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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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Runer A, Klotz S, Schneider F, Egelseer T, Csapo R, Hoser C, Abermann E, Mayr R, Raas C, Attal R, Arora R, Fink C, Liebensteiner M. Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient-Reported Outcomes but Less Donor-Site Morbidity Compared With Gracilis Tendon Autograft. Arthroscopy 2024; 40:438-445. [PMID: 37479150 DOI: 10.1016/j.arthro.2023.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To compare clinical and patient-reported outcome measures (PROMs) in patients with recurrent patellar dislocation after medial patellofemoral ligament (MPFL) reconstruction using either a gracilis tendon (GT) or quadriceps tendon autograft (QT). METHODS All MPFL reconstruction performed between 2017 and 2019 were reviewed retrospectively. Only patients with isolated MPFL reconstruction, without any major patellofemoral risk factors and a minimum follow-up of 24 months, were included in the study. Patients were matched with respect to sex, age, and body mass index. All patients were evaluated clinically and using PROMs. RESULTS A total of 64 patients with an average follow up of 28.7 ± 7.5 months were included in this study. The mean Kujala score (GT: 84.8 ± 12.9, QT: 88.9 ± 10.1), Lysholm score (GT: 89.4 ± 10.2, QT: 88.4 ± 5.0), and visual analog scale score for pain (GT: 1.9 ± 1.8, QT: 1.1 ± 1.3) did not significantly differ between both groups. Tegner activity level was significantly greater (P = .027) in the QT group (5.5 ± 1.9) compared with the GT group (4.6 ± 1.8), but within the minimal clinically important differences. Occasional patellar instability events, but no recurrent dislocation, were reported in 12.5% in the GT group and 6.3% in the QT group (P = .39). Of all patients, 90.6% in the QT and 68.8% in the HT group exceeded the PASS for the Kujala score (P = .06). Significantly more patients (59.4%) treated with GT reported donor-site morbidity in the form of sensitivity deficit at the lower leg compared with those treated with QT (3.1%, P = .001). CONCLUSIONS GT and QT MPFL reconstruction have comparable PROMs and patellar redislocation rates 2 years' postoperatively. Significantly more patients treated with GT reported lower-leg sensitivity deficit compared with those treated with QT. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Stefan Klotz
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Friedemann Schneider
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tim Egelseer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Csapo
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Centre for Sport Science and University Sports, University of Vienna, Vienna, Austria
| | - Christin Hoser
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Hall in Tirol, Austria
| | | | - Raul Mayr
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Raas
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rene Attal
- Department of Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, LKH Feldkirch, Austria
| | - Rohit Arora
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Hall in Tirol, Austria
| | - Michael Liebensteiner
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Orthopädie Knie & Fuß im Zentrum, Innsbruck, Austria
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Dickschas J, Schmeling A, Perl M, Simon M. [Treatment of Permanent Patellar Dislocation in Flexion by Patellar Osteotomy Combined with Modified Trochleoplasty and Tibial Tubercle Medialisation]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023. [PMID: 37604169 DOI: 10.1055/a-2113-1750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Affiliation(s)
- Jörg Dickschas
- Klinik für Orthopädie und Unfallchirurgie, Sozialstiftung Bamberg, Bamberg, Deutschland
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Deutschland
| | - Arno Schmeling
- Sporthopaedicum Berlin, Sporthopaedicum Berlin, Berlin, Deutschland
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Deutschland
| | - Michael Simon
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Deutschland
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Abelleyra Lastoria DA, Kenny B, Dardak S, Brookes C, Hing CB. Is the patella apprehension test a valid diagnostic test for patellar instability? A systematic review. J Orthop 2023; 42:54-62. [PMID: 37483643 PMCID: PMC10362729 DOI: 10.1016/j.jor.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/03/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Patellar instability can arise from a traumatic event with anatomical predisposing factors increasing the risk of dislocation. Accurate diagnosis is required to initiate appropriate treatment. We aimed to evaluate the patella apprehension test (PAT) as a method to diagnose patellar instability. Methods The PRISMA diagnostic test accuracy checklist was followed. The review protocol was registered on PROSPERO with registration number CRD42022357898. Electronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched. A narrative synthesis evaluated the validity of the PAT as a method of diagnosing patellar instability. Results A total of 4867 records were screened in the initial search. Of these, 34 articles satisfied the inclusion criteria, assessing 1139 knees of 1046 patients. The PAT was found to have a high sensitivity and specificity. Its intra and inter-rater reliability was highly variable among studies. Studies reporting patellar instability correction following surgery also found a decrease in the number of patients exhibiting a positive PAT. Conclusion Current evidence suggests that the PAT has a high sensitivity and specificity. The intra- and inter-rater validities of the PAT are widely variable due to its subjective nature. Thus, though the PAT can be used to provide a provisional clinical diagnosis of patellar instability, formal functional assessment and imaging should be performed to confirm the diagnosis. Further research should explore the association between a positive PAT and anatomical parameters. In addition, studies comparing the accuracy of the PAT and radiological investigations should be performed.
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Affiliation(s)
| | - Bethany Kenny
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0RE, United Kingdom
| | - Sara Dardak
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0RE, United Kingdom
- Department of Trauma and Orthopaedics, Queen Elizabeth the Queen Mother Hospital, Margate, CT9 4AN, United Kingdom
| | - Charlotte Brookes
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0RE, United Kingdom
| | - Caroline Blanca Hing
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0RE, United Kingdom
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Ferner F, Dickschas J, Jasinski M, Huettner F, Harrer J, Lutter C. Correction of tibial tubercle trochlea groove distance is related to torsional correction in high tibial derotational osteotomy. Knee Surg Sports Traumatol Arthrosc 2023; 31:1176-1182. [PMID: 36198835 DOI: 10.1007/s00167-022-07190-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE High tibial osteotomy with internal tibial derotation (high tibial derotation osteotomy = HTDRO) is a common surgical treatment in patients with patellofemoral malalignment alone or in combination with patellofemoral instability. Operative techniques and theoretical calculations may assume that correction of the tibial tubercle-trochlear groove (TTTG) distance is related to the amount of torsional correction. The purpose of this investigation was to predict the change in TTTG distance in HTDRO through a clinical study. METHODS Twenty-one consecutive cases of derotational HTO were evaluated by torsional CT scanning in terms of the pre- and postoperative tibial torsion and TTTG distance. Changes in the TTTG distance were related to the changes in the amount of torsional correction. The change in patellar height was measured pre- and postoperatively, and the Caton-Deschamps Index (CDI) was calculated. RESULTS The mean change in tibial torsion was 13.9°, and the mean change in the TTTG distance was 6.3 mm. A strong relationship (0.90) between the change in torsion and the change in TTTG distance from pre- to postoperative status was found (p < 0.001). No statistically significant change in CDI could be seen between the preoperative [mean value (MV) 1.0] and postoperative (MV 1.1) periods. CONCLUSIONS In patients with patellofemoral instability or patellofemoral maltracking with both a high tibial external torsion and a high TTTG distance, a derotational HTO can correct both bony deformities. Patella height does not change significantly with this surgical technique. With 1° of torsional correction, the TTTG distance decreases 0.45 mm with our surgical technique of derotational HTO.
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Affiliation(s)
- Felix Ferner
- Regiomed Klinik Lichtenfels, Prof. Arneth Str. 2b, 96125, Lichtenfels, Germany.
| | | | - Markus Jasinski
- Regiomed Klinik Lichtenfels, Prof. Arneth Str. 2b, 96125, Lichtenfels, Germany
| | - Felix Huettner
- Regiomed Klinik Lichtenfels, Prof. Arneth Str. 2b, 96125, Lichtenfels, Germany
| | - Joerg Harrer
- Regiomed Klinik Lichtenfels, Prof. Arneth Str. 2b, 96125, Lichtenfels, Germany
| | - Christoph Lutter
- Department of Orthopedics, University Medical Center, Rostock, Germany
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Jackson GR, Tuthill T, Gopinatth V, Mameri ES, Jawanda H, Sugrañes J, Asif S, Wessels M, McCormick JR, Kaplan DJ, Yanke AB, Knapik DM, Verma NN, Chahla J. Complication Rates After Medial Patellofemoral Ligament Reconstruction Range From 0% to 32% With 0% to 11% Recurrent Instability: A Systematic Review. Arthroscopy 2023; 39:1345-1356. [PMID: 36764559 DOI: 10.1016/j.arthro.2023.01.098] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/15/2023] [Accepted: 01/27/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE To review the incidence of complications following primary medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. METHODS A literature search was conducted by querying PubMed and Scopus databases from database inception through August 2022 according to the 2020 Preferred Reporting Items for Systematic Review and Meta-analysis guidelines using the terms "Medial Patellofemoral Ligament," "MPFL," "reconstruction," "patellar," and "instability." Inclusion criteria included studies reporting complications following primary MPFL reconstruction for recurrent patellar instability. Exclusion criteria consisted of studies reporting on patients undergoing concurrent osteotomy procedures, revision reconstruction, and biomechanical or anatomic studies. The incidence of specific complications was aggregated from the included studies. RESULTS Twenty-eight studies, consisting of 1,478 patients (n = 1521 knees), with a mean age of 23.3 years (mean range, 19-34.3 years) were identified. The overall incidence of complications ranged from 0% to 32.3% of knees. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures occurred in 0% to 8.3% of knees, primarily in patients treated with full-length transverse tunnel or 2-tunnel techniques. All patellar fractures occurred in patients with patellar tunnels ranging from 4.5 to 6.0 mm in diameter. The incidence of postoperative knee stiffness/range of motion deficit ranged from 0% to 20%. Persistent anterior knee pain, ranged from 0% to 32.3%. CONCLUSIONS Complications following primary MPFL reconstruction ranged from 0% to 32.3% of knees, primarily consisting of residual anterior knee pain. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures were reported in 0% to 8.3% of knees. Fractures primarily occurred with a full-length transverse tunnel or 2-tunnel techniques, whereas all fractures occurred with patellar tunnels ranging from 4.5 mm to 6.0 mm in diameter. LEVEL OF EVIDENCE IV; Systematic Review of Level I-IV studies.
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Affiliation(s)
- Garrett R Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Trevor Tuthill
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Varun Gopinatth
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Enzo S Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Instituto Brasil de Tecnologia da Saúde, Rio de Janeiro, Brazil; Department of Orthopedics and Traumatology, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Joan Sugrañes
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Department of Orthopaedic Surgery, Hospital de La Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Shaan Asif
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Morgan Wessels
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Johnathon R McCormick
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Daniel J Kaplan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Adam B Yanke
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Sherman SL, Rund JM, Welsh JW, Ray T, Worley JR, Oladeji LO, Gray AD, Hinckel BB. Medial Patellofemoral Ligament Reconstruction in Obese Patients Results in Low Complication Rates and Improved Subjective Outcomes. Arthrosc Sports Med Rehabil 2023; 5:e257-e262. [PMID: 36866317 PMCID: PMC9971998 DOI: 10.1016/j.asmr.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/10/2022] [Indexed: 01/06/2023] Open
Abstract
Purpose To compare outcomes, activity scores, and complication rates of obese and non-obese patients undergoing medial patellofemoral ligament (MPFL) reconstruction. Methods A retrospective review identified patients undergoing MPFL reconstruction for recurrent patellofemoral instability. Patients were included if they had undergone MPFL reconstruction and had follow-up for a minimum of 6 months. Patients were excluded if they underwent surgery less than 6 months earlier, had no outcome data recorded, or underwent concomitant bony procedures. Patients were divided into 2 groups based on body mass index (BMI): BMI of 30 or greater and BMI less than 30. Presurgical and postsurgical patient-reported outcomes including Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and the Tegner score were collected. Complications requiring reoperation were recorded. P < .05 was defined as a statistically significant difference. Results A total of 55 patients (57 knees) were included. There were 26 knees with a BMI of 30 or greater and 31 knees with a BMI less than 30. There were no differences in patient demographic characteristics between the 2 groups. Preoperatively, no significant differences were found in KOOS subscores or Tegner scores (P = .21) between groups. At minimum 6-month follow-up (range, 6.1-70.5 months), patients with a BMI of 30 or greater showed statistically significant improvements in the KOOS Pain, Activities of Daily Living, Symptoms, and Sport/Recreation subscores. Patients with a BMI less than 30 showed a statistically significant improvement in the KOOS Quality of Life subscore. The group with a BMI of 30 or greater had significantly lower KOOS Quality of Life (33.34 ± 19.10 vs 54.47 ± 28.00, P = .03) and Tegner (2.56 ± 1.59 vs 4.78 ± 2.68, P = .05) scores. Complication rates were low, with 2 knees (7.69%) requiring reoperation in the cohort with a BMI of 30 or greater and 4 knees (12.90%) requiring reoperation in the cohort with a BMI less than 30, including 1 reoperation for recurrent patellofemoral instability (P = .68). Conclusions In this study, MPFL reconstruction in obese patients was safe and effective, with low complication rates and improvements in most patient-reported outcomes. Compared with patients with a BMI less than 30, obese patients had lower quality-of-life and activity scores at final follow-up. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Seth L. Sherman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California, U.S.A.,Address correspondence to Seth L. Sherman, M.D., 450 Broadway Pavilion A, Redwood City, CA 94063, U.S.A.
| | - Joseph M. Rund
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa, U.S.A
| | - John W. Welsh
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Taylor Ray
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California, U.S.A
| | - John R. Worley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Lasun O. Oladeji
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Aaron D. Gray
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Betina B. Hinckel
- Oakland University, Rochester, Michigan, U.S.A.,Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, U.S.A
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Milinkovic DD, Zimmermann F, Balcarek P. Medial patellofemoral ligament reconstruction using nonresorbable sutures yields comparable outcomes to reconstruction with a pedicled quadriceps tendon autograft when performed in addition to bony risk factor correction. Knee Surg Sports Traumatol Arthrosc 2023; 31:264-271. [PMID: 35972519 PMCID: PMC9859873 DOI: 10.1007/s00167-022-07104-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate the results for reconstruction of the medial patellofemoral ligament using synthetic nonresorbable sutures (S-MPFL-R) in comparison to MPFL-R using quadriceps tendon autograft (QT-MPFL-R) in patients undergoing simultaneous correction of anatomic risk factors for lateral patellar instability (LPI) at a minimum of 2 years of follow-up. METHODS Between November 2018 and June 2019, 19 patients (male/female 8/11; mean age 26 ± 7 years) underwent S-MPFL-R (FiberTape®) in combination with the correction of predisposing risk factors for LPI. The control group of 38 patients (male/female 16/22, mean age 26 ± 6 years) who underwent QT-MPFL-R was matched 1:2 by sex, age, anatomic risk factors, and concomitant surgical correction of bony risk factors. The Banff Patella Instability Instrument 2.0 (BPII 2.0) and a numerical analog scale (NAS 0-10) for patellofemoral pain and subjective knee joint function were used to assess patients' reported quality of life before and after surgery. RESULTS The BPII 2.0 score increased from 35.0 ± 21.7 points to 79.7 ± 13.3 points (p < 0.0001) in the S-MPRL-R group and from 44.3 ± 19.6 points to 80.9 ± 15 points (p < 0.0001) in the QT-MPFL-R group from preoperatively to postoperatively, respectively, without any significant difference between the groups. In the S-MPFL-R group and QT-MPFL-R group, 95% (18/19) and 92% (35/38) of patients, respectively, crossed the minimally clinically important difference reported for the BPII 2.0. NAS values for pain and subjective knee joint function improved significantly in both groups (p < 0.0001, p < 0.0001) without any significant difference between the groups at the final follow-up. CONCLUSIONS This study demonstrates that nonresorbable sutures can serve as a viable option for MPFL-R, yielding comparable outcomes compared to quadriceps tendon autograft reconstruction when performed concomitantly with the correction of anatomic risk factors for LPI. This option reduces the need for autologous tendon harvesting or the use of allografts for MPFL-R. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Danko Dan Milinkovic
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Luisenstrasse 64, 10117, Berlin, Germany.
| | - Felix Zimmermann
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Peter Balcarek
- Arcus Sportklinik, Pforzheim, Germany ,Department of Trauma Surgery, Orthopaedics, and Plastic Surgery, University Medicine Göttingen, Göttingen, Germany
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Koshino Y, Taniguchi S, Kobayashi T, Samukawa M, Inoue M. Protocols of rehabilitation and return to sport, and clinical outcomes after medial patellofemoral ligament reconstruction with and without tibial tuberosity osteotomy: a systematic review. INTERNATIONAL ORTHOPAEDICS 2022; 46:2517-2528. [PMID: 35701590 DOI: 10.1007/s00264-022-05480-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/08/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE No consensus exists on rehabilitation programmes after medial patellofemoral ligament reconstruction (MPFLR) with or without tibial tuberosity osteotomy (TTO). This systematic review examined the content and timeline of rehabilitation (weightbearing, range of motion [ROM] and exercise therapy) and return to sport (RTS), as well as patient-reported outcomes after MPFLR with or without TTO. METHODS The PubMed, Cochrane Library, Web of Sciences, CINAHL and SPORTDiscus databases were searched from inception to December 2021. Studies that reported postoperative rehabilitation programmes and patient-reported outcomes for patients aged ≥ 18 years who underwent MPFLR with or without concomitant TTO were included. RESULTS Eighty-five studies were included, 57 of which were case series and only one randomised controlled trial on rehabilitation programmes. Non-weightbearing was set within one week post-operatively in approximately 80% of weightbearing programmes for MPFLR without and with TTO. Joint immobilisation was set within one week post-operatively in 65.3% and 93.8% of programmes for MPFLR without and with TTO, respectively. Weightbearing and ROM (≤ 90°) restriction were within three weeks post-operatively for > 50% of the programmes. Quadriceps strengthening was the most cited exercise therapy (33 programmes), most often initiated within two weeks post-operatively. However, few other exercise programmes were cited (only nine programmes). RTS was mostly noted at six months post-operatively (35 programmes). The weighted mean Kujala score was 87.4 points. CONCLUSION Regardless of TTO addition to MPFLR, most studies restricted weightbearing and ROM only in the early post-operative period, with seemingly favourable clinical results. Limited information was available on post-operative exercise therapy.
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Affiliation(s)
- Yuta Koshino
- Rehabilitation Center, NTT Medical Center Sapporo, South 1, West 15, Chuo-ku, Sapporo, Hokkaido, 060-0061, Japan.
| | - Shohei Taniguchi
- Rehabilitation Center, NTT Medical Center Sapporo, South 1, West 15, Chuo-ku, Sapporo, Hokkaido, 060-0061, Japan
| | - Takumi Kobayashi
- Department of Rehabilitation, Hokkaido Chitose College of Rehabilitation, Chitose, Japan
| | - Mina Samukawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Masayuki Inoue
- Department of Orthopaedic Surgery, NTT Medical Center Sapporo, Sapporo, Japan
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10
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Influence of the Fluoroscopy Setting towards the Patient When Identifying the MPFL Insertion Point. Diagnostics (Basel) 2022; 12:diagnostics12061427. [PMID: 35741237 PMCID: PMC9221608 DOI: 10.3390/diagnostics12061427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 11/24/2022] Open
Abstract
(1) The malposition of the femoral tunnel in medial patellofemoral ligament (MPFL) reconstruction can lead to length changes in the MPFL graft, and an increase in medial peak pressure in the patellofemoral joint. It is the cause of 36% of all MPFL revisions. According to Schöttle et al., the creation of the drill canal should be performed in a strictly lateral radiograph. In this study, it was hypothesized that positioning the image receptor to the knee during intraoperative fluoroscopy would lead to a relevant mispositioning of the femoral tunnel, despite an always adjusted true-lateral view. (2) A total of 10 distal femurs were created from 10 knee CT scans using a 3D printer. First, true-lateral fluoroscopies were taken from lateral to medial at a 25 cm (LM25) distance from the image receptor, then from medial to lateral at a 5 cm (ML5) distance. Using the method from Schöttle, the femoral origin of the MPFL was determined when the femur was positioned distally, proximally, superiorly, and inferiorly to the image receptor. (3) The comparison of the selected MPFL insertion points according to Schöttle et al. revealed that the initial determination of the point in the ML5 view resulted in a distal and posterior shift of the point by 5.3 mm ± 1.2 mm when the point was checked in the LM25 view. In the opposite case, when the MPFL insertion was initially determined in the LM25 view and then redetermined in the ML5 view, there was a shift of 4.8 mm ± 2.2 mm anteriorly and proximally. The further positioning of the femur (distal, proximal, superior, and inferior) showed no relevant influence. (4) For fluoroscopic identification of the femoral MPFL, according to Schöttle et al., attention should be paid to the position of the fluoroscopy in addition to a true-lateral view.
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11
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Meynard P, Malatray M, Sappey-Marinier E, Magnussen RA, Bodiou V, Lustig S, Servien E. Medial patellofemoral ligament reconstruction for recurrent patellar dislocation allows a good rate to return to sport. Knee Surg Sports Traumatol Arthrosc 2022; 30:1865-1870. [PMID: 34846539 DOI: 10.1007/s00167-021-06815-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Recurrent patellar dislocation is a frequent knee disorders in young, active patients. Medial patellofemoral ligament reconstruction (MPFLR) can restore knee stability and function, but the rate of return to sports is less clear. The aim of this study was to evaluate rate of return to sport following treatment of recurrent patellar dislocation with isolated MPFLR. METHODS Between 2011 and 2018, 113 patients with recurrent patellar dislocation were treated with isolated MPFLR at an academic center. Pre-injury sports participation and Tegner score, pre-operative subjective IKDC score, time to return to sports, and post-operative Tegner and subjective IKDC scores were collected, with a minimum of follow-up of 2 years. RESULTS One hundred and three patients (91%) were evaluated at a mean of 4.5 ± 2.5-year post-operative. 92 patients (89%) participated in sports prior to onset of patellar instability. At final follow-up, 84 of these 92 patients (91%) were able to return to sports. The mean time from surgery to return to sports was 10.4 ± 8.6 months (range: 2-48 months). 62 patients (67%) returned to the same (50 patients) or higher (12 patients) level. 22 patients (26%) returned at a lower level. 19 of these patients attributed this decreased participation to ongoing knee problems. The median Tegner score was noted to decrease from 5 pre-injury to 4 post-operatively (p = 0.02). CONCLUSION Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients, with 67% of patients returning to the same or higher level than pre-injury. Mean time to return to sports was 10 months and post-operative Tegner score was noted to be modestly decreased from pre-injury level. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Pierre Meynard
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France.
| | - Matthieu Malatray
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France
| | - Elliot Sappey-Marinier
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France
| | - Robert A Magnussen
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, OH, USA
| | - Victor Bodiou
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France
| | - Sébastien Lustig
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France.,LBMC UMR T 9406, Laboratory of Chock Mechanics and Biomechanics, Claude Bernard Lyon 1 University, 69100, Villeurbanne, France
| | - Elvire Servien
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France.,LIBM-EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, 69100, Villeurbanne, France
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12
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Lubis AMT, Menkher MAR, Setyawan R. Medial patellofemoral ligament reconstruction using superficial layer of quadriceps tendon autograft: A case series of three patients. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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13
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Kamalapathy P, K Rush J, Montgomery SR, Diduch DR, Werner BC. A National Perspective of Patellar Instability in Children and Adolescents in the United States: MPFL Reconstruction Is Three Times Higher Than the Incidence of Isolated Lateral Release. Arthroscopy 2022; 38:466-473.e1. [PMID: 34126218 DOI: 10.1016/j.arthro.2021.05.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/17/2021] [Accepted: 05/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The objective was to (1) evaluate any recent changes in the United States in the incidences of medial patellofemoral ligament (MPFL) reconstruction and isolated lateral release for patellar instability in children and adolescents, (2) identify concomitant procedures with MPFL, and (3) report national complication rates after MPFL reconstruction with and without concomitant procedures in children and adolescents. METHODS A national database was queried for patients aged 5 to 18 years who underwent operative treatment for patellar instability from 2010 to 2018. Inclusion criteria were either an MPFL reconstruction or lateral release for a diagnosis of patellar instability. Concomitant procedures with MPFL reconstruction assessed were tibial tubercle osteotomy, associated arthroscopic procedures, and lateral release. Changes in incidence in MPFL reconstruction, lateral release and concomitant procedures were assessed. The following postoperative complications were assessed: knee stiffness, infection, patella fracture, and growth arrest or angular deformity. RESULTS 2,161 patients who underwent MPFL reconstruction and 1,159 patients who underwent isolated lateral release for patellar instability were identified. The incidence of MPFL reconstruction in adolescents from 2010 to 2018 did not change significantly (2010: 7.11, 2018: 5.91, P = .137), while isolated lateral release decreased (2010: 6.06, 2018: 1.83, P < .0001). Concomitant procedures with MPFL reconstruction were common, with arthroscopy being the most frequent (58-67%). The most common complication within 90 days of surgery was patella fracture (0.4% to 2.0%). Infection (0.4% to 1.0%) and growth arrest (0.09% to 0.61%) were the least common. MPFL and arthroscopy had a decreased risk of growth arrest following surgery compared to MPFL alone (P = .038). CONCLUSIONS The incidence of MPFL reconstruction remained high from 2010 to 2018, while isolated lateral release decreased during the same time period. Complications after MPFL reconstruction, isolated lateral release, and concomitant procedures were infrequent, with postoperative patella fracture the most common. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Pramod Kamalapathy
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Jeremy K Rush
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Samuel R Montgomery
- School of Medicine, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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14
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Kim HJ, Shin JY, Kim KR, Lee HJ, Park KH, Kim JW, Oh CW, Kyung HS. Results and Factors Affecting Clinical Efficacy of Medial Patellofemoral Ligament Reconstruction Using a Gracilis Tendon Suture Technique. Clin Orthop Surg 2022; 14:386-392. [PMID: 36061836 PMCID: PMC9393271 DOI: 10.4055/cios21093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 12/04/2022] Open
Abstract
Background This study evaluated the outcomes of medial patellofemoral ligament (MPFL) reconstruction using a gracilis tendon suture technique for patients with patellar instability. Potential factors affecting clinical efficacy were also evaluated. Methods This study included 22 patients diagnosed with patellar instability, who underwent MPFL reconstruction using a gracilis tendon. Their mean age was 21.5 years (range, 15–48 years), and the mean follow-up period was 26.8 months (range, 12–66 months). Clinical evaluation included the determination of Kujala, Lysholm, and Tegner scores. Radiographic evaluation included changes in congruence angle and arthritic changes in the patellofemoral joint. Additionally, patients were examined for any complications, including recurrent dislocation. Factors affecting clinical efficacy were also evaluated. Results All clinical scores improved at final follow-up. The mean congruence angle improved from 23.6° before surgery to –6.5° at final follow-up. Two of 15 patients developed osteoarthritic changes in the patellofemoral joint. Dislocation recurred in 2 patients with type C trochlear dysplasia, which showed a statistically significant association with recurrent dislocation when compared to type A and B dysplasia (p = 0.026). Kujala scores were significantly lower among patients with abnormal patellar tilts (p = 0.038), and Lysholm scores were significantly lower among patients with femoral internal rotation deformity (p = 0.024). Conclusions Satisfactory results were obtained after MPFL reconstruction using a gracilis tendon suture technique for patients with patellar instability. However, dislocation recurred in patients with type C trochlear dysplasia, and clinical efficacy was lower among patients with femoral internal rotation and patellar tilt.
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Affiliation(s)
- Hee-June Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ji-Yeon Shin
- Department of Preventive Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kyung-Rock Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun-Joo Lee
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hee-Soo Kyung
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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15
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Migliorini F, Baroncini A, Eschweiler J, Tingart M, Maffulli N. Interference screws vs. suture anchors for isolated medial patellofemoral ligament femoral fixation: A systematic review. JOURNAL OF SPORT AND HEALTH SCIENCE 2022; 11:123-129. [PMID: 33259964 PMCID: PMC8847917 DOI: 10.1016/j.jshs.2020.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/02/2020] [Accepted: 10/19/2020] [Indexed: 06/12/2023]
Abstract
PURPOSE The present study aimed to systematically review and compare 2 femoral autograft fixation techniques, namely, interference screws and suture anchors, for isolated medial patellofemoral ligament reconstruction in patients with recurrent patellofemoral instability at mid- to long-term follow-up. METHODS A literature search was performed in September 2020. All studies reporting the outcomes of primary isolated medial patellofemoral ligament reconstruction for recurrent patellofemoral instability were considered for inclusion. Only studies reporting the type of femoral autograft fixation under examination were considered. Studies reporting data from patients with elevated tibial tuberosity-tibial groove, patella alta, and/or Dejour's trochlear dysplasia types C and D, were not included. Only articles reporting data with a minimum follow-up period of 18 months were considered. RESULTS Data from 19 studies (615 patients) were retrieved. The overall age was 24.4 ± 6.7 years (mean ± SD). The mean follow-up was 46.5 ± 20.9 months. There were 76 patients in the anchor group and 539 in the screw group. Comparability was found with regard to age and follow-up duration between the 2 study groups. There was comparability between the Kujala, Lysholm, and Tegner scores at baseline. At the last follow-up, no worthy differences were found in terms of mean Kujala (+2.1%; p = 0.04), Lysholm (+1.7%; p = 0.05), and Tegner (+15.8%; p = 0.05) scores. Although complications occurred almost exclusively in the screw cohort, no statistically significant difference was found. CONCLUSION Femoral autograft fixation through interference screws or suture anchors report similar clinical scores and rate of apprehension test, persistent joint instability, re-dislocations, and revisions. These results must be interpreted within the limitations of the present study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Clinic, Aachen 52074, Germany.
| | - Alice Baroncini
- Department of Orthopaedics, University Clinic Aachen, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Clinic, Aachen 52074, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics, University Clinic Aachen, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Clinic, Aachen 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics, University Clinic Aachen, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Clinic, Aachen 52074, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi 84081, Italy; School of Pharmacy and Bioengineering, School of Medicine, Keele University, Stoke on Trent ST4 7QB, UK; Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London E1 4DG, UK
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16
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Biomechanical comparison of two medial patellofemoral ligament reconstruction techniques: Quadriceps tendon fixation versus single-tunnel patella fixation with gracilis autograft did not differ in load to failure and stiffness. Knee 2021; 33:169-175. [PMID: 34626887 DOI: 10.1016/j.knee.2021.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/08/2021] [Accepted: 09/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the ultimate failure load and stiffness of two patellar fixation techniques for medial patellofemoral ligament (MPFL) reconstruction: (1) quadriceps tendon fixation (QT), (2) single tunnel (STG) patella fixation with gracilis autograft. METHODS A total of 16 fresh-frozen cadaveric knees (eight matched pairs) were randomized into two groups (QT vs. STG). The MPFL reconstructions were subjected to cyclic loading for 10 cycles to 30 N and then tested to failure at a constant displacement rate of 15 mm/min using a materials-testing machine (MTS 810 Universal Testing System). Failure mode, ultimate failure load and stiffness were recorded for each cadaveric specimen. RESULTS There was no significant difference in mean ultimate failure load among groups (P = 0.35). The STG group failed at a mean ultimate load of 190.04 N [standard deviation (SD) 23.18] and the QT group failed at 206.24 N (SD 37.99). The STG group had a mean stiffness of 21.38 N/mm (SD 1.44). This was not significantly higher than the mean stiffness value achieved for the QT group at 20.36 N/mm (SD 1.3) (P = 0.19). In the QT group all reconstructions failed due to tendon rupture at the patella attachment. The reason for failure in the STG group was the graft-suture connection. CONCLUSIONS This cadaver study showed no statistically significant difference in biomechanical performance of the evaluated patella fixation techniques, in terms of maximum load to failure and stiffness. Both techniques are reliable in terms of biomechanical properties and could offer additional surgical solutions.
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Olotu O, Siddiqui A, Peterson D, de Sa D. The Superficial "Swing-Down" Quadriceps Tendon Autograft Is a Viable Option for Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Arthroscopy 2021; 37:3187-3197. [PMID: 33961979 DOI: 10.1016/j.arthro.2021.04.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review is to ascertain the reported clinical outcomes and complication profiles of medial patellofemoral ligament (MPFL) reconstruction performed using a superficial "swing-down" quadriceps tendon autograft. METHODS Three databases (PubMed, EMBASE, and MEDLINE) were searched from January 1, 2000, to April 06, 2020. Keywords used in the search included: "medial patellofemoral ligament" and "reconstruction". After screening based on inclusion and exclusion criteria, patient demographics, graft type, outcomes, and complications were extracted. Methodological Index for Non-Randomized Studies criteria were used to assess the quality of each included study. RESULTS Eleven studies were included, comprising data from 226 patients with mean follow up ranging from 12 to 38 months. All reconstructions used a superficial "swing-down" quadriceps tendon autograft fixed at 20-30 degrees of knee flexion where reported. Eight of eleven studies reported significant improvement in patient reported outcomes such as Kujala score, Lysholm score, and Tegner score. The mean preoperative Kujala score ranged from 35.8 to 82.1 (167 patients), while the mean postoperative Kujala score ranged from 88.4 to 94.8 (197 patients). The mean of the preoperative Lysholm score ranged from 43.3 to 79.3 (77 patients), while the mean of the postoperative Lysholm score ranged from 81.9 to 90.9 (99 patients). The I2 statistic for Lysholm and Kujala scores was 94% and 97%, respectively. Across data reported on 194 patients, there was no incidence of patellar redislocation, patellar fracture, or graft site morbidity. CONCLUSION The quadriceps tendon produced improved clinical outcomes with low rates of recurrent postoperative patellar dislocation. These data suggest that the quadriceps tendon remains a suitable alternative for MPFL reconstruction and should remain part of the arsenal of knee ligament surgeons. LEVEL OF EVIDENCE Systematic review of Level III and IV studies.
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Affiliation(s)
- Olumide Olotu
- MACSports Research Program, McMaster University, Hamilton, Ontario, Canada; School of Medicine, St. George's University, True Blue, Grenada, West Indies
| | - Ali Siddiqui
- MACSports Research Program, McMaster University, Hamilton, Ontario, Canada
| | - Devin Peterson
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
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Parvaresh K, Huddleston HP, Yanke AB. Medial Patellofemoral Ligament Reconstruction With Concomitant Lateral Patellofemoral Reconstruction for Patellar Instability. Arthrosc Tech 2021; 10:e2099-e2106. [PMID: 34504748 PMCID: PMC8417223 DOI: 10.1016/j.eats.2021.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/17/2021] [Indexed: 02/03/2023] Open
Abstract
Patients with bidirectional patellar instability who are unresponsive to conservative management may benefit from a medial patellofemoral ligament (MPFL) reconstruction and lateral patellofemoral ligament (LPFL) reconstruction. If an isolated MPFL reconstruction does not provide adequate stabilization intraoperatively, combined MPFL and LPFL reconstruction allows independent reconstruction, which can be performed with a facile, reproducible technique. The purpose of this report was to describe our technique for performing an MPFL reconstruction with a concurrent soft-tissue LPFL reconstruction combined with a distalizing tibial tubercle osteotomy to correct patella alta.
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Affiliation(s)
| | | | - Adam B. Yanke
- Address correspondence to Adam B. Yanke, M.D., Ph.D., Rush University Medical Center, 1611 W Harrison St., Chicago, IL 60612.
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Milinkovic DD, Fink C, Kittl C, Sillanpää P, Herbst E, Raschke MJ, Herbort M. Anatomic and Biomechanical Properties of Flat Medial Patellofemoral Ligament Reconstruction Using an Adductor Magnus Tendon Graft: A Human Cadaveric Study. Am J Sports Med 2021; 49:1827-1838. [PMID: 33960859 DOI: 10.1177/03635465211009540] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND In contrast to the majority of existing techniques for reconstruction of the medial patellofemoral ligament (MPFL), the technique described in this article uses the adductor magnus muscle tendon to gain a flat, broad graft, leaving its distal femoral insertion intact, and does not require drilling within or near the femoral physis. It also allows for soft tissue patellar fixation and could facilitate anatomic MPFL reconstruction in skeletally immature patients. PURPOSE To evaluate the anatomic and structural properties of the native MPFL and the adductor tendon (AT), followed by biomechanical evaluation of the proposed reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS The morphological and topographical features of the AT and MPFL were evaluated in 12 fresh-frozen cadaveric knees. The distance between the distal insertion of the AT on the adductor tubercle and the adductor hiatus, as well as the desired length of the graft, was measured to evaluate this graft's application potential. Load-to-failure tests were performed to determine the biomechanical properties of the proposed reconstruction construct. The construct was placed in a uniaxial testing machine and cyclically loaded 500 times between 5 and 50 N, followed by load to failure, to measure the maximum elongation, stiffness, and maximum load. RESULTS The mean ± SD length of the AT was 12.6 ± 1.5 cm, and the mean distance between the insertion on the adductor tubercle and adductor hiatus was 10.8 ± 1.3 cm, exceeding the mean desired length of the graft (7.5 ± 0.5 cm) by 3.3 ± 0.7 cm. The distal insertion of the AT was slightly proximal and posterior to the insertion of the MPFL. The maximum elongation after cyclical loading was 1.9 ± 0.4 mm. Ultimately, the mean stiffness and load to failure were 26.2 ± 7.6 N/mm and 169.7 ± 19.2 N, respectively. The AT graft failed at patellar fixation in 2 of the initially tested specimens and at the femoral insertion in the remaining 10. CONCLUSION The described reconstruction using the AT has potential for MPFL reconstruction. The AT graft presents a graft of significant volume, beneficial anatomic topography, and adequate tensile properties in comparison with the native MPFL following the data from previously published studies. CLINICAL RELEVANCE Given its advantageous anatomic relationship as an application that avoids femoral drilling and osseous patellar fixation, the AT may be considered a graft for MPFL reconstruction in skeletally immature patients.
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Affiliation(s)
| | - Christian Fink
- Gelenkpunk-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | | | - Petri Sillanpää
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Pihlajalinna Koskisairaala Hospital, Tampere, Finland
| | | | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.,OCM Orthopedic Surgery Munich Clinic, Munich, Germany
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Migliorini F, Trivellas A, Eschweiler J, Betsch M, Tingart M, Maffulli N. Pedicled Strip of Quadriceps Tendon Graft for Primary Medial Patellofemoral Ligament Reconstruction in Recurrent Patellofemoral Instability: A Systematic Review. Arthroscopy 2021; 37:1992-1999. [PMID: 33539974 DOI: 10.1016/j.arthro.2021.01.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 01/10/2021] [Accepted: 01/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE A systematic review of the literature was conducted to ascertain advantages and limitations, update current evidences, and investigate the role of a pedicled quadriceps tendon autograft for primary medio-patellofemoral ligament (MPFL) reconstruction in patients with recurrent patellofemoral instability. METHODS The present systematic review was performed according to the PRISMA guidelines. The literature search was conducted in September 2020. All the clinical studies investigating the role of a pedicled strip of quadriceps tendon autograft for primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. Studies investigating the role of MPFL reconstruction combined with additional surgical procedures except for lateral retinacular release were excluded. The methodological quality assessment was performed through the modified Coleman Methodology score. RESULTS Data from 9 articles (191 procedures) were retrieved. The mean follow-up was 12 to 38 months. The mean age of the patients was 11.5 to 25.2 years. One hundred twenty of 191 patients were female. All clinical scores showed significant improvement following the procedures. The Kujala score improved of 32.52% points (P < 0.0001), the Lysholm score of 23.74% (P = 0.006), the Tegner scale improved of 8.6% (P = 0.02). Concerning complications, after surgery the apprehension test was positive in 5 of 166 patients, and persistent joint instability was found in 5 of 149 patients. No patient experienced any re-dislocations or underwent reoperations. CONCLUSIONS The use of pedicled strip of quadriceps tendon as graft for MPFL reconstruction is a suitable choice in patients with recurrent patellar instability. Although frequently associated with a lateral release, it is unclear whether the latter is necessary for the success of the technique. Appropriately powered randomized controlled trials comparing this graft source to the others commonly used are necessary to at least ascertain the noninferiority of this graft to the others. LEVEL OF EVIDENCE IV, Systematic review of Level III-IV studies.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Aachen, Germany
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Jörg Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Aachen, Germany
| | - Marcel Betsch
- University of Toronto Orthopaedic Sports Medicine Program (UTOSM), Womenás College Hospital, Toronto, Canada
| | - Markus Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, England; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, England.
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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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Migliorini F, Oliva F, Maffulli GD, Eschweiler J, Knobe M, Tingart M, Maffulli N. Isolated medial patellofemoral ligament reconstruction for recurrent patellofemoral instability: analysis of outcomes and risk factors. J Orthop Surg Res 2021; 16:239. [PMID: 33823887 PMCID: PMC8022360 DOI: 10.1186/s13018-021-02383-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/24/2021] [Indexed: 12/17/2022] Open
Abstract
Background The medial patellofemoral ligament (MPFL) is always damaged after patellar dislocation. In selected patients, MPFL reconstruction is necessary to restore a correct patellar tracking. Despite the large number of different techniques reported to reconstruct the MPFL, there is no consensus concerning the optimal procedure, and debates is still ongoing. The present study analysed the results after isolated MPFL reconstruction in patients with patellofemoral instability. Furthermore, a subgroup analysis of patients presenting pathoanatomical risk factors was made. Methods In November 2020, the main electronic databases were accessed. All articles reporting the results of primary isolated MPFL reconstruction for recurrent patellofemoral instability were considered for inclusion. Only articles reporting a minimum 12-month follow-up were eligible. Results Data from a total of 1777 knees were collected. The mean age of the patients involved was 22.8 ± 3.4 years. The mean follow-up was 40.7 ± 25.8 months. Overall, the range of motion (+ 27.74; P < 0.0001) and all the other scores of interests improved at last follow-up: Kujala (+ 12.76; P = 0.0003), Lysholm (+ 15.69; P < 0.0001), Tegner score (+ 2.86; P = 0.006). Seventy-three of 1780 patients (4.1%) showed a positive apprehension test. Thirty of 1765 patients (1.7%) experienced re-dislocations, while 56 of 1778 patients (3.2%) showed persisting joint instability. Twenty-five of 1786 patients (1.4%) underwent revision surgeries. Conclusion Isolated MPFL reconstruction for recurrent patellofemoral instability provides reliable surgical outcomes. Patients with pathoanatomical predisposing factors reported worse surgical outcomes.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | | | - Jörg Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Matthias Knobe
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Markus Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, 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, UK.,School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, UK
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Manjunath AK, Hurley ET, Jazrawi LM, Strauss EJ. Return to Play After Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Am J Sports Med 2021; 49:1094-1100. [PMID: 32866030 DOI: 10.1177/0363546520947044] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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 being performed more frequently in athletes experiencing recurrent patellar instability. PURPOSE/HYPOTHESIS The purpose was to systematically review the evidence in the orthopaedic sports medicine literature to determine both the rate and timing of return to play after MPFL reconstruction and the rate of further patellar instability. Our hypothesis was that there would be a high rate of return to play after MPFL reconstruction. STUDY DESIGN Systematic review. METHODS A systematic literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which utilized EMBASE, MEDLINE, and the Cochrane Library databases. Inclusion criteria for literature included clinical studies reporting on return to play after MPFL reconstruction. Rate of return to play, level of return, timing of return, rate of recurrent instability, and patient-reported outcomes were evaluated. Statistical analysis was performed using SPSS. RESULTS Our review found 27 studies including 1278 patients meeting our inclusion criteria. The majority of patients were women (58%), and the total group had a mean age of 22.0 years and a mean follow-up of 39.3 months. The overall rate of return to play was 85.1%, with 68.3% returning to the same level of play. The average time to return to play was 7.0 months postoperatively. The rate of recurrent instability events following reconstruction was 5.4%. There was an improvement in both mean visual analog scale, pain scores (preoperative: 4.3, postoperative: 1.6) and Tegner activity scores (preoperative: 4.8, postoperative: 5.5). CONCLUSION The overall rate of return to play was high after MPFL reconstruction for the treatment of recurrent patellar instability. However, a relatively high percentage of those patients were unable to return to their preoperative level of sport. Additionally, there was a moderate time taken to return to play, at approximately 7 months after the procedure.
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Affiliation(s)
- Amit K Manjunath
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
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Migliorini F, Maffulli N, Eschweiler J, Quack V, Tingart M, Driessen A. Lateral retinacular release combined with MPFL reconstruction for patellofemoral instability: a systematic review. Arch Orthop Trauma Surg 2021; 141:283-292. [PMID: 33315122 PMCID: PMC7886734 DOI: 10.1007/s00402-020-03689-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 11/11/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The role of the lateral retinaculum in patellofemoral instability is still debated. Lateral retinacular release (LRR), has been extensively performed in combination with different surgical procedures, including reconstruction of medio-patellofemoral ligament (MPFL). Despite controversial indications, the results from these studies seem promising. The present study conducts a systematic review about current biomechanical and clinical evidence concerning the role of LRR in combination with MPFL reconstruction. We performed a comprehensive literature research, comparing the outcomes of MPFL reconstruction with and without LRR. MATERIALS AND METHODS This systematic review was conducted according to the PRISMA guidelines. The literature search was performed in August 2020. All articles describing the outcome of isolated MPFL reconstruction alone or in combination with a LRR in patients with recurrent patellofemoral instability were considered for inclusion. Only articles reporting data on patients with a minimum of 12-month follow-up were included. Only articles reporting quantitative data under the outcomes of interest were included. RESULTS A total of 63 articles were eligible for this systematic review, including 2131 knees. The mean follow-up was 40.87 ± 24.1 months. All scores of interests improved in favour of the combined group: Kujala + 3.8% (P = 0.01), Lysholm + 4.2% (P = 0.004), Tegner + 0.8 points (P = 0.04), IKDC + 9.8% (P = 0.02). The ROM was comparable between the two groups (P = 0.4). Similarity was found in terms of positivity to the apprehension test (P = 0.05), rate of complications (P = 0.1), re-dislocations (P = 0.8), and revision surgeries (P = 0.1). CONCLUSION There is no evidence that adding a lateral release impacts positively on the outcome of MPFL reconstruction. LEVEL OF EVIDENCE IV, Systematic review.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074 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 ,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
| | - Jörg Eschweiler
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Valentin Quack
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Arne Driessen
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074 Aachen, Germany
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Mayer P, Schuster P, Schlumberger M, Eichinger M, Pfaff M, Immendörfer M, Richter J. Midterm Results after Implant-Free Patellar Fixation Technique for Medial Patellofemoral Ligament Reconstruction. J Knee Surg 2020; 33:1140-1146. [PMID: 31269526 DOI: 10.1055/s-0039-1692654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Problems and complications concerning the patellar fixation in medial patellofemoral ligament reconstruction (MPFLR) have been reported. The purpose of this retrospective study was to systematically analyze the surgical technique for MPFLR with a V: -shaped patellar bonetunnel for implant-free fixation of an autologous gracilis tendon, allowing early functional rehabilitation, regarding restoration of the patellofemoral stability, patient satisfaction, return to sports, and technique-specific complications. In 2010, 128 cases of consecutive isolated MPFLR were performed. All these cases were included. After a minimum follow-up of 3 years, 104 cases were retrospectively analyzed (follow-up: 81.3%) with regard to redislocation, subjective functional outcome (Tegner's score and sports level compared with preoperative level), patient satisfaction, revision surgery, and technique-specific complications. After a follow-up of 45.7 ± 3.2 months, 101 of 104 cases (97.1%) showed no redislocation. Mean Tegner's score was 5.1 ± 1.8 (range, 2-9). A total of 61.5% patients reported about a higher sports level compared with their preoperative level. The patient satisfaction was high with 94.2%. In two cases (1.9%), technique-specific problems occurred as the bone bridge of the V: -shaped tunnel was insufficient due to a malpositioning of the aiming device. No further technique-specific problems occurred and no revision surgery was necessary during the observational period. The presented surgical technique is safe and it reliably restores the patellofemoral stability, with a low rate of redislocations, an excellent subjective functional outcome, and a high-patient-reported satisfaction. No major technique-specific complications occurred.
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Affiliation(s)
- Philipp Mayer
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Philipp Schuster
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany.,Paracelsus Medical Private University, Clinic Nuremberg Departement of Orthopedics and Traumatology, Nuremberg, Germany
| | - Michael Schlumberger
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Martin Eichinger
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Michael Pfaff
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Micha Immendörfer
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
| | - Jörg Richter
- Center for Sports Orthopedics and Special joint surgery, Orthopedic Hospital Markgröningen, Markgröningen, Germany
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Medial patellofemoral ligament reconstruction using a central strip of the quadriceps tendon in patients with recurrent patellar instability: a prospective case series. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Medial patellofemoral ligament reconstruction using a partial-thickness quadriceps tendon graft: Short-term clinical outcome retrospective case series. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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An VV, Sivakumar BS, Phan K, Fritsch BA, Sher D. Isolated versus combined medial patellofemoral ligament reconstruction for lateral instability of the patella. J Orthop Surg (Hong Kong) 2020; 27:2309499018820698. [PMID: 30798706 DOI: 10.1177/2309499018820698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Medial patellofemoral ligament reconstruction (MPFLR) is regularly combined with a tibial tuberosity transfer (TTT) in cases of recurrent patellar instability with underlying structural deformity. However, these indications for a TTT have recently come into question. This study aimed to assess the traditional indications by comparing the outcomes of isolated and combined MPFLR for the treatment of recurrent lateral patellar dislocation. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies were those which reported the outcomes of either isolated or combined or both MPFLR. Studies were required to report at least one of the following: redislocation rate, revision due to instability, or the Kujala score. RESULTS We found no difference between isolated and combined MPFLR in terms of redislocation ( p = 0.48), revisions due to instability ( p = 0.36), positive apprehension tests ( p = 0.25), or the Kujala score ( p = 0.58). Combined reconstruction presented more complications compared to isolated procedures ( p = 0.05). Subgroup analysis revealed no significant difference between studies investigating isolated medial patellofemoral ligament reconstruction MPFLR performed in patients with normal tibial tuberosity-trochlear groove (TT-TG) distances only or in patients with both normal and elevated TT-TG distances. CONCLUSIONS According to the published data, there is no difference in outcomes between isolated and combined MPFLR. Underlying structural deformity did not demonstrate any significant effect on the success of the isolated MPFLR. Although there are definite indications for combined reconstruction, the current evidence suggests that our inclusion criteria may not be entirely correct. Further study is required to clarify and refine the true indications for combined MPFLR. LEVEL OF EVIDENCE III, meta-analysis of nonrandomized studies.
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Affiliation(s)
- Vincent Vg An
- 1 Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Brahman S Sivakumar
- 2 Department of Orthopaedics, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Kevin Phan
- 1 Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Brett A Fritsch
- 3 Department of Orthopaedics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Doron Sher
- 4 Department of Orthopaedics, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Migliorini F, Trivellas A, Driessen A, Quack V, Tingart M, Eschweiler J. Graft choice for isolated MPFL reconstruction: gracilis versus semitendinosus. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:763-770. [PMID: 32008097 PMCID: PMC7990750 DOI: 10.1007/s00590-020-02636-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/29/2020] [Indexed: 01/25/2023]
Abstract
INTRODUCTION After the first patellar dislocation, most patients report damage of the medio-patellofemoral ligament (MPFL) and surgical reconstruction is required. The purpose of this study is to systematically review current evidence and to clarify the role of the gracilis and semitendinosus tendons as graft for isolated MPFL reconstruction. MATERIALS AND METHODS The present systematic review was conducted according to the PRISMA guidelines. The literature search was conducted in October 2019. All clinical trials using the semitendinosus and/or gracilis tendon grafts for isolated MPFL reconstruction in patients with patellofemoral instability were considered for inclusion. Only articles reporting a minimum of 12-month follow-up were considered. The PEDro score was used for the methodological quality assessment. RESULTS Data from 1491 procedures were collected. The mean follow-up was 36.12 months. There was comparability among the patient baseline. All the scores of interests (Kujala, Tegner, Lysholm) and range of motion scored better in the semitendinosus group. Moreover, in favour of the semitendinosus group, a statistically significant reduction of the revision surgeries and re-dislocations were evidenced. Apprehension test and persistent instability sensation found any statistical correlations. CONCLUSION Isolated MPFL reconstruction through semitendinosus tendon graft performed better than the gracilis in selected patients suffering from recurrent patellofemoral instability.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Suite 755, Los Angeles, CA, 90095, USA
| | - Arne Driessen
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Valentin Quack
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
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30
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Migliorini F, Trivellas A, Colarossi G, Eschweiler J, Tingart M, Rath B. Single- versus double-bundle patellar graft insertion for isolated MPFL reconstruction in patients with patellofemoral instability: a systematic review of the literature. Arch Orthop Trauma Surg 2020; 140:769-776. [PMID: 32086557 PMCID: PMC8289805 DOI: 10.1007/s00402-020-03376-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The MPFL reconstruction is performed either via a single-bundle (SB) or double-bundle (DB) procedure. The purpose of this study is to perform a systematic review comparing SB versus DB graft for recurrent patellofemoral instability, to summarize current evidence, and to clarify the role of both techniques. We focused on clinical scores, physical examination, complications, revision surgeries, and failures. MATERIAL AND METHODS In May of 2019 the main online databases were accessed. All the clinical studies treating isolated MPFL reconstruction for patellofemoral instability through a single and/or double-bundle graft were enrolled in the present systematic review. Only articles reporting primary isolated MPFL reconstruction, reporting a minimum of 12-months follow-up were considered for inclusion. RESULTS The scores of interest were in favour of the DB cohort: Kujala (+ 3.2, P = 0.03), Lysholm (+ 5.1, P = 0.001), Tegner (+ 0.3, P = 0.2), IKDC (+ 5.4, P = 0.01), VAS (+ 0.8, P = 0.3), ROM (+ 9.96, P = 0.04). In the DB graft, a reduction of overall complications (OR 0.59; P = 0.1), further surgeries (OR 0.64; P = 0.12) and re-dislocations (OR 0.61; P = 0.16) was observed. The SB group reported a reduction in the post-operative apprehension test (OR 2.42; P = 0.24). CONCLUSION Current study support the use of double-bundle tendon graft for isolated MPFL reconstruction in selected patients with recurrent patellofemoral instability.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Andromahi Trivellas
- Department of Orthopaedics, David Greffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Giorgia Colarossi
- Department of Cardiosurgery, RWTH Aachen University Clinic, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Björn Rath
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
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Devgan A, Yadav U, Sharma P, Rohilla R, Devgan R, Mudgil P, Verma A, Dhupper V. Implantless patellar fixation in medial patellofemoral ligament reconstruction. Chin J Traumatol 2019; 22:281-285. [PMID: 31447309 PMCID: PMC6823724 DOI: 10.1016/j.cjtee.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 06/06/2019] [Accepted: 06/12/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The medial patellofemoral ligament (MPFL) acts as primary restraint to lateral patellar dislocation and its rupture has been reported in almost all cases of acute patellar dislocation. Various surgical techniques have been described for MPFL reconstruction, using many femoral and patellar fixation techniques and different grafts. This article details our technique for MPFL reconstruction using semitendinosus graft which avoids the use of implant at patellar end. METHODS Twenty patients (8 males and 12 females) with complaints regarding acute and chronic lateral patellar instability were evaluated and treated by MPFL reconstruction procedure. The mean age of patients was 21 years (range 17-34 years). MPFL reconstruction was performed using semitendinosus graft passing through two parallel, obliquely directed tunnels created in patella. Fixation of graft was done with an interference screw only at the femoral end. Mean follow-up period after intervention was 26.4 months (range 23-30 months). Results were evaluated using Kujala score. RESULTS All patients gained adequate patellar stability and full arc of motion. No incidence of patella fracture was noted. There were no postoperative complications related to the procedure. There was no recurrence of instability in patella at final follow-up. CONCLUSION Passing the graft through the tunnels in patella without use of any implant has given excellent functional outcome and moreover has the advantages of less implant-related complications and cost-effectiveness.
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Affiliation(s)
- Ashish Devgan
- Department of Orthopaedics, PGIMS, Rohtak, Haryana, India
| | - Umesh Yadav
- Department of Orthopaedics, PGIMS, Rohtak, Haryana, India.
| | - Pankaj Sharma
- Department of Orthopaedics, PGIMS, Rohtak, Haryana, India
| | - Rajesh Rohilla
- Department of Orthopaedics, PGIMS, Rohtak, Haryana, India
| | | | - Pravesh Mudgil
- Department of Orthopaedics, PGIMS, Rohtak, Haryana, India
| | - Aman Verma
- Department of Orthopaedics, PGIMS, Rohtak, Haryana, India
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Medial patellofemoral ligament (MPFL) reconstruction using quadriceps tendon autograft provides good clinical, functional and patient-reported outcome measurements (PROM): a 2-year prospective study. Knee Surg Sports Traumatol Arthrosc 2019; 27:2426-2432. [PMID: 30374571 DOI: 10.1007/s00167-018-5226-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The medial patellofemoral ligament (MPFL) is the most important ligamentous stabilizer preventing lateral patella dislocation. Numerous surgical procedures for MPFL reconstruction have been described in the literature. The aim of this study was to investigate the clinical, functional and patient-reported (PROM) outcomes 2 years after minimally invasive MPFL reconstruction performed using an autologous strip of the quadriceps tendon. METHODS Thirty-six patients (38 knees) were included in the study. For MPFL reconstruction, a partial thickness autologous quadriceps tendon graft was used. All patients were evaluated clinically and with patient-reported outcome questionnaires including the Tegner, Lysholm and Kujala scores as well as a visual analogue scale (VAS) for pain preoperatively and at 6, 12 and 24 months postoperatively. A functional Back-in-Action (BIA) test battery, including a total of seven stability, agility and jumping tests, was performed on 19 (50%) patients at the final follow-up. One patient was lost to follow-up at 24 months. RESULTS The mean age at the time of operation was 25.2 ± 6.1 years. No redislocations occurred during the period of investigation. The mean Lysholm score improved significantly from 79.3 ± 16.1 preoperatively to 83.2 ± 14.4 at 6 months, 88.1 ± 11.3 at 12 months and to 90.0 ± 9.6 at 24 months follow-up. No change throughout the study period was observed for the median Tegner Activity Score (median 6). The mean Kujala score increased from a preoperative value of 82.0 ± 12.4, to 84.5 ± 8.4 at 6 months, and 88.2 ± 5.8 at 12 months up to 88.7 ± 4.5 at 24 months follow-up. A total of 77.8% of the performed functional BIA tests were equal to or above the norm for patients of the corresponding ages and activity levels. CONCLUSIONS Minimally invasive MPFL reconstruction with a partial thickness strip of quadriceps tendon is a safe and effective treatment for patellofemoral instability. Good clinical, functional and subjective results were observed at the 2-year follow-up. LEVEL OF EVIDENCE Prospective cohort study, non-randomized, Level IV.
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Sanchis-Alfonso V, Alastruey-López D, Ginovart G, Montesinos-Berry E, García-Castro F, Ramírez-Fuentes C, Monllau JC, Alberich-Bayarri A, Pérez MA. Parametric finite element model of medial patellofemoral ligament reconstruction model development and clinical validation. J Exp Orthop 2019; 6:32. [PMID: 31278510 PMCID: PMC6611858 DOI: 10.1186/s40634-019-0200-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Currently, there is uncertainty regarding the long-term outcome of medial patellofemoral ligament reconstructions (MPFLr). Our objectives were: (1) to develop a parametric model of the patellofemoral joint (PFJ) enabling us to simulate different surgical techniques for MPFLr; (2) to determine the negative effects on the PFJ associated with each technique, which could be related to long-term deterioration of the PFJ. Methods A finite element model of the PFJ was created based on CT data from 24 knees with chronic lateral patellar instability. Patella contact pressure and maximum MPFL-graft stress at five angles of knee flexion (0, 30, 60, 90 and 120°) were analysed in three types of MPFLr: anatomic, non-anatomic with physiometric behaviour, and non-anatomic with non-physiometric behaviour. Results An increase in patella contact pressure was observed at 0 and 30° of knee flexion after both anatomic and non-anatomic MPFLr with physiometric behaviour. In both reconstructions, the ligament was tense between 0 and 30° of knee flexion, but at 60, 90 and 120°, it had no tension. In the third reconstruction, the behaviour was completely the opposite. Conclusion A parametric model of the PFJ enables us to evaluate different types of MPFLr throughout the full range of motion of the knee, regarding the effect on the patellofemoral contact pressure, as well as the kinematic behaviour of the MPFL-graft and the maximum MPFL-graft stress. Electronic supplementary material The online version of this article (10.1186/s40634-019-0200-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vicente Sanchis-Alfonso
- Department of Orthopaedic Surgery, Hospital Arnau de Vilanova, C/Sant Climent, 12, 46015, Valencia, Spain.
| | - Diego Alastruey-López
- Multiscale in Mechanical and Biological Engineering (M2BE), Aragón Institute of Engineering Research (I3A), Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain
| | - Gerad Ginovart
- Department of Orthopaedic Surgery, Hospital Terres de l'Ebre, Tortosa, Spain
| | | | | | - Cristina Ramírez-Fuentes
- Hospital Universitario y Politécnico La Fe and Biomedical Imaging Research Group (GIBI230), IIS La Fe Research Group, Valencia, Spain
| | - Joan Carles Monllau
- Department of Orthopaedic Surgery and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angel Alberich-Bayarri
- QUIBIM SL, Quantitative Imaging Biomarkers in Medicine, GIBI230, Biomedical Imaging Research Group, La Fe Health Research Institute, Valencia, Spain
| | - María Angeles Pérez
- Multiscale in Mechanical and Biological Engineering (M2BE), Aragón Institute of Engineering Research (I3A), Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain
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Patel NK, de Sa D, Vaswani R, Kay J, Musahl V, Lesniak BP. Knee Flexion Angle During Graft Fixation for Medial Patellofemoral Ligament Reconstruction: A Systematic Review of Outcomes and Complications. Arthroscopy 2019; 35:1893-1904. [PMID: 30954322 DOI: 10.1016/j.arthro.2018.11.071] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 11/29/2018] [Accepted: 11/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the effect of knee flexion angle during graft fixation on outcomes and complications following medial patellofemoral ligament (MPFL) reconstruction. METHODS Three databases (PubMed, EMBASE, and MEDLINE) were searched from database inception to January 2018. After screening based on inclusion and exclusion criteria, patient demographics, fixation technique, graft selection, outcomes, and complications were extracted from the included studies. The studies were grouped based on flexion angle used during graft fixation: low (0°-30°) and high (45°-90°) flexion angle group. Methodological Index for Non-Randomized Studies criteria were used to assess the quality of each included study. Descriptive statistics are presented. RESULTS Seventeen studies (of 3,399) were included and were either cohort (n = 1) or case series (n = 17) study designs. A total of 556 patients with a mean age of 23.6 years (range, 10-60 years) underwent MPFL reconstructions, with 458 patients in the 0° to 30° fixation group and 98 in the 45° to 90° fixation group. The mean Kujala score improved from 45 to 72.9 (365 patients) preoperatively to 83 to 94.5 (460 patients) postoperatively for the 0° to 30° fixation group and from 53.3 to 72 preoperatively to 92.2 to 95.2 postoperatively for the 45° to 90° fixation group (98 patients). CONCLUSIONS The knee flexion angle during MPFL graft fixation ranges from 20° to 90°. Graft fixation at low and high knee flexion angles during MPFL reconstruction showed excellent patient-reported outcomes and low patellar redislocation rates overall, with no clear differences between the 2 groups based on the currently available data. LEVEL OF EVIDENCE Level IV, systematic review of Level III-IV studies.
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Affiliation(s)
- Neel K Patel
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Darren de Sa
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Ravi Vaswani
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Jeffrey Kay
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A..
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Desai VS, Tagliero AJ, Parkes CW, Camp CL, Cummings NM, Stuart MJ, Dahm DL, Krych AJ. Systematic Review of Medial Patellofemoral Ligament Reconstruction Techniques: Comparison of Patellar Bone Socket and Cortical Surface Fixation Techniques. Arthroscopy 2019; 35:1618-1628. [PMID: 31000392 DOI: 10.1016/j.arthro.2018.10.150] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patellar bone socket and cortical surface fixation techniques for isolated medial patellofemoral ligament (MPFL) reconstruction and determine whether there was a difference in (1) complication rates, including fracture of the patella; (2) redislocation rates; or (3) patient-reported outcomes. METHODS A literature search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, or less than 3 months of follow-up were excluded. Risk-of-bias assessment was performed using the Methodological Index for Non-randomized Studies (MINORS) system. Studies were classified by surgical technique (patellar bone socket group [group S] vs cortical fixation group [group F]), and complications, redislocations, and patient-reported outcomes were collected. RESULTS A total of 29 studies yielded 981 patients with MPFL reconstruction for inclusion. Of the patients, 620 underwent a patellar bone socket technique and 361 underwent a cortical fixation technique. Patients ranged in age from 11 to 68 years. Patellar fracture rates ranged from 0% to 17% in group S and were 0% in all group F studies. Mean Kujala scores ranged from 83.5 to 93.6 in group S and from 84.4 to 94.5 in group F. Mean Lysholm scores ranged from 84.6 to 91.7 in group S and from 83.5 to 95 in group F. Redislocation rates ranged from 0% to 21% in group S and from 0% to 13% in group F. Although heterogeneous in nature, complication rates ranged from 0% to 28% in group S and from 0% to 4% in group F. CONCLUSIONS MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall, complications remained uncommon. Clinically, the bone socket group had comparable postoperative redislocation rates and patient outcomes to the group treated with cortical fixation techniques. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Vishal S Desai
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Adam J Tagliero
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Chad W Parkes
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nancy M Cummings
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Diane L Dahm
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A..
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Mochizuki Y, Kaneko T, Kawahara K, Toyoda S, Ikegami H, Musha Y. A 2-year follow-up of isolated Medial Patellofemoral Ligament Reconstruction by using soft suture anchor and adjustable cortical fixation system. J Orthop 2019; 16:356-360. [PMID: 31015756 DOI: 10.1016/j.jor.2019.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/25/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Numerous surgical techniques and fixation methods have been described in medial patellofemoral ligament (MPFL) reconstruction such as choice of graft, graft fixation method of patella/femur and initial tension. We describe short term clinical results of MPFL reconstruction by using soft suture anchor and adjustable cortical fixation system. Methods Twenty-four patients who underwent isolated MPFL reconstruction by using soft suture anchor and adjustable cortical fixation system were included in this study. All patients were followed up for at least 2 years, and pre-operative and 2 years post-operative Kujala score, IKDC score and Knee Injury and Osteoarthritis Outcome Score were used to assess clinical outcome. Radiographic evaluation included the Q angle, congruence angle and patellar tilt angle. Pre- and post-operative changes were evaluated by Mann-Whitney U test. Results There were no complications including re-dislocation, patella fracture, infection, and joint contracture. The apprehension test was positive in 4.2% post-operatively. A statistically significant improvement in clinical scores and radiographic evaluation were evident after surgery. Conclusions Isolated MPFL Reconstruction using soft suture anchor and adjustable cortical fixation system led good restoration of patellar stability and significant improvement of knee function in short-term results. This surgical technique can reduce complications such as patella fractures, and can be done safely. Clinical relevance This technique may be a treatment option with little associated complications in the treatment for patellar instability. Level of Evidence Case series, Level IV.
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Affiliation(s)
- Yuta Mochizuki
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Takao Kaneko
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Keisuke Kawahara
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Shinya Toyoda
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Hiroyasu Ikegami
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
| | - Yoshiro Musha
- Department of Orthopaedics Surgery (Ohashi), School of Medicine, Toho University, Japan
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Ferrua P, Kruckeberg BM, Pasqualotto S, Berruto M, Randelli P, Arendt EA. Proximal medial patellar restraints and their surgical reconstruction. J Orthop Traumatol 2019; 20:17. [PMID: 30915690 PMCID: PMC6435766 DOI: 10.1186/s10195-019-0525-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/08/2019] [Indexed: 01/27/2023] Open
Abstract
Reconstruction of the medial patellofemoral ligament (MPFL) has been increasing as a surgical solution for treatment of recurrent lateral patellofemoral dislocation. Recent attention has been given to fibers extending from the femur to the quadriceps tendon, proximal to the MPFL, termed the medial quadriceps tendon-femoral ligament. This article briefly reviews the proximal medial patellar restraints and surgical procedures for their reconstruction.
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Affiliation(s)
- Paolo Ferrua
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Bradley M Kruckeberg
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Stefano Pasqualotto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Massimo Berruto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Pietro Randelli
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
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Steinwachs M, Cavalcanti N, Mauuva Venkatesh Reddy S, Werner C, Tschopp D, Choudur HN. Arthroscopic and open treatment of cartilage lesions with BST-CARGEL scaffold and microfracture: A cohort study of consecutive patients. Knee 2019; 26:174-184. [PMID: 30579660 DOI: 10.1016/j.knee.2018.11.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 10/18/2018] [Accepted: 11/09/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND CARGEL (Smith & Nephew Inc.), a chitosan-based polymer scaffolding biomaterial, has been used since 2012 for treating articular cartilage lesions. Limited data are available on patient outcomes following CARGEL treatment. This study aimed to describe short-term clinical and radiographic outcomes in a cohort of patients treated with CARGEL and microfracture surgery for articular cartilage defects in the knee. METHODS A retrospective cohort study was conducted of consecutive patients with articular cartilage defects who had undergone microfracture surgery with CARGEL, or in patellar lesions microfracture and CARGEL plus Chondro-Gide (at SportsClinic Zurich). Study outcomes included reoperations, infections, allergic reactions, pain, swelling, range of motion, and tissue quality and quantity. Ethics approval was obtained from the local ethics committee on 05/09/2017 (Basec. Nr: 2017-01441). RESULTS A total of 91 participants, with 93 treated lesions, consenting to chart review were included. No participants required reoperation due to complications on the index lesion. Fifteen participants had second-look surgery on the index knee for other reasons, allowing for visual confirmation of cartilage repair. No study participants experienced a post-surgical infection or suffered an allergic reaction. No significant changes in range of motion or T2 values were observed from pre-treatment to post-treatment follow-up. However, significant decreases were found in pain (P < 0.001) and swelling (P < 0.001), along with significant increases in MOCART II scores (P < 0.001). Similar results were found in a subgroup of patients with patellar lesions. CONCLUSIONS Patients treated with CARGEL experienced few postoperative complications and reported promising reductions in pain and swelling after treatment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Matthias Steinwachs
- Facharzt für Orthopädische Chirurgie und Traumatologie des Bewegungsapparates SportClinic Zürich, Klinik Hirslanden, Zürich, Switzerland.
| | - Nicola Cavalcanti
- Facharzt für Orthopädische Chirurgie und Traumatologie des Bewegungsapparates SportClinic Zürich, Klinik Hirslanden, Zürich, Switzerland
| | | | - Clement Werner
- Ortho Clinic Zürich, Hirslanden Klinik Im Park, Zürich, Switzerland
| | | | - Hema N Choudur
- Division of MSK Imaging, McMaster University, Hamilton, Ontario, Canada
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Abstract
Compared with skeletally mature patients, skeletally immature patients are at a higher risk of acute traumatic patellar dislocation. Surgical treatment is the standard of care for patients with recurrent instability and requires important and technically challenging physeal considerations. Physeal-sparing medial patellofemoral ligament reconstruction is the treatment of choice for these patients, replacing older nonanatomic extensor mechanism realignment techniques. Implant-mediated guided growth is an important adjunct to correct genu valgum angular deformities that contribute to patellar instability. Patient-specific surgical techniques and proper surgical indications are crucial for successful outcomes.
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Zaman S, White A, Shi WJ, Freedman KB, Dodson CC. Return-to-Play Guidelines After Medial Patellofemoral Ligament Surgery for Recurrent Patellar Instability: A Systematic Review. Am J Sports Med 2018; 46:2530-2539. [PMID: 28678520 DOI: 10.1177/0363546517713663] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [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 and repair continue to gain acceptance as viable treatment options for recurrent patellar instability in patients who wish to return to sports after surgery. Return-to-play guidelines with objective or subjective criteria for athletes after MPFL surgery, however, have not been uniformly defined. PURPOSE To determine whether a concise and objective protocol exists that may help athletes return to their sport more safely after MPFL surgery. STUDY DESIGN Systematic review. METHODS The clinical evidence for return to play after MPFL reconstruction was evaluated through a systematic review of the literature. Studies that measured outcomes for isolated MPFL surgery with greater than a 12-month follow-up were included in our study. We analyzed each study for a return-to-play timeline, rehabilitation protocol, and any measurements used to determine a safe return to play after surgery. RESULTS Fifty-three studies met the inclusion criteria, with a total of 1756 patients and 1838 knees. The most commonly cited rehabilitation guidelines included weightbearing restrictions and range of motion restrictions in 90.6% and 84.9% of studies, respectively. Thirty-five of 53 studies (66.0%) included an expected timeline for either return to play or return to full activity. Ten of 53 studies (18.9%) in our analysis included either objective or subjective criteria to determine return to activity within their rehabilitation protocol. CONCLUSION Most studies in our analysis utilized time-based criteria for determining return to play after MPFL surgery, while only a minority utilized objective or subjective patient-centric criteria. Further investigation is needed to determine safe and effective guidelines for return to play after MPFL reconstruction and repair.
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Affiliation(s)
| | - Alex White
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Weilong J Shi
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin B Freedman
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the current understanding of the medial patellofemoral complex, including recent anatomic advances, evaluation of indications for reconstruction with concomitant pathology, and surgical reconstruction techniques. RECENT FINDINGS Recent advances in our understanding of MPFC anatomy have found that there are fibers that insert onto the deep quadriceps tendon as well as the patella, thus earning the name "medial patellofemoral complex" to allow for the variability in its anatomy. In MPFC reconstruction, anatomic origin and insertion points and appropriate graft length are critical to prevent overconstraint of the patellofemoral joint. The MPFC is a crucial soft tissue checkrein to lateral patellar translation, and its repair or reconstruction results in good restoration of patellofemoral stability. As our understanding of MPFC anatomy evolves, further studies are needed to apply its relevance in kinematics and surgical applications to its role in maintaining patellar stability.
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Affiliation(s)
- Alexander E Loeb
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD, 21287, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD, 21287, USA.
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The medial patellofemoral ligament: Review of the literature. J Orthop 2018; 15:596-599. [PMID: 29881201 DOI: 10.1016/j.jor.2018.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/06/2018] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE Critically evaluate the published literature related to quadriceps tendon (QT) medial patellofemoral ligament (MPFL) reconstruction. RECENT FINDINGS Hamstring tendon (HT) MPFL reconstruction techniques have been shown to successfully restore patella stability, but complications including patella fracture are reported. Quadriceps tendon (QT) reconstruction techniques with an intact graft pedicle on the patella side have the advantage that patella bone tunnel drilling and fixation are no longer needed, reducing risk of patella fracture. Several QT MPFL reconstruction techniques, including minimally invasive surgical (MIS) approaches, have been published with promising clinical results and fewer complications than with HT techniques. Parallel laboratory studies have shown macroscopic anatomy and biomechanical properties of QT are more similar to native MPFL than hamstring (HS) HT, suggesting QT may more accurately restore native joint kinematics. Quadriceps tendon MPFL reconstruction, via both open and MIS techniques, have promising clinical results and offer valuable alternatives to HS grafts for primary and revision MPFL reconstruction in both children and adults.
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McNeilan RJ, Everhart JS, Mescher PK, Abouljoud M, Magnussen RA, Flanigan DC. Graft Choice in Isolated Medial Patellofemoral Ligament Reconstruction: A Systematic Review With Meta-analysis of Rates of Recurrent Instability and Patient-Reported Outcomes for Autograft, Allograft, and Synthetic Options. Arthroscopy 2018; 34:1340-1354. [PMID: 29366741 DOI: 10.1016/j.arthro.2017.11.027] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether graft selection or patient age affects the following after isolated medial patellofemoral ligament (MPFL) reconstruction: (1) rates of recurrent instability, (2) rates of postoperative complications (other than instability), and (3) subjective symptom improvement. METHODS A systematic search identified studies reporting outcomes for isolated MPFL reconstruction. Rates of recurrent instability, subjective Kujala knee function scores, and complications were tabulated. Symptom improvement was defined as change in Kujala score (preoperative evaluation to final follow-up). RESULTS Forty-five studies were included with 27 documented cases of recurrent instability among 1,504 patients (1.8%); instability rates ranged from 0% to 20.0% overall; among autograft in adults, 0% to 11.1% (1.4%, 18/1,260); among autograft in adolescents, 0% to 20% (10.0%, 8/80); among allograft, 0% (0/65 cases); and among synthetic, 0% to 3.3% (1.3%, 1/76). Among autograft choices in adults, rates of recurrent instability were low; recurrence with gracilis ranged from 0% to 11.1% (0.9%, 1/116); with semitendinosus, 0% to 6.3% (0.6%, 4/676); with quad or patellar tendon, 0% (0/65); and with adductor tendon, 5.6% to 8.3% (6.7%, 2/30). Complication rates ranged from 0% to 34.4%. All included studies reported significant improvement in Kujala scores after surgery (P < .01). There was significant heterogeneity in effect size and evidence of reporting bias among small studies, precluding reliable pooled analysis of treatment effect. CONCLUSIONS Autograft is not superior to allograft or synthetic grafts for isolated reconstruction of the MPFL, and rates of recurrent instability are generally low. Isolated MPFL reconstruction can provide significant symptom relief regardless of graft selection, although there is a bias toward reporting better than expected results among smaller studies. Pediatric patients and patients treated with adductor tendon autograft have higher recurrent instability rates. While caution should be used in making definitive recommendations secondary to the small number of allograft and synthetic studies, selection of graft type based on surgeon preference, comfort, and prior experience remains appropriate. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Ryan J McNeilan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Joshua S Everhart
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Patrick K Mescher
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Moneer Abouljoud
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.; Cartilage Restoration Program, The Ohio State University, Columbus, Ohio, U.S.A..
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Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents using a pedicled quadriceps tendon graft shows favourable results at a minimum of 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2018; 26:1210-1215. [PMID: 28601942 DOI: 10.1007/s00167-017-4597-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/06/2017] [Indexed: 01/17/2023]
Abstract
PURPOSE In adults, reconstruction of the medial patellofemoral ligament (MPFL) has shown good results. Treatment for recurrent patellar instability in children and adolescents with open growth plates, however, requires alternative MPFL reconstruction techniques. This study presents the outcomes of a minimally invasive technique for anatomic reconstruction of the MPFL in children using a pedicled superficial quadriceps tendon graft, hardware-free patellar graft attachment, and anatomic femoral fixation that spares the distal femoral physis. METHODS Twenty-five consecutive patients with patellofemoral instability and open growth plates underwent anatomic reconstruction of the MPFL using a pedicled superficial quadriceps tendon graft. Preoperative radiographic examination included AP and lateral views to assess patella alta and limb alignment. Magnetic resonance imaging was performed to evaluate trochlear dysplasia and tibial tubercle-trochlear groove distance. Evaluation included pre- and post-operative physical examination, Kujala score, visual analog scale (VAS), and Tegner activity score. RESULTS The average age at the time of operation was 12.8 years (9.5-14.7). The average follow-up after operation was 2.6 years (2.0-3.4). No recurrent dislocation occurred. Twenty patients were very satisfied (80%), four patients were satisfied (16%), and one patient was partially satisfied with the surgical procedure (4%). No patient was dissatisfied. The median Kujala score significantly improved from 63 (44-81) preoperatively to 89 (77-100) post-operatively (P < 0.01), and the median VAS score improved significantly from 4 (1-7) to 1 (0-4) (P < 0.01). The Tegner activity score increased, but not significantly, from 4 (3-8) preoperatively to 5 (3-8) post-operatively (non-significant). CONCLUSION The described technique for MPFL reconstruction with a pedicled quadriceps tendon is a safe and effective technique with good clinical results and allows patients to return to sports without redislocation of the patella. It might therefore be a valuable alternative to more extensive procedures in paediatric and adolescent patients. LEVEL OF EVIDENCE Prospective study, Level III.
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Smeets K, Bellemans J, Scheys L, Eijnde BO, Slane J, Claes S. Mechanical Analysis of Extra-Articular Knee Ligaments. Part two: Tendon grafts used for knee ligament reconstruction. Knee 2017; 24:957-964. [PMID: 28789872 DOI: 10.1016/j.knee.2017.07.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/19/2017] [Accepted: 07/20/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this study was to provide information about the mechanical properties of grafts used for knee ligament reconstructions and to compare those results with the mechanical properties of native knee ligaments. METHODS Eleven cadaveric knees were dissected for the semitendinosus, gracilis, iliotibial band (ITB), quadriceps and patellar tendon. Uniaxial testing to failure was performed using a standardized method and mechanical properties (elastic modulus, ultimate stress, ultimate strain, strain energy density) were determined. RESULTS The elastic modulus of the gracilis tendon (1458±476MPa) (P<0.001) and the semitendinosus tendon (1036±312MPa) (P<0.05) was significantly higher than the ITB (610±171MPa), quadriceps tendon (568±194MPa), and patellar tendon (417±107MPa). In addition, the ultimate stress of the hamstring tendons (gracilis 155.0±30.7MPa and semitendinosus 120.1±30.0MPa) was significantly higher (P<0.001, respectively P<0.05), relative to the ITB (75.0±11.8MPa), quadriceps tendon (81.0±27.6MPa), and patellar tendon (76.2±25.1MPa). A significant difference (P<0.05) could be noticed between the ultimate strain of the patellar tendon (24.6±5.9%) and the hamstrings (gracilis 14.5±3.1% and semitendinosus 17.0±4.0%). No significant difference in strain energy density between the grafts was observed. CONCLUSIONS Material properties of common grafts used for knee ligament reconstructions often differ significantly from the original knee ligament which the graft is supposed to emulate.
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Affiliation(s)
- Kristof Smeets
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department of Orthopedic Surgery, Ziekenhuis Oost-, Limburg, Genk, Belgium.
| | - Johan Bellemans
- Department of Orthopedic Surgery, Ziekenhuis Oost-, Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Lennart Scheys
- Institute for Orthopaedic Research and Training, Division of Orthopaedics, University Hospitals Leuven/Department of Development and Regenartion, Faculty of Medicine, KULeuven, Leuven, Belgium
| | - Bert O Eijnde
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Joshua Slane
- Institute for Orthopaedic Research and Training, Division of Orthopaedics, University Hospitals Leuven/Department of Development and Regenartion, Faculty of Medicine, KULeuven, Leuven, Belgium
| | - Steven Claes
- Department of Orthopedic Surgery, AZ Herentals Hospital, Herentals, Belgium; Department of Orthopedic Surgery, University Hospitals Leuven, Pellenberg, Belgium
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Ferrari MB, Sanchez G, Chang A, Ferdousian S, Provencher MT. Medial Patellofemoral Ligament Reconstruction in a Revision Setting: Anchor and Interference Screw Fixation. Arthrosc Tech 2017; 6:e927-e932. [PMID: 28970976 PMCID: PMC5620562 DOI: 10.1016/j.eats.2017.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 03/02/2017] [Indexed: 02/03/2023] Open
Abstract
Recurrent patellar instability is a common pathology and typically affects younger and more active patients. To prevent complete lateral dislocation of the patella, several osseous and soft-tissue procedures have been previously described, including reconstruction of the medial patellofemoral ligament (MPFL), which has been identified as the primary medial stabilizer of the patella. Several techniques have been reported for reconstruction of the MPFL, sometimes in conjunction with other procedures, with the majority showing success in the treatment and resolution of patellar instability. However, MPFL reconstruction is not free of complications, with previous reports of recurrence of medial patellar instability and patellar fracture after surgery. The objective of this Technical Note is to describe our preferred technique, comprising anchor as well as interference screw fixation, for reconstruction of the MPFL in a primary or revision setting.
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Affiliation(s)
| | - George Sanchez
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Angela Chang
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Sami Ferdousian
- University of California Santa Barbara, Santa Barbara, California, U.S.A
| | - Matthew T. Provencher
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Matthew T. Provencher, M.D., Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, U.S.A.Steadman Philippon Research Institute181 W Meadow DrSte 1000VailCO81657U.S.A.
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Leal-Blanquet J, Alentorn-Geli E, Torres-Claramunt R, Monllau JC. Partial quadriceps tendon transfer for revision medial patellofemoral ligament reconstruction: A new surgical technique. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:258-261. [PMID: 28457794 PMCID: PMC6197314 DOI: 10.1016/j.aott.2017.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 07/05/2015] [Accepted: 07/20/2015] [Indexed: 11/27/2022]
Abstract
Medial patellofemoral ligament (MPFL) reconstruction for patellofemoral instability is a common procedure. Although MPFL reconstruction is a successful procedure in terms of return to normal life or sports, revision cases are challenging due to previous holes into the patella or implants placed in the anatomical femoral insertion site. In this technical note, the use of a partial quadriceps tendon transfer to the adductor magnus tendon is presented as a good solution for revision cases to avoid the use of implants, bone drilling, use of allografts, or two-stage surgical procedures. In addition, this procedure could be also used as a primary procedure in skeletally immature patients.
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Affiliation(s)
- Joan Leal-Blanquet
- Department of Orthopedic Surgery and Traumatology, Hospital del Mar i l'Esperança - Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - Eduard Alentorn-Geli
- Department of Orthopedic Surgery and Traumatology, Hospital del Mar i l'Esperança - Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Raúl Torres-Claramunt
- Department of Orthopedic Surgery and Traumatology, Hospital del Mar i l'Esperança - Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Joan Carles Monllau
- Department of Orthopedic Surgery and Traumatology, Hospital del Mar i l'Esperança - Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Converting round tendons to flat tendon constructs: Does the preparation process have an influence on the structural properties? Knee Surg Sports Traumatol Arthrosc 2017; 25:1561-1567. [PMID: 26272060 DOI: 10.1007/s00167-015-3749-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 07/31/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The structural properties of hamstring tendon grafts were evaluated in a porcine model, after processing it to a flat shape, to better replace or augment anatomic flat structures (e.g. ACL, MPFL or MCL). METHODS In this biomechanical study, porcine flexor tendons were used which have a comparable shape to semitendinosus and gracilis tendons. One part of the tendon was prepared to a flat tendon construct by splitting the tendon longitudinally with a knife to half of the diameter of the tendon. The semi-split tendon was scratched out to a flat shape. The other matched part was tested in its original round shape. The tendons (n = 40) have been fixed in a uniaxial testing machine (Zwick/Roell) by cryo-clamps after preparing the fixed ends by 2-0 polyester sutures (2-0 Ethibond® EXCEL, Ethicon, Somerville, NJ). In every specimen, there was a free 60-mm tendon part between both clamps. The tendons have been loaded to failure to evaluate typical biomechanical parameters such as stiffness, yield load and maximum load. RESULTS No statistically significant differences (n.s.) regarding stiffness, yield load and maximum load between natively round and processed flat tendons could be detected. CONCLUSION A prepared flat-shaped tendon does not show any different structural properties compared with an original round tendon. Therefore, a flat tendon seems to be a biomechanical stable graft option for anatomic reconstruction or augmentation of injured natively flat-shaped structures such as MCL, MPFL or ACL.
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Schneider DK, Grawe B, Magnussen RA, Ceasar A, Parikh SN, Wall EJ, Colosimo AJ, Kaeding CC, Myer GD. Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for the Treatment of Recurrent Lateral Patellar Dislocations: A Systematic Review and Meta-analysis. Am J Sports Med 2016; 44:2993-3005. [PMID: 26872895 PMCID: PMC5502077 DOI: 10.1177/0363546515624673] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A patellar dislocation is a common knee injury in the young, athletic patient population. Recent trends indicate that the use of long-term nonoperative treatment is decreasing, and surgical intervention is more commonly recommended for those patients who fail initial nonoperative management with recurrent patellar dislocations. Medial patellofemoral ligament (MPFL) reconstruction has become increasingly utilized in this regard. PURPOSE To evaluate outcomes, particularly return to sports and its relationship to postoperative instability, of isolated MPFL reconstruction for the treatment of recurrent patellar dislocations. STUDY DESIGN Systematic review and meta-analysis. METHODS A review of the current literature was performed using the terms "medial patellofemoral ligament reconstruction" and "MPFL reconstruction" in the electronic search engines PubMed and EBSCOhost (CINAHL, MEDLINE, SPORTDiscus) on July 29, 2015, yielding 1113 abstracts for review. At the conclusion of the search, 14 articles met the inclusion criteria and were included in this review of the literature. Means were calculated for population size, age, follow-up time, and postoperative Tegner scores. Pooled estimates were calculated for postoperative Kujala scores, return to play, total risk of postoperative instability, risk of positive apprehension sign, and risk of reoperation. RESULTS The mean patient age associated with MPFL reconstruction was 24.4 years, with a mean postoperative Tegner score of 5.7. The pooled estimated mean postoperative Kujala score was 85.8 (95% CI, 81.6-90.0), with 84.1% (95% CI, 71.1%-97.1%) of patients returning to sports after surgery. The pooled total risk of recurrent instability after surgery was 1.2% (95% CI, 0.3%-2.1%), with a positive apprehension sign risk of 3.6% (95% CI, 0%-7.2%) and a reoperation risk of 3.1% (95% CI, 1.1%-5.0%). CONCLUSION A high percentage of young patients return to sports after isolated MPFL reconstruction for chronic patellar instability, with short-term results demonstrating a low incidence of recurrent instability, postoperative apprehension, and reoperations.
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Affiliation(s)
- Daniel K Schneider
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brian Grawe
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Sports Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Robert A Magnussen
- Department of Orthopaedics, Sports Health and Performance Institute, The Ohio State University, Columbus, Ohio, USA
| | - Adrick Ceasar
- Visiting Nurse Association, Cincinnati, Ohio, USA
- United Way of Greater Cincinnati, Cincinnati, Ohio, USA
| | - Shital N Parikh
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eric J Wall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Angelo J Colosimo
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Sports Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christopher C Kaeding
- Department of Orthopaedics, Sports Health and Performance Institute, The Ohio State University, Columbus, Ohio, USA
| | - Gregory D Myer
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
- Department of Orthopaedics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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