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Hiemstra LA, Kerslake S, Sasyniuk TM, Lafave MR. Palpation and fluoroscopy are valid but unreliable for the assessment of femoral tunnel position after medial patellofemoral ligament reconstruction. J ISAKOS 2024; 9:348-352. [PMID: 38492848 DOI: 10.1016/j.jisako.2024.03.005] [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: 01/11/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES The purpose of this study was to evaluate the validity and reliability of two techniques, palpation and fluoroscopy, for assessing medial patellofemoral ligament (MPFL) reconstruction femoral tunnel position accuracy. METHODS Twenty-one fresh frozen cadaveric knees had an MPFL femoral tunnel drilled and filled with a metal screw. Tunnels were created in a nonstandard fashion to ensure the sample included a range of tunnel positions from poor to ideal. Six experienced sport medicine and arthroscopy surgeons evaluated the placement of the femoral tunnel by palpating the screw in relation to anatomic landmarks and by fluoroscopy related to Schöttle's Point. They evaluated 1) the accuracy of femoral tunnel placement, 2) the direction of tunnel error, and 3) the clinical acceptability of the tunnel position. Validity measures included sensitivity, specificity, and correlation to clinical acceptability, which were calculated for the palpation and fluoroscopic assessments. Reliability measures included interrater reliability (ICC 2,k) for femoral tunnel accuracy and percent agreement of the raters' tunnel direction assessment. RESULTS The palpation method demonstrated a sensitivity of 0.79 and specificity of 0.84 for assessing the accuracy of femoral tunnel placement, while the fluoroscopic method showed a sensitivity of 0.83 and specificity of 0.92. Pearson correlation coefficients for clinical acceptability of tunnel position were high, with both techniques ranging from .589 to .854. Interrater reliability for the palpation and fluoroscopic techniques for assessment of tunnel accuracy were 0.31 and 0.55 (ICC 2,k), respectively. Assessment of the direction of tunnel error was good with the fluoroscopic technique slightly more accurate than palpation. CONCLUSION This study demonstrated that both palpation and fluoroscopy are valid techniques for assessing femoral tunnel position after MPFL reconstruction. Despite demonstrating good validity, the accuracy of assessing tunnel position was unreliable in a group of six experienced knee surgeons. Further research into MPFL reconstruction femoral tunnel assessment techniques, including patient-specific reference standards, is warranted. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Laurie A Hiemstra
- Banff Sport Medicine Foundation, PO Box 1300, Banff, Alberta, T1L 1B3, Canada; Department of Surgery, University of Calgary, North Tower Foothills Medicine Centre, 1403 29th St. NW, Calgary, Alberta, T2N 2T9, Canada.
| | - Sarah Kerslake
- Banff Sport Medicine Foundation, PO Box 1300, Banff, Alberta, T1L 1B3, Canada.
| | - Treny M Sasyniuk
- Banff Sport Medicine Foundation, PO Box 1300, Banff, Alberta, T1L 1B3, Canada.
| | - Mark R Lafave
- Department of Health & Physical Education, Mount Royal University, 4825 Mount Royal Gate SW, Calgary, Alberta, T3E 6K6, Canada.
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Yoon KH, Jeong BO, Hwang SH, Kim JH, Kim YS, Lee HS. MPFL reconstruction with proximal rather than distal femoral tunnel position leads to less favorable short-term results. Orthop Traumatol Surg Res 2024:103816. [PMID: 38246491 DOI: 10.1016/j.otsr.2024.103816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 01/06/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament (MPFL) reconstruction (MPFLR) between anatomic femoral tunnel positions: proximal (near adductor tubercle [AT]) and distal (near medial epicondyle [ME]). HYPOTHESIS MPFLR with the proximal femoral tunnel position has worse clinical and radiological outcomes than those with the distal femoral tunnel position. PATIENTS AND METHODS Fifty-five patients who underwent isolated MPFLR with proximal or distal femoral tunnels with at least 2 years of follow-up were retrospectively analyzed. Based on postoperative CT images, 28 patients were classified as group AT and the remaining 27 patients were classified as group ME. The International Knee Documentation Committee, Lysholm, Tegner, Kujala scores, and complications were evaluated. Radiologically, the Caton-Deschamps Index (CDI), patellar tilt angle, patellofemoral osteoarthritis (PFOA), patellofemoral cartilage status by the International Cartilage Repair Society (ICRS) grade, bone contusion, and MPFL graft signal intensity were evaluated. RESULTS All clinical scores significantly improved in both groups (p<0.01). No statistically significant difference was noted between the two groups in regards to their preoperative demographic data, postoperative clinical scores, complications, or radiological findings (CDI, patellar tilt angle, PFOA, bone contusion, and graft signal intensity). The group AT had worse cartilage status on the medial facet of the patella (p=0.02). The ICRS grade for the medial facet of the patella statistically progressed in group AT compared to group ME (p=0.04) as well. DISCUSSION Both groups showed significantly improved clinical outcomes. However, for the medial facet of the patella, MPFLR with the proximal femoral tunnel position had worse cartilage status and ICRS grade progression than those with the distal femoral tunnel position. LEVEL OF EVIDENCE III; retrospective comparative study.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Bi O Jeong
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sung Hyun Hwang
- Department of Orthopaedic Surgery, Pohang St. Mary's Hospital, Pohang-si, Gyeongsangbuk-do, Republic of Korea
| | - Jin Hyung Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Yoon Seok Kim
- Department of Orthopaedic Surgery, Armed Forces Hongcheon Hospital, Hongcheon-gun, Gangwon-do, Republic of Korea
| | - Hee Sung Lee
- Department of Medicine, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, 02453 Seoul, Republic of Korea.
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Yoon KH, Park CH, Hwang SH, Baek H, Lee HS. Anatomic femoral tunnel position in medial patellofemoral ligament reconstruction: anterior versus posterior. BMC Musculoskelet Disord 2023; 24:945. [PMID: 38057743 DOI: 10.1186/s12891-023-07069-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/25/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament reconstruction (MPFLR) between anatomic femoral tunnel positions at anterior and posterior footprints. METHODS Fifty-seven patients who underwent MPFLR for patellofemoral instability with anterior or posterior femoral tunnels between 2014 and 2021 with at least 2 years of follow-up were retrospectively analyzed. Based on postoperative images, the femoral tunnel positions anterior to the line connecting the adductor tubercle and medial epicondyle were assigned to the anterior group, group A, and those posterior to the line to the posterior group, group P. Thirty-two patients were included in group A (mean age, 22.4 ± 8.8 years), and another 25 patients were included in group P (mean age, 21.1 ± 6.1 years). The International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity score, Kujala score, and complications were evaluated. Radiologically, the Caton-Deschamps index (CDI), patellar tilt angle, and patellofemoral osteoarthritis (PFOA) using the Kellgren-Lawrence (KL) scale were evaluated. The patellofemoral cartilage status according to the International Cartilage Repair Society (ICRS) grade, bone contusion, femoral tunnel enlargement, and MPFL graft signal intensity were also evaluated. RESULTS All clinical scores significantly improved in both groups (p < 0.01). No differences were noted between the two groups in terms of their preoperative demographic data, postoperative clinical scores (IKDC, Lysholm, Tegner, and Kujala), complications, or radiological findings (CDI, patellar tilt angle, PFOA, bone contusion, femoral tunnel enlargement, and graft signal intensity). The ICRS grade for the medial facet of the patella progressed in group A (30%, p = 0.02) but not in group P (18%, p = n.s.). Additionally, no significant differences were observed in the other compartments of the patellofemoral joint. CONCLUSIONS The clinical outcomes were significantly improved in both groups; however, MPFLR with anterior femoral tunnel position had worse cartilage status on the medial facet of the patella than the posterior femoral tunnel position. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Cheol Hee Park
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Sung Hyun Hwang
- Department of Orthopaedic Surgery, Pohang St. Mary's Hospital, Pohang-si, Gyeongsangbuk-do, Republic of Korea
| | - Hyunjae Baek
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Hee Sung Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea.
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Masquijo J, Parikh SN, Kothari A. Evaluation of the Optimal Femoral Fixation Site for Medial Patellofemoral Ligament Reconstruction in the Skeletally Immature Patient. Orthopedics 2023; 46:108-113. [PMID: 36343644 DOI: 10.3928/01477447-20221031-07] [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] [Indexed: 11/09/2022]
Abstract
The aim of this study was to assess which femoral fixation site, distal to the physis, most closely emulates the native medial patellofemoral ligament (nMPFL) length relationship in the pediatric knee. Lateral knee radiographs were taken incrementally, from 0° to 120° of flexion. The femoral origin of the nMPFL and 3 other MPFL femoral fixation sites distal to the physis were identified (P1, 1 cm distal to physis along the posterior femoral cortex; P2, 2 cm distal to physis along the posterior femoral cortex; P3, 1 cm distal and 1 cm anterior). Virtual MPFL lengths were measured from all sites. Measurement reliability was assessed using intraclass correlation coefficients. Primary comparison between simulated MPFL length at native and femoral fixation sites was made using a repeated measures analysis of variance at 30° flexion. Bivariate Pearson correlation was used to assess the relationship between fixation sites and nMPFL through the range of motion (alpha=0.05). The intra-class correlation coefficient for intraobserver reliability of MPFL length measurement was excellent. Analysis of variance showed virtual MPFL lengths from proposed femoral fixation sites at 30° were significantly different from nMPFL length (P<.01). The P1 MPFL had the least difference in means compared with nMPFL (-2.6±1.8 mm). Correlational analysis showed that P1 MPFL had the closest relationship with nMPFL compared with other femoral fixation sites (R=0.91, P<.01). The P1 MPFL had the length change most comparable to that of nMPFL (23.9±3.1 mm vs 13.3±2.85 mm) compared with the other simulated MPFLs. Femoral graft fixation site 1 cm distal to the physis in the lateral view along the posterior femoral cortex closely represents the length relationship of the nMPFL. [Orthopedics. 2023;46(2):108-113.].
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Chen J, Xiong Y, Han K, Xu C, Cai J, Wu C, Ye Z, Zhao J, Xie G. Computed Tomography Imaging Analysis of the MPFL Femoral Footprint Morphology and the Saddle Sulcus: Evaluation of 1094 Knees. Orthop J Sports Med 2022; 10:23259671211073608. [PMID: 35155709 PMCID: PMC8829748 DOI: 10.1177/23259671211073608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The medial patellofemoral ligament (MPFL) has been reported to be anatomically attached from an osseous saddle region (saddle sulcus) between neighboring landmarks on the femur, including the adductor tubercle (AT), medial epicondyle (ME), and medial gastrocnemius tubercle (MGT). However, the position and prevalence of the saddle sulcus remain unknown. Purpose: To study the femoral footprint of MPFL and the prevalence of the saddle sulcus with computed tomography (CT) imaging; quantify the position of the saddle sulcus; and determine the relevant factors of the identified position and measuring distances. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1094 knees in 753 patients were studied. Knees were organized into an anterior cruciate ligament reconstruction (ACLR) group (controls) and a recurrent patellar dislocation (RPD) group. Using 3-dimensionally reconstructed CT images, the authors determined the prevalence of the saddle sulcus and its position relative to the AT, the ME, the Schöttle point (1.3 mm anterior to the distal posterior cortex and 2.5 mm distal to the posterior origin of the medial femoral condyle), and the Fujino point (approximately 10 mm distal to the AT). Analysis of covariance was used to adjust for age, sex, side, and body mass index on the measurements. Results: There were 555 knees in the control group and 539 knees in the RPD group. The MPFL femoral footprint presented as an oblique, oblong, osseous region (saddle sulcus) in 75.7% of knees (75.0%, ACLR group vs 76.4%, RPD group; P < .001). The saddle sulcus was located a mean of 12.2 mm (95% CI, 12.0-12.4 mm) from a line connecting the apex of the AT to the ME (AT-ME) and a mean of 7.6 mm (95% CI, 7.5-7.8 mm) posteriorly perpendicular to that line. The location as a proportion of the AT-ME distance was 63.1% (95% CI, 62.6%-63.7%) in the X direction and 39.8% (95% CI, 39.1%-40.5%) in the Y direction. The Schöttle and Fujino points lay anterior and proximal to the saddle sulcus more than 5 mm away from the center of the saddle sulcus. Women had a higher prevalence of saddle sulcus (odds ratio [OR], 1.33 [95% CI, 1.00-1.75]; P = .046) compared with men. Conclusion: The saddle sulcus was identified in 75.7% of knees from the medial femoral aspect, with its center located consistently between the AT and ME.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yijia Xiong
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jiangyu Cai
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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White AE, Otlans PT, Horan DP, Calem DB, Emper WD, Freedman KB, Tjoumakaris FP. Radiologic Measurements in the Assessment of Patellar Instability: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:2325967121993179. [PMID: 34095324 PMCID: PMC8142007 DOI: 10.1177/2325967121993179] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/19/2020] [Indexed: 01/27/2023] Open
Abstract
Background: Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings across multiple studies. Purpose: To review the different imaging measurements used to evaluate patellar instability and to assess the prevalence of each measure and its utility in predicting instability. We focused on reliability across imaging modalities and between patients with and without patellar instability. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a systematic review of the literature using the PubMed, SCOPUS, and Cochrane databases. Each database was searched for variations of the terms “patellar instability,” “patellar dislocation,” “trochlear dysplasia,” “radiographic measures,” “computed tomography,” and “magnetic resonance imaging.” Studies were included if they were published after May 1, 2009, and before May 1, 2019. A meta-analysis using a random effects model was performed on several measurements, comparing instability and control groups to generate pooled values. Results: A total of 813 articles were identified, and 96 articles comprising 7912 patients and 106 unique metrics were included in the analysis. The mean patient age was 23.1 years (95% CI, 21.1-24.5), and 41% were male. The tibial tubercle–trochlear groove (TT-TG) distance was the most frequently included metric (59 studies), followed by the Insall-Salvati ratio and Caton-Deschamps index (both 26 studies). The interobserver intraclass correlation coefficients were excellent or good for the TT-TG distance and Insall-Salvati ratio in 100% of studies reporting them; however, for the Caton-Deschamps index and Blackburne-Peel ratio, they were excellent or good in only 43% and 40% of studies. Pooled magnetic resonance imaging values for TT-TG distance (P < .01), Insall-Salvati ratio (P = .01), and femoral sulcus angle (P = .02) were significantly different between the instability and control groups. Values for tibial tubercle–posterior cruciate ligament distance (P = .36) and Caton-Deschamps index (P = .09) were not significantly different between groups. Conclusion: The most commonly reported measurements for evaluating patellar instability assessed patellar tracking and trochlear morphology. The TT-TG distance was the most common measurement and was greater in the patellar instability group as compared with the control group. In addition, the TT-TG, tibial tubercle–posterior cruciate ligament, and patellar tendon–trochlear groove distances were highly reproducible measurements for patellar tracking, and the Insall-Salvati ratio had superior reproducibility for assessing patellar height.
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Affiliation(s)
- Alex E White
- Hospital for Special Surgery, New York, New York, USA
| | - Peters T Otlans
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dylan P Horan
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Daniel B Calem
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - William D Emper
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fotios P Tjoumakaris
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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