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Balcarek P, Zimmerer A, Wassilew GI, Gebhardt S. Implications for Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction Considering the Sagittal Trochlear Groove Curvature in Severe Trochlear Dysplasia Before and After Deepening Trochleoplasty. Am J Sports Med 2024; 52:2799-2806. [PMID: 39207361 DOI: 10.1177/03635465241271900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Medial patellofemoral ligament reconstruction (MPFL-R) aims to restore proper ligament function with minimal changes in length during range of motion, yet the ideal area for femoral fixation of the graft remains controversial. PURPOSE To determine the region where the isometric circular path of a simulated MPFL graft (best-fit circle) follows the sagittal radius curvature of the trochlea in normal (nontrochlear dysplastic) knees and to evaluate the best-fit circle coverage of different femoral fixation points in knees with severe trochlear dysplasia (TD) and after deepening trochleoplasty. STUDY DESIGN Controlled laboratory study. METHODS Twelve patients (4 male, 8 female; mean age, 24 ± 8 years) who underwent surgical treatment for recurrent lateral patellar instability due to severe TD were prospectively enrolled in this study. Four previously defined reference points for the femoral MPFL-R (Schöttle, Fujino, Stephen, and Oka) were identified, and the best-fit circle was drawn along the sagittal trochlear groove curvature. The divergence between each best-fit circle and the trochlear groove was calculated, with negative values indicating relative slackening and positive values indicating relative tightening of the simulated MPFL graft. Measurements were made on true-lateral fluoroscopic images before and after deepening trochleoplasty and compared with those of a sex-matched control group. RESULTS The best-fit circle of the Schöttle point followed the sagittal curvature of the trochlea most closely in both the control and trochlear dysplastic knees, followed by the Fujino, Stephen, and Oka points. As the radius of the trochlear groove curvature increased, the divergence of all best-fit circles to the trochlear groove became negative (all P < .05). This effect was most pronounced at the Stephen and Oka points, followed by the Fujino and Schöttle points (all P < .05). After deepening trochleoplasty, the divergence of the Schöttle point changed toward positive values (11.6% at 40°; P < .001). Concurrently, the best-fit circle divergence of all other reference points improved toward baseline (all P < .05). CONCLUSION The isometric circle of the Schöttle point provides the best congruence with the sagittal trochlear groove curvature in both the normal trochlea and the dysplastic trochlea. After trochleoplasty, the best-fit circles of more distal femoral fixation points resulted in better congruence with the deepened trochlear groove, whereas the best-fit circle of Schöttle indicated graft tension during flexion. CLINICAL RELEVANCE According to the present study, different femoral fixation points should be considered depending on whether the TD is corrected.
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Affiliation(s)
- Peter Balcarek
- Arcus Sportklinik, Pforzheim, Germany
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Göttingen, Germany
| | - Alexander Zimmerer
- Diakonieklinikum Stuttgart, Department of Orthopaedic and Trauma Surgery, Orthopädische Klinik Paulinenhilfe, Stuttgart, Germany
| | - Georgi I Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Gebhardt
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
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Cetin H, Kose O, Selcuk H, Egerci OF, Kilic KK, Sarikcioglu L. Lateral to medial fluoroscopic view improves the accuracy of identifying the MPFL femoral footprint using Schottle's technique. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39049513 DOI: 10.1002/ksa.12373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 07/01/2024] [Accepted: 07/05/2024] [Indexed: 07/27/2024]
Abstract
PURPOSE This study investigated the effect of different fluoroscopy settings on the accuracy of locating Schottle's point during medial patellofemoral ligament (MPFL) reconstruction. METHODS The centre of the MPFL femoral footprint was identified and marked on 44 dry femurs. Two standard true lateral knee fluoroscopic images were obtained: (1) medial to lateral (ML) and (2) lateral to medial (LM). The deviation between the anatomically determined MPFL femoral footprint and the fluoroscopically identified point was measured on both fluoroscopic images. An 'acceptable tunnel location' was defined as within a 5- or 7-mm margin of error from the anatomic MPFL footprint. Distal femoral morphometric dimensions were also measured using digital calipers. Statistical analysis determined discrepancies between techniques and their relation to femoral morphometry. RESULTS The LM view yielded a significantly smaller distance between the anatomical MPFL footprint and Schottle's point compared to the ML view (3.2 ± 1.5 vs. 4.5 ± 2.1 mm, p < 0.001). The LM view achieved acceptable tunnel locations, meeting the 5-mm error criterion in 90.9% of cases, while the ML view achieved 65.9% (p < 0.001). Both views yielded acceptable tunnel locations at similar rates using the 7-mm error criterion (n.s.). The anatomic MPFL footprint was displaced towards the anterior and proximal location in the ML view in reference to the Schottle point. No correlation was observed between any of the morphometric measurements and the deviations. CONCLUSIONS This study demonstrated that using the LM fluoroscopic view improves the accuracy of femoral tunnel placement when identifying the MPFL footprint via the Schottle technique. Adopting the LM view in surgical practice will help surgeons locate the anatomical femoral footprint accurately, replicating the native MPFL and enhancing clinical outcomes. LEVEL OF EVIDENCE Level 4, cadaveric study.
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Affiliation(s)
- Hakan Cetin
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Omer Faruk Egerci
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Koray Kaya Kilic
- Department of Radiology, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Levent Sarikcioglu
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey
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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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Emre TY, Cetin H, Selcuk H, Kilic KK, Aykanat F, Sarikcioglu L, Kose O. Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint. Arch Orthop Trauma Surg 2024; 144:1675-1684. [PMID: 38400901 PMCID: PMC10965741 DOI: 10.1007/s00402-024-05213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/24/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE The success of medial patellofemoral ligament (MPFL) reconstruction is closely linked to the precise positioning of the femoral tunnel. Intraoperative fluoroscopy is commonly utilized to identify the MPFL footprint. This study aimed to ascertain the most accurate fluoroscopic method among the five previously described methods used to determine the MPFL femoral footprint. MATERIALS AND METHODS Using 44 well-preserved dry femur bones, the MPFL femoral insertion site was demarcated using anatomical bony landmarks, namely the center of the saddle sulcus between the medial epicondyle, adductor tubercle and gastrocnemius tubercle. Fluoroscopic true lateral knee images were acquired and measurements taken, referencing established methods by Schottle et al., Redfern et al., Wijdicks et al., Barnett et al., and Kaipel et al. The distance between anatomic and fluoroscopic MPFL footprints was then measured on digital fluoroscopic images. The accuracy of the locations was compared using a margin of error of 5 and 7 mm. RESULTS The Schottle method consistently emerged superior, showcasing the smallest mean distance (3.2 ± 1.2 mm) between the anatomic and radiographic MPFL footprints and a high in-point detection rate of 90.9% under 5 mm criteria. While the Redfern method displayed perfect accuracy (100%) within the 7 mm criteria, the Schottle method also performed 97.7% accuracy. CONCLUSIONS For intraoperative identification of the MPFL footprint using fluoroscopy, the Schottle method is the most consistent and accurate among the assessed methods. Thus, its accuracy in detecting the MPFL footprint makes it recommended for MPFLR to ensure optimal outcomes. LEVEL OF EVIDENCE Level IV, cadaveric study.
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Affiliation(s)
- Tuluhan Yunus Emre
- Department of Orthopaedics and Traumatology, Kadikoy Hospital, Acıbadem University, Istanbul, Turkey
| | - Hakan Cetin
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey
| | - Koray Kaya Kilic
- Department of Radiology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Faruk Aykanat
- Medical Faculty Department of Orthopaedics and Traumatology, Sanko University, Gaziantep, Turkey
| | - Levent Sarikcioglu
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey.
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey.
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Hu F, Shi W, Wang H, Wang C. A Novel Technique of Arthroscopic Femoral Tunnel Placement during Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation. J Clin Med 2023; 12:jcm12020680. [PMID: 36675609 PMCID: PMC9860788 DOI: 10.3390/jcm12020680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Recurrent patellar dislocation is a commonly encountered patellofemoral disease. Prompt surgical intervention is indicated for recurrent dislocation to restore patellofemoral stability. As one of the most preferred procedures, medial patellofemoral ligament (MPFL) reconstruction has been implemented on a large scale. Femoral tunnel placement remains a crucial technical issue during MPFL reconstruction and is critical to ensure the isometry and proper tension of the graft. Currently, visual-palpatory anatomic landmarks and fluoroscopy-guided radiographic landmarks comprise the main approaches to intraoperative femoral tunnel positioning. However, the accuracy of both methods has been questioned. This article introduces an arthroscopic femoral tunnel placement technique. Apart from traditional anteromedial and anterolateral portals, two auxiliary arthroscopic portals are specially designed. The adductor tubercle, the medial epicondyle and the posterior edge are selected as main anatomic landmarks and are directly visualized in sequence under arthroscope. The relative position between the femoral attachment of the MPFL and the three landmarks is measured on preoperative three-dimensional computed tomography, providing semi-quantified reference for intraoperative localization. This technique achieves minimally invasive tunnel placement without X-ray exposure, and especially suits obese patients for whom palpatory methods are difficult to perform.
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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: 8] [Impact Index Per Article: 4.0] [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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Zhang YQ, Zhang Z, Wu M, Zhou YD, Tao SL, Yang YL, Li Y, Liu JL, Li P, Teng YS, Guo YM. Medial patellofemoral ligament reconstruction: A review. Medicine (Baltimore) 2022; 101:e28511. [PMID: 35029909 PMCID: PMC8735765 DOI: 10.1097/md.0000000000028511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/09/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Reconstruction of the medial patellofemoral ligament (MPFL) is an effective surgical method for the treatment of lateral patellar instability. At present, there is not much controversies regarding the femoral attachment, however, the controversies regarding patellar attachment versus attachment, number of graft strands, tension, isometry and so on. The following electronic databases will be searched: PubMed, the Cochrane Library, Embase, Web of Science, Medline. We will consider articles published between database initiation and March 2021. MPFL in the subject heading will be included in the study. Language is limited to English. Research selection, data extraction, and research quality assessment were independently completed by 2 researchers. CONCLUSIONS MPFL reconstruction is a reliable technique for the treatment of patellofemoral instability. The Schöttle point is still the mainstream method for locating the femoral attachment, the patellar attachment for single-bundle is located at the junction of the proximal one third and the distal two third of the longitudinal axis of the patella. For double-bundles, one is located in the proximal one third of the medial patellar edge and another is in the center of the patellar edge. Meanwhile, the adjustment of graft tension during operation is very important.
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Zhang Y, Li Y, Liu D, Wang G. [Research progress in femoral tunnel positioning points of medial patellofemoral ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:258-264. [PMID: 33624484 DOI: 10.7507/1002-1892.202006059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress of location methods and the best femoral insertion position of medial patellofemoral ligament (MPFL) reconstruction of femoral tunnel, and provide reference for surgical treatment. Methods The literature about femoral insertion position of the MPFL reconstruction in recent years was extensively reviewed, and the anatomical and biomechanical characteristics of MPFL, as well as the advantages and disadvantages of femoral tunnel positioning methods were summarized. Results The accurate establishment of the femoral anatomical tunnel is crucial to the success of MPFL reconstruction. At present, there are mainly two kinds of methods for femoral insertion: radiographic landmark positioning method and anatomical landmark positioning method. Radiographic landmark positioning method has such advantages as small incision and simple operation, but it can not be accurately positioned for patients with severe femoral trochlear dysplasia. It is suggested to combine with the anatomical landmark positioning method. These methods have their own advantages and disadvantages, and there is no unified positioning standard. In recent years, the use of three-dimensional design software can accurately assist in the MPFL reconstruction, which has become a new trend. Conclusion Femoral tunnel positioning of the MPFL reconstruction is very important. The current positioning methods have their own advantages and disadvantages. Personalized positioning is a new trend and has not been widely used in clinic, its effectiveness needs further research and clinical practice and verification.
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Affiliation(s)
- Yan Zhang
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
| | - Yanlin Li
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
| | - Dejian Liu
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
| | - Guoliang Wang
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
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Chen J, Han K, Jiang J, Huangfu X, Zhao S, Zhao J, Xie G. Radiographic Reference Points Do Not Ensure Anatomic Femoral Fixation Sites in Medial Patellofemoral Ligament Reconstruction: A Quantified Anatomic Localization Method Based on the Saddle Sulcus. Am J Sports Med 2021; 49:435-441. [PMID: 33175561 DOI: 10.1177/0363546520972420] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is one of the main treatments for lateral patellar translation. Based on intraoperative true lateral radiographs, the accepted methods for femoral MPFL tunnel location are potentially inaccurate. Direct assessment of anatomic characteristics during surgery through palpation of the anatomic landmarks involving the saddle sulcus might help eliminate tunnel malposition. HYPOTHESIS The saddle sulcus is a reliable osseous landmark where the MPFL attaches for tunnel placement. STUDY DESIGN Descriptive laboratory study. METHODS A total of 9 fresh-frozen unpaired human cadaveric knees were dissected; MPFL insertion point and relative osseous structures were marked. Three-dimensional images and transformed true lateral radiographs were obtained for analysis; 3 previously reported radiographic reference points for MPFL femoral tunnel placement were determined on all images and compared with the anatomic insertion. RESULTS A saddle sulcus consistently existed where the MPFL was attached, located at 11.7 ± 5.9 mm from the apex of the adductor tubercle (AT) to the medial epicondyle (ME), 62.8% of the average distance between the apexes of the AT and ME, and 5.6 ± 2.8 mm perpendicular-posterior to the border connecting the AT and ME. The reported radiographic reference points were located at average distances of 6.2 ± 3.2 mm (Schöttle method), 5.9 ± 2.3 mm (Redfern method), and 7.3 ± 6.6 mm (Fujino method) from the saddle sulcus center on the true lateral radiographs. CONCLUSION The saddle sulcus was a reliable landmark where the MPFL was anatomically attached, located approximately 12 mm from the AT to the ME (approximately 60% along a line from the AT to the ME) and 6 mm perpendicular-posterior to the border connecting the apexes of the AT and ME. Additionally, the saddle sulcus position presented variability on the femoral aspect of different knees. All of the average direct distances from the sulcus to the reference radiographic points exceeded 5 mm, and tunnel localizations on a true lateral radiograph were inaccurate. CLINICAL RELEVANCE This study demonstrates the potential precise position of the saddle sulcus, according to the ME and AT, as a reliable anatomic landmark for MPFL femoral tunnel location. Radiographic reference points were not accurate during MPFL reconstruction. Direct palpation of the landmarks might be effective for femoral MPFL tunnel placement.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, 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
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoqiao Huangfu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Song Zhao
- 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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Feucht MJ, Mehl J, Forkel P, Achtnich A, Schmitt A, Izadpanah K, Imhoff AB, Berthold DP. Failure Analysis in Patients With Patellar Redislocation After Primary Isolated Medial Patellofemoral Ligament Reconstruction. Orthop J Sports Med 2020; 8:2325967120926178. [PMID: 32613021 PMCID: PMC7309400 DOI: 10.1177/2325967120926178] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/13/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Reconstruction of the medial patellofemoral ligament (MPFL) has become a popular surgical procedure to address patellofemoral instability. As a consequence of the growing number of MPFL reconstructions performed, a higher rate of failures and revision procedures has been seen. Purpose: To perform a failure analysis in patients with patellar redislocation after primary isolated MPFL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing revision surgery for reinstability after primary isolated MPFL reconstruction were included. Clinical notes were reviewed to collect demographic data, information on the primary surgery, and the mechanism of patellar redislocation (traumatic vs nontraumatic). Preoperative imaging was analyzed regarding femoral tunnel position and the prevalence of anatomic risk factors (ARFs) associated with patellofemoral instability: trochlear dysplasia (types B through D), patella alta (Caton-Deschamps index >1.2, patellotrochlear index <0.28), lateralization of the tibial tuberosity (tibial tuberosity–trochlear groove distance >20 mm, tibial tuberosity–posterior cruciate ligament [TT-PCL] distance >24 mm), valgus malalignment (mechanical valgus axis >5°), and torsional deformity (internal femoral torsion >25°, external tibial torsion >35°). The prevalence of ARF was compared between patients with traumatic and nontraumatic redislocations and between patients with anatomic and nonanatomic femoral tunnel position. Results: A total of 26 patients (69% female) with a mean age of 25 ± 7 years were included. The cause of redislocation was traumatic in 31% and nontraumatic in 69%. Position of the femoral tunnel was considered nonanatomic in 50% of patients. Trochlear dysplasia was the most common ARF with a prevalence of 50%, followed by elevated TT-PCL distance (36%) and valgus malalignment (35%). The median number of ARFs per patient was 3 (range, 0-6), and 65% of patients had 2 or more ARFs. Patients with nontraumatic redislocations showed significantly more ARFs per patient, and the presence of 2 or more ARFs was significantly more common in this group. No significant difference was observed between patients with anatomic versus nonanatomic femoral tunnel position. Conclusion: Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction. Before revision surgery, a focused clinical examination and adequate imaging including radiographs, magnetic resonance imaging (MRI), standing full-leg radiographs, and torsional measurement with computed tomography or MRI are recommended to assess all relevant anatomic parameters to understand an individual patient’s risk profile. During revision surgery, care must be taken to ensure anatomic placement of the femoral tunnel through use of anatomic and/or radiographic landmarks.
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Affiliation(s)
- Matthias J Feucht
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany.,Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Julian Mehl
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Philipp Forkel
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Andrea Achtnich
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Andreas Schmitt
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Kaywan Izadpanah
- Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Andreas B Imhoff
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel P Berthold
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
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