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Xu T, Zhu Y, Zhang L, Xie H, Fu W. Results of Medial Patellofemoral Ligament Reconstruction with and without Tibial Tubercle Transfer in Patellar Instability: A Systematic Review and Meta-Analysis. Orthop Surg 2023; 15:2766-2776. [PMID: 37688429 PMCID: PMC10622283 DOI: 10.1111/os.13870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 09/10/2023] Open
Abstract
The optimal surgical intervention for lateral patellar instability remains a topic of controversy despite satisfactory clinical outcomes and low re-dislocation rates reported in numerous studies following medial patellofemoral ligament reconstruction (MPFLR) with and without tibial tubercle transfer (TTT). The purpose of this systematic review and meta-analysis is to investigate the hypothesis that combining MPFLR with TTT provides reduced complication rates and improved clinical outcomes to isolated MPFLR in patients with lateral patellar instability. We conducted a comprehensive systematic review and meta-analysis of comparative trials involving MPFLR with and without TTT, sourcing data from PubMed, the Cochrane Library, Embase, and Web of Science. The primary clinical outcomes analyzed included the Kujala score, the Lysholm score, complication rates, and the Caton-Deschamps index (CDI). Random or fixed effects were used for the meta-analysis. Postoperatively, there were no significant differences observed in the Kujala and Lysholm scores between MPFLR and MPFLR + TTT (p = 0.053). At the final follow-up, the CDI had decreased 0.015 (95% CI -0.044, 0.013; p = 0.289) points in the MPFLR group, with no statistical significance. In contrast, the MPFLR + TTT group demonstrated a significant decrease of 0.207 (95% CI -0.240, -0.174; p = 0.000) points in CDI. Notably, the complication rate was higher in the MPFLR + TTT group compared to the MPFLR-only group (RR = 2.472; 95% CI 1.638, 3.731; p = 0.000). Both MPFLR and MPFLR + TTT procedures yield significant improvements in the Kujala and Lysholm scores. However, the MPFLR + TTT approach results in an apparent improvement in CDI and corrects patellar maltracking, particularly in cases involving high tibial tuberosity-trochlear groove (TT-TG) (>20 mm) or patella alta (CDI > 1.2), while MPFLR alone cannot. It is essential to consider the higher complication rate of MPFLR + TTT, which suggests that MPFLR alone may be sufficient for patients without high TT-TG or patella alta.
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Affiliation(s)
- Tianhao Xu
- Sports Medicine Center, Department of Orthopaedic Surgery/Orthopaedic Research InstituteWest China Hospital, Sichuan UniversitySichuanChina
| | - Yanlin Zhu
- Sports Medicine Center, Department of Orthopaedic Surgery/Orthopaedic Research InstituteWest China Hospital, Sichuan UniversitySichuanChina
| | - Lei Zhang
- Sports Medicine Center, Department of Orthopaedic Surgery/Orthopaedic Research InstituteWest China Hospital, Sichuan UniversitySichuanChina
| | - Hui‐Qi Xie
- Laboratory of Stem Cell and Tissue Engineering, Orthopaedic Research Institute, Med‐X Center for Materials, State Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversitySichuanChina
| | - Weili Fu
- Sports Medicine Center, Department of Orthopaedic Surgery/Orthopaedic Research InstituteWest China Hospital, Sichuan UniversitySichuanChina
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Žlak N, Kacin A, Martinčič D, Drobnič M. Age, body mass index, female gender, and patellofemoral cartilage degeneration predict worse patient outcome after patellofemoral instability surgery. Knee Surg Sports Traumatol Arthrosc 2022; 30:3751-3759. [PMID: 35524797 DOI: 10.1007/s00167-022-06986-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 04/11/2022] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate predicting factors for patient-reported outcomes and revision interventions following surgical treatment of patients with patellofemoral instability. METHODS From a prospective database at the university Orthopedic Department, 138 knees from 116 patients who underwent patellofemoral instability surgery (2012-2019) were enrolled in a retrospective analysis: 34 cases of isolated MPFLrec; 92 cases of MPFLrec plus tibial tuberosity transfer; and 12 cases of MPFLrec plus trochleoplasty. Patient-reported outcome measures were recorded for knee-specific function (KOOS), general quality of life (EQ-5D), and activity level (Tegner scale). Post-operative revision interventions were also actively recorded. As potential predicting factors, patient demographic (gender, age, BMI) and radiographic (pre-operative: patellar height and tilt, tibial tuberosity-trochlear groove distance, trochlear dysplasia, knee osteoarthritis; post-operative: MPFL insertion point; intra-operative: isolated vs. combined procedures, chondropenia severity score) parameters were analyzed using multivariate linear regression models. RESULTS With median follow-up of 4.4 (1.0-8.9) years, all patient-reported outcome measures had significantly improved from pre-operative levels: KOOS cumulative, from 71 (15) to 78 (16); EQ-5D, from 0.68 (0.20) to 0.78 (0.21); and Tegner activity scale, from 3 (0-10) to 4 (0-10). No patellofemoral instability revision procedures were performed. One-fifth (27/138) of the operated knees required second surgical interventions, predominately due to hardware or arthrofibrosis. Patients who required post-operative knee manipulation under anesthesia or arthroscopic debridement showed lower post-operative improvement for KOOS cumulative and EQ-5D. Age, BMI, patellofemoral knee osteoarthritis, and shorter follow-up time revealed significant negative correlations to some of the post-operative KOOS subscales. Age was negatively correlated to post-operative EQ-5D, while post-operative Tegner activity scale was negatively correlated to female gender and patellofemoral chondropenia severity score. Femoral MPFL insertion point revealed no association with any outcome measures. CONCLUSION Patellofemoral instability surgery for isolated or combined MPFLrec is safe and substantially improves knee function and patient quality of life and activity levels. Serious adverse events are rare, with no recurrent patellofemoral instability. Patients who required post-operative knee manipulation or arthroscopic debridement showed less improvement in subjective measures of treatment outcomes. Older age, higher BMI, worse pre-operative patellofemoral cartilage status, and female gender had negative effects on outcome. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nik Žlak
- Department of Orthopedic Surgery, University Medical Centre Ljubljana, Zaloška cesta 9, 1000, Ljubljana, Slovenia. .,Chair of Orthopedics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Alan Kacin
- Department of Physiotherapy, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - David Martinčič
- Department of Orthopedic Surgery, University Medical Centre Ljubljana, Zaloška cesta 9, 1000, Ljubljana, Slovenia.,Chair of Orthopedics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matej Drobnič
- Department of Orthopedic Surgery, University Medical Centre Ljubljana, Zaloška cesta 9, 1000, Ljubljana, Slovenia.,Chair of Orthopedics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Jing L, Wang X, Qu X, Liu K, Wang X, Jiang L, Wu D, Zhang Z, Li Z, Yu L, Wang S, Yang J. Closing-wedge distal femoral osteotomy combined with medial patellofemoral ligament reconstruction for recurrent patellar dislocation with genu valgum. BMC Musculoskelet Disord 2021; 22:668. [PMID: 34372805 PMCID: PMC8351451 DOI: 10.1186/s12891-021-04554-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medial patellofemoral ligament reconstruction (MPFLR) is a well-established procedure for addressing recurrent patellar dislocation (RPD) in young patients. However, despite being a promising procedure for RPD with genu valgum, there is a scarcity of reports on simultaneous MPFLR and closing-wedge distal femoral osteotomy (CWDFO). The purpose of the present study was to observe and analyse the clinical and imaging findings of CWDFO combined with MPFLR for RPD with genu valgum. METHODS From May 2015 to April 2018, 25 patients with RPD and genu valgum were surgically treated in our department. Anteroposterior long-leg, weight-bearing, lower-extremity radiographs, lateral radiographs and computed tomography (CT) scans of the patellofemoral joint were obtained, and the anatomical femorotibial angle (aFTA), mechanical lateral distal femoral angle (mLDFA), weight-bearing line rate (WBLR), patellar height, patellar lateral shift (PLS) and tibial tubercle-trochlear groove (TT-TG) distance were analysed. Validated knee scores, such as the Kujala, Lysholm, visual analogue scale (VAS) scores and Tegner socres, were evaluated preoperatively and 2 years postoperatively. RESULTS 25 patients, with an average age of 19.8 years (14-27), were evaluated. During the 2-year follow-up period, all patients were able to achieve a better sports level without any problems, with no recurrence of patellar instability. Compared with preoperation, the aFTA, mLDFA, WBLR and PLS showed statistically significant improvement following the procedure (p < 0.001). Meanwhile, no significant differences in the Insall index and TT-TG distance were found. The mean Kujala score, average Lysholm score, VAS score and Tegner socres showed significant postoperative improvement. CONCLUSIONS CWDFO combined with MPFLR is a suitable treatment for RPD with genu valgum, and can lead to significant improvement in the clinical and imaging findings of the knee in the short term.
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Affiliation(s)
- Lizhong Jing
- Department of Orthopedics, Affiliated Hospital to Shandong University of Traditional Chinese Medicine, Jinan, 250011, China
| | - Xiaole Wang
- Department of Orthopedics, Affiliated Hospital to Shandong University of Traditional Chinese Medicine, Jinan, 250011, China
| | - Xiaoliang Qu
- Department of Orthopedics, Dongying Hospital of Traditional Chinese Medicine, Dongying, 257000, China
| | - Kun Liu
- Department of Orthopedics, Penglai Traditional Chinese Medicine Hospital, Yantai, 265600, China
| | - Xiaotan Wang
- Shandong University of Traditional Chinese Medicine, Jinan, 250000, China
| | - Lu Jiang
- Shandong University of Traditional Chinese Medicine, Jinan, 250000, China
| | - Di Wu
- Shandong University of Traditional Chinese Medicine, Jinan, 250000, China
| | - Zhiwei Zhang
- Shandong University of Traditional Chinese Medicine, Jinan, 250000, China
| | - Zhuang Li
- Shandong University of Traditional Chinese Medicine, Jinan, 250000, China
| | - Le Yu
- Department of Orthopedics, Affiliated Hospital to Shandong University of Traditional Chinese Medicine, Jinan, 250011, China
| | - Shaoshan Wang
- Department of Orthopedics, Affiliated Hospital to Shandong University of Traditional Chinese Medicine, Jinan, 250011, China
| | - Jiushan Yang
- Department of Orthopedics, Affiliated Hospital to Shandong University of Traditional Chinese Medicine, Jinan, 250011, China.
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Migliorini F, Eschweiler J, Betsch M, Knobe M, Tingart M, Maffulli N. Prognostic factors for isolated medial patellofemoral ligament reconstruction: A systematic review. Surgeon 2021; 20:e112-e121. [PMID: 33962891 DOI: 10.1016/j.surge.2021.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/28/2021] [Accepted: 03/16/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Evidence concerning the influence gender, age, and the time elapsed from the first dislocation to surgery in the outcomes of Medial Patella Femoral Ligament (MPFL) reconstruction are lacking. This systematic review was conducted to investigate whether patient characteristics have an influence in the clinical outcomes of MPFL reconstruction for patients with patellofemoral instability. MATERIAL AND METHODS This study followed the PRISMA guidelines. The main databases were accessed in February 2021. All the studies reporting outcomes of primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. A multivariate analysis diagnostic tool was used to analyse the association between age, gender and time from injury to surgery and the surgical outcomes at last follow-up. RESULTS A total of 50 articles (2037 procedures) were included. The mean follow-up was 40.90 ± 24.8 months. The mean age was 23.6 ± 3.9 years. 64.3% (1309 of 2037 patients) were female. The mean time from injury to surgery was 64.5 ± 48.9 months. Women showed no statistically significant association with the Kujala score or complications. Older patients had a reduced risk to incur re-dislocations (P = 0.01) and revisions (P = 0.01). Longer time from injury to surgery was associated with greater risk to incur re-dislocations (P = 0.01), and with lower Kujala score (P < 0.0001). No other statistically significant association was evidenced. CONCLUSION The time span from the first patellar dislocation to the surgical reconstruction was a negative prognostic factor, while sex had no influence on surgical outcomes. The role of patients age on surgical outcomes remains unclear.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Jörg Eschweiler
- Department of Orthopaedic, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Marcel Betsch
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Matthias Knobe
- Department of Orthopaedics and Trauma Surgery, University Medical Centre Mannheim of the University Heidelberg, 68167 Mannheim, Germany
| | - Markus Tingart
- Department of Orthopaedic, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; 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.
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Wong TT, Denning J, Moy MP, Rasiej MJ, Redler LH, Ahmad CS, Popkin CA. MRI following medial patellofemoral ligament reconstruction: assessment of imaging features found with post-operative pain, arthritis, and graft failure. Skeletal Radiol 2021; 50:981-991. [PMID: 33083857 DOI: 10.1007/s00256-020-03655-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/30/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess MR features following MPFL reconstruction and determine their influence on post-operative pain, progressive arthritis, or graft failure. MATERIALS AND METHODS Retrospective study on 38 patients with MPFL reconstruction and a post-operative MRI between January 2010 and June 2019. Two radiologists assessed MPFL graft signal, graft thickness, femoral screw, femoral tunnel widening, and patellofemoral cartilage damage. The third performed patellofemoral instability measurements. All three assessed femoral tunnel position with final result determined by majority consensus. Imaging findings were evaluated in the setting of post-operative pain, patellofemoral arthritis, and MPFL graft failure including need for MPFL revision. Statistics included chi-square, Fisher's exact test, t test, and kappa. RESULTS Mean graft thickness was 6.0 ± 1.8 mm; 24% of the grafts were diffusely hypointense. Mean femoral tunnel widening was 2.5 ± 1.8 mm; 34% of the femoral screws were broken or extruded. Fifty-two percent of the patients had no interval cartilage change. Non-anatomic femoral tunnels were found in 66% of patients, including in all 9 patients requiring revision MPFL reconstruction (p = 0.013). Revised MPFL grafts had more abnormal femoral screws compared to those that did not (67% vs. 24%) (p = 0.019). Other MR features did not significantly influence the evaluated outcomes. CONCLUSION The need for revision MPFL reconstruction occurs more frequently when there is a non-anatomic femoral tunnel and broken or extruded femoral screws. The appearance of the MPFL graft itself is not an influencing factor for post-operative pain, progression of patellofemoral arthritis, or graft failure.
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Affiliation(s)
- Tony T Wong
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA.
| | - John Denning
- New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, New York, NY, 10032, USA
| | - Matthew P Moy
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA
| | - Michael J Rasiej
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA
| | - Lauren H Redler
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
| | - Charles A Popkin
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
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Marcheggiani Muccioli GM, Lullini G, Grassi A, Macchiarola L, Cammisa E, Maccaferri B, Rinaldi VG, Di Paolo S, Zaffagnini S. Good results are reported at 60-month follow-up after medial patello-femoral ligament reconstruction with fascia lata allograft for recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2021; 29:1191-1196. [PMID: 32651802 DOI: 10.1007/s00167-020-06142-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to evaluate the efficacy of a new minimally invasive surgical technique for the reconstruction of the medial patellofemoral ligament (MPFL) with fascia lata allograft at 60-month minimum follow-up. METHODS Nineteen consecutive patients with chronic recurrent patellar dislocation were treated with MPFL reconstruction (53% isolate procedure, 47% in combination with other treatments). Seventeen patients (11 males/6 females) were available at 60-month follow-up and were clinically evaluated with validated scores. New episodes of patellar dislocation were considered failures. Radiographic and CT scan evaluation were executed preoperatively and at 60-month follow-up. RESULTS All clinical scores improved from preoperative assessment to 24-month and 60-month follow-up (p < 0.001). Kujala score increased from 61.2 ± 18.1 to 86.7 ± 8.7 and 82.1 ± 10.2; KOOS increased from 54.5 ± 19 to 86.8 ± 9.6 and 84.3 ± 7.6; VAS for pain decreased from 5.1 ± 2.2 to 2.4 ± 1.5 and 1.7 ± 1.2; Tegner score increased from 3 [2-4] to 5 [3-8] and 5 [3-9], respectively. Objective IKDC improved too. No significant improvements between the 24-month and 60-month follow-up evaluations were recorded. Anterior knee pain was reported in two patients (12%). Treatment failure, a new episode of patellar dislocation 25 months after the surgery, was observed in one patient (6%). Radiographic OA changes were not statistically significant between preop and 60-month follow-up. Tuberosity-troclear groove (TT-TG) distance and the patellar tilt angle were subjected to significant changes due to MPFL reconstruction and associated procedures. CONCLUSION MPFL reconstruction with fascia lata allograft, alone or combined with other procedures, is a reliable treatment option for recurrent patellar dislocation with a success rate of 94% and without cartilage deterioration at 60-month follow-up. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Giulio Maria Marcheggiani Muccioli
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
- DIBINEM, University of Bologna, via di Barbiano, 1/10, c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy.
| | - Giada Lullini
- Laboratorio di Analisi del Movimento e di Valutazione Funzionale Protesi, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- DIBINEM, University of Bologna, via di Barbiano, 1/10, c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy
| | - Alberto Grassi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Macchiarola
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eugenio Cammisa
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Bruna Maccaferri
- Medicina Fisica e Riabilitativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Vito Gaetano Rinaldi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- DIBINEM, University of Bologna, via di Barbiano, 1/10, c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy
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Paiva M, Blønd L, Hölmich P, Barfod KW. Effect of Medialization of the Trochlear Groove and Lateralization of the Tibial Tubercle on TT-TG Distance: A Cross-sectional Study of Dysplastic and Nondysplastic Knees. Am J Sports Med 2021; 49:970-974. [PMID: 33595335 DOI: 10.1177/0363546520987819] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial tubercle-trochlear groove (TT-TG) distance is often used as a measure of lateralization of the TT and is important for surgical planning. PURPOSE To investigate if increased TT-TG distance measured on axial magnetic resonance images is due to lateralization of the TT or medialization of the TG. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 84 knees (28 normal [NK], 28 with trochlear dysplasia [TD], and 28 with patellar dislocation without TD [PD]) were examined. The medial border of the posterior cruciate ligament (PCL) was chosen as the central anatomic landmark. The distance from the TT to PCL (TT-PCL) was measured to examine the lateralization of the TT. The distance from the TG to the PCL (TG-PCL) was measured to examine the medialization of the TG. Between-group differences were investigated by use of 1-way analysis of variance. RESULTS The mean values for TT-TG distance were 8.7 ± 3.6 mm for NK, 12.1 ± 6.0 mm for PD, and 16.7 ± 4.3 mm in the TD group (P < .01). The mean values for TT-PCL distance were 18.5 ± 3.6 mm for NK, 18.5 ± 4.5 mm for PD, and 21.2 ± 4.2 mm in the TD group (P = .03). The mean values for TG-PCL distance were 9.6 ± 3.0 mm for NK, 7.1 ± 3.4 mm for PD, and 5.1 ± 3.3 mm in the dysplastic group (P < .01). CONCLUSION The present results indicate that increased TT-TG distance is due to medialization of the TG and not lateralization of the TT. Knees with TD had increased TT-TG distance compared with the knees of the control group and the knees with PD. The TT-PCL distance did not differ significantly between groups, whereas the TG-PCL distance declined with increased TT-TG.
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Affiliation(s)
- Mathias Paiva
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Lars Blønd
- Zealand University Hospital, Køge and Aleris-Hamlet Parken, Koge, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
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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: 14] [Impact Index Per Article: 3.5] [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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Ren B, Zhang X, Zhang L, Zhang M, Liu Y, Tian B, Zhang B, Zheng J. Isolated trochleoplasty for recurrent patellar dislocation has lower outcome and higher residual instability compared with combined MPFL and trochleoplasty: a systematic review. Arch Orthop Trauma Surg 2019; 139:1617-1624. [PMID: 31372713 DOI: 10.1007/s00402-019-03244-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE To identify the efficacy of isolated trochleoplasty (TP) as an independent treatment for severe trochlear dysplasia compared with TP combined with medial patellofemoral ligament (MPFL) reconstruction. METHODS Search of current literature using terms (trochleoplasty and medial patellofemoral ligament reconstruction) in the electronic search engines PubMed and Embase, and Medline databases was performed on February 25, 2018, and it yielded 515 abstracts for review. At the end of the search, six articles met specific inclusion criteria and were included in this review. Means were calculated for population size, age and follow-up time. The Kujala score was analyzed as the primary clinical outcome parameter in the meta-analysis. Pooled estimates were calculated for postoperative complications. RESULTS Six studies with a total of 192 knees (168 patients) were included in this analysis. The isolated TP group comprised of 3 articles with a total of 111 knees, and the TP combined with MPFL group comprised of 3 articles with a total of 81 knees. At the final follow-up, the preoperative Kujala score increased significantly by 21.39 (95% CI 18.94, 23.84; P < 0.00001) points in the isolated TP group and by 24.91 (95% CI 15.47, 34.36; P < 0.00001) points in the TP combined with MPFL group. The rates of subjective patellar instability including subluxation and anterior knee pain were 1.03% and8.45% respectively. Meanwhile, the rate of objective patellar redislocation was 2.06% in isolated TP group and 0% in TP combined with MFPL group. A total of 8.24% returned to the operating room for additional procedures in the isolated TP group and 7.04% in the TP combined with MPFL group. CONCLUSION Trochleoplasty is a useful and reliable surgical technique to improve patellofemoral instability in patients with a dysplastic trochlea. However, it as isolated treatment for patients has lower outcome and higher residual instability compared with combined MPFL and trochleoplasty.
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Affiliation(s)
- Bo Ren
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China
| | - Xian Zhang
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China
| | - Liang Zhang
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China
| | - Mingyu Zhang
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China
| | - Yang Liu
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China
| | - Bin Tian
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China
| | - Bohao Zhang
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China
| | - Jiang Zheng
- Sports Medicine Center, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Shan'xi Province, Nanguo Road No. 76, Xi'an, 710054, China.
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Kang H, Zheng R, Dai Y, Lu J, Wang F. Single- and double-bundle medial patellofemoral ligament reconstruction procedures result in similar recurrent dislocation rates and improvements in knee function: a systematic review. Knee Surg Sports Traumatol Arthrosc 2019; 27:827-836. [PMID: 30136103 DOI: 10.1007/s00167-018-5112-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 08/10/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate medial patellofemoral ligament (MPFL) reconstruction using hamstring tendon autografts using single-bundle (SB) and double-bundle (DB) techniques, and compare the clinical outcomes including the Kujala score, postoperative apprehension, recurrent subluxation or dislocation, and complications. METHODS The PubMed, Embase, and Cochrane Library databases were searched for relevant literature using the terms ''medial patellofemoral ligament'' and ''MPFL''. The pooled mean values of improvement in the Kujala score were calculated by random effects meta-analysis. Unweighted estimates for the rates of postoperative apprehension, recurrent subluxation or dislocation, and complications were determined by dividing the total number of occurrences by the total number of knees. RESULTS Thirty-one articles were included, involving 1063 patients (1116 knees). Two hundred and forty-four patients (254 knees) underwent SB reconstruction, while 819 patients (862 knees) underwent DB reconstruction. The pooled mean values of Kujala score improvement were similar in the SB group (30.1; 95% CI 26.6-33.6) and DB group (30.7; 95% CI 27.7-33.7). The SB group had a significantly greater rate of postoperative apprehension (7.9%) than the DB group (4.1%; P = 0.014). There were no significant differences between the two groups in the rates of recurrent subluxation or dislocation (1.2 and 1.6%) and complications (10.6 and 7.7%). CONCLUSION With variability in patient populations and surgical techniques, the DB procedure for isolated MPFL reconstruction demonstrates similar outcomes to the SB technique regarding improvement of knee function, recurrent subluxation or dislocation, and complications. The SB technique may have a greater risk of postoperative apprehension, whereas the DB technique may cause more stiffness. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Huijun Kang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China
| | - Rui Zheng
- Department of Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yike Dai
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China
| | - Jiangfeng Lu
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China
| | - Fei Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China.
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No influence of patellar fixation technique on clinical outcomes of double-bundle medial patellofemoral ligament reconstruction: a systematic review. Arch Orthop Trauma Surg 2019; 139:79-90. [PMID: 30046892 DOI: 10.1007/s00402-018-3008-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 02/09/2023]
Abstract
PURPOSE To compare clinical outcomes of double-bundle medial patellofemoral ligament (MPFL) reconstruction with different patellar fixation techniques including Kujala score, functional failure and complications. METHODS Pubmed, Embase, and Cochrane Library databases were searched for studies with clinical results of double-bundle MPFL reconstruction. The hamstring tendon autografts were used, and femoral fixation was performed with bone tunnel and an interference screw, and knee fixation angle was less than or equal to 45°. Patellar fixation methods were broadly categorized into 3 treatment groups: suture anchor (SA), bone tunnel (BT) and suture techniques (SU). Pooled means for Kujala score and pooled estimates for functional failure rate and complication rate were compared. RESULTS 21 studies (23 groups) consisting of 691 knees met the inclusion criteria. 12 groups with 344 knees were in SA group, 5 groups of 161 knees were in BT group and 6 groups with 186 knees were in SU group. Statistically significant differences in Kujala score were found among three groups, 90.2 (95% CI 88.7-91.7) in SA group, 88.7 (95% CI 85.3-92.2) in BT group and 89.4 (95% CI 84.2-94.6) in SU group (all P < 0.001), but these differences were not clinically significant. No statistically significant differences were found in the positive apprehension sign rate, recurrent subluxation or dislocation rate, and major or minor complication rate among three groups. CONCLUSION Patellar fixation with bone tunnel, suture anchor or suture techniques were all effective in the double-bundle MPFL reconstruction. The present systematic review failed to show that one technique was better than the others. More high-quality trials and randomized controlled trials are needed.
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MRI findings associated with medial patellofemoral capsuloligamentous plication. Skeletal Radiol 2018; 47:1229-1235. [PMID: 29500485 DOI: 10.1007/s00256-018-2916-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/25/2017] [Accepted: 02/08/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To review the MRI appearance of medial patellofemoral capsuloligamentous plication (also known as reefing or imbrication) for proximal patellar realignment in patients with patellofemoral instability. MATERIALS AND METHODS Retrospective analysis of our surgical and PACS databases identified cases of medial plication performed between June 2011 and July 2016. Pre- and postoperative MRI characteristics were reviewed. Correlation was made with operative reports and clinical records to define postoperative appearances on MRI. RESULTS Forty-one patients underwent medial plication during the study period; 29 were excluded owing to a lack of postoperative imaging. Ultimately, 12 knees were included in 11 patients who had postoperative MRI studies available (8 women and 3 men, mean age 27.3 ± 10.2 years). Ten (83%) of the surgeries were performed open and 2 (17%) arthroscopically. There were differences in the post-surgical MRI appearance of medial plications carried out after surgery using the open and arthroscopic techniques. The open technique produces a "heaped up" distal vastus medialis obliquus (VMO) with centralized patellar insertion (100%), which was absent in the case of arthroscopic plication, where subtle medial retinaculum thickening was demonstrated without alteration of its patellar insertion. The mean postoperative lateral patellar and patellofemoral congruence angles measured 2.5° ± 5.6° and 12.4° ± 19.9° respectively. A significant association was found regarding change in patellofemoral alignment (p = 0.018 and p = 0.004 respectively). CONCLUSION The MRI appearance of medial plication is not well described in the radiology literature; radiologists should be familiar with anticipated post-plication findings to avoid potential confusion for pathology and allow more accurate interpretation of postoperative imaging findings from this common surgery.
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Schüttler KF, Hoeger A, Heyse TJ, Figiel J, Timmesfeld N, Stein T, Ziring E, Efe T. Femoral tunnel widening is associated with tunnel malposition but not with clinical failure after medial patellofemoral ligament reconstruction with a free gracilis tendon graft. Arch Orthop Trauma Surg 2018; 138:979-984. [PMID: 29611007 DOI: 10.1007/s00402-018-2923-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Indexed: 01/16/2023]
Abstract
INTRODUCTION MPFL reconstruction is widely and successfully used for treating patella instability, either as a standalone procedure or in combination. Although different techniques allow for MPFL reconstruction, the use of a free tendon graft is one of the most commonly used. The phenomenon of tunnel widening or tunnel enlargement is well described in ACL reconstruction, but so far only little effort has been put into evaluating this phenomenon after MPFL reconstruction. MATERIALS AND METHODS Patients who received an MPFL reconstruction with a free gracilis tendon graft were identified by review of patient files. Additional clinical examination and magnetic resonance imaging were performed to assess tunnel enlargement and clinical outcome. RESULTS Fifty-one knees of 49 patients (34 female, 17 male) with a mean follow-up of 3.0 ± 1.4 years were included in this study. Mean age at the time of surgery was 22.6 ± 8.5 years. Mean Tegner score decreased from preoperative 5.3 ± 2.0 to 4.0 ± 1.4 postoperative. Postoperative IKDC and Kujala scores were 74 ± 16 and 80 ± 15, respectively. Twenty-three patients showed a tunnel enlargement at follow-up examination. Of these 23 patients, 20 showed a tunnel that was positioned too proximal, whereas only 13 of the 28 patients showing no enlargement had a tunnel that was positioned too proximal (p = 0.0033). Interestingly, patients showing a tunnel enlargement at follow-up examination also showed significantly better Kujala (84 ± 12 vs. 75 ± 16; p = 0.03) and IKDC scores (80 ± 7 vs. 70 ± 19; p = 0.02) when compared to the non-enlarged group. CONCLUSION Tunnel enlargement after MPFL reconstruction with a free gracilis tendon graft seems to be connected to mechanical overload due to a proximal malposition of the femoral tunnel. Interestingly, this did not influence clinical outcome as patients with tunnel enlargement showed better Kujala and IKDC scores.
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Affiliation(s)
- Karl-Friedrich Schüttler
- Center of Orthopedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - A Hoeger
- Center of Orthopedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - T J Heyse
- Center of Orthopedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - J Figiel
- Department of Diagnostic and Interventional Radiology, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - N Timmesfeld
- Institut of Medical Biometrics and Epidemiology, University Marburg, Bunsenstrasse 3, 35037, Marburg, Germany
| | - T Stein
- Department of Sporttraumatology, Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany.,Department of Sports Science, University of Bielefeld, Bielefeld, Germany
| | - E Ziring
- Center of Orthopedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - T Efe
- Center of Orthopedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany.,Orthopaedicum Lich, Gottlieb-Daimler-Str. 7a, 35423, Lich, Germany
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Tibial tuberosity to trochlear groove distance and its association with patellofemoral osteoarthritis-related structural damage worsening: data from the osteoarthritis initiative. Eur Radiol 2018; 28:4669-4680. [DOI: 10.1007/s00330-018-5460-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/22/2018] [Accepted: 04/03/2018] [Indexed: 12/29/2022]
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Hernigou J, Chahidi E, Bouaboula M, Moest E, Callewier A, Kyriakydis T, Koulalis D, Bath O. Knee size chart nomogram for evaluation of tibial tuberosity-trochlear groove distance in knees with or without history of patellofemoral instability. INTERNATIONAL ORTHOPAEDICS 2018; 42:2797-2806. [DOI: 10.1007/s00264-018-3856-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 02/18/2018] [Indexed: 01/11/2023]
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