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Boot MR, van de Groes SA, Dunning H, Tanck E, Janssen D. Length Changes of the Medial Patellofemoral Ligament During In Vivo Knee Motion: An Evaluation Using Dynamic Computed Tomography. Am J Sports Med 2023; 51:3724-3731. [PMID: 37960850 PMCID: PMC10691293 DOI: 10.1177/03635465231205597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/23/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is associated with high complication rates because of graft overloading from incorrect graft positioning. To improve clinical outcomes, it is crucial to gain a better understanding of MPFL elongation patterns. PURPOSE To assess MPFL length changes in healthy knees from 0° to 90° of dynamic flexion and their relationship with anatomic parameters of the patellofemoral joint. STUDY DESIGN Descriptive laboratory study. METHODS Dynamic computed tomography scans of an active flexion-extension-flexion movement in 115 knees from 63 healthy participants were evaluated to construct knee joint models. Using these models, the MPFL length was measured as the shortest wrapping path from the Schöttle point on the femur to 3 insertion points on the superomedial border of the patella (proximal, central, and distal). MPFL length changes (%) relative to the length in full extension were calculated, and their correlations with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination were analyzed. RESULTS The proximal fiber was the longest in full extension and progressively decreased to a median length of -6.0% at 90° of flexion. The central fiber exhibited the most isometric pattern during knee flexion, showing a median maximal decrease of 2.8% relative to the full extension length and no evident elongation. The distal fiber first slightly decreased in length but increased at deeper flexion angles. The median overall length changes were 4.6, 4.7, and 5.7 mm for the proximal, central, and distal patellar insertion, respectively. These values were either not or very weakly correlated with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination when the anatomic parameters were within the healthy range. CONCLUSION The median MPFL length changed by approximately 5 mm between 0° and 90° of flexion. Proximally, the length continuously decreased, indicating slackening behavior. Distally, the length increased at deeper flexion angles, indicating tightening behavior. CLINICAL RELEVANCE In MPFL reconstruction techniques utilizing the Schöttle point to establish the femoral insertion, one should avoid distal patellar insertion, as it causes elongation of the ligament, which may increase the risk for complications due to overloading.
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Affiliation(s)
- Miriam R. Boot
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Hans Dunning
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dennis Janssen
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
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Reconstruction of the medial patellofemoral ligament with nonresorbable suture tape normalizes patellar maltracking independent of patella-side fixation technique. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07256-0. [PMID: 36454291 DOI: 10.1007/s00167-022-07256-0] [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: 07/29/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Patellar maltracking caused by a rupture of the medial patellofemoral ligament (MPFL) can be improved by MPFL reconstruction (MPFL-R) with a tendon graft. Nonresorbable suture tape (FiberTape®, FT) is possibly becoming an option to tendon grafts for MPFL-R. Patella-side fixation of FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate patellar tracking considering soft-tissue-based and anchor-based patella-side fixation techniques. METHODS In eight fresh-frozen human knee joint specimens (m/f 4/4; age 75 ± 10 years), the MPFL was identified, and a rupture was placed near the femoral insertion site. In the study group (SG; 4 knees), soft-tissue fixation of the FT was performed at the medial patellar retinaculum; in the control group (CG; 4 knees), FT was fixed at the patella via suture anchors. For native MPFL (nMPFL), ruptured ("injured") MPFL (iMPFL) and reconstructed MPFL (FT-MPFL-SG, respectively, FT-MPFL-CG) cone beam CT scans were performed in 15°, 30°, and 45° of knee joint flexion. Patellar tracking was assessed using the radiological parameters patellar tilt (PT), congruence angle (CA) and posterior patellar edge-trochlear groove ratio (PTR). RESULTS All recorded radiological parameters increased, respectively, decreased in the CG and SG from the nMPFL to the iMPFL state. After MPFL-R, all parameters normalized when compared to the intact state (nMPFL), regardless of patella-side fixation technique. All investigated parameters of patellotrochlear alignment were positively, respectively, negatively significantly (p < 0.05) correlated throughout all evaluated conditions (nMPFL, iMPFL, FT-MPFL-SG, FT-MPFL-CG). CONCLUSION MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique. The investigated parameters of patellotrochlear alignment correlate with each other.
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Raoulis V, Fyllos A, Klontzas ME, Chytas D, Mitrousias V, Banios K, Maris TG, Karantanas AH, Zibis A. Surgical and Radiological Anatomy of the Medial Patellofemoral Ligament: A Magnetic Resonance Imaging and Cadaveric Study. Diagnostics (Basel) 2021; 11:diagnostics11112076. [PMID: 34829423 PMCID: PMC8625885 DOI: 10.3390/diagnostics11112076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 11/24/2022] Open
Abstract
The purpose of this study was to compare the measurement of several anatomical features of the medial patellofemoral ligament (MPFL) between magnetic resonance imaging (MRI) and by direct fashion during dissection. We hypothesized that the measurements between these two techniques would agree. MRI of 30 fresh-frozen cadaveric knees was followed by dissection. MPFL patella and femoral attachment were evaluated; their shape, length, and width were measured; and measurements were compared. MRI was deemed unreliable for the determination of several of the aforementioned anatomical features. Important findings include: (a) observations on MPFL attachment at medial patella side and attachment to quadriceps were identical between dissection and MRI; (b) average width at patella insertion was significantly different between the two methods (p = 0.002); and (c) an attachment to the quadriceps tendon was present in 20/30 specimens and d. detailed measurements of a thin, non-linear, and three-dimensional structure, such as the MPFL, cannot be performed on MRI, due to technical difficulties. This anatomical radiological study highlights the shape, anatomical measurements (length and width), and attachment of the MPFL using a relatively large cadaveric sample and suggests that MRI is not reliable for detailed imaging of its three-dimensional anatomy.
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Affiliation(s)
- Vasileios Raoulis
- Laboratory of Anatomy, Department of Medicine, School of Health Sciences, University of Thessaly, 3 University Str., Biopolis, 41110 Larissa, Greece; (V.R.); (A.F.)
| | - Apostolos Fyllos
- Laboratory of Anatomy, Department of Medicine, School of Health Sciences, University of Thessaly, 3 University Str., Biopolis, 41110 Larissa, Greece; (V.R.); (A.F.)
| | - Michail E. Klontzas
- Department of Radiology, Medical School, University of Crete, 71500 Heraklion, Greece; (M.E.K.); (A.H.K.)
- Department of Medical Imaging, University Hospital of Heraklion, 71110 Heraklion, Greece
| | - Dimitrios Chytas
- Department of Physiotherapy, University of Peloponnese, 20 Plateon Str., 23100 Sparta, Greece;
| | - Vasileios Mitrousias
- Department of Orthopedic Surgery, University Hospital of Larissa, 3 University Str., Biopolis, 41110 Larissa, Greece;
| | - Konstantinos Banios
- Department of Orthopedic Surgery, General Hospital of Karditsa, Peripheral Road Karditsa-Kastania, 43100 Karditsa, Greece;
| | - Thomas G. Maris
- Department of Medical Physics, School of Medicine, University of Crete, 71500 Heraklion, Greece;
| | - Apostolos H. Karantanas
- Department of Radiology, Medical School, University of Crete, 71500 Heraklion, Greece; (M.E.K.); (A.H.K.)
- Department of Medical Imaging, University Hospital of Heraklion, 71110 Heraklion, Greece
| | - Aristeidis Zibis
- Laboratory of Anatomy, Department of Medicine, School of Health Sciences, University of Thessaly, 3 University Str., Biopolis, 41110 Larissa, Greece; (V.R.); (A.F.)
- Correspondence:
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White AE, Otlans PT, Horan DP, Calem DB, Emper WD, Freedman KB, Tjoumakaris FP. Radiologic Measurements in the Assessment of Patellar Instability: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:2325967121993179. [PMID: 34095324 PMCID: PMC8142007 DOI: 10.1177/2325967121993179] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/19/2020] [Indexed: 01/27/2023] Open
Abstract
Background: Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings across multiple studies. Purpose: To review the different imaging measurements used to evaluate patellar instability and to assess the prevalence of each measure and its utility in predicting instability. We focused on reliability across imaging modalities and between patients with and without patellar instability. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a systematic review of the literature using the PubMed, SCOPUS, and Cochrane databases. Each database was searched for variations of the terms “patellar instability,” “patellar dislocation,” “trochlear dysplasia,” “radiographic measures,” “computed tomography,” and “magnetic resonance imaging.” Studies were included if they were published after May 1, 2009, and before May 1, 2019. A meta-analysis using a random effects model was performed on several measurements, comparing instability and control groups to generate pooled values. Results: A total of 813 articles were identified, and 96 articles comprising 7912 patients and 106 unique metrics were included in the analysis. The mean patient age was 23.1 years (95% CI, 21.1-24.5), and 41% were male. The tibial tubercle–trochlear groove (TT-TG) distance was the most frequently included metric (59 studies), followed by the Insall-Salvati ratio and Caton-Deschamps index (both 26 studies). The interobserver intraclass correlation coefficients were excellent or good for the TT-TG distance and Insall-Salvati ratio in 100% of studies reporting them; however, for the Caton-Deschamps index and Blackburne-Peel ratio, they were excellent or good in only 43% and 40% of studies. Pooled magnetic resonance imaging values for TT-TG distance (P < .01), Insall-Salvati ratio (P = .01), and femoral sulcus angle (P = .02) were significantly different between the instability and control groups. Values for tibial tubercle–posterior cruciate ligament distance (P = .36) and Caton-Deschamps index (P = .09) were not significantly different between groups. Conclusion: The most commonly reported measurements for evaluating patellar instability assessed patellar tracking and trochlear morphology. The TT-TG distance was the most common measurement and was greater in the patellar instability group as compared with the control group. In addition, the TT-TG, tibial tubercle–posterior cruciate ligament, and patellar tendon–trochlear groove distances were highly reproducible measurements for patellar tracking, and the Insall-Salvati ratio had superior reproducibility for assessing patellar height.
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Affiliation(s)
- Alex E White
- Hospital for Special Surgery, New York, New York, USA
| | - Peters T Otlans
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dylan P Horan
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Daniel B Calem
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - William D Emper
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fotios P Tjoumakaris
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Ambra LF, Franciozi CE, Phan A, Faloppa F, Gomoll AH. Isolated MPTL reconstruction fails to restore lateral patellar stability when compared to MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:793-799. [PMID: 32347346 DOI: 10.1007/s00167-020-06015-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To biomechanically evaluate MPTL reconstruction and compare it with two techniques for MPFL reconstruction in regard to changes in patellofemoral contact pressures and restoration of patellar stability. METHODS This is an experimental laboratory study in eight human cadaveric knees. None had patellofemoral cartilage lesions or trochlear dysplasia as evaluated by conventional radiographs and MRI examinations. The specimens were secured in a testing apparatus, and the quadriceps was tensioned in line with the femoral shaft. Contact pressures were measured using the TekScan sensor at 30°, 60° and 90°. The sensor was placed in the patellofemoral joint through a proximal approach between femoral shaft and quadriceps tendon to not violate the medial and lateral patellofemoral complex. TekScan data were analysed to determine mean contact pressures on the medial and lateral patellar facets. Patellar lateral displacement was evaluated with the knee positioned at 30° of flexion and 9 N of quadriceps load, then a lateral force of 22 N was applied. The same protocol was used for each condition: native, medial patellofemoral complex lesion, medial patellofemoral ligament reconstruction (MPFL-R) using gracilis tendon, MPFL-R using quadriceps tendon transfer, and medial patellotibial ligament reconstruction (MPTL-R) using patellar tendon transfer. RESULTS No statistical differences were found for mean and peak contact pressures, medial or lateral, among all three techniques. However, while both techniques of MPFL-R were able to restore the medial restraint, MPTL-R failed to restore resistance to lateral patellar translation to the native state (mean lateralization of the patella [mm]: native: 9.4; lesion: 22; gracilis MPFL-R: 8.1; quadriceps MPFL-R: 11.3; MPTL-R: 23.4 (p < 0.001). CONCLUSION MPTL-R and both techniques for MPFL-R did not increase patellofemoral contact pressures; however, MPTL-R failed to provide a sufficient restraint against lateral patellar translation lateral translation in 30° of flexion. It, therefore, cannot be recommended as an isolated procedure for the treatment of patellar instability.
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Affiliation(s)
- Luiz Felipe Ambra
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 1o.andar, Vila Clementino, São Paulo, Brazil. .,Center for Regenerative Medicine and Cartilage Repair Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA.
| | - Carlos Eduardo Franciozi
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 1o.andar, Vila Clementino, São Paulo, Brazil.,Knee Institute, Hospital do Coração, São Paulo, SP, Brazil.,Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Amy Phan
- Center for Regenerative Medicine and Cartilage Repair Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Flavio Faloppa
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 1o.andar, Vila Clementino, São Paulo, Brazil
| | - Andreas H Gomoll
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Hartanto J, Leow WK, Yew AKS, Koh JSB, Howe TS. Studies of the criteria for determining optimal location of medial patellofemoral ligament attachment sites. Med Biol Eng Comput 2021; 59:693-702. [PMID: 33598884 DOI: 10.1007/s11517-021-02330-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 01/29/2021] [Indexed: 11/30/2022]
Abstract
Identifying appropriate attachment sites is important in the planning of medial patellofemoral ligament (MPFL) reconstruction. Two criteria are advanced to describe normal MPFL function, namely isometric criterion and desired pattern criterion. Subsequently, computational methods have applied these criteria to determine optimal attachment sites. So far, there is no study that compares the outcomes of these two criteria. For five subjects' 3D models of the patella and femur, three patellar sites and many femoral sites were identified as pairs of candidate attachment sites. For each patellar site, the criteria were applied to identify the matching femoral sites that satisfy them. The matching femoral site with the smallest length change was identified as the optimal femoral site. The desired pattern criterion finds fewer matching sites compared to the isometric criterion. In contrast, the isometric criterion can always find matching sites. The optimal femoral sites obtained vary significantly across different subjects. For most subjects, the optimal sites obtained using the isometric criterion are closer to known anatomical sites than those obtained using the desired pattern criterion. This study reaffirms that MPFL reconstruction is subject specific. The isometric criterion may be more reliable than the desired pattern criterion for determining optimal attachment sites. Graphical Abstract. Highlight of the paper. The location of the patella site significantly affects the location of the optimal femoral site. The isometric criterion option 1, with length at 0° regarded as MPFL's natural length, may be more reliable than other criteria or options for the planning of MPFL surgery because the optimal sites that it finds are closest to known anatomical sites.ᅟ.
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Affiliation(s)
- Jeffry Hartanto
- Department of Computer Science, National University of Singapore, Singapore, Singapore.
| | - Wee Kheng Leow
- Department of Computer Science, National University of Singapore, Singapore, Singapore
| | - Andy Khye Soon Yew
- Department of Orthopaedics, Singapore General Hospital, Singapore, Singapore
| | - Joyce Suang Bee Koh
- Department of Orthopaedics, Singapore General Hospital, Singapore, Singapore
| | - Tet Sen Howe
- Department of Orthopaedics, Singapore General Hospital, Singapore, Singapore
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Techniques for In Vivo Measurement of Ligament and Tendon Strain: A Review. Ann Biomed Eng 2020; 49:7-28. [PMID: 33025317 PMCID: PMC7773624 DOI: 10.1007/s10439-020-02635-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
Abstract
The critical clinical and scientific insights achieved through knowledge of in vivo musculoskeletal soft tissue strains has motivated the development of relevant measurement techniques. This review provides a comprehensive summary of the key findings, limitations, and clinical impacts of these techniques to quantify musculoskeletal soft tissue strains during dynamic movements. Current technologies generally leverage three techniques to quantify in vivo strain patterns, including implantable strain sensors, virtual fibre elongation, and ultrasound. (1) Implantable strain sensors enable direct measurements of tissue strains with high accuracy and minimal artefact, but are highly invasive and current designs are not clinically viable. (2) The virtual fibre elongation method tracks the relative displacement of tissue attachments to measure strains in both deep and superficial tissues. However, the associated imaging techniques often require exposure to radiation, limit the activities that can be performed, and only quantify bone-to-bone tissue strains. (3) Ultrasound methods enable safe and non-invasive imaging of soft tissue deformation. However, ultrasound can only image superficial tissues, and measurements are confounded by out-of-plane tissue motion. Finally, all in vivo strain measurement methods are limited in their ability to establish the slack length of musculoskeletal soft tissue structures. Despite the many challenges and limitations of these measurement techniques, knowledge of in vivo soft tissue strain has led to improved clinical treatments for many musculoskeletal pathologies including anterior cruciate ligament reconstruction, Achilles tendon repair, and total knee replacement. This review provides a comprehensive understanding of these measurement techniques and identifies the key features of in vivo strain measurement that can facilitate innovative personalized sports medicine treatment.
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Fujii Y, Nakagawa S, Arai Y, Inoue H, Kan H, Hino M, Kaihara K, Mikami Y. Clinical outcomes after medial patellofemoral ligament reconstruction: an analysis of changes in the patellofemoral joint alignment. INTERNATIONAL ORTHOPAEDICS 2020; 45:1215-1222. [PMID: 32770307 DOI: 10.1007/s00264-020-04765-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/28/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE Medial patellofemoral ligament (MPFL) reconstruction using the hamstring tendon is widely performed to treat recurrent patellar dislocation. MPFL reconstruction includes a post-operative process of necrosis and reperfusion of the hamstring tendon graft. We hypothesise that the patella gradually shifts laterally because of this process, ultimately affecting the patellofemoral joint alignment. This study aimed to analyse the chronological changes in the patellofemoral joint alignment and the outcomes of MPFL reconstruction. METHODS In this retrospective case-series study, the Knee Society, Lysholm, and Kujala scores were evaluated in 24 consecutive patients (27 knees). To evaluate patellar tracking defects, radiographic indices including the tilting angle, the lateral shift ratio, and the congruence angle were measured before, immediately after, and three, 12, and 36 months after MPFL reconstruction. RESULTS Post-operative Kujala, Knee Society, and Lysholm scores for the study population significantly improved relative to the pre-operative scores. The tilting and congruence angles at three months after the operation significantly increased relative to those recorded immediately after the operation. The tilting and congruence angles were not significantly different at three, 12, and 36 months after the operation. CONCLUSIONS The post-operative outcomes of MPFL reconstruction for recurrent patellar dislocation were favourable. Insufficient union between the bone tunnel and tendon graft, along with an elongation of the necrotic tendon graft, may change the alignment of the patellofemoral joint within three months after the operation. Therefore, we believe it is necessary to refrain from knee rotation that places lateral stress on the patella until three months after the operation.
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Affiliation(s)
- Yuta Fujii
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shuji Nakagawa
- Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Yuji Arai
- Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Hiroaki Inoue
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroyuki Kan
- Department of Orthopaedics, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Japan
| | - Manabu Hino
- Department of Orthopaedics, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Japan
| | - Kenta Kaihara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuo Mikami
- Department of Rehabilitation Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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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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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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Garms E, Carvalho RTD, Janovsky C, Nicolini AP, Salviani RS, Liggieri AC. Avaliação funcional da reconstrução do ligamento patelofemoral medial em atletas. Rev Bras Ortop 2019; 54:178-182. [PMID: 31363264 PMCID: PMC6529324 DOI: 10.1016/j.rbo.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/19/2017] [Indexed: 10/25/2022] Open
Abstract
Resumo
Objetivo Avaliar os resultados clínicos e funcionais da reconstrução anatômica do ligamento patelofemoral medial com tendões flexores em atletas.
Métodos Estudo tipo série de casos, prospectivo, que analisou a reconstrução do ligamento patelofemoral medial em 32 pacientes (34 joelhos). A avaliação funcional foi feita pelos escores Lysholm e Kujala nos períodos pré e pós-operatórios e os fatores de risco envolvidos foram avaliados.
Resultados Dos 32 pacientes analisados, todos obtiveram melhoria dos escores funcionais comparativamente ao período pré-operatório. Pacientes com menos de cinco episódios de luxação prévios obtiveram melhores resultados funcionais. O valor médio de Lysholm no pré-operatório foi de 62,8 e no pós-operatório de 94,3, quanto ao escore de Kujala a média pré-operatório foi de 63,0 e pós-operatória de 94,0.
Conclusão A reconstrução do ligamento patelofemoral medial com enxerto de tendão flexor do joelho em atletas propiciou melhoria dos escores clínicos e funcionais nos pacientes com instabilidade patelofemoral. A perfuração óssea da patela e o posicionamento do túnel femoral devem ocorrer de forma judiciosa.
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Affiliation(s)
- Emerson Garms
- Universidade Federal de São Paulo, Centro de Traumatologia do Esporte (CETE), São Paulo, SP, Brasil
| | | | - César Janovsky
- Universidade Federal de São Paulo, Centro de Traumatologia do Esporte (CETE), São Paulo, SP, Brasil
| | - Alexandre Pedro Nicolini
- Universidade Federal de São Paulo, Centro de Traumatologia do Esporte (CETE), São Paulo, SP, Brasil
| | - Rafael Salmeron Salviani
- Universidade Federal de São Paulo, Centro de Traumatologia do Esporte (CETE), São Paulo, SP, Brasil
| | - Andre Cicone Liggieri
- Universidade Federal de São Paulo, Centro de Traumatologia do Esporte (CETE), São Paulo, SP, Brasil
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12
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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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13
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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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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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15
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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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17
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Jia R, Monk P, Murray D, Noble JA, Mellon S. CAT & MAUS: A novel system for true dynamic motion measurement of underlying bony structures with compensation for soft tissue movement. J Biomech 2017; 62:156-164. [PMID: 28456332 DOI: 10.1016/j.jbiomech.2017.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 04/05/2017] [Accepted: 04/09/2017] [Indexed: 11/29/2022]
Abstract
Optoelectronic motion capture systems are widely employed to measure the movement of human joints. However, there can be a significant discrepancy between the data obtained by a motion capture system (MCS) and the actual movement of underlying bony structures, which is attributed to soft tissue artefact. In this paper, a computer-aided tracking and motion analysis with ultrasound (CAT & MAUS) system with an augmented globally optimal registration algorithm is presented to dynamically track the underlying bony structure during movement. The augmented registration part of CAT & MAUS was validated with a high system accuracy of 80%. The Euclidean distance between the marker-based bony landmark and the bony landmark tracked by CAT & MAUS was calculated to quantify the measurement error of an MCS caused by soft tissue artefact during movement. The average Euclidean distance between the target bony landmark measured by each of the CAT & MAUS system and the MCS alone varied from 8.32mm to 16.87mm in gait. This indicates the discrepancy between the MCS measured bony landmark and the actual underlying bony landmark. Moreover, Procrustes analysis was applied to demonstrate that CAT & MAUS reduces the deformation of the body segment shape modeled by markers during motion. The augmented CAT & MAUS system shows its potential to dynamically detect and locate actual underlying bony landmarks, which reduces the MCS measurement error caused by soft tissue artefact during movement.
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Affiliation(s)
- Rui Jia
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK.
| | - Paul Monk
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Murray
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J Alison Noble
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Stephen Mellon
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Hiemstra LA, Kerslake S, Lafave M. Medial Patellofemoral Ligament Reconstruction Femoral Tunnel Accuracy: Relationship to Disease-Specific Quality of Life. Orthop J Sports Med 2017; 5:2325967116687749. [PMID: 28210659 PMCID: PMC5302095 DOI: 10.1177/2325967116687749] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Medial patellofemoral ligament (MPFL) reconstruction is a procedure aimed to reestablish the checkrein to lateral patellar translation in patients with symptomatic patellofemoral instability. Correct femoral tunnel position is thought to be crucial to successful MPFL reconstruction, but the accuracy of this statement in terms of patient outcomes has not been tested. Purpose: To assess the accuracy of femoral tunnel placement in an MPFL reconstruction cohort and to determine the correlation between tunnel accuracy and a validated disease-specific, patient-reported quality-of-life outcome measure. Study Design: Case series; Level of evidence, 4. Methods: Between June 2008 and February 2014, a total of 206 subjects underwent an MPFL reconstruction. Lateral radiographs were measured to determine the accuracy of the femoral tunnel by measuring the distance from the center of the femoral tunnel to the Schöttle point. Banff Patella Instability Instrument (BPII) scores were collected a mean 24 months postoperatively. Results: A total of 155 (79.5%) subjects had adequate postoperative lateral radiographs and complete BPII scores. The mean duration of follow-up (±SD) was 24.4 ± 8.2 months (range, 12-74 months). Measurement from the center of the femoral tunnel to the Schöttle point resulted in 143 (92.3%) tunnels being categorized as “good” or “ideal.” There were 8 failures in the cohort, none of which occurred in malpositioned tunnels. The mean distance from the center of the MPFL tunnel to the center of the Schöttle point was 5.9 ± 4.2 mm (range, 0.5-25.9 mm). The mean postoperative BPII score was 65.2 ± 22.5 (range, 9.2-100). Pearson r correlation demonstrated no statistically significant relationship between accuracy of femoral tunnel position and BPII score (r = –0.08; 95% CI, –0.24 to 0.08). Conclusion: There was no evidence of a correlation between the accuracy of MPFL reconstruction femoral tunnel in relation to the Schöttle point and disease-specific quality-of-life scores. Graft failure was not related to femoral tunnel placement. The patellofemoral instability population is complex, and patients present with multiple risk factors that, in addition to the accuracy of femoral tunnel position, contribute to quality of life and warrant further investigation.
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Affiliation(s)
- Laurie A Hiemstra
- Banff Sport Medicine, Banff, Alberta, Canada.; Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Kerslake
- Banff Sport Medicine, Banff, Alberta, Canada.; Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Mark Lafave
- Department of Health & Physical Education, Mount Royal University, Calgary, Alberta, Canada
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Kang H, Wang F, Cao J, Liu X, Ji G. A prospective randomized trial evaluating two different tensioning techniques for medial patellofemoral ligament reconstruction. Knee 2016; 23:826-9. [PMID: 27372556 DOI: 10.1016/j.knee.2016.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/05/2016] [Accepted: 02/10/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND In the literature, graft tension was mostly assessed under direct arthroscopy vision for a MPFL reconstruction. The purpose of this study was to prospectively assess the outcomes of MPFL reconstruction with graft tension of self-balance technique in comparison with arthroscopy-view technique. METHODS Sixty patients with recurrent patellar dislocation were randomly divided into two groups to undergo MPFL reconstruction with graft tension either by the self-balance technique (SB group) or the arthroscopy-view technique (AV group). At a minimum of 24months of follow up, patellar stability was evaluated with the apprehension test. Patellofemoral morphology was measured on an axial CT scan and knee function was evaluated using the Kujala and Lysholm scores. RESULTS Twenty-three patients in the SB group and 25 patients in the AV group were followed for a minimum of 24months. No recurrent dislocation or subluxation was reported. Apprehension signs remained in two patients in the SB group and in one patient in the AV group. The postoperative Kujala score for the SB group and AV group were 91.4±5.1 and 90.3±5.5, respectively, and the Lysholm score was 90.1±6.4 and 88.4±6.3, respectively, with no significant differences. On CT images, congruence angle, patellar tilt angle and lateral patellar angle were restored to the normal range. CONCLUSIONS At a minimum of 24months of follow-up, graft tensioning using the self-balance technique yielded similar patellar stability and knee function compared with the arthroscopy-view procedure in the MPFL reconstruction. The self-balance technique as a simple procedure is recommended as a good alternative method for graft tensioning in the MPFL reconstruction.
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Affiliation(s)
- Huijun Kang
- Department of Orthopaedic Surgery, Shijiazhuang No. 1 Hospital, Shijiazhuang, China
| | - Fei Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Jianhui Cao
- Department of Orthopaedic Surgery, Shijiazhuang No. 1 Hospital, Shijiazhuang, China
| | - Xiaohui Liu
- Department of Orthopaedic Surgery, Shijiazhuang No. 1 Hospital, Shijiazhuang, China
| | - Gang Ji
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
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Negrín R, Duboy J, Olavarría F, Wainer M, Jimenez H, Las Heras F, Reyes N, Godoy H. Biomechanical and histological comparison between the cryopreserved and the lyophilized Gracilis tendon allograft for MPFL reconstruction, a cadaveric experimental study. J Exp Orthop 2016; 3:20. [PMID: 27600522 PMCID: PMC5013004 DOI: 10.1186/s40634-016-0056-2] [Citation(s) in RCA: 5] [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: 05/10/2016] [Accepted: 08/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) is the main restrictor of lateral shifting of the patella, contributing by 60 % in the first 20° flexion of the knee. MPFL reconstruction has been performed in order to restore the stability of the patella with good results.Lyophilized Gracilis tendon allograft (LGA) compared to Cryopreserved Gracilis tendon allograft (CGA) has a lower cost, does not require to maintain cooling chain or preparation. The purpose of this study is to compare the histological and biomechanical characteristics of an experimental model of reconstruction of the MPFL in porcine patellas with LGA versus CGA. METHODS Randomized controlled experimental study in porcine model conducted on 36 porcine patellas in which 18 were intervened with LGA and 18 were intervened with CGA. The confluent tunnel technique was used for MPFL reconstruction. Maximum tensile force, allograft elongation and stiffness of the construct were measured. The cellularity and collagen tissue distribution were evaluated in the allografts. The histological and biomechanical characteristics of the LGA were compared to those of the CGA. RESULTS The median of the maximum tensile force for the LGA group was 299.63 N and 280.86 N for the CGA group (p = 0.45). The median of the stiffness was 57.86 N/mm for the LGA and 54.23 N/mm for the CGA (p = 0.2). The median of the elongation for the LGA was 5.95 mm and 6.12 mm for the CGA (p = 0,29). The bone bridge failed in 88.88 % of the constructs with LGA and 94.44 % in those with CGA (p = 0.5). CONCLUSIONS No differences were observed between the LGA group and the CGA group in maximum tensile force, elongation, stiffness, site of rupture and histological characteristics. The use of a lyophilized Gracilis tendon allograft for MPFL reconstruction confers the same histological and biomechanical characteristics as a cryopreserved Gracilis tendon allograft.
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Affiliation(s)
- Roberto Negrín
- Department of Orthopaedics and Traumatology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile.
| | - Jaime Duboy
- Department of Orthopaedics and Traumatology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile
| | - Fernando Olavarría
- Department of Orthopaedics and Traumatology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile
| | - Mauricio Wainer
- Department of Orthopaedics and Traumatology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile
| | - Horacio Jimenez
- Department of Orthopaedics and Traumatology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile
| | - Facundo Las Heras
- Department of Pathology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile
| | - Nicolas Reyes
- Department of Orthopaedics and Traumatology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile
| | - Hugo Godoy
- Department of Orthopaedics and Traumatology, Clinica Las Condes, Lo Fontecilla 196, Santiago, 7591018, Chile
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Sandhu SS, Dreckmann S, Binhammer PA. Change in the collateral and accessory collateral ligament lengths of the proximal interphalangeal joint using cadaveric model three-dimensional laser scanning. J Hand Surg Eur Vol 2016; 41:380-5. [PMID: 26261228 DOI: 10.1177/1753193415597845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 06/09/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED The purpose of this study was to assess the lengths of the index and middle finger proximal interphalangeal joint ligaments and determine the relative changes in the collateral and accessory collateral ligament lengths at 0°, 45° and 90° flexion. We generated three-dimensional scans of 16 finger (eight index and eight middle) proximal interphalangeal joints to assess relative changes in ligament length. Significant changes were found between 45°-90° and 0°-90° for the ulnar collateral ligament of the index finger and both collateral ligaments of the middle finger between 45°-90° and 0°-90°. No significant changes in length were found for the radial collateral ligament of the index finger or the accessory collateral ligaments of the index and middle fingers. Overall, it was found that the collateral ligament length changed significantly, but there was no significant change in the accessory collateral ligaments. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- S S Sandhu
- School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, UK
| | - S Dreckmann
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, ON, Canada
| | - P A Binhammer
- Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Netto ADS, de Brito MBS, Severino FR, Campos LRA, Nico MAC, de Oliveira VM, Severino NR. STUDY ON THE PATELLOFEMORAL JOINT USING MAGNETIC RESONANCE IMAGING: MORPHOLOGICAL VARIATION OF THE MEDIAL PATELLOFEMORAL LIGAMENT. Rev Bras Ortop 2015; 47:204-9. [PMID: 27042622 PMCID: PMC4799380 DOI: 10.1016/s2255-4971(15)30087-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 09/22/2011] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To study the measurements and anatomical relationships of the patellofemoral joint using magnetic resonance imaging, and to evaluate the variation in the morphology of the medial patellofemoral ligament (MPFL) according to patients' heights and ages and the variation in measurements on other structures that are known to be involved in predisposition to patellar instability. METHOD Twenty-three knees (18 patients) underwent magnetic resonance imaging and their interepicondylar distance, patellar height, trochlear depth, ventral trochlear prominence, trochlear groove angle, lateral facet tilt, lateral patellar tilt and size of the lateral and medial facets and their ratio were measured. These measurements were compared with the length and thickness of the MPFL. RESULTS The average length of the MPFL was 46.4 mm, while the average thicknesses of its patellar insertion, middle third and femoral insertion were, respectively, 1.7 mm, 1.4 mm and 1.2 mm. The thickness of the MPFL correlated positively with the lateral condyle and interepicondylar distance measurements, and negatively with the patients' ages. CONCLUSION The morphology of the MPFL varies with the interepicondylar distance and the lateral condyle distance, and with patients' ages.
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Affiliation(s)
- Alfredo Dos Santos Netto
- Resident Physician in the Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Botelho Soares de Brito
- Resident Physician in the Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Fabrício Roberto Severino
- Trainee Physician in the Knee Surgery Group, Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Leila Rodrigues Andrade Campos
- Resident Physician in the Musculoskeletal Radiology Group, Department of Imaging Diagnostics, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Astolfi Caetano Nico
- Attending Physician in the Musculoskeletal Radiology Group, Department of Imaging Diagnostics, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Victor Marques de Oliveira
- Attending Physician in the Knee Surgery Group, Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Nilson Roberto Severino
- Physician and Head of the Knee Surgery Group, Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
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Zhang N, Jiang Z, Wen X, Sugamoto K, Yang C. The triangle zone as a femoral attachment location in medial patellofemoral ligament reconstruction: An in vivo three-dimensional analysis using an open MRI scanner. Knee 2015; 22:585-90. [PMID: 26277882 DOI: 10.1016/j.knee.2015.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/02/2015] [Accepted: 04/15/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The exact isometric points for medial patellofemoral ligament (MPFL) fixation during MPFL reconstruction remain a matter of debate. PURPOSE The aim of this study was to characterize the functional length changes of various patellar and femoral fixation sites using in vivo three-dimensional (3D) movement patterns and to determine the ideal fixation sites at which the graft remains largely isometric. METHODS Twelve right knees of healthy volunteers were examined at early flexion angles (0°, 10°, 20°, 30°, 40°, 50°, and 60°) with a horizontal-type open magnetic resonance scanner, and 3D models were reconstructed using the marching cubes algorithm. Six points on the femoral condyle and three points on the medial aspect of the patella were simulated. The matching points represented the MPFL, which crossed the bony obstacle. The MPFL length changes were analyzed at various flexion degrees. RESULTS The lengths from the dome of Blumensaat's line (G), the point 10mm inferior to the adductor tubercle (H), to the midpoint between the adductor tubercle and the medial epicondyle (I) were more isometric than other points. The lengths between the dome of Blumensaat's line and the superior pole of the patella changes significantly between 20° and 60° of flexion (p=0.040). CONCLUSIONS The femoral fixation site may be more accurately located during MPFL reconstruction at the G, H, and I points to restore the native biomechanical function of the MPFL. The dome of Blumensaat's line should be avoided during MPFL reconstruction with the superficial quad technique. CLINICAL RELEVANCE A triangular region composed of the dome of Blumensaat's line, 10mm inferior to the adductor tubercle, and the midpoint between the adductor tubercle and medial epicondyle is recommended as the femoral fixation site.
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Affiliation(s)
- Ning Zhang
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Xinmin Street No.71, Changchun, China.
| | - Zhengang Jiang
- School of Computer Science and Technology, Changchun University of Science and Technology, Weixing Street No.7089, Changchun, China.
| | - Xiaoyu Wen
- Department of Hepatology, The First Hospital of Jilin University, Xinmin Street No.71, Changchun, China.
| | - Kazuomi Sugamoto
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka 565-0871, Japan.
| | - Chen Yang
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Xinmin Street No.71, Changchun, China.
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Song SY, Pang CH, Kim CH, Kim J, Choi ML, Seo YJ. Length change behavior of virtual medial patellofemoral ligament fibers during in vivo knee flexion. Am J Sports Med 2015; 43:1165-71. [PMID: 25649086 DOI: 10.1177/0363546514567061] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In vivo length change behavior of native medial patellofemoral ligament (MPFL) fibers throughout the range of knee motion has not been reported in vivo. PURPOSE To measure the length changes of various fibers of the MPFL and to determine their length change patterns during in vivo passive knee flexion. STUDY DESIGN Descriptive laboratory study. METHODS The right knees of 11 living subjects were scanned with a high-resolution computed tomography scanner at 0°, 30°, 60°, 90°, and 120° of knee flexion, and 3-dimensional (3D) models were constructed using customized software. Five patellar points were determined: 20% (point 20), 30% (point 30), 40% (point 40), 50% (point 50), and 60% (point 60) from the superior pole of the patella. The Schöttle femoral point (point F) was marked on a translucent 3D model of a true lateral view. Five virtual fibers connecting these points on the 3D knee model were created, and the lengths of various fibers were digitally measured. RESULTS The average length changes were 9.1±2.5 mm in F20, 9.1±2.5 mm in F30, 8.1±2.6 mm in F40, 6.9±2.4 mm in F50, and 6.9±1.7 mm in F60. There were significant differences in length changes of these 5 fibers (P<.001). The lengths of 2 superior fibers (F20 and F30) increased as the knee flexed from 0° to 30° and decreased as the knee flexed over 30°. The lengths of a middle fiber (F40) and an inferior fiber (F50) increased from 0° to 30°, reached a plateau from 30° to 60°, and then decreased from 60° to 120°. F60 showed an increase from 0° to 30°, and then a plateau pattern from 30° to 90°, followed by a decrease during further flexion. CONCLUSION Superior fibers exhibited their maximum lengths at low flexion angles, and inferior fibers exhibited their maximum lengths at midflexion angles. The MPFL is a complex of functionally various fibers with some taut and others slack over the whole range of knee motion. CLINICAL RELEVANCE The results for lengths and length change patterns of various MPFL fibers are expected to serve as a theoretical background for anatomic double-bundle MPFL reconstruction.
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Affiliation(s)
- Si Young Song
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Chae-Hyun Pang
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Chan Hyoek Kim
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Jeehyoung Kim
- Department of Orthopaedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Republic of Korea
| | - Mi Lim Choi
- Department of Data Statistics, Korea Culture & Tourism Institute, Seoul, Republic of Korea
| | - Young-Jin Seo
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
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Morphology of the femoral insertion site of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2015; 23:998-1003. [PMID: 24296991 DOI: 10.1007/s00167-013-2797-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 11/24/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study was to identify the femoral insertion of the medial patellofemoral ligament (MPFL) and related osseous landmarks. METHODS A total of 31 unpaired human cadaveric knees were studied. The MPFL was identified, and the site of its femoral insertion was marked. Three-dimensional images were created, and the location and morphology of the femoral insertion of the MPFL and related osseous structures were analyzed. RESULTS The MPFL was identified in all knees. The femoral insertion of the MPFL was elliptical in shape, and the mean surface area was 56.5 ± 16.9 mm(2). The characteristic features of the femoral insertion of the MPFL could not be identified, but the adductor tubercle was clearly identified in all knees. The centre of the femoral insertion of the MPFL was 10.6 ± 2.5 mm distal to the apex of the adductor tubercle on the long axis of the femur, and the position of the insertion site was consistent in all knees. CONCLUSION The adductor tubercle was clearly identified as an osseous landmark. The femoral insertion of the MPFL was approximately 10 mm distal to the adductor tubercle. These findings may improve understanding of the anatomy of the femoral insertion of the MPFL and may assist surgeons in performing anatomical reconstruction.
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Two patients with osteochondral injury of the weight-bearing portion of the lateral femoral condyle associated with lateral dislocation of the patella. Case Rep Orthop 2014; 2014:876410. [PMID: 25506015 PMCID: PMC4251879 DOI: 10.1155/2014/876410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 11/09/2014] [Indexed: 01/03/2023] Open
Abstract
Complications of patellar dislocation include osteochondral injury of the lateral femoral condyle and patella. Most cases of osteochondral injury occur in the anterior region, which is the non-weight-bearing portion of the lateral femoral condyle. We describe two patients with osteochondral injury of the weight-bearing surface of the lateral femoral condyle associated with lateral dislocation of the patella. The patients were 18- and 11-year-old females. Osteochondral injury occurred on the weight-bearing surface distal to the lateral femoral condyle. The presence of a free osteochondral fragment and osteochondral injury of the lateral femoral condyle was confirmed on MRI and reconstruction CT scan. Treatment consisted of osteochondral fragment fixation or microfracture, as well as patellar stabilization. Osteochondral injury was present in the weight-bearing portion of the lateral femoral condyle in both patients, suggesting that the injury was caused by friction between the patella and lateral femoral condyle when the patella was dislocated or reduced at about 90° flexion of the knee joint. These findings indicate that patellar dislocation may occur and osteochondral injury may extend to the weight-bearing portion of the femur even in deep flexion, when the patella is stabilized on the bones of the femoral groove.
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Simulation of the optimal femoral insertion site in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:2364-71. [PMID: 25051911 DOI: 10.1007/s00167-014-3192-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 07/15/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To develop and validate a new simulation system to predict the optimal femoral insertion site of the medial patellofemoral ligament (MPFL) using preprogrammed conditions of graft length change. METHODS A computed tomography scan was performed for constructing bone surface models of the patella and the femur. Lateral radiographs of the knee and axial radiographs of the patellofemoral joint at knee flexion were used for constructing a three-dimensional patellofemoral joint model by 3D-2D image matching at each knee flexion angle. To determine the optimal femoral insertion site, the following three conditions were devised: (1) MPFL behaves isometric from 0° to 60°, (2) MPFL is most taut at full extension, and (3) MPFL is slack at more than 60° of knee flexion. Every condition was applied to the femoral bone surface model, and the area that fulfilled all three conditions was defined as the optimal femoral insertion site of MPFL. Twenty knees of ten healthy volunteers were assessed to verify the simulation. Comparison between simulated optimal femoral insertion and anatomical insertion was done. RESULTS The mean simulated optimal femoral insertion was close to the anatomical insertion site. There were no significant differences in the proximal-distal position and anterior-posterior position between the simulated insertion and the anatomical insertion sites. CONCLUSION The system can be useful for predicting the optimal femoral insertion site as a part of a preoperative plan for MPFL reconstruction, and it may help surgeons to determine the optimal femoral insertion site during MPFL reconstruction.
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de Oliveira V, de Souza V, Cury R, Camargo OP, Avanzi O, Severino N, Fucs P. Medial patellofemoral ligament anatomy: is it a predisposing factor for lateral patellar dislocation? INTERNATIONAL ORTHOPAEDICS 2014; 38:1633-9. [PMID: 24817023 DOI: 10.1007/s00264-014-2357-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/09/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Because the medial patellofemoral ligament (MPFL) is the primary restraint to lateral dislocation of the patella, we aimed, in this controlled study, to verify whether the MPFL with different measurements could be considered another predisposing factor for patellar dislocation. METHODS A group of 100 consecutive individuals without the criteria for patellar dislocation (trochlear dysplasia, patella alta and lateral patellar tilt) was recruited as a control group and underwent magnetic resonance imaging (MRI) study and another group of 50 patients with patellar instability. Femoral condyles, interepicondylar distance, length and thickness of the MPFL were measured. RESULTS In the control group, the MPFL was 38-60 mm long. Individuals with patellar instability who had no episode of patellar dislocation had a 4.11-mm longer ligament than controls (p = 0.032), while patients with instability with a previous history of dislocation had a 13.54-mm longer MPFL than controls (p < 0.001). Thickness of the MPFL at the patellar insertion was lower in individuals with patellar instability with a history of dislocation (p < 0.001). An instability coefficient (IC) less than 1.3 indicates that the MPFL is insufficient. CONCLUSIONS Individuals with patellar instability and previous patellar dislocation present with longer MPFL when compared to controls, and an associated IC less than 1.3 can be considered a predisposing factor for patellar dislocation. Treatment of patellar instability is a challenge, and it is difficult to identify what is the predisposing factor. This study has verified the measurements of the MPFL for the first time and presents values of thickness and length that can be considered as indications for surgical reconstruction. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Victor de Oliveira
- Orthopaedic and Traumatology, Santa Casa Medical School and Hospitals, São Paulo, Brazil
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Mofidi A, Veravalli K, Jinnah RH, Poehling GG. Association and impact of patellofemoral dysplasia on patellofemoral arthropathy and arthroplasty. Knee 2014; 21:509-13. [PMID: 24417902 DOI: 10.1016/j.knee.2013.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 07/15/2013] [Accepted: 09/25/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND The association of patellar and trochlear anomalies resulting in isolated patellofemoral osteoarthritis has often been postulated but rarely studied. The purpose of this study was to examine the association of patellofemoral dysplasia, specifically trochlear anomalies, which are a cause for degenerative disease and may result in a worse outcome after arthroplasty for isolated patellofemoral arthritis. METHODS Eighteen consecutive patients who underwent robotic image-based patellofemoral arthroplasty were compared with an age and sex-matched group of patients who underwent medial unicompartmental arthroplasty using the same image-based navigation system and had no patellofemoral, lateral disease or malalignment. The compared parameters were the patellofemoral-trochlear angle and Dejour score in the preoperative radiographs and patellofemoral-trochlear angle and internal rotation of the trochlea compared to the intercondylar line in the proximal, middle and distal trochlea. RESULTS Significantly higher rates of patella alta (T=5, P=0.0001) and trochlear dysplasia (6% vs. 55%) were found, as manifested by an increase in the trochlear angle and Dejour score. Furthermore, the trochlea was found to have a higher degree of internal rotation in patients with isolated patellofemoral arthritis compared to the control group. CONCLUSIONS In conclusion, patellofemoral anomalies such as patella alta and trochlear dysplasia are present in association with isolated patellofemoral arthritis. Isolated patellofemoral arthritis is also associated with higher rates of trochlear internal rotation. Correction of this internal rotation is essential in the success of arthroplasty in patients with patellofemoral disease. LEVEL OF EVIDENCE Level III study, It is a case control study.
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Affiliation(s)
- Ali Mofidi
- Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK.
| | | | - Riaz H Jinnah
- Wake Forest University Baptist Medical Centre, Winston-Salem, USA
| | - Gary G Poehling
- Wake Forest University Baptist Medical Centre, Winston-Salem, USA
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Effectiveness and limitations of reconstruction of the medial patellofemoral ligament using a titanium interference screw in single patellar and femoral bone tunnels. Asia Pac J Sports Med Arthrosc Rehabil Technol 2014. [DOI: 10.1016/j.asmart.2013.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Nakagawa S, Arai Y, Kan H, Ueshima K, Ikoma K, Terauchi R, Kubo T. Medial patellofemoral ligament reconstruction procedure using a suspensory femoral fixation system. Arthrosc Tech 2013; 2:e491-5. [PMID: 24892014 PMCID: PMC4040016 DOI: 10.1016/j.eats.2013.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/17/2013] [Indexed: 02/03/2023] Open
Abstract
Recurrent patellar dislocation has recently been treated with anatomic medial patellofemoral ligament (MPFL) reconstruction using a semitendinosus muscle tendon. Although it is necessary to add tension to fix the tendon graft without loading excess stress on the patellofemoral joint, adjustment of the tension can be difficult. To resolve this problem, we developed an MPFL reconstruction procedure using the ToggleLoc Fixation Device (Biomet, Warsaw, IN), in which the semitendinosus muscle tendon is folded and used as a double-bundle tendon graft and 2 bone tunnels and 1 bone tunnel are made on the patellar and femoral sides, respectively. The patellar side of the tendon graft is fixed with an EndoButton (Smith & Nephew, London, England), and the femoral side is fixed with the ToggleLoc. Stepless adjustment of tension of the tendon graft is possible by reducing the size of the loop of the ToggleLoc hung onto the tendon graft. It may be useful to position the patella in the center of the femoral sulcus by confirming the patellofemoral joint fitting. Stability can be confirmed by loading lateral stress on the patella in the extended knee joint. This procedure is less invasive because opening of the lateral side of the femur is not necessary, and it may be useful for MPFL reconstruction.
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Affiliation(s)
| | - Yuji Arai
- Address correspondence to Yuji Arai, M.D., Ph.D., Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
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Zaffagnini S, Colle F, Lopomo N, Sharma B, Bignozzi S, Dejour D, Marcacci M. The influence of medial patellofemoral ligament on patellofemoral joint kinematics and patellar stability. Knee Surg Sports Traumatol Arthrosc 2013. [PMID: 23179455 DOI: 10.1007/s00167-012-2307-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Retinacular restraints have a critical role in patellar tracking, limiting the movement of the patella in the trochlear groove. The medial patellofemoral ligament (MPFL) is probably the main stabilizer against lateral displacement; few studies are focused on MPFL role on patellofemoral kinematics and patellar stability. The main goal of this in vitro study was to analyse the influence of the MPFL on the kinematics of the patellofemoral joint and patellar stability. METHODS Using a non-image-based navigation system, kinematics and anatomical data of six fresh-frozen specimens were collected. A passive flexion-extension from 0° to 90° and static acquisitions at 0°, 30°, 60° and 90°, with and without 25 N of lateral load, were performed with intact and resected MPFL with a 60 N axial force applied to the isolated quadriceps tendon. Patellar tilt and shift were analysed. RESULTS The MPFL intact state showed a shift in medial direction during the first degrees of knee flexion-that disappeared in MPFL resected condition-followed by a lateral shift, similar to that of MPFL resected condition. Tilt analysis showed that patella rotated laterally until 85° of knee flexion for intact MPFL condition and until 70° for resected MPFL condition and after rotated medially. Static tests showed that patellar stability was significantly affected by MPFL resected condition in particular at 30° and 60°. CONCLUSIONS The MPFL has an aponeurotic nature. It works as a restraint during motion, with an active role under high stress on lateral side, but with a small contribution during neutral knee flexion. Its biomechanical behaviour under loading conditions should be kept into account when performing surgical reconstruction of this ligamentous structure.
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Affiliation(s)
- Stefano Zaffagnini
- Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy.
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Medial patellofemoral ligament reconstruction: fixation strength of 5 different techniques for graft fixation at the patella. Arthroscopy 2013; 29:766-73. [PMID: 23395115 DOI: 10.1016/j.arthro.2012.12.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 12/02/2012] [Accepted: 12/06/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the structural properties of 5 different fixation strategies for a free tendon graft at the patella in medial patellofemoral ligament (MPFL) reconstruction under cyclic loading and load to failure testing. METHODS We used porcine patella and flexor tendons. We tested the following fixation techniques: 3.5-mm titanium anchor, transosseous 1-mm braided polyester suture, interference screw fixation, medial bone bridge, and transpatellar tunnels. We preconditioned each graft between 5 and 20 Nm before cyclic loading with 100 Nm for 1,000 cycles was started, and then performed load to failure testing. We recorded maximum load, stiffness, and elongation. RESULTS In the bone bridge group, 60% of all specimens failed during cyclic testing. Fixation by transosseous sutures showed significantly less stiffness compared with all other techniques (P < .05). The bone bridge technique showed significantly lower load to failure compared with all other techniques (P < .05). Differences between the other groups were not significant. CONCLUSIONS Fixation of a free tendon graft by transosseous sutures provides similar load to failure and elongation but less stiffness compared with fixation by anchors, interference screws, or transverse tunnels. Load to failure for the bone bridge technique was significantly lower than that for all other techniques. Furthermore, this fixation technique had a lower load to failure than that of the native MPFL. CLINICAL RELEVANCE Fixation of soft tissue grafts at the patella by 1-mm braided polyester suture provides adequate fixation strength without implants in the patella, which might cause soft tissue irritation. Further studies will have to show if the lesser stiffness of this technique causes problems in the clinical setting or if this laxity might even be an advantage because it makes this reconstruction more forgiving concerning overtensioning the graft. Significantly lower load to failure of the bone bridge technique should be considered in postoperative treatment.
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Petri M, von Falck C, Broese M, Liodakis E, Balcarek P, Niemeyer P, Hofmeister M, Krettek C, Voigt C, Haasper C, Zeichen J, Frosch KH, Lill H, Jagodzinski M. Influence of rupture patterns of the medial patellofemoral ligament (MPFL) on the outcome after operative treatment of traumatic patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2013; 21:683-9. [PMID: 22569631 DOI: 10.1007/s00167-012-2037-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 04/19/2012] [Indexed: 01/03/2023]
Abstract
PURPOSE Patellar dislocation usually occurs to the lateral side, leading to ruptures of the medial patellofemoral ligament (MPFL) in about 90 % of all cases. Reliable prognostic factors for the stability of the patellofemoral joint after MPFL surgery and satisfaction of the patient have not been established as yet. METHODS This multicentric study retrospectively included 40 patients with a mean age of 22.4 ± 8.1 years (range 9-48) from 5 German Trauma Departments with first-time traumatic patellar dislocation and operative treatment. Surgery was limited to soft tissue repairs, and a preoperative magnetic resonance imaging (MRI) was performed in all cases. Evaluation of the MRI included sulcus angle, dysplasia of the trochlea, depth and facet asymmetry of the trochlea, Insall-Salvati index, Tibial tuberosity to trochlear groove (TTTG) distance, and rupture patterns of the MPFL. Patients were interrogated after 2 years about recurrent dislocation, satisfaction, and the Kujala score. RESULTS Trochlea facet asymmetry was significantly lower in patients with redislocation (23.5 ± 18.8) than in patients without redislocation (43.1 ± 16.5, p = 0.03). Patients with a patellar-based rupture were significantly younger (19.5 ± 7.2 years) than patients without patellar-based rupture (25.4 ± 8.1 years, p < 0.02). Patients with femoral-based ruptures were significantly older (25.7 ± 9.2 years) than patients without femoral-based rupture (19.7 ± 6.1 years, p < 0.02), and had a significantly higher TTTG distance (10.2 ± 6.9 vs. 4.5 ± 5.5, p < 0.02). Patients with incomplete ruptures of the MPFL had a significantly lower Insall-Salvati index (1.2 ± 0.2 vs. 1.4 ± 0.2, p = 0.05). The Kujala score in patients with redislocations was significantly lower (81.0 ± 10.5 points) than in patients without redislocation (91.9 ± 9.2 points, p < 0.02). CONCLUSION Younger patients more often sustain patellar-based ruptures following first-time traumatic patella dislocation, while older patients more often sustain femoral-based ruptures of the MPFL. Incomplete MPFL ruptures are correlated with lower Insall-Salvati indices. Low trochlear facet asymmetry is correlated with higher rates of redislocation. These results may be of relevance for the operative and postoperative treatment in the future. LEVEL OF EVIDENCE Prognostic study, Level IV.
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Affiliation(s)
- M Petri
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Stephen JM, Lumpaopong P, Deehan DJ, Kader D, Amis AA. The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and nonanatomic attachments. Am J Sports Med 2012; 40:1871-9. [PMID: 22729504 DOI: 10.1177/0363546512449998] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Incompetence of the medial patellofemoral ligament (MPFL) is an integral factor in patellofemoral instability. Reconstruction of this structure is gaining increasing popularity. However, the natural behavior of the ligament is still not fully understood, and crucially, the correct landmark for femoral attachment of the MPFL at surgery is poorly defined. PURPOSE To determine the length change pattern of the native MPFL, investigate the effect of nonanatomic femoral and differing patellar attachment sites on length changes, and recommend a reproducible femoral attachment site for undertaking anatomic MPFL reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS Eight cadaveric knees were dissected of skin and subcutaneous fat and mounted in a kinematics rig with the quadriceps tensioned. The MPFL length change patterns were measured for combinations of patellar and femoral attachments using a suture and displacement transducer. Three attachments were along the superomedial border of the patella, and 5 femoral attachments were at the MPFL center and 5 mm proximal, distal, anterior, and posterior to this point. Reproducibility of attachment sites was validated radiographically. RESULTS The femoral attachment point, taking the anterior-posterior medial femoral condyle diameter to be 100%, was identified 40% from the posterior, 50% from the distal, and 60% from the anterior border of the medial femoral condyle. This point was most isometric, with a mean maximal length change to the central patellar attachment of 2.1 mm from 0° to 110° of knee flexion. The proximal femoral attachment resulted in up to 6.4 mm mean lengthening and the distal attachment up to 9.1 mm mean shortening through 0° to 110° of knee flexion, resulting in a significantly nonisometric graft (P < .05). CONCLUSION We report the anatomic femoral and patellar MPFL graft attachments, with confirmation of the reproducibility of their location and resulting kinematic behavior. Nonanatomic attachments caused significant loss of isometry. CLINICAL RELEVANCE The importance of an anatomically positioned MPFL reconstruction is highlighted, and an identifiable radiographic point for femoral tunnel position is suggested for use intraoperatively.
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Affiliation(s)
- Joanna M Stephen
- Mechanical Engineering Department, Imperial College London, London, United Kingdom
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Abstract
Magnetic resonance imaging-based methods for measuring the mechanics of human joints have been successfully applied to quantitatively evaluate biomechanics in a wide variety of joints, pathologies, and interventions. The objective of this review was to provide a detailed overview of methods in the literature for measuring joint kinematics, meniscal and ligament movement, and cartilage strain using MRI.
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