. [PMID: 30300273 DOI: 10.1097/bpo.0000000000001259] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES A variety of surgical options exist to treat the challenging problem of recurrent patellar instability in children and adolescents. The goal of the current study is to describe a novel combined reconstruction technique of both the medial patellofemoral ligament (MPFL) and the medial quadriceps tendon-femoral ligament (MQTFL) and report patient outcomes of a single-surgeon series. METHODS All patients studied underwent simultaneous MPFL and MQTFL reconstruction for patellar instability using gracilis allograft. Demographic, clinical, and radiographic data were collected. Subjective outcomes were assessed for a minimum of 1 year postoperatively. RESULTS Twenty-five patients (27 knees), including 15 female and 10 male individuals with an average age of 15.0±2.2 years (range, 10.3 to 18.9), were included. Prior ipsilateral patellofemoral surgery had been performed in 6 of 25 (24%) patients. Simultaneous hemiepiphysiodesis for valgus deformity at the time of combined reconstruction was performed in 5 of 25 (20%) patients. Preoperative imaging showed a mean tibial tubercle-trochlear groove of 17.2±3.8, Caton-Deschamps Index (CDI) of 1.13±0.16, and trochlear dysplasia Dejour A/B [22/26 (85%)] or Dejour C/D [4/26 (15%)]. A total of 18 patients (19 knees, 72%) returned outcomes questionnaires at a mean 2.0±0.5 years after surgery. Mean Kujala, Pedi-IKDC, and Lysholm scores were 85.9±13.9, 81.5±15.2, and 84.3±13.5, respectively. Later revision procedure (tibial tubercle osteotomy) for recurrent patellar instability was required in 2 of 25 patients (8%) patients, and another patient reported persistent instability not requiring revision. Return to sports was possible in 10 of 13 self-reported athletes (77%) at a mean of 5.8±3.9 months (range, 2 to 15). CONCLUSIONS The present study describes a combined MPFL-MQTFL reconstruction technique with favorable short-term results. Although particularly useful in the skeletally immature patient where tibial tubercle osteotomy should be avoided and patellar fixation minimized, combined reconstruction may potentially be appropriate for older patients with patellofemoral instability as well. This technique more closely recreates the native anatomy of both the MPFL and MQTFL, may decrease the risk of patellar fracture, and can be useful in the revision setting. LEVEL OF EVIDENCE Level IV.
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Koenen P, Shafizadeh S, Pfeiffer TR, Wafaisade A, Bouillon B, Kanakamedala AC, Jaecker V. Intraoperative fluoroscopy during MPFL reconstruction improves the accuracy of the femoral tunnel position. Knee Surg Sports Traumatol Arthrosc 2018; 26:3547-3552. [PMID: 29752499 DOI: 10.1007/s00167-018-4983-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 05/04/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE Reconstruction of the medial patellofemoral ligament (MPFL) has been established as standard of care for patellofemoral instability. An anatomic femoral tunnel position has been shown to be a prerequisite for restoration of patellofemoral stability and biomechanics. However, the incidence of malpositioning of the femoral tunnel during MPFL reconstruction continues to be notable. Palpation of anatomic landmarks and intraoperative fluoroscopy are the two primary techniques for tunnel placement. The aim of this study was to compare the accuracy of these two methods for femoral tunnel placement. METHODS From 2016 to 2017, 64 consecutive patients undergoing MPFL reconstruction for patelllofemoral instability were prospectively enrolled. During surgery, the presumed femoral MPFL insertion was identified by both palpation of anatomic landmarks and using fluoroscopy, both of these points were separately documented on true lateral radiographs. They were then analysed and deviations from the Schoettle's Point were measured as anterior-posterior and proximal-distal deviations. A tunnel position within a radius of 7 mm around the Schoettle's Point was designated as an "accurate tunnel position". RESULTS Compared to the method of palpation, fluoroscopy led to significantly more anatomic femoral tunnel positoning (p < 0.0001). The mean proximal-distal and anterior-posterior distances between the femoral insertion site identified by palpation and the Schoettle's Point were 5.7 ± 4.5 mm (0.3-20.3 mm) and 4.1 ± 3.7 mm (0.1-20.3 mm), respectively, versus 1.7 ± 0.9 mm (0.1-3.6 mm) and 1.8 ± 1.3 mm (0.1-4.8 mm) for fluoroscopy, respectively. Using fluoroscopy, all femoral insertion sites were identified within a 7 mm radius around the centre of the Schoettle's Point. In contrast, only 52% (33) of femoral insertion sites identified by palpation were within this radius. These data were independent of patients' age, gender and BMI. No improvement in accuracy of femoral tunnel positions was detected over time. CONCLUSIONS The main finding of this study was that, compared to the method of palpation of anatomic landmarks, the use of intraoperative fluoroscopy in MPFL reconstruction leads to more accurate femoral tunnel positioning. Based on these results, the use of intraoperative fluoroscopy has to be recommended for femoral tunnel placement in daily surgical practice to minimize the incidence of malpositioning and to restore native patellofemoral biomechanics. STUDY DESIGN Level III Case-control study.
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Affiliation(s)
- P Koenen
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - S Shafizadeh
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - T R Pfeiffer
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - A Wafaisade
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - B Bouillon
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - A C Kanakamedala
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, Pittsburgh, USA
| | - V Jaecker
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
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Liu JN, Steinhaus ME, Kalbian IL, Post WR, Green DW, Strickland SM, Shubin Stein BE. Patellar Instability Management: A Survey of the International Patellofemoral Study Group. Am J Sports Med 2018; 46:3299-3306. [PMID: 28985094 DOI: 10.1177/0363546517732045] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although patellofemoral instability is among the most prevalent knee disorders, the management of patients with this condition is complex and remains variable, given the lack of long-term, high-level clinical outcome studies to compare various operative and nonoperative modalities. PURPOSE To discover a consensus within treatment controversies in patellofemoral instability among experienced knee surgeons with a specific interest in the patellofemoral joint. STUDY DESIGN Expert opinion; Level of evidence, 5. METHODS A 3-step modified Delphi technique was used to establish a consensus. A 34-question, case-based online survey regarding patellofemoral instability was distributed to all active members of the International Patellofemoral Study Group. Consensus statements were generated if at least 66% of the respondents agreed and then redistributed to the same panel. Modifications to the consensus statements were made based on the iterative feedback process until no discordance was encountered in the third stage. RESULTS Eight consensus statements were achieved. Nonoperative management is the current standard of care for a first-time dislocation in the absence of an osteochondral fragment or loose body requiring excision (100% agreement). In patients with a first-time dislocation with an operative osteochondral fracture requiring excision or repair, patellar instability should be addressed concurrently (89% agreement). Recurrent instability should be treated surgically, with most surgeons favoring medial reconstruction (77%-86% agreement). While there is general agreement that bony procedures should be performed to correct underlying bony deformities, there is no consensus regarding the most appropriate type of procedure performed. Lateral release should not be performed in isolation for the treatment of patellar instability (89% agreement). CONCLUSION Despite the consensus generated in this study, our current understanding remains limited by a lack of high-level evidence as well as the numerous complex variables influencing treatment decision making. High-quality, multicenter randomized controlled trials, particularly those directly comparing specific surgical treatment methods while controlling for underlying risk factors, are needed to address these areas of uncertainty.
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Affiliation(s)
- Joseph N Liu
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael E Steinhaus
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Irene L Kalbian
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - William R Post
- Mountaineer Orthopedic Specialists LLC, Morgantown, West Virginia, USA
| | - Daniel W Green
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Sabrina M Strickland
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Beth E Shubin Stein
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
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Gao Z, Li Y, Wang G, Cai G. [Influencing factors of medial patellofemoral ligament reconstruction for patellar dislocation]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1047-1051. [PMID: 30238733 DOI: 10.7507/1002-1892.201710049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the influencing factors of medial patellofemoral ligament (MPFL) reconstruction for patellar dislocation. Methods The literature of MPFL reconstruction for patellar dislocation at home and abroad in recent years were summarized and analyzed. Results The influencing factors such as the location of the femoral insertion point, the tension and the fixed angle of the grafts, the dysplasia of the femoral trochlear before operation, the abnormal tuberositas tibiae-trochlear groove value, the high position of the patellar, and the tilting angle of the patellar, are all the factors affecting the effectiveness of MPLF reconstruction. Conclusion During MPFL reconstruction, the surgical techniques and elimination of other factors that caused patellar instability need to be focused in order to reduce the complications and operation failure.
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Affiliation(s)
- Zhitao Gao
- The 4th Department of Surgery, the People's Hospital of Anning, Anning Yunnan, 650300, P.R.China
| | - Yanlin Li
- Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032,
| | - Guoliang Wang
- Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
| | - Guofeng Cai
- Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
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75
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Bedi A, LaPrade RF, Burrus MT. Radiographic and Anatomic Landmarks of the Major Knee Ligaments. J Bone Joint Surg Am 2018; 100:1241-1250. [PMID: 30020131 DOI: 10.2106/jbjs.17.01135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Asheesh Bedi
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Robert F LaPrade
- Complex Knee and Sports Medicine Surgery, The Steadman Clinic, Steadman Philippon Research Institute, Vail, Colorado.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota.,College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Vail, Colorado
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76
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Razu SS, Guess TM. Electromyography-Driven Forward Dynamics Simulation to Estimate In Vivo Joint Contact Forces During Normal, Smooth, and Bouncy Gaits. J Biomech Eng 2018; 140:2664392. [PMID: 29164228 PMCID: PMC6056185 DOI: 10.1115/1.4038507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 10/25/2017] [Indexed: 11/08/2022]
Abstract
Computational models that predict in vivo joint loading and muscle forces can potentially enhance and augment our knowledge of both typical and pathological gaits. To adopt such models into clinical applications, studies validating modeling predictions are essential. This study created a full-body musculoskeletal model using data from the "Sixth Grand Challenge Competition to Predict in vivo Knee Loads." This model incorporates subject-specific geometries of the right leg in order to concurrently predict knee contact forces, ligament forces, muscle forces, and ground contact forces. The objectives of this paper are twofold: (1) to describe an electromyography (EMG)-driven modeling methodology to predict knee contact forces and (2) to validate model predictions by evaluating the model predictions against known values for a patient with an instrumented total knee replacement (TKR) for three distinctly different gait styles (normal, smooth, and bouncy gaits). The model integrates a subject-specific knee model onto a previously validated generic full-body musculoskeletal model. The combined model included six degrees-of-freedom (6DOF) patellofemoral and tibiofemoral joints, ligament forces, and deformable contact forces with viscous damping. The foot/shoe/floor interactions were modeled by incorporating shoe geometries to the feet. Contact between shoe segments and the floor surface was used to constrain the shoe segments. A novel EMG-driven feedforward with feedback trim motor control strategy was used to concurrently estimate muscle forces and knee contact forces from standard motion capture data collected on the individual subject. The predicted medial, lateral, and total tibiofemoral forces represented the overall measured magnitude and temporal patterns with good root-mean-squared errors (RMSEs) and Pearson's correlation (p2). The model accuracy was high: medial, lateral, and total tibiofemoral contact force RMSEs = 0.15, 0.14, 0.21 body weight (BW), and (0.92 < p2 < 0.96) for normal gait; RMSEs = 0.18 BW, 0.21 BW, 0.29 BW, and (0.81 < p2 < 0.93) for smooth gait; and RMSEs = 0.21 BW, 0.22 BW, 0.33 BW, and (0.86 < p2 < 0.95) for bouncy gait, respectively. Overall, the model captured the general shape, magnitude, and temporal patterns of the contact force profiles accurately. Potential applications of this proposed model include predictive biomechanics simulations, design of TKR components, soft tissue balancing, and surgical simulation.
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Affiliation(s)
- Swithin S. Razu
- Department of Bioengineering,
University of Missouri,
801 Clark Hall,
Columbia, MO 65211-4250
e-mail:
| | - Trent M. Guess
- Department of Physical Therapy,
University of Missouri,
801 Clark Hall,
Columbia, MO 65211-4250;
Department of Orthopaedic Surgery,
University of Missouri,
1100 Virginia Ave,
Columbia, MO 65201
e-mail:
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77
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Dornacher D, Lippacher S, Nelitz M, Reichel H, Ignatius A, Dürselen L, Seitz AM. Impact of five different medial patellofemoral ligament-reconstruction strategies and three different graft pre-tensioning states on the mean patellofemoral contact pressure: a biomechanical study on human cadaver knees. J Exp Orthop 2018; 5:25. [PMID: 29956015 PMCID: PMC6023804 DOI: 10.1186/s40634-018-0140-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/20/2018] [Indexed: 11/10/2022] Open
Abstract
Background The medial patellofemoral ligament (MPFL) is the main stabiliser of the patella and thus mostly reconstructed in the surgical treatment of patellofemoral dislocation. The aims of this study were to gain a better understanding of the influence of altered MPFL graft-fixation locations and different graft pre-tensions on patellofemoral contact pressure. Methods Six human cadaveric knee joints were placed in a six-degree-of-freedom knee simulator. Mean PFCP (mPFCP) was evaluated in knee flexion of 0, 30 and 90° using a calibrated pressure-measurement system. After data assessment of the native knee joint, five MPFL reconstruction conditions were conducted: Anatomical double bundle; non-anatomical proximal patellar; non-anatomical distal patellar; non-anatomical proximal femoral; non-anatomical ventral femoral. The gracilis graft was fixed at a defined knee flexion of 30° and pre-tensioned to 2, 10 and 20 N. Results Kruskal-Wallis testing resulted in no mPFCP differences between the native and anatomical reconstruction states. Comparing the native and anatomical reconstruction states with the non-anatomical reconstruction states, no difference in the mPFCP both in knee extension (0°) (p>0.366) and in 30° knee flexion (p>0.349) was found. At 90° knee flexion, the following differences were identified: compared to the native knee state, the mPFCP increased after non-anatomical proximal femoral and non-anatomical ventral femoral reconstruction by 257% (p=0.04) and 292% (p=0.016), respectively. Compared to the anatomical reconstruction state, the mPFCP increased after non-anatomical proximal femoral reconstruction by 199% (p=0.042). Discussion and Conclusions With respect to all study findings and to restore a physiological PFCP, we recommend using the anatomical footprints for MPFL reconstruction and a moderate graft pretensioning of 2-10 N.
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Affiliation(s)
- Daniel Dornacher
- Department of Orthopaedics, Ulm University Medical Centre, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Sabine Lippacher
- Department of Orthopaedics, Ulm University Medical Centre, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Manfred Nelitz
- Department of Orthopaedics, Ulm University Medical Centre, Oberer Eselsberg 45, 89081, Ulm, Germany.,MVZ Oberstdorf, Clinics Kempten-Oberallgäu, Trettachstr. 16, 87561, Oberstdorf, Germany
| | - Heiko Reichel
- Department of Orthopaedics, Ulm University Medical Centre, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, Ulm University Medical Centre, Helmholtzstr. 14, 89081, Ulm, Germany
| | - Lutz Dürselen
- Institute of Orthopaedic Research and Biomechanics, Ulm University Medical Centre, Helmholtzstr. 14, 89081, Ulm, Germany
| | - Andreas Martin Seitz
- Institute of Orthopaedic Research and Biomechanics, Ulm University Medical Centre, Helmholtzstr. 14, 89081, Ulm, Germany
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78
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Lateral Patellar Instability in the Skeletally Mature Patient: Evaluation and Surgical Management. J Am Acad Orthop Surg 2018; 26:429-439. [PMID: 29787463 DOI: 10.5435/jaaos-d-16-00052] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Lateral patellar instability is a common disease process that affects all types of patients. Depending on the patient's anatomy and the results of preoperative imaging, surgical management options include medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, and sulcus-deepening trochleoplasty. Medial patellofemoral ligament reconstruction or repair is useful for almost all patients, whereas tibial tubercle osteotomy is helpful to correct a lateralized tibial tubercle and the associated elevated lateral pull of the extensor mechanism. For a select subset of patients with severe trochlear dysplasia, a sulcus-deepening trochleoplasty can be a useful option to prevent future patellar instability. Many technical considerations exist for each procedure, and in most situations, no consensus exists to direct surgeons on the superior technique.
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79
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Biomechanical Analysis of Tibial Tuberosity Medialization and Medial Patellofemoral Ligament Reconstruction. Sports Med Arthrosc Rev 2018; 25:58-63. [PMID: 28459747 DOI: 10.1097/jsa.0000000000000152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Biomechanical studies are commonly performed to evaluate the influence of medial patellofemoral ligament (MPFL) reconstruction and tibial tuberosity medialization on patellar tracking and patellofemoral contact pressures. The most common method is in vitro simulation of knee function, but computational simulation of knee function and computational reconstruction of in vivo motion can also be utilized. The current review of the biomechanical literature indicates that MPFL reconstruction and tibial tuberosity medialization reduce lateral patellar tracking. Decreased lateral patellofemoral contact pressures have also been noted. For MPFL reconstruction, the most commonly noted biomechanical concerns are graft overtensioning and nonanatomic attachment on the femur leading to overconstraint of the patella and elevated medial contact pressures. For tuberosity medialization, the influence of altered tibiofemoral kinematics on postoperative function is unknown. Future biomechanical studies should emphasize inclusion of anatomic features and tracking patterns related to patellar instability, with comparison between the surgical approaches for continued development of treatment guidelines.
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80
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Abstract
The term "medial patellofemoral complex" (MPFC) was proposed to describe the static medial stabilizer of the patella, typically referred to as the medial patellofemoral ligament. In light of our increasing understanding of the attachment of its fibers to the quadriceps tendon in addition to the patella, the term MPFC is used in this article. The purpose of this article is to describe and discuss the anatomy of the MPFC.
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81
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Abstract
PURPOSE OF REVIEW To discuss the potentially significant complications associated with medial patellofemoral ligament (MPFL) reconstruction. Additionally, to review the most current and relevant literature with an emphasis on avoiding these potential complications. RECENT FINDINGS Multiple cadaveric studies have characterized the anatomy of the MPFL and the related morphologic abnormalities that contribute to recurrent lateral patellar instability. Such abnormalities include patella alta, excessive tibial tubercle to trochlear grove (TT-TG) distance, trochlear dysplasia, and malalignment. Recent studies have evaluated the clinical outcomes associated with the treatment of concomitant pathology in combination with MPFL reconstruction, which is critical in avoiding recurrent instability and complications. Although there remains a lack of consensus regarding various critical aspects of MPFL reconstruction, certain concepts remain imperative. Our preferred methods and rationales for surgical techniques are described. These include appropriate work up, a combination of procedures to address abnormal morphology, anatomical femoral insertion, safe and secure patellar fixation, appropriate graft length fixation, and thoughtful knee flexion during fixation.
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Affiliation(s)
- Marvin K Smith
- Department of Orthopaedic Surgery, Sports Medicine Division, University of Virginia, 400 Ray C. Hunt Drive, Third Floor, Charlottesville, FL, 22903, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, Sports Medicine Division, University of Virginia, 400 Ray C. Hunt Drive, Third Floor, Charlottesville, FL, 22903, USA
| | - David R Diduch
- Department of Orthopaedic Surgery, Sports Medicine Division, University of Virginia, 400 Ray C. Hunt Drive, Third Floor, Charlottesville, FL, 22903, USA.
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82
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Length change patterns and shape of a grafted tendon after anatomical medial patellofemoral ligament reconstruction differs from that in a healthy knee. Knee Surg Sports Traumatol Arthrosc 2018; 26:1245-1251. [PMID: 28741155 DOI: 10.1007/s00167-017-4620-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Recurrent patellar dislocation is currently treated with anatomical reconstruction of the medial patellofemoral ligament (MPFL), and favourable postoperative outcomes have been reported. However, it is uncertain if healthy MPFL function is restored by anatomical reconstruction. The hypothesis in this study was that stabilization of the patella following MPFL reconstruction would be improved compared with that before surgery, but that function of the grafted tendon would differ from that of a healthy MPFL. The objective was to analyse the length change patterns of the MPFL before surgery and the grafted tendon after surgery in patients with recurrent patellar dislocation treated with anatomical MPFL reconstruction. METHODS The subjects were 12 patients (13 knees) in whom recurrent patellar dislocation was treated with anatomical MPFL reconstruction. The length change patterns of the MPFL and reconstructed ligament were analysed at extension and flexion of the knee joint using open MRI. RESULTS The postoperative grafted tendon length was significantly shorter than that of the preoperative MPFL at knee extension, and significantly longer at 90° and 120° of knee flexion. The postoperative length of the grafted tendon only changed slightly from 0° to 30° of knee flexion, and then significantly decreased at flexion of 30° or more. The morphology of the grafted tendon was linear until 60° knee flexion, but became convex toward the extraarticular side at flexion of 90° or more. CONCLUSION The grafted tendon length at knee extension was shorter than that of the preoperative MPFL, but there was no significant difference at 30° flexion. These findings suggest that the effect of damping of the patella with a grafted tendon after MPFL reconstruction may differ from that in a healthy knee. In addition, the morphology at 60° knee flexion was improved to linear after surgery, suggesting that ligament morphology at this flexion was normalized by MPFL reconstruction. LEVEL OF EVIDENCE III.
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83
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Matsushita T, Araki D, Hoshino Y, Oka S, Nishida K, Tanaka T, Miyaji N, Kanzaki N, Ibaraki K, Matsumoto T, Kurosaka M, Kuroda R. Analysis of Graft Length Change Patterns in Medial Patellofemoral Ligament Reconstruction via a Fluoroscopic Guidance Method. Am J Sports Med 2018; 46:1150-1157. [PMID: 29466677 DOI: 10.1177/0363546517752667] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A fluoroscopic guidance method for medial patellofemoral ligament (MPFL) reconstruction has been widely used to determine the anatomic femoral attachment site. PURPOSE To examine the graft length change patterns in MPFL reconstruction with a fluoroscopic guidance method. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Forty-four knees of 42 patients who underwent MPFL reconstruction for the treatment of recurrent patellar dislocation were examined prospectively. During surgery, suture anchors were inserted into the proximal one-third and center of the patella. A guide pin for the femoral tunnel was inserted into the position reported by Schöttle et al based on the true lateral view of the knee under fluoroscopic control. Changes in graft length patterns of the proximal and center anchors were examined through 0° to 120° of knee flexion. Favorable changes in length patterns were defined as meeting 2 of 3 criteria: (1) not long during flexion (≤3 mm between 30° and 120° of flexion) and either (2) nearly isometric during flexion between 0° and 90° or (3) slightly long during maximum extension (≤3 mm). Other patterns were considered unfavorable. If the change in length pattern was unfavorable, then the pin for the femoral tunnel was moved to different positions until it was favorable. Knees were separated into the favorable group and the unfavorable group. Differences between the groups regarding radiographic parameters were assessed. Student t test or chi-square test was used for statistical analysis. RESULTS Of the 44 knees, 31 (70.5%) showed favorable patterns. However, 13 knees (29.5%) showed unfavorable patterns; therefore, the position of the pin was changed. The mean ± SD distance from the original position to the final position was 5.3 ± 1.1 mm distal for 7 patients and 5.2 ± 0.4 mm posterodistal for 6 patients. Technical errors, including a nontrue lateral view and the tip of the wire not being in the determined area, were found for 4 of 13 knees in the unfavorable group. There was no statistical difference in radiographic parameters between the groups. CONCLUSION The graft length change pattern could be nonphysiologic at the position determined through the fluoroscopic guidance method; thus, caution may be necessary. The change in length pattern should be checked before graft fixation. If the length change pattern is unfavorable, then it is advisable to move it approximately 5 to 7 mm distally or posterodistally from the first position.
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Affiliation(s)
- Takehiko Matsushita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Daisuke Araki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Shinya Oka
- Department of Orthopaedic Surgery, Meiwa Hospital, Kobe, Japan
| | - Kyohei Nishida
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Toshikazu Tanaka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Nobuaki Miyaji
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Kazuyuki Ibaraki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Masahiro Kurosaka
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
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Medial Patellofemoral Ligament Reconstruction: Impact of Knee Flexion Angle During Graft Fixation on Dynamic Patellofemoral Contact Pressure-A Biomechanical Study. Arthroscopy 2018; 34:1072-1082. [PMID: 29305291 DOI: 10.1016/j.arthro.2017.09.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 09/17/2017] [Accepted: 09/19/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Objective evaluation of the optimal graft tension angle to fully restore patellofemoral contact pressure in reconstruction of the medial patellofemoral ligament (MPFL) in comparison to the native knee. METHODS Twelve cadaveric knee specimens were fixed in a custom-made fixation device. A sensitive pressure film (Tekscan) was fixed in the patellofemoral joint, and patellofemoral contact pressure was assessed during a dynamic flexion movement from 0° to 90°. The MPFL was cut and measurements were repeated. Reconstruction of the MPFL was performed with the gracilis tendon subsequently fixed in the femur at 15°, 30°, 45°, 60°, 75°, and 90° of knee flexion under controlled tension (2 N). The sequence of the flexion angles was alternated. Pressure measurements were repeated after every fixation of the graft. RESULTS No significant differences were seen in the overall patellofemoral contact pressure compared to the native knee (P > .05). However, medial patellofemoral pressure showed a significant increased patellofemoral contact pressure after MPFL reconstruction at a knee flexion angle during graft fixation of 15° (P = .027), 45° (P = .050, P = .044), and 75° (P = .039). Moreover, proximal/distal patellofemoral contact pressure revealed a significantly reduced contact pressure at 15° (P = .003), 30° (P = .009), 45° (P = .025), 75° (P = .021), and 90° (P = .022) of flexion distal after MPFL reconstruction compared with the intact knee. Lateral patellofemoral contact pressure was significantly reduced in all performed reconstructions (P < .05). CONCLUSIONS The flexion angle during graft fixation for MPFL reconstruction did not have a significant impact on the overall patellofemoral contact pressure. However, selective medial, proximal, distal, and lateral patellofemoral contact pressure was significantly altered for all reconstructions. Fixation of the MPFL graft at 60° of flexion was able to most closely restore patellofemoral contact pressure compared with the intact knee. CLINICAL RELEVANCE Based on the findings of the present study, fixation of the graft in anatomic reconstruction of the MPFL should be considered in 60° of flexion under low tension (2 N) to most closely restore patellofemoral contact pressure compared with the native knee.
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85
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Stephen JM, Marsland D, Masci L, Calder JDF, Daou HE. Differential Motion and Compression Between the Plantaris and Achilles Tendons: A Contributing Factor to Midportion Achilles Tendinopathy? Am J Sports Med 2018; 46:955-960. [PMID: 29253349 DOI: 10.1177/0363546517745291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The plantaris tendon (PT) has been thought to contribute to symptoms in a proportion of patients with Achilles midportion tendinopathy, with symptoms improving after PT excision. HYPOTHESIS There is compression and differential movement between the PT and Achilles tendon (AT) during ankle plantarflexion and dorsiflexion. STUDY DESIGN Descriptive laboratory study. METHODS Eighteen fresh-frozen cadaveric ankles (mean ± SD age: 35 ± 7 years, range = 27-48 years; men, n = 9) were mounted in a customized testing rig, where the tibia was fixed but the forefoot could be moved freely. A Steinmann pin was drilled through the calcaneus, enabling a valgus torque to be applied. The soleus, gastrocnemius, and plantaris muscles were loaded with 63 N with a weighted pulley system. The test area was 40 to 80 mm above the os calcis, corresponding to where the injury is observed clinically. Medially, the AT and PT were exposed, and a calibrated flexible pressure sensor was inserted between the tendons. Pressure readings were recorded with the ankle in full dorsiflexion, full plantarflexion, and plantargrade and repeated in these positions with a 5 N·m torque, simulating increased hindfoot valgus. The pressure sensor was removed and the PT and AT marked with ink at the same level, with the foot held in neutral rotation and plantargrade. Videos and photographs were taken to assess differential motion between the tendons. After testing, specimens were dissected to identify the PT insertion. One-way analysis of variance and paired t tests were performed to make comparisons. RESULTS The PT tendons with an insertion separate from the AT demonstrated greater differential motion through range (14 ± 4 mm) when compared with those directly adherent to the AT (2 ± 2 mm) ( P < .001). Mean pressure between the PT and AT rose in terminal plantarflexion for all specimens ( P < .001) and was more pronounced with hindfoot valgus ( P < .001). CONCLUSION The PT inserting directly into the calcaneus resulted in significantly greater differential motion as compared with the AT. Tendon compression was elevated in terminal plantarflexion, suggesting that adapting rehabilitation tendon-loading programs to avoid this position may be beneficial. CLINICAL RELEVANCE The insertion pattern of the PT may be a factor in plantaris-related midportion Achilles tendinopathy. Terminal range plantarflexion and hindfoot valgus both increased AT and PT compression, suggesting that these should be avoided in this patient population.
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Affiliation(s)
- Joanna M Stephen
- Fortius Clinic, London, UK.,The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | - Daniel Marsland
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | | | - James D F Calder
- Fortius Clinic, London, UK.,The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | - Hadi El Daou
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
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86
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Redler LH, Meyers KN, Brady JM, Dennis ER, Nguyen JT, Shubin Stein BE. Anisometry of Medial Patellofemoral Ligament Reconstruction in the Setting of Increased Tibial Tubercle-Trochlear Groove Distance and Patella Alta. Arthroscopy 2018; 34:502-510. [PMID: 29100777 DOI: 10.1016/j.arthro.2017.08.256] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 08/14/2017] [Accepted: 08/14/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the impact elevated tibial tubercle-trochlear groove (TT-TG) distance and patella height, as measured by the Caton-Deschamps Index (CDI), have on the isometry of a reconstructed medial patellofemoral ligament (MPFL). METHODS Nine fresh-frozen cadaveric knees were placed on a custom testing fixture, with a fixed femur and a mobile tibia. A suture fixed to the MPFL origin on the patella and free to move at the Schöttle point on the femur represented a reconstructed MPFL. A local coordinate system was established, and retroreflective markers attached to the suture quantified MPFL length changes by use of a 3-dimensional motion capture system. The tubercle was transferred to create TT-TG distances of 20 mm and 25 mm and CDIs of 1.2 and 1.4 (patella alta). Recordings of the MPFL suture length change as the knee was brought through a range of motion were made using all combinations of tubercle anatomy in a randomized order for each specimen. A generalized estimating equation modeling technique was used to analyze and control for the clustered nature of the data. RESULTS Knees with native tibial tubercle anatomy showed MPFL isometry through 20° to 70° range of motion. Tibial tubercle lateralization (increased TT-TG distance) significantly altered MPFL isometry with a TT-TG distance of 20 mm (P < .0001). Patella alta significantly altered MPFL isometry with a CDI of 1.2 (P = .0182). The interaction of tibial tubercle lateralization combined with patella alta significantly increased the amount of anisometry seen in the reconstructed MPFL (P < .001). CONCLUSIONS Increased tibial tubercle lateralization and patella alta produce anisometry in an MPFL reconstruction using currently recommended landmarks, leading to potentially increased graft tension and potential failure. CLINICAL RELEVANCE Tibial tubercle transfer should be considered when performing an MPFL reconstruction for recurrent patellofemoral instability in the setting of significant patella alta and an elevated TT-TG distance-especially when both are present-because an isolated MPFL reconstruction will be prone to failure given the anisometry shown in this study.
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Affiliation(s)
- Lauren H Redler
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York.
| | - Kathleen N Meyers
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Jacqueline M Brady
- Department of Orthopedic Surgery, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth R Dennis
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Joseph T Nguyen
- Department of Biostatistics, Hospital for Special Surgery, New York, New York
| | - Beth E Shubin Stein
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York; Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York
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87
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Kruckeberg BM, Chahla J, Moatshe G, Cinque ME, Muckenhirn KJ, Godin JA, Ridley TJ, Brady AW, Arendt EA, LaPrade RF. Quantitative and Qualitative Analysis of the Medial Patellar Ligaments: An Anatomic and Radiographic Study. Am J Sports Med 2018; 46:153-162. [PMID: 29016187 DOI: 10.1177/0363546517729818] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The qualitative and quantitative anatomy of the medial patellar stabilizers has been reported; however, a quantitative analysis of the anatomic and radiographic attachments of all 4 ligaments relative to anatomic and osseous landmarks, as well as to one another, has yet to be performed. PURPOSE To perform a qualitative and quantitative anatomic and radiographic evaluation of the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), medial patellomeniscal ligament (MPML), and medial quadriceps tendon femoral ligament (MQTFL) attachment sites, with attention to their relationship to pertinent osseous and soft tissue landmarks. STUDY DESIGN Descriptive laboratory study. METHODS Ten nonpaired fresh-frozen human cadaveric knees were dissected, and the MPFL, MPTL, MPML, and MQTFL were identified. A coordinate measuring device quantified the attachment areas of each structure and its relationship to pertinent bony landmarks. Radiographic analysis was performed through ligament attachment sites and relevant anatomic structures to assess their locations relative to pertinent bony landmarks. RESULTS Four separate medial patellar ligaments were identified in all specimens. The center of the MPFL attachments was 14.3 mm proximal and 2.1 mm posterior to the medial epicondyle and 8.3 mm distal and 2.7 mm anterior to the adductor tubercle on the femur and 8.9 mm distal and 19.9 mm medial to the superior pole on the patella. The MQTFL had a mean insertion length of 29.3 mm on the medial aspect of the distal quadriceps tendon. The MPTL and MPML shared a common patellar insertion and were 9.1 mm proximal and 15.4 mm medial to the inferior pole. The MPTL attachment inserted on a newly identified bony ridge, which was located 5.0 mm distal to the joint line. The orientation angles of the MPTL and MPML with respect to the patellar tendon were 8.3° and 22.7°, respectively. CONCLUSION The most important findings of this study were the correlative anatomy of 4 distinct medial patellar ligaments (MPFL, MPTL, MPML, MQTFL), as well as the identification of a bony ridge on the medial proximal tibia that consistently served as the attachment site for the MPTL. The quantitative and radiographic measurements, while comparable with current literature, detailed the meniscal insertion of the MPML and defined a patellar insertion of the MPTL and the MPML as a single attachment. The data allow for reproducible landmarks to be established from previously known bony and soft tissue structures. CLINICAL RELEVANCE The findings of this study provide the anatomic foundation needed for an improved understanding of the role of medial-sided patellar restraints. This will help to further refine injury patterns and/or soft tissue deficiencies that result in lateral patellar instability, which can then be addressed with an anatomic-based reconstruction or repair technique and potentially lead to improved outcomes.
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Affiliation(s)
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Gilbert Moatshe
- The Steadman Clinic, Vail, Colorado, USA.,Oslo University Hospital and University of Oslo, Oslo, Norway.,Norwegian School of Sports Sciences, Oslo Sports Trauma Research Center, Oslo, Norway
| | - Mark E Cinque
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | - Taylor J Ridley
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Elizabeth A Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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88
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Campos T, Soogumbur A, McNamara IR, Donell ST. The trochlear isometric point is different in patients with recurrent patellar instability compared to controls: a radiographical study. Knee Surg Sports Traumatol Arthrosc 2018; 26:2797-2803. [PMID: 29204862 PMCID: PMC6105162 DOI: 10.1007/s00167-017-4740-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 10/02/2017] [Indexed: 11/03/2022]
Abstract
PURPOSE The purpose of the study was to investigate the theoretical isometric point based of the curve of the femoral groove and relating it to the origin of the MPFL femoral tunnel on lateral radiograph by comparing a patellar instability cohort with a control cohort. METHODS From a Patellar Instability database the radiographs of 40 consecutive patients were analysed to define Schöttle's point, and the arc of the circle of the trochlear groove. A comparison population of 20 radiographs from comparable patients with tibiofemoral joint disorders was used as a control. The distance from Schöttle's point to the most anterior part of the groove (extension) was also compared to the distance to the distal end of the roof of the notch (flexion). RESULTS The trochlea was circular in the controls but not the Patellofemoral Instability cohort where trochlear dysplasia is usually present. The difference between the extension and flexion length was a mean of - 2.0 ± 0.5 mm in the controls and + 6.0 ± 0.5 mm in the patellofemoral cohort. In neither cohort did the centre of the circle correspond to Schöttle's point. The extension distance correlated with the boss height. CONCLUSIONS The dysplastic trochlea is not circular and the centre of the best matched circle was different to the control trochleae which were circular. The circle centres did not correlate with Schöttle's point for either cohort, and was more proximal in the Patellofemoral Instability cohort. CLINICAL RELEVANCE For the MPFL to have equal tension throughout flexion within the groove, the length should not change. In normal knees the MPFL does not behave isometrically. The change in length, as measured from Schöttle's point to the trochlea, was greater for patellofemoral instability patients explaining why an isolated MPFL reconstruction in the presence of severe trochlear dysplasia risks poor outcomes. Level of evidence III.
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Affiliation(s)
- Tulio Campos
- 0000 0001 2181 4888grid.8430.fDepartment of Orthopaedics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Akash Soogumbur
- grid.416391.8Department of Orthopaedics, Norfolk and Norwich University Hospital, Norwich, Norfolk, NR4 7UY UK
| | - Iain R. McNamara
- grid.416391.8Department of Orthopaedics, Norfolk and Norwich University Hospital, Norwich, Norfolk, NR4 7UY UK
| | - Simon T. Donell
- 0000 0001 1092 7967grid.8273.eNorwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ UK
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89
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Aframian A, Smith TO, Tennent TD, Cobb JP, Hing CB. Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy. Knee Surg Sports Traumatol Arthrosc 2017; 25:3755-3772. [PMID: 27631645 PMCID: PMC5698363 DOI: 10.1007/s00167-016-4272-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/03/2016] [Indexed: 01/01/2023]
Abstract
PURPOSE The medial patellofemoral ligament (MPFL) is the major medial soft-tissue stabiliser of the patella, originating from the medial femoral condyle and inserting onto the medial patella. The exact position reported in the literature varies. Understanding the true anatomical origin and insertion of the MPFL is critical to successful reconstruction. The purpose of this systematic review was to determine these locations. METHODS A systematic search of published (AMED, CINAHL, MEDLINE, EMBASE, PubMed and Cochrane Library) and unpublished literature databases was conducted from their inception to the 3 February 2016. All papers investigating the anatomy of the MPFL were eligible. Methodological quality was assessed using a modified CASP tool. A narrative analysis approach was adopted to synthesise the findings. RESULTS After screening and review of 2045 papers, a total of 67 studies investigating the relevant anatomy were included. From this, the origin appears to be from an area rather than (as previously reported) a single point on the medial femoral condyle. The weighted average length was 56 mm with an 'hourglass' shape, fanning out at both ligament ends. CONCLUSION The MPFL is an hourglass-shaped structure running from a triangular space between the adductor tubercle, medial femoral epicondyle and gastrocnemius tubercle and inserts onto the superomedial aspect of the patella. Awareness of anatomy is critical for assessment, anatomical repair and successful surgical patellar stabilisation. LEVEL OF EVIDENCE Systematic review of anatomical dissections and imaging studies, Level IV.
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Affiliation(s)
- Arash Aframian
- Trauma and Orthopaedics Department, 5th Floor St James' Wing, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
- St George's, University of London, London, SW17 0RE, UK.
- Imperial College, London, W6 8RP, UK.
| | - Toby O Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
| | - T Duncan Tennent
- Trauma and Orthopaedics Department, 5th Floor St James' Wing, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
- St George's, University of London, London, SW17 0RE, UK
| | | | - Caroline Blanca Hing
- Trauma and Orthopaedics Department, 5th Floor St James' Wing, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
- St George's, University of London, London, SW17 0RE, UK
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90
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Tischer T, Geier A, Lenz R, Woernle C, Bader R. Impact of the patella height on the strain pattern of the medial patellofemoral ligament after reconstruction: a computer model-based study. Knee Surg Sports Traumatol Arthrosc 2017; 25:3123-3133. [PMID: 27289460 DOI: 10.1007/s00167-016-4190-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 05/31/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Medial patellofemoral ligament (MPFL) reconstruction is a key procedure for treating patellofemoral instability. However, controversy exists regarding the correct graft placement in different patellar heights. Therefore, our study aimed to investigate the influence of patellar height on MPFL insertion points. METHODS Strain patterns of the reconstructed MPFL were calculated using a dynamic musculoskeletal multibody simulation. Numerous patellar (proximal, central, distal) and femoral attachment sites (around the radiological point according to Schöttle) were analysed in the presence of different patella heights [Insall-Salvati (IS) indices 0.74, 1.0, 1.5] during dynamic knee flexion from 0° to 120°. RESULTS The reconstructed MPFL showed an almost isometric behaviour at the anatomic insertion (IS 1.0). Slight variation (<5 mm) around the ideal femoral insertion point resulted in only small changes in MPFL tension. However, a displacement of 10 mm led to a significant increase in MPFL tension, especially in the more anteriorly/proximally located femoral attachment points. Depending on the patella height, there exists an area of absolute isometry of the MPFL (length change <3 %) on the femoral condyle, which did not necessarily coincide exactly with the radiological point, but was located within a radius of 5 mm around it. CONCLUSIONS When reconstructed in the radiological femoral insertion point, MPFL strain patterns were only slightly affected by different patella heights (IS 0.74-1.5) suggesting that MPFL reconstruction could be safely performed using the radiological insertion. However, in case of a patella alta (IS 1.5), a slightly more proximal femoral insertion is beneficial for the biomechanical behaviour of the reconstructed MPFL.
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Affiliation(s)
- Thomas Tischer
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany.
| | - Andreas Geier
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany
| | - Robert Lenz
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany
| | - Christoph Woernle
- Chair of Technical Dynamics, University of Rostock, Rostock, Germany
| | - Rainer Bader
- Department of Orthopaedics, University of Rostock, Doberaner Strasse 142, 18057, Rostock, Germany
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91
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Burrus MT, Werner BC, Cancienne JM, Gwathmey FW, Diduch DR. MPFL graft fixation in low degrees of knee flexion minimizes errors made in the femoral location. Knee Surg Sports Traumatol Arthrosc 2017; 25:3092-3098. [PMID: 27085363 DOI: 10.1007/s00167-016-4111-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/25/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the appropriate amount of knee flexion in which to secure the graft during medial patellofemoral ligament (MPFL) reconstruction. METHODS Heavy suture was used to simulate graft tissue during MPFL reconstruction on eight fresh-frozen cadaveric knees. The sutures were passed through two transverse patellar tunnels and draped over a Kirschner wire at Schöttle's point on the femur. Suture displacement at the location of the wire was measured during knee range of motion from 0 to 135°. The wire's location was then moved to 3 additional locations (1 cm proximal, 1 cm distal, and 1 cm anterior), and the measurements were repeated. RESULTS Using Schöttle's point, the suture length did not vary throughout all ranges of knee flexion. The distal location resulted in a greater distance between attachment points (i.e. graft tightened) if the measurements began with the knee flexed and then brought into extension. Conversely, with the proximal location, the opposite occurred as the knee was extended (i.e. graft loosened). For all locations other than Schöttle's point, the amount of initial knee flexion for fixation was directly related to the amount of suture length change when the knee was brought into extension. CONCLUSION For non-anatomic femoral MPFL graft fixation locations, suture length (and thus graft length) in full extension becomes increasingly altered if the graft is secured in high degrees of knee flexion. Thus, graft fixation in lower degrees of knee flexion is recommended to minimize over or under tensioning the graft when the knee goes into extension if the graft position is placed in a non-anatomic location. To avoid this problem, fluoroscopy should be used to locate the anatomic footprint of the MPFL insertion. While recognizing the limitations of cadaveric research, this study is the first to provide any data to corroborate the widely used practice of securing the MPFL in lower degrees of knee flexion.
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Affiliation(s)
- M Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Virginia Health System (HSC), PO Box 800159, Charlottesville, VA, 22908, USA.
| | - Brian C Werner
- Sports Medicine and Shoulder Surgery, Hospital For Special Surgery, New York, NY, USA
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System (HSC), PO Box 800159, Charlottesville, VA, 22908, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia Health System (HSC), PO Box 800159, Charlottesville, VA, 22908, USA
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System (HSC), PO Box 800159, Charlottesville, VA, 22908, USA
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92
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An evaluation of the effectiveness of medial patellofemoral ligament reconstruction using an anatomical tunnel site. Knee Surg Sports Traumatol Arthrosc 2017; 25:3206-3212. [PMID: 27565481 DOI: 10.1007/s00167-016-4292-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 08/11/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability has gained popularity, and anatomical and biomechanical studies have recently altered our operative techniques. The aim of this study was to report the clinical outcome of this new anatomical MPFL reconstructive technique and investigate whether correlating factors could be identified. METHODS Between 2009 and 2012, a total of 31 consecutive patients underwent MPFL reconstruction using an autologous gracilis graft and anatomical tunnel placement. Pre- and post-operative data were collected as a part of routine clinical practice. The preoperative assessment included a rotational profile CT scan of the lower extremity according to the Lyon protocol with TT-TG distance measurement. Outcomes were evaluated with the Kujala and Norwich patella instability (NPI) scores preoperatively and at follow-up (1.5-5.1 years). RESULTS A significant improvement in both the Kujala (p < 0.001) and NPI (p = 0.012) scores was recorded. A medium and large negative correlations were found between TT-TG distance and Kujala score improvement (ρ = -0.48, p = 0.020) and NPI score improvement (ρ = -0.83, p = 0.042), respectively. Multiple regression analysis identified TT-TG distance, Beighton score and BMI as factors explaining the variance of Kujala score improvement. CONCLUSION Anatomical MPFL reconstruction with the gracilis autograft for patellar instability resulted in good outcome. This underlines the importance of anatomical tunnel placement in MPFL reconstruction. With a precise preoperative work-up, factors can be identified that may guide selecting the optimal operative strategy and improve counselling of the patient. LEVEL OF EVIDENCE Case series, Level IV.
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93
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A novel functional correction method for habitual patellar dislocation using autologous hamstring tendon: a case report. J Pediatr Orthop B 2017; 26:465-469. [PMID: 28118233 DOI: 10.1097/bpb.0000000000000431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Habitual patellar dislocation is an uncommon condition. In this case, a patient demonstrated lateral patellar dislocation in the middle or terminal range of flexion. A functional correction of the patella was devised so that the fixation site of the autologous graft on the femur was able to stabilize the patella selectively during the middle or terminal range of flexion. It is not the anatomical medial patellofemoral ligament attachment of the femur that is essential, but that a relevant fixation point on the femur should be sought in each patient to obtain stabilization of the patella to reverse habitual patellar dislocation.
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94
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Isolated medial patellofemoral ligament reconstruction for posttraumatic recurrent lateral patellar instability. How can it be successful? CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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95
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Fluoroscopic control allows for precise tunnel positioning in MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:2688-2694. [PMID: 25957603 DOI: 10.1007/s00167-015-3613-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE In MPFL reconstruction, anatomical graft positioning is required to restore physiological joint biomechanics and patellofemoral stability. Considerable rates of non-anatomical femoral tunnel placement exist. The purpose of this study was to analyse whether intraoperative fluoroscopic control is applicable to reduce variability of femoral tunnel positioning. METHODS Femoral tunnel positions of 116 consecutive MPFL reconstructions applying intraoperative fluoroscopic images were analysed. Tunnel positions were determined by two independent observers according to Schöttle's radiographic measurement method. Mean positions, standard deviations and ranges were calculated to determine the variability of the tunnel positions. Interclass correlation coefficient (ICC) was calculated. RESULTS The mean anterior/posterior distances from the anatomical insertion of the MPFL to the centre of the femoral tunnel were 2.34 mm (range 0.0-5.9 mm) and 1.7 mm (range 0.1-7.3 mm, SD 1.3) for proximal/distal deviations; 95.7 % (111/116) of femoral tunnel positions were found to be within the anatomical insertion area defined by Schöttle. Interobserver tunnel position measurements were highly reliable (ICC: depth 0.979; height 0.979). CONCLUSION The study demonstrates that intraoperative fluoroscopic control is a feasible and effective method that enables to create reproducible and precise anatomical femoral tunnel positions in MPFL reconstruction. Accordingly, the routine use of intraoperative fluoroscopy can be recommended. Furthermore, the results indicate Schöttle's method as a reliable method for intraoperative control and postoperative analysis of femoral tunnel positioning. LEVEL OF EVIDENCE IV.
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96
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Sanchis-Alfonso V, Ramirez-Fuentes C, Montesinos-Berry E, Domenech J, Martí-Bonmatí L. Femoral insertion site of the graft used to replace the medial patellofemoral ligament influences the ligament dynamic changes during knee flexion and the clinical outcome. Knee Surg Sports Traumatol Arthrosc 2017; 25:2433-2441. [PMID: 26658569 DOI: 10.1007/s00167-015-3905-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 11/26/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE This study's purpose was to investigate how an ideal anatomic femoral attachment affects the dynamic length change pattern of a virtual medial patellofemoral ligament (MPFL) from an extended to a highly flexed knee position; to determine the relative length and length change pattern of a surgically reconstructed MPFL; and to correlate femoral attachment positioning, length change pattern, and relative graft length with the clinical outcome. METHODS Twenty-four knees with isolated nonanatomic MPFL reconstruction were analysed by three-dimensional computed tomography at 0°, 30°, 60°, 90°, and 120° of knee flexion. The lengths of the MPFL graft and a virtual anatomic MPFL were measured. The pattern of length change was considered isometric if the length distance changed <5 mm through the entire dynamic range of motion. RESULTS Knee flexion significantly affected the path lengths between the femoral and patellar attachments. The length of the anatomic virtual MPFL decreased significantly from 60° to 120°. Its maximal length was 56.4 ± 6.8 mm at 30°. It was isometric between 0° and 60°. The length of the nonanatomic MPFL with a satisfactory clinical result decreased during flexion from 0° to 120°. Its maximal length was 51.6 ± 4.6 mm at 0° of knee flexion. The lengths measured at 0° and 30° were isometric and statistically greater than the lengths measured at higher flexion degrees. The failed nonanatomic MPFL reconstructions were isometric throughout the dynamic range, being significantly shorter (27.1 ± 13.3 %) than anatomic ligaments. CONCLUSION The femoral attachment point significantly influences the relative length and the dynamic length change of the grafts during knee flexion-extension and graft isometry. Moreover, it influences the long-term outcome of the MPFL reconstructive surgery. A nonanatomic femoral fixation point should not be considered the cause of persistent pain and instability after MPFL reconstruction in all cases. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Cristina Ramirez-Fuentes
- Department of Radiology, Hospital Universitario y Politécnico La Fe and GIBI230 IIS La Fe Research Group, Valencia, Spain
| | | | | | - Luis Martí-Bonmatí
- Department of Radiology, Hospital Universitario y Politécnico La Fe and GIBI230 IIS La Fe Research Group, Valencia, Spain
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Lorbach O, Haupert A, Efe T, Pizanis A, Weyers I, Kohn D, Kieb M. Biomechanical evaluation of MPFL reconstructions: differences in dynamic contact pressure between gracilis and fascia lata graft. Knee Surg Sports Traumatol Arthrosc 2017; 25:2502-2510. [PMID: 26820966 DOI: 10.1007/s00167-016-4005-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 01/18/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the knee kinematics of the intact, MPFL-ruptured and MPFL-reconstructed knee and, moreover, to compare dynamic patellofemoral contact pressure of the gracilis tendon and the fascia lata as an alternative graft option for reconstruction of the MPFL. METHODS Eight paired human cadaveric knees were fixed in a custom-made fixation device. Patellofemoral contact pressure was assessed during a dynamic flexion movement at 15°-30°-45°-60°-75° and 90° using a pressure-sensitive film (Tekscan). The medial patellofemoral ligament was cut, and measurements were repeated. Finally, reconstruction of the MPFL was performed using the gracilis tendon (group I) or a fascia lata graft (group II). Tunnel localization was performed under fluoroscopic control. Grafts were fixed at 30° of flexion, and pressure measurements were repeated. RESULTS Incision of the medial patellofemoral ligament significantly reduced patellofemoral contact pressure at 15°, 30° and 45° of knee flexion compared to the intact knee (p < 0.05), whereas reconstruction of the MPFL using either gracilis tendon of the fascia lata was able to restore pressure distributions at 15° and 30° of knee flexion. However, in the hamstring group, reconstruction of the MPFL revealed a significantly reduced contact pressure at 45° of flexion (p = 0.038) compared to the intact knee. In the fascia lata group, a significant reduction in patellofemoral contact pressure was observed after MPFL reconstruction at 45°, 60°, 75° and 90° of knee flexion (p < 0.05). CONCLUSIONS Anatomic reconstruction of the MPFL with either a gracilis or a fascia lata graft showed comparable patellofemoral pressure distributions which were closely restored compared to the native knee. Therefore, the fascia lata has shown to be a viable alternative to the gracilis tendon for reconstruction of the MPFL. However, anatomic reconstruction of the MPFL may lead to persistently altered patellofemoral contact pressure during knee flexion compared to the native knee independent of the tested graft.
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Affiliation(s)
- Olaf Lorbach
- Department of Orthopaedic Surgery, Saarland University, Kirrberger Str, Geb. 37, 66421, Homburg (Saar), Germany.
| | - Alexander Haupert
- Department of Orthopaedic Surgery, Saarland University, Kirrberger Str, Geb. 37, 66421, Homburg (Saar), Germany
| | - Turgay Efe
- Department of Orthopaedic Surgery, Marburg University, Marburg, Germany
| | - Antonius Pizanis
- Department of Trauma-Hand and Reconstructive Surgery, Saarland University, Homburg (Saar), Germany
| | - Imke Weyers
- Institute of Anatomy, Lübeck University, Lübeck, Germany
| | - Dieter Kohn
- Department of Orthopaedic Surgery, Saarland University, Kirrberger Str, Geb. 37, 66421, Homburg (Saar), Germany
| | - Matthias Kieb
- Department of Orthopaedic and Trauma Surgery, Klinikum Ernst von Bergmann, Potsdam/Bad Belzig, Germany
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Arai Y, Nakagawa S, Higuchi T, Inoue A, Honjo K, Inoue H, Ikoma K, Ueshima K, Ikeda T, Fujiwara H, Kubo T. Comparative analysis of medial patellofemoral ligament length change pattern in patients with patellar dislocation using open-MRI. Knee Surg Sports Traumatol Arthrosc 2017; 25:2330-2336. [PMID: 26154483 DOI: 10.1007/s00167-015-3689-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 06/29/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Medial patellofemoral ligament (MPFL) reconstruction has become a common form of treatment for recurrent patellar dislocation. This study was performed using open-MRI to compare the length change pattern of MPFL in patients with a history of patellar dislocation to that in healthy subjects. METHODS The subjects comprised 10 knees of 8 males and 13 knees of 12 females with a history of one or more patellar dislocations. The length of the MPFL was measured using open-MRI in both the leg-extended position and knee-flexed positions to analyse the length change pattern. RESULTS The average MPFL lengths were 58.6 ± 6.5 mm and 52.0 ± 4.6 mm for males and females in the extended knee position, respectively. The length change pattern of the MPFL showed slight variation up to a flexion angle of 30° and a clear decrease above 30°. This pattern differed from that of normal MPFL. In terms of morphology, the fibre bundle of the damaged MPFL followed a convex course towards the side of the patellofemoral joint surface at a knee flexion angle of 60°, whereas that of the normal MPFL followed a straight course. CONCLUSION The in vivo damaged MPFL length change pattern was specific and differed distinctly from that of normal MPFL. The results of the present study suggested that MPFL fibres with a history of patellar dislocation lack sufficient tension at knee flexion angles of 0°-60°. However, further studies are needed to obtain a better understanding of cases with a patellar dislocation or postsurgical cases of MPFL reconstruction. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yuji Arai
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Shuji Nakagawa
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Tetsuo Higuchi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Atsuo Inoue
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kuniaki Honjo
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hiroaki Inoue
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kazuya Ikoma
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Keiichiro Ueshima
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Takumi Ikeda
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hiroyoshi Fujiwara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Toshikazu Kubo
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
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Trinh TQ, Ferrel JR, Bentley JC, Steensen RN. The Anatomy of the Medial Patellofemoral Ligament. Orthopedics 2017; 40:e583-e588. [PMID: 28241086 DOI: 10.3928/01477447-20170223-03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 08/23/2016] [Indexed: 02/03/2023]
Abstract
Recurrent patellar dislocation is observed in many patients treated nonoperatively following primary dislocation. Injury to the medial patellofemoral ligament (MPFL) is reported in the majority of patients following dislocation. There is an increased interest in repair or reconstruction of the MPFL for patients experiencing recurrent instability. The femoral attachment of the MPFL is critical in determining graft behavior following reconstruction. The femoral attachment can be determined by referencing local anatomy, fluoroscopic imaging or on the basis of desired graft-length changes. This article reviews the anatomy of the MPFL, with a focus on its femoral insertion site as it pertains to anatomic, isometric, and anisometric reconstruction. [Orthopedics. 2017; 40(4):e583-e588.].
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Kita K, Tanaka Y, Toritsuka Y, Amano H, Uchida R, Shiozaki Y, Takao R, Horibe S. 3D Computed Tomography Evaluation of Morphological Changes in the Femoral Tunnel After Medial Patellofemoral Ligament Reconstruction With Hamstring Tendon Graft for Recurrent Patellar Dislocation. Am J Sports Med 2017; 45:1599-1607. [PMID: 28277745 DOI: 10.1177/0363546517690348] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reconstruction of the medial patellofemoral ligament (MPFL) for recurrent lateral patellar dislocation is gaining popularity. However, the morphological changes in the femoral tunnel after MPFL reconstruction are still not fully documented. PURPOSE This study used 3-dimensional (3D) computed tomography to evaluate morphological changes in the femoral tunnel after MPFL reconstruction with hamstring tendon graft to investigate factors affecting the phenomenon and to elucidate whether it is associated with clinical outcomes. STUDY DESIGN Case series; Level of evidence, 4. METHODS Twenty-three patients with recurrent patellar dislocation were prospectively enrolled in this study. The patients included 6 males and 17 females with a mean age of 24 years (range, 14-53). The MPFL was reconstructed by creating 2 patellar bone sockets and 1 femoral bone socket anatomically under X-ray control, and the semitendinosus autograft was fixed with cortical suspension devices. Computed tomography scans obtained 3 weeks and 1 year after surgery were reconstructed into 3D constructs with a volume analyzer. Cross-sectional areas (CSAs) of the aperture and inside the femoral tunnel were compared between the 2 time points. Likewise, the location of tunnel walls and center of the femoral tunnel footprint were evaluated. Relationships were assessed between femoral tunnel morphological changes and potential risk factors-such as age, body mass index, sex, femoral tunnel positioning, patellar height, sulcus angle, congruence angle, lateral tilt angle, degree of trochlear dysplasia, lateral deviation of the tibial tubercle, and Kujala score. RESULTS No patient reported recurrence of patellar dislocation during the follow-up period. The CSA of the femoral tunnel aperture enlarged by 41.1% ± 34.7% ( P < .01). The center, anterior border, and proximal border of the femoral tunnel significantly shifted in the anterior direction ( P < .01). The distal border significantly shifted in both anterior and distal directions ( P < .01). Patella alta was associated with distal migration of the tunnel center ( P < .05). Morphological changes were not associated with other risk factors or Kujala score. CONCLUSION The CSA of the femoral tunnel aperture enlarged, and the tunnel aperture migrated anteriorly with time after MPFL reconstruction. Risk factors for patellar dislocation other than patella alta did not influence morphological changes of the femoral tunnel.
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Affiliation(s)
- Keisuke Kita
- Department of Sports Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | - Yoshinari Tanaka
- Department of Sports Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | | | - Hiroshi Amano
- Department of Sports Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | - Ryohei Uchida
- Department of Sports Orthopaedics, Seihu Hospital, Sakai, Japan
| | | | - Rikio Takao
- Faculty of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Japan
| | - Shuji Horibe
- Faculty of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Japan
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