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Zein AMN, Allam AFA, Hassan AZM, Soliman AM, Mohamed MMA. Outcomes of an All-Soft Tissue Fixation Technique for Reconstruction of the Medial Patellofemoral Complex Using Double-Bundle Quadriceps Tendon Autograft for Recurrent Patellar Dislocation in Skeletally Immature Patients. Orthop J Sports Med 2024; 12:23259671241259051. [PMID: 38895137 PMCID: PMC11185005 DOI: 10.1177/23259671241259051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/16/2024] [Indexed: 06/21/2024] Open
Abstract
Background Patellar fracture, femoral physis injury, and recurrent instability are concerning complications in medial patellofemoral ligament (MPFL) reconstruction (MPFLR) techniques for recurrent patellar dislocation in children and adolescents. Purpose To evaluate the outcomes of an anatomic all-soft tissue fixation technique for reconstruction of the medial patellofemoral complex (MPFC) using a double-bundle quadriceps tendon (QT) autograft for recurrent patellar dislocation in skeletally immature patients. Study Design Case series; Level of evidence, 4. Methods This retrospective study involved 24 skeletally immature patients (24 knees; 16 women and 8 men; age range, 9.5-15 years) with recurrent patellar dislocation who underwent MPFC reconstruction using a double-bundle QT autograft between September 2018 and January 2021. Only soft tissue suture fixation was used on the femoral and patellar sides of the 2 bundles of the QT. Radiographs, computed tomography, and magnetic resonance imaging were used to evaluate physeal status, lower limb alignment, patellar height and tilt, trochlear morphology, tibial tubercle-trochlear groove distance, and any associated knee pathology. Functional outcomes were assessed with the Kujala score, the visual analog scale (VAS) for pain, and the grading system of Insall et al.22. Results The mean follow-up time was 40 ± 9.6 months (range, 28-56 months). At the final follow-up, the Kujala and VAS pain scores showed a significant improvement versus preoperative scores (P < .001), and the passive lateral patellar glide showed a significant reduction (P < .001). All patients had negative apprehension and J signs. Of the 24 patients, 23 regained full range of motion, while 1 patient had a knee flexion deficit. The patellar tilt angle improved significantly at the final follow-up (P < .001). There was no patellar fracture, femoral physis injury, or recurrence of patellar dislocation. According to the grading system of Insall et al, the results were excellent in 15 knees (62.5%), good in 8 knees (33.3%), fair in 1 knee (4.2%), and no knees showed poor results. Conclusion Reconstruction of the MPFC using a double-bundle QT autograft with an all-soft tissue fixation technique was an effective method for treating patellar instability in skeletally immature patients.
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Affiliation(s)
- Assem Mohamed Noureldin Zein
- Department of Orthopedic Surgery and Traumatology, Minia University Hospital, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ahmad Fouad AbdElbaki Allam
- Department of Orthopedic Surgery and Traumatology, Minia University Hospital, Faculty of Medicine, Minia University, Minia, Egypt
| | - Alaa Zenhom Mahmoud Hassan
- Department of Orthopedic Surgery and Traumatology, Minia University Hospital, Faculty of Medicine, Minia University, Minia, Egypt
| | - Amr Mohamed Soliman
- Department of Orthopedic Surgery and Traumatology, Minia University Hospital, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mohamed Mohamed Azmy Mohamed
- Department of Orthopedic Surgery and Traumatology, Minia University Hospital, Faculty of Medicine, Minia University, Minia, Egypt
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Zein A, Hassan AZM, Soliman AM, Mohamed MMA. Outcomes of surgical treatment of patellar instability in children with Down syndrome. J Orthop Surg Res 2024; 19:263. [PMID: 38664709 PMCID: PMC11044411 DOI: 10.1186/s13018-024-04730-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND patellar instability is a relatively frequent musculoskeletal disorder in children with Down syndrome (DS). However, such a condition has seldom been studied in the literature, even less its surgical treatment. Different techniques have been offered for this condition; the evidence for surgical options is scarce and primarily based on case reports or case series with few patients and heterogeneous techniques. Given this background, we aimed to evaluate the outcomes of a uniform kind of surgical procedure for such a condition that combined lateral soft tissue release, medial patellofemoral ligament (MPFL) reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty (if needed). MATERIALS AND METHODS This retrospective study involved 11 skeletally immature patients (12 knees; 9 males and 2 females), 5.5 to 14.1 years of age, with DS who had patellofemoral instability (PFI) and were managed by this technique between October 2018 and March 2020. Preoperative radiography, CT scan, and MRI were performed to evaluate the physis status, lower limb alignment, patellar height, trochlear morphology, and any associated knee pathology. A functional knee assessment was done by using the Kujala score and the modified Lysholm score. RESULTS The mean time of follow-up (± SD) was 47.7 ± 5.8 months (range: 39-56). Pre-operatively, the Kujala score (± SD) was 52.6 ± 14.3 (range: (31-74), and at final follow-up, it was 92.2 ± 4.4 (range: (88-98), showing a significant improvement (P < 0.001). The preoperative modified Lysholm score (± SD) was 54.3 ± 8.1 (range: 39-62), and at final follow-up it was 92.4 ± 5.3 (range: 82-96), showing a significant improvement (P < 0.001). All patients had a stable patella without a recurrence of instability and regained full ROM. There was no incidence of a patellar fracture or femoral physis injury. CONCLUSIONS Our proposed technique of combined soft tissue procedures, including lateral soft tissue release, MPFL reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty, was an effective method for treating patellar instability in children with DS while avoiding physeal injury and patellar fracture. Functional scores and radiological outcomes were improved. LEVEL OF EVIDENCE IV; retrospective case series.
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Affiliation(s)
- Assem Zein
- Department of Orthopaedics and Trauma Surgery, Minia University, Minia, Egypt.
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Kahlon H, Vivekanantha P, Blackman B, Cohen D, Mckechnie T, Park L, de Sa D. Surgical techniques for medial Patellofemoral ligament reconstruction: a systematic review and meta-analysis of level I and II studies. Knee Surg Sports Traumatol Arthrosc 2023; 31:4368-4378. [PMID: 37347281 DOI: 10.1007/s00167-023-07494-w] [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: 04/22/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
PURPOSE To determine the most optimal surgical technique for medial patellofemoral ligament reconstruction (MPFLR). METHODS Three databases MEDLINE, PubMed, and EMBASE were searched from inception to December 13th, 2022, for level I or II studies comparing MPFLR techniques. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on patient-reported outcome measures were recorded. Quality assessment was carried out using the MINORS and Cochrane Risk of Bias assessment tools. Certainty of evidence was carried out with the GRADE assessment tool. RESULTS Ten studies comprising 723 patients (723 knees) were included in this review. The weighted mean difference in Kujala, Lysholm, and IKDC scores comparing single- and double-tunnel patellar drilling techniques was 2.66 (95% CI -1.05-6.37, p = 0.16, I2 = 0%) with moderate certainty, 0.78 (95% CI -9.02-10.58, p = 0.88, I2 = 87%) with low certainty, and 1.71 (95% CI -2.43-5.86, p = 0.42, I2 = 0%) with low certainty, respectively. Double-suture anchor patellar fixation demonstrated greater Kujala scores than transpatellar fixation (87.1 ± 2.8 vs 84.0 ± 3.8, p < 0.001) with moderate certainty. Y-shaped graft patellar fixation demonstrated superior Kujala scores to C-shaped graft patellar fixation (95.9 ± 4.7 vs 91.3 ± 9.7, p = 0.001) with moderate certainty. Augmentation of femoral fixation with polyester sutures demonstrated superior Kujala scores (97.8 ± 6.4. vs 88.0 ± 6.3, p < 0.005) with low certainty. Four-stranded grafts demonstrated greater Kujala scores than two-stranded grafts (93.5 ± 2.6 vs 91.6 ± 3.5, p = 0.01) with low certainty. CONCLUSION The optimal MPFLR surgical technique is likely to utilize a four-stranded graft using either endobutton, double-suture anchor, or transosseous suture patellar fixation with polyester suture augmented interference screw femoral fixation. Orthopedic surgeons can consider employing such a technique to improve patient outcomes by conferring greater graft stability, strength, and function. Level of evidence Level II.
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Affiliation(s)
- Harjind Kahlon
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Benjamin Blackman
- Department of Medicine, Department of Surgery, University of Limerick, Limerick, Ireland
| | - Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada
| | - Tyler Mckechnie
- Division of General Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Lily Park
- Division of General Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada.
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Migliorini F, Maffulli N, Söllner S, Pasurka M, Kubach J, Bell A, Betsch M. Allografts for Medial Patellofemoral Ligament (MPFL) Reconstruction in Adolescent Patients with Recurrent Patellofemoral Instability: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050840. [PMID: 37238388 DOI: 10.3390/children10050840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
This systematic review updates the currently available evidence on medial patella-femoral ligament (MPFL) reconstruction using allografts. The outcomes were measured with patient-reported outcome measures (PROMs), redislocation and complication rates. This study was performed according to the 2020 PRISMA guidelines using the PubMed, Scopus, Web of Science databases, accessed in February 2023. Studies examining the clinical outcomes of MPFL reconstruction with allografts in adolescents and children with recurrent patellofemoral instability (PFI) were included. Data from three trials, including 113 surgical procedures in 121 children, were retrieved. 40% (48/121) of the included patients were girls. The mean age of the patients was 14.7 ± 0.8 years, and the mean follow-up length was 38.1 ± 16.5 months. With MPFL allograft reconstruction, the Kujala score improved by 14.7% (p < 0.0001) and the IKDC by 38.8% (p < 0.0001). The rate of dislocations was 5% (6 of 121), reoperation for instability was 11% (13 of 121), and subluxation was 2% (1 of 47). Conclusion: These results encourage the use of allografts for MPFL reconstruction in adolescent patients with recurrent patellofemoral instability. Though patellofemoral instability is common in clinical practice, the current literature lacks clinical evidence on allograft MPFL reconstruction. Additional high-quality investigations are required to properly establish the long-term advantages of allograft MPFL and its complication rate.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke-on-Trent ST4 7QB, UK
- Barts and The London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, London E1 4DG, UK
| | - Stefan Söllner
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
| | - Mario Pasurka
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
| | - Joshua Kubach
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Marcel Betsch
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany
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Duchman KR. Editorial Commentary: The Medial Patellofemoral Ligament Is Not Isometric and Anatomic Reconstruction Is Important, But Just a Small Piece of the Patellar Instability Puzzle. Arthroscopy 2022; 38:1568-1570. [PMID: 35501021 DOI: 10.1016/j.arthro.2021.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 11/16/2021] [Indexed: 02/02/2023]
Abstract
Medial patellofemoral ligament (MPFL) reconstruction has proven to be a reliable procedure to reduce patellar instability events in patients with recurrent patellar instability. As our reconstruction techniques have evolved to address pathology in a diverse patient population, there continues to be an obsessive focus on the precise anatomy of the MPFL origin on the medial knee, due in large part to concerns that improper femoral tunnel position may result in excessive graft anisometry and failure. However, recurrent patellar instability involves many complexities and should not be simply reduced to a single point on the medial knee.
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Marín Fermín T, Migliorini F, Kalifis G, Zikria BA, D'Hooghe P, Al-Khelaifi K, Papakostas ET, Maffulli N. Hardware-free MPFL reconstruction in patients with recurrent patellofemoral instability is safe and effective. J Orthop Surg Res 2022; 17:121. [PMID: 35193641 PMCID: PMC8864882 DOI: 10.1186/s13018-022-03008-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE This systematic review evaluated the clinical outcomes of hardware-free MPFL reconstruction techniques in patients with recurrent patellofemoral instability, focusing on patient-reported outcome measures (PROMs), redislocation rate, and complications. The hypothesis was that hardware-free MPFL reconstruction in patients with recurrent patellofemoral instability is safe and effective. METHODS This systematic review was conducted following the PRISMA guidelines. PubMed, Scopus, and Virtual Health Library databases were accessed in October 2021. All the clinical studies investigating the efficacy and feasibility of hardware-free MPFL reconstruction were screened for inclusion. Only studies with a minimum 24-month follow-up were considered eligible. Kujala Anterior Knee Pain Scale improvement and redislocation rate after surgical treatment were evaluated as primary outcomes. The rate of postoperative complications was evaluated as a secondary outcome. The quality of the methodological assessment was assessed using the Modified Coleman Methodology Score. RESULTS Eight studies were included in the present systematic review. The quality of the methodological assessment was moderate. Short- to long-term improvement of Kujala score was observed in all included studies. Mean score improvement ranged from + 13.2/100 to + 54/100, with mean postoperative scores ranging from 82/100 to 94/100. Patellar redislocation was observed in 8.33% (8 of 96) patients. CONCLUSION Hardware-free MPFL reconstruction with or without associated soft-tissue or bony realignment procedures provided reliable clinical improvements and was associated with a low rate of redislocation in patients with recurrent patellofemoral instability. Advantages such as safety, femoral physis preservation, and comparable complication profiles with implant-based techniques endorse its implementation. Orthopedic surgeons in cost-sensitive environments may also benefit their patients with lower costs, no need for implants, lack of implant-related complications, or surgery for implant removal. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Giorgos Kalifis
- Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, UK
| | | | - Pieter D'Hooghe
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | | | | | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, England.,Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, England
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Medial Patellofemoral Ligament Reconstruction Techniques and Outcomes: a Scoping Review. Curr Rev Musculoskelet Med 2021; 14:321-327. [PMID: 34893964 DOI: 10.1007/s12178-021-09719-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this scoping literature review was to summarize the current evidence on techniques and outcomes following MPFL reconstruction including sources of evidence, key concepts, and gaps in the literature. RECENT FINDINGS A thorough electronic database search included studies published from 2016 to April 26, 2021, identified a total of 144 peer reviewed articles. Of the 144 identified clinical papers, 80 (56%) were of level IV evidence, 49 (34%) were of level III evidence, 11 (8%) were level II evidence, and 4 (3%) were level I evidence. Overall, 10,710 patients (11,466 knees) were included with 6871 (64%) female. The mean age of patients included in these studies was 23.5 years (range=5 to 59). In recent years, there has been a substantial quantity of evidence published on MPFL reconstruction from a variety of different countries and journals and of variable methodological design. Isolated MPFL reconstruction results in a decrease in patellar height postoperatively. Indications for isolated MPFL reconstruction versus concomitant procedures to address bony morphology is still incompletely defined. When failure does occur after MPFL reconstruction, femoral tunnel malposition is the most commonly cited cause. Despite several recent studies focused on optimal MPFL reconstruction techniques, there is currently no consensus on optimal graft type (most common being hamstring autografts, allografts, and recently synthetic grafts) or femoral fixation strategies, with similar results reported with each technique. Future studies should focus on optimal techniques for each patient population as well as specific indications for additional concomitant realignment procedures.
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Single-Incision, Single Patellar Tunnel For Double-Bundle Medial Patellofemoral Ligament Reconstruction: A Technical Note. Arthrosc Tech 2021; 10:e2107-e2112. [PMID: 34504749 PMCID: PMC8417225 DOI: 10.1016/j.eats.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/17/2021] [Indexed: 02/03/2023] Open
Abstract
The medial patellofemoral ligament (MPFL) is the main medial stabilizer of the patella, while reconstruction of the ligament is a common surgery performed by orthopedic surgeons. Although several surgical methods have been described regarding MPFL reconstruction, the common goals of these surgeries are to imitate the anatomic features of the native MPFL. In the single-incision and single patellar tunnel and double-bundle MPFL reconstruction technique, we will present the anatomical footprint of the MPFL located in the medial aspect of the patella, which is filled with the graft. In this technique, graft fixation is performed in the femoral tunnel using only one bioabsorbable screw without the need for fixation in the patella.
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Tan CMP, Zhu Y, Guo L, Loh SYJ. Medial patellofemoral ligament reconstruction with and without trochleoplasty for patients with patella instability-correlation of trochlear dysplasia and patient outcome, classification and outcome measure in the past decade-a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:595-607. [PMID: 34120236 DOI: 10.1007/s00590-021-03030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The primary aim of the study is to compare the patient outcome in medial patellofemoral ligament reconstruction (MPFLR) or MPFLR concurrent with trochleoplasty (MPFLR + TP) and correlate it with the degree of trochlear dysplasia (TD). The secondary aim is to review TD classification, outcome measure, chronological and geographical trend of such studies in the past decade. METHODS A systemic review of the literature in the past decade on studies of patients with patella instability and underwent either a MPFLR or MPFLR + TP. The degree of TD with the patient outcome was correlated and compared between the 2 groups. The TD classification, outcome measures, chronological and geographical trends of these studies were documented. RESULTS There is no statistical difference in the overall improvement in the compared outcome scores between the 2 groups. However, the MPFLR studies reported a total of 16 re-dislocation in contrast to none in the MPFLR + TP studies. The 24 selected studies in the current review utilized different TD classification as well as outcome measures. A more homogeneous subgroup of 12 studies utilized Dejour classification as well as Kujala score that enabled comparison and showed no significant difference in outcome. The highest number of MPFLR publications was in 2019 and was from North and South Americas, Asia and Europe. The MPFLR + TP studies were from Europe during 2013 to 2017. CONCLUSION Though there is an overall improvement in post-operative outcomes scores with no statistical significance between MPFLR and MPFLR + TP, the documented re-dislocations in the MPFLR studies suggested an undetermined zone where the choice of procedure could result in a different outcome. The current review did not show correlation between the degree of TD with the patient outcome to provide a clear indication for either procedure according to the degree of TD. The diverse TD classifications and varied outcome measures indicated the need for standardization and consistency in documentation to guide the treating clinician in the choice of procedure. MPFLR was more commonly performed and studied than MPFLR + TP in the past decade.
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Affiliation(s)
- Cheryl Marise Peilin Tan
- Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore.
| | - Yanan Zhu
- Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
- , Cochrane, Singapore
| | - Liang Guo
- Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
- , Cochrane, Singapore
| | - Sir Young James Loh
- Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
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Marot V, Sanchis-Alfonso V, Perelli S, Gelber PE, Sánchez Rábago CJ, Ginovart G, Monllau JC. Isolated reconstruction of medial patellofemoral ligament with an elastic femoral fixation leads to excellent clinical results. Knee Surg Sports Traumatol Arthrosc 2021; 29:800-805. [PMID: 32358632 DOI: 10.1007/s00167-020-06016-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 04/17/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The primary objective was to compare the functional outcomes after an isolated MPFL reconstruction using either a quasi-anatomical technique (group A) or an anatomical MPFL reconstruction (group B). The secondary objectives were to compare the rates of redislocation, range-of-motion and subjective patellar instability (Smillie test). METHODS A multicenter longitudinal prospective comparative study was performed. Group A had 29 patients and 28 were included in Group B. Patients with trochlear dysplasia types C and D and patients who had undergone a trochleoplasty, a distal realignment or patella distalization concurrently with MPFL reconstruction were excluded. The main evaluation criterion was the Kujala functional score. RESULTS The mean postoperative Kujala was 90.4 (89.4 in group A and 92.1 in group B). Upon comparing the mean difference between pre- and post-operative values, no differences were detected between the two groups (n.s). CONCLUSIONS Isolated quasi-anatomical MPFL reconstruction using a gracilis tendon autograft for recurrent patellar dislocation provides outcomes as good as the isolated anatomical MPFL reconstruction in patients with no trochlear dysplasia up to those with trochlear dysplasia type A and B at the 2-5 years follow-up. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Vincent Marot
- Musculoskeletal Institute, Hôpital Pierre Paul Riquet, CHU Toulouse, 1 place Baylac, 31000, Toulouse, France.
| | | | - Simone Perelli
- Institut Català de Traumatologia I Medicina de L'Esport-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pablo E Gelber
- Institut Català de Traumatologia I Medicina de L'Esport-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Orthopaedic Surgery, Hospital de la Sta Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Joan C Monllau
- Institut Català de Traumatologia I Medicina de L'Esport-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Orthopaedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
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Aicale R, Maffulli N. Combined medial patellofemoral and medial patellotibial reconstruction for patellar instability: a PRISMA systematic review. J Orthop Surg Res 2020; 15:529. [PMID: 33183310 PMCID: PMC7663880 DOI: 10.1186/s13018-020-02072-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The medial patellofemoral ligament (MPFL) works in association with the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML) to impart stability to the patellofemoral joint. The anatomy and biomechanical characteristics of the MPFL have been well described but little is known about the MPTL and MPML. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, patellar and quadriceps tendons, allografts and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident. METHODS A systematic review of the literature was conducted using PRISMA guidelines. Inclusion criteria were articles that reported clinical outcomes of combined reconstruction of MPTL and MPFL. The methodological quality of the articles was determined using the modified Coleman Methodology Score (CMS). RESULTS Nine articles were included, reporting the clinical outcomes of 197 operated knees. The surgical procedures described include hamstrings grafting and transfer of the medial patellar and quadriceps tendons with or without bony procedures to reconstruct the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved. The median CMS is 70.6 ± 14.4 (range 38 to 84). CONCLUSION Different techniques are reported, and outcomes are good with low rates of recurrence. The quality of the articles is variable, ranging from low to high. Appropriately powered randomized controlled trials are needed to better understand what the adequate indications for surgery in patients with patellar instability and clinical outcomes are. Combined reconstruction of MPFL and MPTL leads to favourable clinical outcomes, supporting its role as a valid surgical procedure for patellar stabilization.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG England
- Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB England
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Maffulli N, Aicale R, D'Addona A, Young DA, Kader DF, Oliva F. Combined medial patellofemoral and patellotibial reconstruction with soft tissue fixation in recurrent patellar dislocation. Injury 2020; 51:1867-1873. [PMID: 32580890 DOI: 10.1016/j.injury.2020.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/07/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The medial patellofemoral and patellotibial ligaments (MPFL and MPTL) are the main passive restraints to lateral patellar translation. When nonoperative management of patellofemoral dislocations fails, surgical options can be considered to restore patellofemoral stability. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, quadriceps tendon, and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident. MATERIALS AND METHODS Patients who suffered at least two documented episodes of unilateral patellar dislocation, confirmed radiographically and at clinical examination, underwent combined MPFL and MPTL reconstruction. Patients were regularly followed-up postoperatively at 2, 4, 8, 12, and 24 weeks, and then annually for a minimum of 2.5 years. Clinical and functional evaluations were performed using the modified Cincinnati rating system and the Kujala score, while anthropometry values including thigh volume and cross-sectional area of the thigh were measured before the operation and at the latest follow-up bilaterally. RESULTS There were 7 males and 27 females with a mean age of 26.5 ± 10.7 years (range, 13-39 years). The mean follow-up was 3.1 years (range, 2.5-4 years). The mean modified Cincinnati score Increased from 51 ± 22 preoperatively to 90 ± 19 (P = .001). The mean Kujala scores increased from 47 ± 17 preoperatively to 82 ± 17 (P = .02), with no significant differences between patients with or without osteochondral lesions (P ≥ .05), and between male and female patients (P ≥ .08). The Insall-Salvati index was 1.1 preoperatively and remained within normal range (P = .05) at the latest follow-up. CONCLUSION Combined reconstruction of MPFL and MPTL using an ipsilateral autologous gracilis tendon is satisfactory and effective and can be considered as suitable management option to treat recurrent dislocation of the patella. However, randomized studies are needed to compare different techniques. STUDY DESIGN Case series.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England, UK; Keele University, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England, UK.
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy
| | - Alessio D'Addona
- Department of Public Health, Section of Orthopaedics and Trauma Surgery, A.O.U. Federico II School of Medicine, Surgery and Dentistry, "Federico II" University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - David A Young
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor VIC 3181, Australia
| | - Deiary F Kader
- Academic Unit, South West London Elective Orthopaedic Centre, Epsom, Surrey, UK
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy
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Waterman BR. Editorial Commentary: The "F" in MPFL (Medial Patellofemoral Ligament) Reconstruction-How Should We Fix It and Does It Matter? Arthroscopy 2019; 35:1138-1140. [PMID: 30954107 DOI: 10.1016/j.arthro.2019.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 02/02/2023]
Abstract
Our understanding of the medial patellofemoral complex anatomy has evolved significantly over the past several decades, and this has informed our current surgical approach to management of lateral patellar instability. Medial patellofemoral ligament reconstruction remains the gold standard for decreasing the risk of secondary patellar dislocation and returning patients to active physical function. However, concerns about isometry, overconstraint, secondary arthrosis, and surgical-site morbidity remain with femoral socket fixation, particularly when patella alta, rotational malalignment, or hypermobility is present. Medial patellofemoral ligament reconstruction with soft-tissue fixation, on either the patellar or femoral side, may mitigate some of these risks by offering a more dynamic checkrein to lateral translation. However, longer-term studies are required to determine comparative efficacy with varying surgical techniques, and the ideal graft tension and degree of knee flexion during fixation have not yet been determined.
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