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Hinckel B, Smith J, Tanaka MJ, Matsushita T, Martinez-Cano JP. Patellofemoral instability part 1 (When to operate and soft tissue procedures): State of the art. J ISAKOS 2024:S2059-7754(24)00100-7. [PMID: 38795864 DOI: 10.1016/j.jisako.2024.05.013] [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: 02/23/2024] [Revised: 04/29/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
Patellofemoral instability is usually initially treated non-operatively. Surgery is considered in patients with recurrent patellar dislocation and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence. Stratifying the risk of recurrence includes evaluating risk factors such as age, trochlear dysplasia, contralateral dislocation, and patellar height. Surgery with soft tissue procedures includes restoring the medial patellar restraints and balancing the lateral side of the joint. Reconstruction of the medial patellofemoral ligament is the most frequent way of addressing the medial soft tissues in patients with patellofemoral instability. Meanwhile, lateral tightness can be achieved by lateral retinaculum lengthening or release. Approaching patellofemoral instability in a patient-specific approach, combined with a shared decision-making process with the patient/family, will guide surgeons to the deliver optimal care for the patellar instability patient.
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Affiliation(s)
- Betina Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Justin Smith
- Atrium Health Musculoskeletal Institute & Sports Medicine, Rock Hill, SC, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Abbaszadeh A, Saeedi M, Hoveidaei AH, Dadgostar H, Razi S, Razi M. Combined medial patellofemoral ligament and medial patellotibial ligament reconstruction in recurrent patellar instability: A systematic review and meta-analysis. World J Clin Cases 2023; 11:4625-4634. [PMID: 37469731 PMCID: PMC10353511 DOI: 10.12998/wjcc.v11.i19.4625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/08/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND The medial patellofemoral ligament (MPFL), along with the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament, aid in the stabilization of the patellofemoral joint. Although the MPFL is the primary stabilizer and the MPTL is a secondary limiter, this ligament is critical in maintaining joint stability. There have been few studies on the combined MPFL and MPTL reconstruction and its benefits.
AIM To look into the outcomes of combined MPFL and MPTL reconstruction in frequent patellar instability.
METHODS By May 8, 2022, four electronic databases were searched: Medline (PubMed), Scopus, Web of Science, and Google Scholar. General keywords such as "patellar instability," "patellar dislocation," "MPFL," "medial patellofemoral ligament," "MPTL," and "medial patellotibial ligament" were co-searched to increase the sensitivity of the search.
RESULTS The pooled effects of combined MPFL and MPTL reconstruction for Kujala score (12-mo follow-up) and Kujala score (24-mo follow-up) were positive and incremental, according to the findings of this meta-analysis. The mean difference between the Cincinnati scores was also positive, but not statistically significant. The combination of the two surgeries reduces pain. According to cumulative meta-analysis, the trend of pain reduction in various studies is declining over time.
CONCLUSION The combined MPFL and MPTL reconstruction has good clinical results in knee function and, in addition to providing good control to maintain patellofemoral joint balance, the patient's pain level decreases over time, making it a valid surgical method for patella stabilization.
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Affiliation(s)
- Ahmad Abbaszadeh
- Department of Orthopedic, Emam Khomeini Teaching Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 6135715794, Iran
| | - Mohsen Saeedi
- Department of Orthopedic, Emam Khomeini Teaching Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 6135715794, Iran
| | - Amir Human Hoveidaei
- Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran 14395-578, Iran
| | - Haleh Dadgostar
- Department of Sports and Exercise Medicine, School of Medicine, Rasool Akram Medical Complex, Iran University of Medical Sciences, Tehran 1445613131, Iran
| | - Saeed Razi
- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran 1545913487, Iran
| | - Mohammad Razi
- Department of Orthopedic Surgery, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran 1445613131, Iran
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Leite CBG, Hinckel BB, Ribeiro GF, Giglio PN, Santos TP, Bonadio MB, Arendt E, Gobbi RG. Medial patellofemoral ligament reconstruction in skeletally immature patients without correction of bony risk factors leads to acceptable outcomes but higher failure rates. J ISAKOS 2023; 8:189-196. [PMID: 36924824 DOI: 10.1016/j.jisako.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/29/2023] [Accepted: 02/25/2023] [Indexed: 03/15/2023]
Abstract
OBJECTIVES To report outcomes and re-dislocation rates of medial patellar stabilizers reconstruction without bone procedures for correction of anatomical risk factors for patellar instability in skeletally immature patients; to compare isolated medial patellofemoral ligament (MPFL) reconstruction to combined MPFL and medial patellotibial ligament (MPTL) reconstruction in this population. METHODS Patients with open physis and bone abnormalities including patella alta and/or increased tibial tubercle-trochlear groove (TT-TG) distance and/or trochlear dysplasia underwent MPFL reconstruction, either isolated or associated with MPTL reconstruction. Preoperative, 1-year follow-up and the latest follow-up (5 years minimum) data were collected. Radiological and clinical evaluations were conducted, with special attention to failure rate. Comparison of results from isolated MPFL and combined MPFL/MPTL reconstructions was performed. RESULTS Twenty-nine patients were included, 19 in the isolated MPFL group (median 14 years old; follow-up 5.8 ± 1.7 years) and 10 in the combined MPFL/MPTL group (median 13.5 years old; follow-up 5.2 ± 1.4 years). Kujala and Tegner scores increased over time, although without statistically significant differences between the two groups at the latest follow-up (p = 0.840 and p > 0.999, respectively). During follow-up, 5 of 19 (26.3%) isolated MPFL and 2 of 10 (20%) MPFL/MPTL reconstructions experienced recurrence of patellar dislocation (p > 0.999). Trochlear dysplasia type D (p = 0.028), knee rotation (p = 0.009) and lateral patellar tilt angle (p = 0.003) were associated with patellar instability recurrence. The isolated MPFL group showed increased laxity on physical exam at the latest follow-up compared to the 1-year follow-up (patellar glide test (p = 0.002), patellar tilt test (p = 0.042) and subluxation in extension (p = 0.019). This increased laxity was not observed in the MPFL/MPTL group (p > 0.999). Comparing both groups, the glide test was significantly better in the combined MPFL/MPTL group in comparison to the isolated MPFL reconstruction group at the latest follow-up (p = 0.021). CONCLUSION MPFL reconstruction in isolation or combined with MPTL reconstruction in skeletally immature patients with additional uncorrected anatomical patellofemoral abnormalities leads to acceptable clinical outcomes within a minimum of 5 years follow-up, although has a high failure rate of 24.1%. Addition of a MPTL reconstruction to the MPFL may result in decreased patellar laxity on physical exams, as demonstrated by better patellar glide test, patellar tilt test and subluxation in extension. LEVEL OF EVIDENCE Level III; retrospective cohort study.
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Affiliation(s)
- Chilan Bou Ghosson Leite
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Betina Bremer Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI 48180, USA.
| | - Gabriel Fernandes Ribeiro
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Pedro Nogueira Giglio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Tarsis Padula Santos
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Marcelo Batista Bonadio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Elizabeth Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN 55454, USA
| | - Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
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Sherman SL, Rund JM, Welsh JW, Ray T, Worley JR, Oladeji LO, Gray AD, Hinckel BB. Medial Patellofemoral Ligament Reconstruction in Obese Patients Results in Low Complication Rates and Improved Subjective Outcomes. Arthrosc Sports Med Rehabil 2023; 5:e257-e262. [PMID: 36866317 PMCID: PMC9971998 DOI: 10.1016/j.asmr.2022.11.023] [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: 08/12/2022] [Accepted: 11/10/2022] [Indexed: 01/06/2023] Open
Abstract
Purpose To compare outcomes, activity scores, and complication rates of obese and non-obese patients undergoing medial patellofemoral ligament (MPFL) reconstruction. Methods A retrospective review identified patients undergoing MPFL reconstruction for recurrent patellofemoral instability. Patients were included if they had undergone MPFL reconstruction and had follow-up for a minimum of 6 months. Patients were excluded if they underwent surgery less than 6 months earlier, had no outcome data recorded, or underwent concomitant bony procedures. Patients were divided into 2 groups based on body mass index (BMI): BMI of 30 or greater and BMI less than 30. Presurgical and postsurgical patient-reported outcomes including Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and the Tegner score were collected. Complications requiring reoperation were recorded. P < .05 was defined as a statistically significant difference. Results A total of 55 patients (57 knees) were included. There were 26 knees with a BMI of 30 or greater and 31 knees with a BMI less than 30. There were no differences in patient demographic characteristics between the 2 groups. Preoperatively, no significant differences were found in KOOS subscores or Tegner scores (P = .21) between groups. At minimum 6-month follow-up (range, 6.1-70.5 months), patients with a BMI of 30 or greater showed statistically significant improvements in the KOOS Pain, Activities of Daily Living, Symptoms, and Sport/Recreation subscores. Patients with a BMI less than 30 showed a statistically significant improvement in the KOOS Quality of Life subscore. The group with a BMI of 30 or greater had significantly lower KOOS Quality of Life (33.34 ± 19.10 vs 54.47 ± 28.00, P = .03) and Tegner (2.56 ± 1.59 vs 4.78 ± 2.68, P = .05) scores. Complication rates were low, with 2 knees (7.69%) requiring reoperation in the cohort with a BMI of 30 or greater and 4 knees (12.90%) requiring reoperation in the cohort with a BMI less than 30, including 1 reoperation for recurrent patellofemoral instability (P = .68). Conclusions In this study, MPFL reconstruction in obese patients was safe and effective, with low complication rates and improvements in most patient-reported outcomes. Compared with patients with a BMI less than 30, obese patients had lower quality-of-life and activity scores at final follow-up. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Seth L. Sherman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California, U.S.A.,Address correspondence to Seth L. Sherman, M.D., 450 Broadway Pavilion A, Redwood City, CA 94063, U.S.A.
| | - Joseph M. Rund
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa, U.S.A
| | - John W. Welsh
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Taylor Ray
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California, U.S.A
| | - John R. Worley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Lasun O. Oladeji
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Aaron D. Gray
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Betina B. Hinckel
- Oakland University, Rochester, Michigan, U.S.A.,Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, U.S.A
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Huddleston HP, Chahla J, Gursoy S, Williams BT, Dandu N, Malloy P, Naveen NB, Cole BJ, Yanke AB. A Comprehensive Description of the Lateral Patellofemoral Complex: Anatomy and Anisometry. Am J Sports Med 2022; 50:984-993. [PMID: 35373608 DOI: 10.1177/03635465221078033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The lateral patellofemoral complex (LPFC) is an important stabilizer of the patella composed of the lateral retinacular structures including the lateral patellofemoral ligament (LPFL), the lateral patellomeniscal ligament (LPML), and the lateral patellotibial ligament (LPTL). While the isolated anatomy of the LPFL has been previously described, no previous study has investigated the entirety of the LPFC structure, length changes, and radiographic landmarks. An understanding of LPFC anatomy is important in the setting of LPFL injury or previous lateral release resulting in iatrogenic medial instability requiring LPFC reconstruction. PURPOSE To both qualitatively and quantitatively describe the anatomy and length changes of the LPFC on gross anatomic dissections and standard radiographic views. STUDY DESIGN Descriptive laboratory study. METHODS Ten nonpaired cadaveric specimens were utilized in this study. Specimens were dissected to identify distinct attachments of the LPFL, LPML, and LPTL. Ligament lengths, footprints, and centers of each attachment were described with respect to osseous landmarks using a 3-dimensional coordinate measuring device. Ligament length changes were also assessed from 0° to 90° of flexion. Radiopaque markers were subsequently utilized to describe attachments on standard anteroposterior and lateral radiographic views. RESULTS The individual elements of the LPFC were identified in all specimens. The LPFL patellar attachment had an average total length of 22.5 mm (range, 18.3-27.5 mm), involving a mean of 59% (range, 50%-75%) of the sagittal patella. Based on the average patellar size, a mean of 63% of the LPFL attached to the patella, and the remainder (11.1 ± 1.4 mm) inserted into the patellar tendon. The femoral attachment of the LPFL had a mean maximum length of 24.4 ± 4.3 mm. The center of the LPFL femoral attachment was a mean distance of 13.5 ± 3.2 mm anterior and distal to the lateral epicondyle. The LPFL demonstrated significant shortening, especially in the first 45° of flexion (7.5 ± 5.1 mm). In contrast, the LPTL (5.5 ± 3.0 mm) and LPML (10.0 ± 3.3 mm) demonstrated significant shortening from 45° to 90°. On lateral radiographs, the center of the femoral attachment of the LPFL was a mean total distance of 19.2 ± 7.2 mm from the lateral epicondyle. CONCLUSION The most important findings of this study were the correlative anatomy of 3 distinct lateral patellar ligaments (LPFL, LPML, and LPTL) and their anisometry through flexion. All 3 components demonstrated significant shortening during flexion. The quantitative and radiographic measurements detailed the LPFL osseous attachment on the patella; soft tissue attachment on the patellar tendon; and finally, the osseous insertion on the femur distal and anterior to the lateral epicondyle. Similarly, the authors documented the meniscal insertion of the LPML and defined a patellar insertion of the LPTL and LPML as a single attachment. These data allow for reproducible landmarks to aid in the understanding and reconstruction of the lateral patellar restraints. CLINICAL RELEVANCE The data produced from this investigation provide a comprehensive description of these 3 lateral patellar stabilizers (LPFL, LPML, LPTL). These data can be used intraoperatively to facilitate anatomic reconstructions of the lateral patellar stabilizers.
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Affiliation(s)
| | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
| | - Safa Gursoy
- Rush University Medical Center, Chicago, Illinois, USA
| | | | - Navya Dandu
- Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Neal B Naveen
- University of Illinois-Chicago, Chicago, Illinois, USA
| | - Brian J Cole
- Rush University Medical Center, Chicago, Illinois, USA
| | - Adam B Yanke
- Rush University Medical Center, Chicago, Illinois, 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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Aicale R, Maffulli N. Combined medial patellofemoral and medial patellotibial reconstruction for patellar instability: a PRISMA systematic review. J Orthop Surg Res 2020; 15:529. [PMID: 33183310 PMCID: PMC7663880 DOI: 10.1186/s13018-020-02072-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The medial patellofemoral ligament (MPFL) works in association with the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML) to impart stability to the patellofemoral joint. The anatomy and biomechanical characteristics of the MPFL have been well described but little is known about the MPTL and MPML. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, patellar and quadriceps tendons, allografts and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident. METHODS A systematic review of the literature was conducted using PRISMA guidelines. Inclusion criteria were articles that reported clinical outcomes of combined reconstruction of MPTL and MPFL. The methodological quality of the articles was determined using the modified Coleman Methodology Score (CMS). RESULTS Nine articles were included, reporting the clinical outcomes of 197 operated knees. The surgical procedures described include hamstrings grafting and transfer of the medial patellar and quadriceps tendons with or without bony procedures to reconstruct the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved. The median CMS is 70.6 ± 14.4 (range 38 to 84). CONCLUSION Different techniques are reported, and outcomes are good with low rates of recurrence. The quality of the articles is variable, ranging from low to high. Appropriately powered randomized controlled trials are needed to better understand what the adequate indications for surgery in patients with patellar instability and clinical outcomes are. Combined reconstruction of MPFL and MPTL leads to favourable clinical outcomes, supporting its role as a valid surgical procedure for patellar stabilization.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG England
- Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB England
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8
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Felli L, Alessio-Mazzola M, Lovisolo S, Capello AG, Formica M, Maffulli N. Anatomy and biomechanics of the medial patellotibial ligament: A systematic review. Surgeon 2020; 19:e168-e174. [PMID: 33121878 DOI: 10.1016/j.surge.2020.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/27/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The knowledge of the anatomy and biomechanics of patellar stabilizers is mandatory to achieve good clinical results with surgical reconstructive procedures. Few articles provide clear anatomical and biomechanical picture of medial patello-tibial ligament (MPTL). METHODS After a systematic review of the literature we selected in vivo or ex vivo studies providing anatomical or biomechanical measurements. We included 7 studies about MPTL anatomy for a total of 96 knees and 4 biomechanical studies. RESULTS The MPTL is a true ligament and important component of the medial patellar stabilizers, together with the medial patello-femoral ligament (MPFL) and medial patello-meniscal ligament. The contribution of MPTL on restriction forces of the patello-femoral joint is still unclear. Quadriceps, patellar, semitendinous and gracilis tendons are adequate grafts for surgical MPTL reconstruction. CONCLUSIONS MPTL is a well defined anathomical structure and histologically can be considered a ligament. It plays an important role in patellar stability especially it has a main role on patellar rotation and tilt instead on shift.
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Affiliation(s)
- Lamberto Felli
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy; Department of Surgical Sciences (DISC), University of Genova, Viale Benedetto XV 8, Genova, 16132, Italy.
| | - Mattia Alessio-Mazzola
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy; Department of Surgical Sciences (DISC), University of Genova, Viale Benedetto XV 8, Genova, 16132, Italy.
| | - Stefano Lovisolo
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy.
| | - Andrea Giorgio Capello
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy.
| | - Matteo Formica
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy; Department of Surgical Sciences (DISC), University of Genova, Viale Benedetto XV 8, Genova, 16132, Italy.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Via Salvator Allende 23, Baronissi, 89100, Salerno, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Largo Città di Ippocrate, Salerno, 84131, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, UK; School of Pharmacy and Bioengineering, Keele University of School of Medicine, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, UK.
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9
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Medial Patellotibial Ligament Reconstruction Improves Patella Tracking When Combined With Medial Patellofemoral Reconstruction: An In Vitro Kinematic Study. Arthroscopy 2020; 36:2501-2509. [PMID: 32442704 DOI: 10.1016/j.arthro.2020.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the isolated and combined effects of medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) deficiency and reconstruction on patellofemoral kinematics. METHODS Sixteen matched-paired female cadaveric knee specimens with a mean age of 53.5 years (range, 26-65) were tested in 5 conditions: (1) intact, (2) MPFL or MPTL cut, (3) MPFL and MPTL combined cut, (4) MPFL or MPTL reconstruction, and (5) MPFL and MPTL combined reconstruction. Dynamic testing allowed continuous analysis of kinematics from 0° to 90° of knee flexion. Knees were also tested statically using a lateral load of 45 N at 0°, 30°, 60°, and 90° of flexion. In both dynamic and static loading tests, a motion capture system detected patellar position for each testing state to distinguish changes in patellar kinematics. Random-intercepts linear mixed-effects models were used to compare patellar kinematics. RESULTS The MPFL is the primary restraint to lateral translation of the patella at all knee flexion angles. MPTL deficiency alone did not create significant patella instability, but further increased instability when the MPFL was deficient. Isolated MPFL and combined reconstruction provided improved stability. Through full range of motion native patella tracking was best recreated with combined ligament reconstruction. CONCLUSIONS The MPFL plays the greatest role in medial patellar stability, but the MPTL appears to have an influence on patella tracking. This study provides further understanding to the impact of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking. CLINICAL RELEVANCE This study provides further understanding of the role of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking.
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Zacchilli MA, Mulcahey MK. Editorial Commentary: As Nature Intended: Will Inclusion of the Medial Patellotibial Ligament Create a Better Medial Patellofemoral Complex Reconstruction? Arthroscopy 2020; 36:2510-2512. [PMID: 32891251 DOI: 10.1016/j.arthro.2020.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 02/02/2023]
Abstract
The medial patellofemoral complex, composed predominantly of the medial patellofemoral ligament, plays an important role in patellar tracking and stability. Medial patellofemoral ligament reconstruction is accordingly one of the most broadly applied surgical techniques for treating patellar instability. Orthopaedic research has demonstrated that surgeries that restore native anatomy are often more effective. The medial patellotibial ligament clearly serves an important supporting role in patellar tracking and stability, particularly in early flexion, and its inclusion in medial soft-tissue reconstructions more closely restores native patella tracking. Whether reconstructions incorporating the medial patellotibial ligament will translate to improved outcomes remains unclear.
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Maffulli N, Aicale R, D'Addona A, Young DA, Kader DF, Oliva F. Combined medial patellofemoral and patellotibial reconstruction with soft tissue fixation in recurrent patellar dislocation. Injury 2020; 51:1867-1873. [PMID: 32580890 DOI: 10.1016/j.injury.2020.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/07/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The medial patellofemoral and patellotibial ligaments (MPFL and MPTL) are the main passive restraints to lateral patellar translation. When nonoperative management of patellofemoral dislocations fails, surgical options can be considered to restore patellofemoral stability. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, quadriceps tendon, and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident. MATERIALS AND METHODS Patients who suffered at least two documented episodes of unilateral patellar dislocation, confirmed radiographically and at clinical examination, underwent combined MPFL and MPTL reconstruction. Patients were regularly followed-up postoperatively at 2, 4, 8, 12, and 24 weeks, and then annually for a minimum of 2.5 years. Clinical and functional evaluations were performed using the modified Cincinnati rating system and the Kujala score, while anthropometry values including thigh volume and cross-sectional area of the thigh were measured before the operation and at the latest follow-up bilaterally. RESULTS There were 7 males and 27 females with a mean age of 26.5 ± 10.7 years (range, 13-39 years). The mean follow-up was 3.1 years (range, 2.5-4 years). The mean modified Cincinnati score Increased from 51 ± 22 preoperatively to 90 ± 19 (P = .001). The mean Kujala scores increased from 47 ± 17 preoperatively to 82 ± 17 (P = .02), with no significant differences between patients with or without osteochondral lesions (P ≥ .05), and between male and female patients (P ≥ .08). The Insall-Salvati index was 1.1 preoperatively and remained within normal range (P = .05) at the latest follow-up. CONCLUSION Combined reconstruction of MPFL and MPTL using an ipsilateral autologous gracilis tendon is satisfactory and effective and can be considered as suitable management option to treat recurrent dislocation of the patella. However, randomized studies are needed to compare different techniques. STUDY DESIGN Case series.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England, UK; Keele University, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England, UK.
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy
| | - Alessio D'Addona
- Department of Public Health, Section of Orthopaedics and Trauma Surgery, A.O.U. Federico II School of Medicine, Surgery and Dentistry, "Federico II" University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - David A Young
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor VIC 3181, Australia
| | - Deiary F Kader
- Academic Unit, South West London Elective Orthopaedic Centre, Epsom, Surrey, UK
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy
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Eliasberg CD, Diduch DR, Strickland SM. Failure of Patellofemoral Joint Preservation. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2019.150715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Concepts of the Distal Medial Patellar Restraints: Medial Patellotibial Ligament and Medial Patellomeniscal Ligament. Sports Med Arthrosc Rev 2019; 27:143-149. [PMID: 31688532 DOI: 10.1097/jsa.0000000000000269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The important medial patellar ligamentous restraints to lateral dislocation are the proximal group (the medial quadriceps tendon femoral ligament and the medial patellofemoral ligament) and the distal group [medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML)]. The MPTL patellar insertion is at inferomedial border of patella and tibial insertion is in the anteromedial tibia. The MPML originates in the inferomedial patella, right proximal to the MPTL, inserting in the medial meniscus. On the basis of anatomy and biomechanical studies, the MPTL and MPML are more important in 2 moments during knee range of motion: terminal extension, when it directly counteracts quadriceps contraction. In a systematic review on MPTL reconstructions 19 articles were included detailing the clinical outcomes of 403 knees. All were case series. Overall, good and excellent outcomes were achieved in >75% of cohorts in most studies and redislocations were <10%, with or without the association of the medial patellofemoral ligament. The MPTL is a relevant additional tool to proximal restraint reconstruction in select patient profiles; however, more definitive clinical studies are necessary to better define surgical indications.
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Medial patellofemoral ligament (MPFL) reconstruction using quadriceps tendon autograft provides good clinical, functional and patient-reported outcome measurements (PROM): a 2-year prospective study. Knee Surg Sports Traumatol Arthrosc 2019; 27:2426-2432. [PMID: 30374571 DOI: 10.1007/s00167-018-5226-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The medial patellofemoral ligament (MPFL) is the most important ligamentous stabilizer preventing lateral patella dislocation. Numerous surgical procedures for MPFL reconstruction have been described in the literature. The aim of this study was to investigate the clinical, functional and patient-reported (PROM) outcomes 2 years after minimally invasive MPFL reconstruction performed using an autologous strip of the quadriceps tendon. METHODS Thirty-six patients (38 knees) were included in the study. For MPFL reconstruction, a partial thickness autologous quadriceps tendon graft was used. All patients were evaluated clinically and with patient-reported outcome questionnaires including the Tegner, Lysholm and Kujala scores as well as a visual analogue scale (VAS) for pain preoperatively and at 6, 12 and 24 months postoperatively. A functional Back-in-Action (BIA) test battery, including a total of seven stability, agility and jumping tests, was performed on 19 (50%) patients at the final follow-up. One patient was lost to follow-up at 24 months. RESULTS The mean age at the time of operation was 25.2 ± 6.1 years. No redislocations occurred during the period of investigation. The mean Lysholm score improved significantly from 79.3 ± 16.1 preoperatively to 83.2 ± 14.4 at 6 months, 88.1 ± 11.3 at 12 months and to 90.0 ± 9.6 at 24 months follow-up. No change throughout the study period was observed for the median Tegner Activity Score (median 6). The mean Kujala score increased from a preoperative value of 82.0 ± 12.4, to 84.5 ± 8.4 at 6 months, and 88.2 ± 5.8 at 12 months up to 88.7 ± 4.5 at 24 months follow-up. A total of 77.8% of the performed functional BIA tests were equal to or above the norm for patients of the corresponding ages and activity levels. CONCLUSIONS Minimally invasive MPFL reconstruction with a partial thickness strip of quadriceps tendon is a safe and effective treatment for patellofemoral instability. Good clinical, functional and subjective results were observed at the 2-year follow-up. LEVEL OF EVIDENCE Prospective cohort study, non-randomized, Level IV.
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Agarwalla A, Gowd AK, Liu JN, Puzzitiello RN, Yanke AB, Verma NN, Forsythe B. Concomitant Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Osteotomy Do Not Increase the Incidence of 30-Day Complications: An Analysis of the NSQIP Database. Orthop J Sports Med 2019; 7:2325967119837639. [PMID: 31019984 PMCID: PMC6463332 DOI: 10.1177/2325967119837639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Lateral patellar dislocations account for 2% to 3% of total knee injuries, especially in adolescents. Depending on the anatomic abnormality contributing to lateral patellar instability, medial patellofemoral ligament reconstruction (MPFLR) and/or tibial tubercle osteotomy (TTO) may be indicated. Purpose: To assess the risk of adverse events (AEs) after TTO, MPFLR, and concomitant MPFLR and TTO. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent MPFLR, TTO, and concomitant MPFLR and TTO between 2005 and 2016 were identified through the American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database. Medical complications (eg, surgical site infection and deep vein thrombosis), readmission rates, and extended hospital stay within 30 days of the procedure were recorded. Outcomes were compared with bivariate and multivariate Poisson regression. Results: Out of 882 patients, 617 (70.0%) underwent isolated MPFLR, 170 (19.3%) underwent TTO, and 95 (10.8%) underwent concomitant MPFLR and TTO. The operative time for concomitant MPFLR and TTO was significantly longer (122 ± 45 minutes) compared with isolated MPFLR (97 ± 55 minutes; P < .001) and isolated TTO (89 ± 51 minutes; P < .001). There were 32 AEs (3.6%), with 10 AEs in the isolated TTO group (5.9%), 18 AEs in the isolated MPFLR group (2.9%), and 4 AEs in the MPFLR + TTO group (4.2%). There was no significant difference in the rate of AEs between the isolated MPFLR and isolated TTO groups (P = .1), isolated MPFLR and MPFLR + TTO groups (P = .5), and isolated TTO and MPFLR + TTO groups (P = .8). Diabetes mellitus was associated with an increased risk of developing an AE (odds ratio, 4.0; P = .003), and hypertension resulted in an increased risk of an extended hospital stay (odds ratio, 4.0; P = .010). Conclusion: While concomitant MPFLR and TTO significantly increased operative time, there was no difference in the rate of AEs, extended hospital stay, and readmissions within 30 days after isolated MPFLR, isolated TTO, and concomitant MPFLR and TTO.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Joseph N Liu
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Richard N Puzzitiello
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Adam B Yanke
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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Hetsroni I, Mann G, Dolev E, Nyska M. Combined reconstruction of the medial patellofemoral and medial patellotibial ligaments: outcomes and prognostic factors. Knee Surg Sports Traumatol Arthrosc 2019; 27:507-515. [PMID: 30238237 DOI: 10.1007/s00167-018-5145-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 09/14/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE To report outcomes after combined medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) reconstruction and test associations between prognostic factors and clinical outcomes. It was hypothesised that combined MPFL and MPTL reconstruction would result in significant improvement in function, and that outcomes would be associated with age, sex, Beighton score, concomitant articular lesions, and preoperative function. METHODS All combined reconstructions of MPFL and MPTL were reviewed. Inclusion criterion was minimum 2-year follow-up. Exclusion criteria were age at surgery ≥ 35 years and concomitant osteotomies. Kujala, Tegner and Marx scores were completed prospectively. Patients were evaluated at a minimum 2-year follow-up. Associations between potential prognostic factors and Kujala and Tegner scores were tested using bivariate analyses followed by multivariate regression models. RESULTS Of 22 patients (26 knees), 19 (23 knees) met inclusion criteria, and 16 (20 knees) were available for follow-up. Mean age at surgery was 18 years (range 14.5-23). Mean follow-up was 43 months (range 24-73). Postoperative Kujala score significantly improved compared to before surgery (86.4 ± 12.5 vs. 54.9 ± 15.2, p < 0.01). Postoperative Tegner score was nonsignificantly higher compared to before surgery (4.8 ± 2.4 vs. 4 ± 3, p = ns) and lower compared to before first patella dislocation (4.8 ± 2.4 vs. 5.9 ± 1.2, p < 0.01). Postoperative Kujala score was associated with male sex (p = 0.02), with medial patellofemoral chondral lesions (p = 0.01) and with preoperative Kujala score (p = 0.05). Postoperative Tegner score was associated with male sex (p < 0.01), with preoperative Tegner level (p < 0.01), and with Beighton score (p < 0.01). Patella apprehension was recorded in two knees (10%) in two patients. CONCLUSION Combined MPFL and MPTL reconstruction in young adults results in significant improvement in subjective knee function with minimal risks, although preinjury activity levels are not consistently restored. Associated factors of improved outcome include higher preoperative knee scores and activity levels, medial patellofemoral chondral lesions, decreased Beighton scores, and male sex. This supports the advisability of the procedure and can also assist in setting realistic goals for specific groups of patients. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Iftach Hetsroni
- Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Gideon Mann
- Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Dolev
- Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel
| | - Meir Nyska
- Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Baumann CA, Pratte EL, Sherman SL, Arendt EA, Hinckel BB. Reconstruction of the medial patellotibial ligament results in favorable clinical outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 2018; 26:2920-2933. [PMID: 29344696 DOI: 10.1007/s00167-018-4833-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE The medial patellotibial ligament (MPTL), the medial patellofemoral ligament (MPFL), and the medial patellomeniscal ligament (MPML) support the stability of the patellofemoral joint. The purpose of this systematic review was to report the surgical techniques and clinical outcomes of the repair or reconstruction of the MPTL in isolation or concomitant with the MPFL and/or other procedures. METHODS A systematic review of the literature was conducted. Inclusion criteria were articles in the English language that reported clinical outcomes of the reconstruction of the MPTL in isolation or in combination with the MPFL and/or other procedures. Included articles were then cross-referenced to find additional journal articles not found in the initial search. The methodological quality of the articles was determined using the Coleman Methodology Score. RESULTS Nineteen articles were included detailing the clinical outcomes of 403 knees. The surgical procedures described included hamstrings tenodesis with or without other major procedures, medial transfer of the medial patellar tendon with or without other major procedures and the reconstruction of the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved in > 75% of cohorts in most studies and redislocations were < 10%, with or without the association of the MPFL. An exception was one study that reported a high failure rate of 82%. Results were consistent across different techniques. The median CMS for the articles was 66 out of 100 (range 30-85). CONCLUSION Across different techniques, the outcomes are good with low rates of recurrence, with one article reporting a high rate of recurrence. Quality of the articles is variable, from low to high. Randomized control trials are needed for a better understanding of the indications, surgical techniques, and clinical outcomes. This systematic review suggests that the reconstruction of the MPTL leads to favorable clinical outcomes and supports the role of the procedure as a valid surgical patellar stabilization procedure. LEVEL OF EVIDENCE IV: systematic review of level I-IV studies.
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Affiliation(s)
- Charles A Baumann
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO, USA
| | - Eli L Pratte
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, MO, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Betina B Hinckel
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA.
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LaPrade MD, Kallenbach SL, Aman ZS, Moatshe G, Storaci HW, Turnbull TL, Arendt EA, Chahla J, LaPrade RF. Biomechanical Evaluation of the Medial Stabilizers of the Patella. Am J Sports Med 2018; 46:1575-1582. [PMID: 29554436 DOI: 10.1177/0363546518758654] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quantification of the biomechanical properties of each individual medial patellar ligament will facilitate an understanding of injury patterns and enhance anatomic reconstruction techniques by improving the selection of grafts possessing appropriate biomechanical properties for each ligament. PURPOSE To determine the ultimate failure load, stiffness, and mechanism of failure of the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), and medial patellomeniscal ligament (MPML) to assist with selection of graft tissue for anatomic reconstructions. STUDY DESIGN Descriptive laboratory study. METHODS Twenty-two nonpaired, fresh-frozen cadaveric knees were dissected free of all soft tissue structures except for the MPFL, MPTL, and MPML. Two specimens were ultimately excluded because their medial structure fibers were lacerated during dissection. The patella was obliquely cut to test the MPFL and the MPTL-MPML complex separately. To ensure that the common patellar insertion of the MPTL and MPML was not compromised during testing, only one each of the MPML and MPTL were tested per specimen (n = 10 each). Specimens were secured in a dynamic tensile testing machine, and the ultimate load, stiffness, and mechanism of failure of each ligament (MPFL = 20, MPML = 10, and MPTL = 10) were recorded. RESULTS The mean ± SD ultimate load of the MPFL (178 ± 46 N) was not significantly greater than that of the MPTL (147 ± 80 N; P = .706) but was significantly greater than that of the MPML (105 ± 62 N; P = .001). The mean ultimate load of the MPTL was not significantly different from that of the MPML ( P = .210). Of the 20 MPFLs tested, 16 failed by midsubstance rupture and 4 by bony avulsion on the femur. Of the 10 MPTLs tested, 9 failed by midsubstance rupture and 1 by bony avulsion on the patella. Finally, of the 10 MPMLs tested, all 10 failed by midsubstance rupture. No significant difference was found in mean stiffness between the MPFL (23 ± 6 N/mm2) and the MPTL (31 ± 21 N/mm2; P = .169), but a significant difference was found between the MPFL and the MPML (14 ± 8 N/mm2; P = .003) and between the MPTL and MPML ( P = .028). CONCLUSION The MPFL and MPTL had comparable ultimate loads and stiffness, while the MPML had lower failure loads and stiffness. Midsubstance failure was the most common type of failure; therefore, reconstruction grafts should meet or exceed the values reported herein. CLINICAL RELEVANCE For an anatomic medial-sided knee reconstruction, the individual biomechanical contributions of the medial patellar ligamentous structures (MPFL, MPTL, and MPML) need to be characterized to facilitate an optimal reconstruction design.
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Affiliation(s)
| | | | - Zachary S Aman
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, USA.,Oslo University Hospital and University of Oslo, Oslo, Norway.,Norwegian School of Sports Sciences, Oslo Sports Trauma Research Center, Oslo, Norway
| | | | | | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota Minneapolis, Minnesota, USA
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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Abstract
PURPOSE Critically evaluate the published literature related to quadriceps tendon (QT) medial patellofemoral ligament (MPFL) reconstruction. RECENT FINDINGS Hamstring tendon (HT) MPFL reconstruction techniques have been shown to successfully restore patella stability, but complications including patella fracture are reported. Quadriceps tendon (QT) reconstruction techniques with an intact graft pedicle on the patella side have the advantage that patella bone tunnel drilling and fixation are no longer needed, reducing risk of patella fracture. Several QT MPFL reconstruction techniques, including minimally invasive surgical (MIS) approaches, have been published with promising clinical results and fewer complications than with HT techniques. Parallel laboratory studies have shown macroscopic anatomy and biomechanical properties of QT are more similar to native MPFL than hamstring (HS) HT, suggesting QT may more accurately restore native joint kinematics. Quadriceps tendon MPFL reconstruction, via both open and MIS techniques, have promising clinical results and offer valuable alternatives to HS grafts for primary and revision MPFL reconstruction in both children and adults.
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Hinckel BB, Gobbi RG, Kaleka CC, Camanho GL, Arendt EA. Medial patellotibial ligament and medial patellomeniscal ligament: anatomy, imaging, biomechanics, and clinical review. Knee Surg Sports Traumatol Arthrosc 2018; 26:685-696. [PMID: 28289819 DOI: 10.1007/s00167-017-4469-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 02/07/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this article is to review anatomical, biomechanical, and clinical data of the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML), as well as studies focusing on the medial patellofemoral ligament (MPFL) but with relevant data about the MPTL and MPML. METHODS A literature search of articles specifically addressing the MPTL and/or MPML was included along with studies focusing on the MPFL but with relevant data about the MPTL and MPML. RESULTS The medial patellar ligaments responsible for maintaining the stability of the patellofemoral (PF) joint include the MPFL, the MPTL, and the MPML. The MPFL is considered the primary restraint to lateral patellar translation, while the latter two are considered secondary restraints. There is robust literature on the anatomical, imaging, and biomechanical characteristics of the MPFL, and also the clinical outcome of its injury and surgical reconstruction; much less is known about the MPTL and MPML. Isolated MPFL reconstruction has good clinical and functional outcomes, with a low failure rate when defined as frank re-dislocation. Complications, including continued episodes of patellar apprehension and subluxation, remain present in most series. In addition, the current literature primarily includes a homogeneous population with few excessive anatomic dysplastic factors. There is lack of knowledge on the role of MPTL and MPML in (potentially) aiding patella stabilization and improving clinical outcomes. Understanding the role of the medial-sided patellar ligaments, in particular the role of the secondary stabilizers, in PF function and injury will aid in this goal. CONCLUSION MPTL and MPML have consistent basic science literature, as well as favorable clinical outcomes of surgical patellar stabilization with reconstruction of the MPTL. However, there is much heterogeneity among clinical case series and lack of comparative studies to allow clear indication for the role of isolated or combined surgical reconstruction in patellar stabilization. Therefore, this comprehensive review helps understand the current knowledge and the possible applications in the orthopedic clinical practice. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Betina Bremer Hinckel
- Missouri Orthopaedic Institute, University of Missouri, 1100 Virginia Ave, Columbia, MO, 65212, USA
| | - Riccardo Gomes Gobbi
- Orthopedics and Traumatology Institute, University of Sao Paulo, Ovidio Pires de Campos St, 333, Sao Paulo, SP, 5403-010, Brazil
| | - Camila Cohen Kaleka
- Albert Einstein Israelite Hospital, Av Albert Einstein, 627, Building A1, unit 306, Sao Paulo, SP, 05652-900, Brazil
| | - Gilberto Luis Camanho
- Orthopedics and Traumatology Institute, University of Sao Paulo, Ovidio Pires de Campos St, 333, Sao Paulo, SP, 5403-010, Brazil
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
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Hinckel BB, Gobbi RG, Demange MK, Pereira CAM, Pécora JR, Natalino RJM, Miyahira L, Kubota BS, Camanho GL. Medial Patellofemoral Ligament, Medial Patellotibial Ligament, and Medial Patellomeniscal Ligament: Anatomic, Histologic, Radiographic, and Biomechanical Study. Arthroscopy 2017; 33:1862-1873. [PMID: 28662894 DOI: 10.1016/j.arthro.2017.04.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 03/31/2017] [Accepted: 04/12/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the anatomy (quantitative macroscopic and histologic), radiographic parameters of the insertions, and biomechanical characteristics of the medial ligamentous restrictors of the patella (medial patellofemoral ligament [MPFL], medial patellotibial ligament [MPTL], and medial patellomeniscal ligament [MPML]) in cadaveric knees. Because the MPTL and the MPML are not as well known as the MPFL, they were the focus of this study. METHODS MPFLs, MPTLs, and MPMLs from 9 knees were dissected. Histologic evaluations were conducted. Length, width, and insertion relations with anatomic references were determined. Metallic spheres were introduced into the insertion points of each ligament, and anteroposterior and lateral radiographs were taken. The distances of the insertions from the baselines were measured on radiographs. Tensile tests of the ligaments were performed. RESULTS All the samples showed dense connective tissue characteristic of ligaments. The MPTL was inserted into the proximal tibia (13.7 mm distal to the joint line) and in the distal end of the patella (3.6 mm proximal to the distal border). The MPTL had a length of 36.4 mm and a width of 7.1 mm. The MPML was inserted into the medial meniscus and distally in the patella (5.7 mm proximal to the distal border). Per radiography, on the anteroposterior view, the tibial insertion of the MPTL was 9.4 mm distal to the joint line and in line with the medial border of the medial spine. On the lateral view, the patellar insertions of the MPTL and MPML were 4.8 and 6.6 mm proximal to its distal border, respectively. The MPTL was stiffer than the MPFL (17.0 N/mm vs 8.0 N/mm, P = .024) and showed less deformation in the maximum tensile strength (8.6 mm vs 19.3 mm, P = .005). CONCLUSIONS The MPTL inserts into the proximal tibia and into the distal pole of the patella. The MPML inserts into the medial meniscus and into the distal pole of the patella. They present with identifiable anatomic and radiographic parameters. Grafts commonly used for ligament reconstructions should be adequate for reconstruction of the MPTL. CLINICAL RELEVANCE The study contributes to the anatomic, radiographic, and biomechanical knowledge of the MPTL to improve the outcomes of its reconstruction.
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Affiliation(s)
- Betina B Hinckel
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil.
| | - Riccardo G Gobbi
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Marco K Demange
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Cesar Augusto M Pereira
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Jose Ricardo Pécora
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Renato Jose M Natalino
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Luciana Miyahira
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Bruno S Kubota
- Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Gilberto Luis Camanho
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
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Sadigursky D, Garcia LC, Armede M, Oliveira LRD, Carneiro RJF, Colavolpe PO. Medial patellofemoral ligament and medial patellotibial ligament reconstruction in children: preliminary results. Rev Bras Ortop 2017; 52:417-422. [PMID: 28884099 PMCID: PMC5582813 DOI: 10.1016/j.rboe.2017.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 08/04/2016] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the reconstruction of the medial patellofemoral ligament associated with the medial patellotibial ligament in skeletally immature patients. METHOD This is a case series study in patients with patellar instability with open physis. In total, seven patients were evaluated: four males and three females were operated using the proposed technique. Patients with open physis who had more than two episodes of recurring patellar dislocation were included. No patients underwent additional procedures. The distance from the anterior tibial tuberosity to the trochlea grove (TT-TG) was measured in all patients. On physical examination, the inverted J-sign, the apprehension sign, and the knee range of motion parameters were used in the pre- and post-operative period. In addition, the Kujala and Lysholm scores were applied before and 12 months after surgery. The results were analyzed with the Wilcoxon test. RESULTS The mean age of the patients was 11.28 in both genders. Comparing the data of the pre- and post-operative period, the inverted J-sign was present in six patients (85.7%) vs. absent in one (14.3%). The apprehension sign was absent in cases in the postoperative period; the range of motion was 117.85 ± 8.09 vs. 148.57 ± 3.77. The Kujala score was 42.57 ± 8.9 vs. 88.57 ± 5.09 and the Lysholm scores were classified as excellent or good in 28.6% and 71.4%, respectively. CONCLUSION The combined reconstruction of the medial patellofemoral ligament combined with the medial patellotibial ligament in skeletally immature patients with predisposing factors, presents satisfactory results without episodes of recurrence or residual subluxation; according to these preliminary results, it should be considered as a treatment option.
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Affiliation(s)
- David Sadigursky
- Clínica Ortopédica Traumatológica, Centro de Estudos em Ortopedia e Traumatologia, Salvador, BA, Brazil
| | - Lucas Cortizo Garcia
- Clínica Ortopédica Traumatológica, Centro de Estudos em Ortopedia e Traumatologia, Salvador, BA, Brazil
| | - Maurício Armede
- Clínica Ortopédica Traumatológica, Centro de Estudos em Ortopedia e Traumatologia, Salvador, BA, Brazil
| | | | | | - Paulo Oliveira Colavolpe
- Clínica Ortopédica Traumatológica, Centro de Estudos em Ortopedia e Traumatologia, Salvador, BA, Brazil
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Sadigursky D, Garcia LC, Armede M, Oliveira LRD, Carneiro RJF, Colavolpe PO. Reconstrução do ligamento patelofemoral medial e ligamento patelotibial medial em crianças. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Converting round tendons to flat tendon constructs: Does the preparation process have an influence on the structural properties? Knee Surg Sports Traumatol Arthrosc 2017; 25:1561-1567. [PMID: 26272060 DOI: 10.1007/s00167-015-3749-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 07/31/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The structural properties of hamstring tendon grafts were evaluated in a porcine model, after processing it to a flat shape, to better replace or augment anatomic flat structures (e.g. ACL, MPFL or MCL). METHODS In this biomechanical study, porcine flexor tendons were used which have a comparable shape to semitendinosus and gracilis tendons. One part of the tendon was prepared to a flat tendon construct by splitting the tendon longitudinally with a knife to half of the diameter of the tendon. The semi-split tendon was scratched out to a flat shape. The other matched part was tested in its original round shape. The tendons (n = 40) have been fixed in a uniaxial testing machine (Zwick/Roell) by cryo-clamps after preparing the fixed ends by 2-0 polyester sutures (2-0 Ethibond® EXCEL, Ethicon, Somerville, NJ). In every specimen, there was a free 60-mm tendon part between both clamps. The tendons have been loaded to failure to evaluate typical biomechanical parameters such as stiffness, yield load and maximum load. RESULTS No statistically significant differences (n.s.) regarding stiffness, yield load and maximum load between natively round and processed flat tendons could be detected. CONCLUSION A prepared flat-shaped tendon does not show any different structural properties compared with an original round tendon. Therefore, a flat tendon seems to be a biomechanical stable graft option for anatomic reconstruction or augmentation of injured natively flat-shaped structures such as MCL, MPFL or ACL.
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Cadaveric study of the secondary medial patellar restraints: patellotibial and patellomeniscal ligaments. Knee Surg Sports Traumatol Arthrosc 2017; 25:144-151. [PMID: 27722769 DOI: 10.1007/s00167-016-4322-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 09/07/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To detail the anatomy of the medial patella stabilizers, medial patellotibial (MPTL), and medial patellomeniscal ligaments (MPML), focusing on the points of origin and insertion, length, thickness, width, and fibres orientation to study the frequency of anatomical variations and the anatomy of these ligaments, thereby improving surgical techniques. METHODS Thirty dissected knees were analysed. A digital caliper was used to measure the length, thickness, and width, as well as the mid-point of the ligaments insertion and the distance from the MPTL insertion to the articular surface of the tibia. The angle of inclination of the ligaments was calculated in the coronal plane. The collected data were tabulated and statistically analysed. RESULTS MPTL was present in 90 % as a visible thickening of the deep medial retinaculum and exhibiting only one anatomical variation. The MPML was absent in one of the dissected knees, and one anatomical variation was found. The tilt angle of the ligaments was very similar, with an average of 22.2° ± 7.6° for the MPTL and 24.2° ± 6.6° for the MPML. CONCLUSION The MPTL is a long visible structure of the deep layer of the medial retinaculum, but with a distinct origin and insertion. The MPML is thicker with an angular direction similar to MPTL. The presence of these ligaments in most of the specimens studied suggests that the real anatomical and biomechanical importance of these ligaments should be further investigated because they play a role in the patellar stability.
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Ding DY, Kanevsky R, Strauss EJ, Jazrawi LM. Anteromedialisation tibial tubercle osteotomy for recurrent patellar instability in young active patients: A retrospective case series. Injury 2016; 47:737-41. [PMID: 26803695 DOI: 10.1016/j.injury.2015.10.005] [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: 09/29/2015] [Accepted: 10/02/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recurrent patellar instability can be a source of continued pain and functional limitation in the young, active patient population. Instability in the setting of an elevated tibial tubercle-trochlear groove (TT-TG) distance can be effectively managed with a tibial tubercle osteotomy. At the present time, clinical outcome data are limited with respect to this surgical approach to patellar instability. METHODS A retrospective chart review was performed to identify all cases of tibial tubercle osteotomy for the management of patellar instability performed at our institution with at least 1 year of post-operative follow-up. Patient demographic information was collected along with relevant operative data. Each patient was evaluated post-operatively with their outcomes assessed utilising a visual analogue score of pain, patient satisfaction, Tegner Activity Scale and Kujala score. RESULTS 31 patients (23 females and 8 males) with mean age of 27 years (17-43 years) and a mean BMI of 26.3kg/m(2) (19.6-35.8) at time of surgery who underwent a tibial tubercle osteotomy as treatment for recurrent patellar instability were identified. The cohort had a mean follow up of 4.4 years (1.5-11.8 years). The mean pre-operative TT-TG distance was 18mm (10-22mm). The mean VAS pain score demonstrated a significant improvement from 6.8 (95% CI 6.1-7.5) at baseline to 2.8 (95% CI 1.9-3.7) post-operatively (p<0.001). The Tegner score improved from 4.1 (95% CI 3.4-4.8) pre-operatively to 5.2 (95% CI 4.5-5.9) at the time of final follow up (p<0.04). The Kujala score for anterior knee pain improved postoperatively from 62 (95% CI 55.4-68.7) to 76.5 (95% CI 69.5-83.5) at final follow up (p<0.001). 26 of the 31 patients (83.8%) had good to excellent Kujala scores. 27 of 31 patients (87.1%) reported that they would undergo the procedure again if necessary. CONCLUSION For the management of recurrent patellar instability in the setting of an increased tibial tubercle-trochlear groove distance, a corrective tibial tubercle osteotomy is an effective treatment modality to reliably prevent patellar instability while reducing pain and improving function in this cohort of young, active patients.
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Affiliation(s)
- David Y Ding
- NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, New York, NY 10003, United States.
| | - Raymond Kanevsky
- NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, New York, NY 10003, United States.
| | - Eric J Strauss
- NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, New York, NY 10003, United States.
| | - Laith M Jazrawi
- NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, New York, NY 10003, United States.
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Hinckel BB, Gobbi RG, Demange MK, Bonadio MB, Pécora JR, Camanho GL. Combined Reconstruction of the Medial Patellofemoral Ligament With Quadricipital Tendon and the Medial Patellotibial Ligament With Patellar Tendon. Arthrosc Tech 2016; 5:e79-84. [PMID: 27073782 PMCID: PMC4810877 DOI: 10.1016/j.eats.2015.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 10/15/2015] [Indexed: 02/03/2023] Open
Abstract
Although the medial patellotibial ligament (MPTL) has been neglected regarding its function in patellar stability, recently, its importance in terminal extension and during flexion has been recognized. Indications for reconstruction of the medial patellofemoral ligament combined with the MPTL are extension subluxation, flexion instability, children with anatomic risk factors for patellar instability, and knee hyperextension associated with generalized laxity. We describe a combined reconstruction of the medial patellofemoral ligament with quadricipital tendon and reconstruction of the MPTL with patellar tendon autografts.
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Affiliation(s)
- Betina Bremer Hinckel
- Institute of Orthopedics and Traumatology, Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil
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Hinckel BB, Gobbi RG, Bonadio MB, Demange MK, Pécora JR, Camanho GL. Reconstruction of medial patellofemoral ligament using quadriceps tendon combined with reconstruction of medial patellotibial ligament using patellar tendon: initial experience. Rev Bras Ortop 2016; 51:75-82. [PMID: 26962504 PMCID: PMC4767827 DOI: 10.1016/j.rboe.2015.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 03/19/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To describe a surgical technique for anatomical reconstruction of the medial patellofemoral ligament using the quadriceps tendon, combined with reconstruction of the medial patellotibial ligament using the patellar tendon; and to present the initial results from a case series. METHOD The proposed technique was used on a series of cases of patients with diagnoses of patellofemoral instability and indications for surgical treatment, who were attended by the Knee Group of HC-IOT, University of São Paulo. The following were evaluated before and after the operation: range of motion (ROM), apprehension test, lateral translation test, patellar inclination test, inverted J sign, subluxation upon extension, pain from compression of the patella and pain from contraction of the quadriceps. After the operation, the patients were asked whether any new episode of dislocation had occurred, what their degree of satisfaction with the surgery was (on a scale from 0 to 10) and whether they would be prepared to go through this operation again. RESULTS Seven knees were operated, in seven patients, with a mean follow-up of 5.46 months (±2.07). Four patients who presented apprehension before the operation did not show this after the operation. The lateral translation test became normal for all the patients, while the patellar inclination test remained positive for two patients. The patients with an inverted J sign continued to be positive for this sign. Five patients were positive for subluxation upon extension before the operation, but all patients were negative for this after the operation. None of the patients presented any new episode of dislocation of the patella. All of them stated that they were satisfied: five gave a satisfaction score of 9 and two, a score of 10. All of them said that they would undergo the operation again. Only one patient presented a postoperative complication: dehiscence of the wound. CONCLUSION Reconstruction of the medial patellofemoral ligament using the quadriceps tendon, combined with reconstruction of the medial patellotibial ligament using the patellar tendon, was technically safe and presented good objective and subjective clinical results in this case series with a short follow-up.
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Affiliation(s)
- Betina Bremer Hinckel
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Hinckel BB, Gobbi RG, Bonadio MB, Demange MK, Pécora JR, Camanho GL. Reconstrução do ligamento patelofemoral medial com tendão quadricipital combinada com patelotibial medial com tendão patelar: experiência inicial. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Tompkins MA, Arendt EA. Patellar instability factors in isolated medial patellofemoral ligament reconstructions--what does the literature tell us? A systematic review. Am J Sports Med 2015; 43:2318-27. [PMID: 25748469 DOI: 10.1177/0363546515571544] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many studies have demonstrated good results after medial patellofemoral ligament (MPFL) reconstruction for patients with patellar instability. The applicability of published studies to the clinical decision-making process for the individual patient with patellar instability, however, is not well elucidated. HYPOTHESIS There is inconsistency in the reporting of preoperative and postoperative variables, which limits the applicability of current studies to patients with patellar instability. STUDY DESIGN Systematic review. METHODS A systematic review of the literature was conducted using the search term medial patellofemoral ligament reconstruction to identify studies with cohorts of patients with isolated MPFL reconstruction. A combination of inclusion and exclusion criteria resulted in 24 studies being reviewed for a variety of preoperative demographics, physical examination findings, and imaging findings, as well as postoperative outcomes, including redislocation and responses to subjective questionnaires. RESULTS A physical examination of lateral patellar translation was reported in 42% of studies, by reporting an apprehension sign (n = 9), reporting quadrant translation (n = 7), or both. For patellar instability factors on imaging, patellar height was reported as a preoperative variable in 75% of studies, and trochlear dysplasia was reported in 83% of studies. The tibial tubercle-trochlear groove distance was reported as a preoperative variable in 42% of studies. The rate of redislocation after index surgery was reported in 92% of studies. Patient-related outcome measures were reported in all of the studies; the Kujala score was the most common. A homogeneous population was selected as part of the authors' surgical indications for "isolated" MPFL in 67% of studies, and a heterogeneous population was selected in 33% of studies. CONCLUSION Current literature on MPFL reconstruction contains diverse methods of recording preoperative and postoperative variables. Most studies report on a homogeneous population, with inconsistent applicability to the broad spectrum of patients with patellar instability. Outcomes reporting in our current literature needs more clarity and consistency regarding reporting methodology to be of value for the treating clinician.
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Affiliation(s)
- Marc A Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA TRIA Orthopaedic Center, Minneapolis, Minnesota, USA
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA TRIA Orthopaedic Center, Minneapolis, Minnesota, USA
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Fink C, Veselko M, Herbort M, Hoser C. MPFL reconstruction using a quadriceps tendon graft: part 2: operative technique and short term clinical results. Knee 2014; 21:1175-9. [PMID: 24927675 DOI: 10.1016/j.knee.2014.05.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/28/2014] [Accepted: 05/13/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND We describe the preliminary clinical results of a new operative technique for MPFL reconstruction using a strip of quadriceps tendon (QT). PATIENTS 17 patients (7 male, 10 female; mean age 21.5 years ± 3.9) have been operated on with this technique. All patients were evaluated clinically, radiologically and with subjective questionnaires (Tegner-, Lysholm-, Kujala Score) pre-operatively and post-operatively at 6 and 12 months (m). SURGICAL TECHNIQUE A 10 to 12 mm wide, 3mm thick and 8 to 10 cm long strip from the central aspect of quadriceps tendon is harvested subcutaneously. The tendon strip is then dissected distally on the patella, left attached, diverged 90° medially underneath the medial prepatellar tissue and fixed with 2 sutures. The graft is fixed in 20° of knee flexion with a bioabsorbable interference screw. RESULTS Lysholm score at 6m was 81.9 ± 11.7 and at 12 m 88.1 ± 10.9, Kujala score at 12 m was 89.2 ± 7.1 and Tegner Score was 4.9 ± 2.0 (6m) and 5.0 ± 1.9 (12 m). Two patients had a positive apprehension test at 12 months. There was no re-dislocation during the follow-up period. CONCLUSION MPFL reconstruction with a strip of QT harvested in a minimal invasive technique was found to be associated with good short term clinical results. We think that this technique presents a valuable alternative to common hamstring techniques for primary MPFL reconstruction in children and adults, as well as for MPFL revision surgery. LEVEL OF EVIDENCE IV, prospective case series.
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Affiliation(s)
| | - Matjaz Veselko
- Department of Traumatology, University Medical Center, Ljubljana, Slovenia
| | - Mirco Herbort
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelian-Wilhelms University of Muenster, Muenster, Germany
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Matic GT, Magnussen RA, Kolovich GP, Flanigan DC. Return to activity after medial patellofemoral ligament repair or reconstruction. Arthroscopy 2014; 30:1018-25. [PMID: 24768468 DOI: 10.1016/j.arthro.2014.02.044] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/21/2014] [Accepted: 02/25/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to determine the ability of patients to return to activity after medial patellofemoral ligament (MPFL) reconstruction or repair for patellar instability. METHODS A systematic review was performed using multiple databases. Studies reporting outcomes with Tegner scores after repair or reconstruction of the MPFL were included. Surgical technique, Tegner scores, and episodes of recurrent patellar instability were recorded. RESULTS Ten articles with a total of 402 patients were included. The mean preoperative Tegner score was 4.7 (2.9 to 7.5). The mean postoperative Tegner score was 5.8 (4.0 to 7.7). Forty-nine patients (12.2%) had a recurrent episode of instability, 11 of whom required additional corrective procedures. There was a statistically significant larger failure rate among those who underwent MPFL repair (26.9%) than those who underwent reconstruction (6.6%) or medial retinacular repair/plication (16.5%). CONCLUSIONS Recurrent dislocation was higher in patients who underwent MPFL repair rather than reconstruction. However, repair and reconstruction had similar Tegner scores. Repair or reconstruction of the soft tissue structures contributing to patellofemoral instability is successful in returning patients to preinjury activity levels. LEVEL OF EVIDENCE Level IV, systematic review of Level II, III, and IV studies.
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Affiliation(s)
- George T Matic
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A
| | - Gregory P Kolovich
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A..
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Sherman SL, Erickson BJ, Cvetanovich GL, Chalmers PN, Farr J, Bach BR, Cole BJ. Tibial Tuberosity Osteotomy: Indications, Techniques, and Outcomes. Am J Sports Med 2014; 42:2006-17. [PMID: 24197613 DOI: 10.1177/0363546513507423] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Tibial tuberosity osteotomy (TTO) is a well-described treatment option for a broad range of patellofemoral joint disorders, including patellofemoral instability, patellar and trochlear focal chondral lesions, and patellofemoral arthritis. The purpose of this article is to review the evolution of the TTO procedure, from the original Hauser procedure to the current anteromedialization procedure, as well as discuss the pertinent anatomy and radiographs that accompany this procedure. The article highlights the surgical techniques for some of the more commonly performed TTO procedures and discusses the outcomes of the various TTO techniques. Complications, as well as clinical pearls to avoid these complications, are also included.
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Affiliation(s)
- Seth L Sherman
- Department of Orthopaedic Surgery, Missouri Orthopedic Institute, University of Missouri Health System, Columbia, Missouri
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Gregory L Cvetanovich
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Bernard R Bach
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Anatomical study of the medial patello-femoral ligament: landmarks for its surgical reconstruction. Surg Radiol Anat 2014; 36:733-9. [PMID: 24549302 DOI: 10.1007/s00276-014-1270-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 02/06/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this dissection study was to describe the anatomical insertions of the medial patello-femoral ligament (MPFL), and to assess its relationship with surrounding structures to improve its surgical reconstruction. METHODS Twelve knees (7 cadavers) were included for the study. Measurements and general features of the MPFL were assessed: lengths, widths and insertions. RESULTS The MPFL was found in all knees, presenting a triangular shape, and extending from the medial part of the patella to its femoral insertion (its length was of 59 ± 6.6 mm), distal to the adductor tubercle. The mean femoral insertion of the MPFL was 7.2 ± 2.7 mm proximal and 7.4 ± 4.0 mm posterior to the medial femoral epicondyle (MFE). It was also at a mean 11 ± 2.8 mm distal and 1.3 ± 2.1 mm posterior to the adductor tubercle, and 22 ± 6.4 mm anterior to the posterior condyle. We did not find any double-bundle organization on the patellar insertion. The width of the MPFL was 8.8 ± 2.9 mm at the femoral insertion, 27 ± 5.9 mm at the patellar insertion, and 12 ± 3.1 mm in the middle of the MPFL. The vastus medialis obliquus was found to be inserted on the superior part of the MPFL. CONCLUSION The adductor tubercle appeared to be a better landmark than the MFE for the femoral tunnel positioning during surgical reconstructions of the MPFL because it was easier to identify and its relationship with the femoral insertion of the MPFL was constant (10 mm below).
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