MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION TO TREAT RECURRENT PATELLAR DISLOCATION

Medial patellofemoral ligament reconstruction using patella bone tunnel techniques with or without implants. A systematic review of outcomes and complications

PURPOSE

Τhe main goal of this study was to compare the clinical results, including the complication rates and patient-reported outcomes, in patients who underwent surgery for recurrent patellar dislocation using different patellar tunnel fixation techniques. This study compared Medial Patellofemoral Ligament (MPFL) reconstruction implant free techniques against ones that used implants.

METHODS

The present systematic review was conducted according to the PRISMA guidelines. The literature search was conducted in January 2023. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, severe patellar dysplasia or less than 6 months of follow-up were excluded. MINORS and MCMS scores were used for the assessment of methodological quality.

RESULTS

Data from 750 procedures were collected, of which 284 used implants to perform the procedure while in 455 an implant-free technique was used. Patient age at the time of surgery ranged from 11 to 60 years while the follow-up time of the studies ranged between 3 and 108 months. Postoperative Kujala (0.3, p = 0.89) and Lysholm (1.2, p = 0.26) scores were better in the implant-free techniques compared to implant-based. A higher rate of recurrent dislocation (OR 0.51; 95% CI 0.10-2.54, p = 0.4), subluxation (OR 0.20; 95% CI 0.40-0.88, p = 0.019) and stiffness (OR 0.76; 95% CI 0.33-1.72, p = 0.55) was noted in the implant-free techniques, while the implant-based techniques displayed increased incidence of patella fractures (OR 3.12; 95% CI 0.77-12.6, p = 0.09), reoperation (OR 1.69; 95% CI 0.78-3.65, p = 0.17) and infection (OR 2.07; 95% CI 0.46-9.32, p = 0.33).

CONCLUSION

There was no significant difference between the 2 techniques in terms of patient reported outcomes. Regarding complications, MPFL reconstruction using implants demonstrated significant higher rate of patella fractures while the implant free technique showed a greater risk of subluxation.

Isolated medial patellofemoral ligament reconstruction for recurrent patellofemoral instability: analysis of outcomes and risk factors

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.

Lateral retinacular release combined with MPFL reconstruction for patellofemoral instability: a systematic review

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.

Graft choice for isolated MPFL reconstruction: gracilis versus semitendinosus

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.

Single- versus double-bundle patellar graft insertion for isolated MPFL reconstruction in patients with patellofemoral instability: a systematic review of the literature

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.

Patellar fixation graft via suture anchors versus tunnel techniques during isolated MPFL reconstruction for recurrent patellofemoral instability: a systematic review of the literature

INTRODUCTION

There is still a lack of evidence concerning the patellar fixation of the medial patellofemoral ligament (MPFL) graft in selected patient with recurrent instability. The purpose of the present study was to investigate and compare clinical outcomes and further complications of isolated MPFL reconstruction via suture anchors versus tunnel techniques for recurrent patellofemoral instability.

MATERIALS AND METHODS

This systematic review of the literature was conducted according to the PRISMA guidelines. In September 2019, the main databases were accessed. All the clinical trials performing isolated MPFL reconstruction in patients with recurrent patellofemoral instability were included in the present study. Only articles fixing the MPFL graft through suture anchors and/ or patellar tunnel techniques were included in the analysis.

RESULTS

Data from 46 papers (1712 patients) were recorded. The mean follow-up was 40 ± 18 months. No differences were found in Kujala, Lysholm and Tegner score, International Knee Documentation Committee, visual analogic scale, range of motion and re-dislocation rate. The suture anchors fixation group detected reduced rate of apprehension test (OR: 0.6; p = 0.03), revision surgeries (OR: 0.4; p = 0.02) and anterior knee pain (OR: 0.05; p < 0.0001) and reduced not-classified complications (OR: 0.18; p < 0.0001).

CONCLUSION

Both the suture anchors and the bone-tunnels are a feasible option for isolated MPFL reconstruction in patients with recurrent patellofemoral instability. Patellar fixation via suture anchors evidenced a reduced rate of anterior knee pain, revision surgeries, apprehension test and an overall reduced complication compared to the bone-tunnel technique.

Recurrent patellar dislocations: trochleoplasty improves the results of medial patellofemoral ligament surgery only in severe trochlear dysplasia

PURPOSE

Medial patellofemoral ligament (MPFL) surgery combined with trochleoplasty (TP), is often performed to restore the normal patellofemoral biomechanics avoiding recurrent lateral patellar dislocation (LPD) in patients with trochlear dysplasia (TD). However, it is still unclear whether combining TP and MPFL surgery would be more beneficial than performing MPFL surgery on its own. This meta-analysis quantitatively synthesizes and compares published data on the outcomes of recurrent LPD treatment using MPFL surgery without or with TP in patients affected by TD.

METHODS

A systematic literature search about the treatment of recurrent LPD in the presence of TD was conducted. The primary outcome was redislocation rate, analyzed for different types of TD. Kujala, and IKDC scores, as well as complication rate, were also analyzed through a separate meta-analysis.

RESULTS

No statistically significant difference was found in the overall redislocation rate of MPFL surgery without and with TP. There was, however, a statistically significant difference (p < 0.001) in redislocation rate after MPFL surgery without TP between patients with type A or B TD (2.7%) and in patients with type C or D TD (18.6%). In the analysis for every single type of TD, the following results were obtained: redislocation rate of 1.8% in type A, 3.2% in type B, 11.9% in type C, and 7.4% in type D. A statistically significant difference in the complication rate, favouring MPFL surgery without TP, was documented. Both surgical approaches provided a significant improvement with no difference in Kujala and IKDC scores. These results were confirmed when data were analyzed including only patients with type B, C, or D TD, or without additional bone remodelling procedures.

CONCLUSION

Isolated MPFL is as effective as combined TP and MPFL surgery in preventing redislocation and improving clinical and functional outcomes in patients with recurrent LPD and knees affected by moderate TD. However, in case of severe TD, the redislocation rate is lower when TP is performed in combination with MPFL surgery, although with comparable clinical outcomes and a higher risk of post-operative range of motion (ROM) limitation.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, Level IV.

Patellar maltracking: an update on the diagnosis and treatment strategies

Patellar maltracking occurs as a result of an imbalance in the dynamic relationship between the patella and trochlea. This is often secondary to an underlying structural abnormality. The clinical evaluation can provide useful clues for the presence of such entity; however, the diagnosis can often be challenging especially in the absence of a documented history of patellar dislocation. Imaging, particularly MRI, can detect subtle features that could lead to the diagnosis, probably even more importantly when there is no clear history of patellar dislocation or before its development. This can provide a road map for formulating a treatment strategy that would be primarily aimed at stabilizing the patellofemoral joint to halt or slow the progression of articular cartilage loss. The purpose of this article is to discuss the clinical and radiologic evaluation of patellar maltracking providing an update on the cross-sectional imaging assessment and also a synopsis of the management options.

Single- and double-bundle medial patellofemoral ligament reconstruction procedures result in similar recurrent dislocation rates and improvements in knee function: a systematic review

PURPOSE

To evaluate medial patellofemoral ligament (MPFL) reconstruction using hamstring tendon autografts using single-bundle (SB) and double-bundle (DB) techniques, and compare the clinical outcomes including the Kujala score, postoperative apprehension, recurrent subluxation or dislocation, and complications.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant literature using the terms ''medial patellofemoral ligament'' and ''MPFL''. The pooled mean values of improvement in the Kujala score were calculated by random effects meta-analysis. Unweighted estimates for the rates of postoperative apprehension, recurrent subluxation or dislocation, and complications were determined by dividing the total number of occurrences by the total number of knees.

RESULTS

Thirty-one articles were included, involving 1063 patients (1116 knees). Two hundred and forty-four patients (254 knees) underwent SB reconstruction, while 819 patients (862 knees) underwent DB reconstruction. The pooled mean values of Kujala score improvement were similar in the SB group (30.1; 95% CI 26.6-33.6) and DB group (30.7; 95% CI 27.7-33.7). The SB group had a significantly greater rate of postoperative apprehension (7.9%) than the DB group (4.1%; P = 0.014). There were no significant differences between the two groups in the rates of recurrent subluxation or dislocation (1.2 and 1.6%) and complications (10.6 and 7.7%).

CONCLUSION

With variability in patient populations and surgical techniques, the DB procedure for isolated MPFL reconstruction demonstrates similar outcomes to the SB technique regarding improvement of knee function, recurrent subluxation or dislocation, and complications. The SB technique may have a greater risk of postoperative apprehension, whereas the DB technique may cause more stiffness.

LEVEL OF EVIDENCE

IV.

Outcomes of medial patellofemoral ligament reconstruction in patients with patella alta

OBJECTIVE

To compare the clinical outcomes and the results of knee functional scores in patients with normal patellar height and patella alta who underwent isolated medial patellofemoral ligament reconstruction.

METHODS

A total of 37 knees from 33 patients with recurrent patellar dislocation who underwent isolated medial patellofemoral ligament reconstruction were included. Retrospectively, the postoperative clinical results were compared using the Kujala and Lysholm scores in the group of patients with normal patellar height and in those with patella alta.

RESULTS

The sample consisted of 37 patients; 16 knees of 14 patients in the group with normal patellar height, 21 knees of 19 patients in the group with patella alta. In the first group, the mean Kujala score was 85.8 and the mean Lysholm score was 85.6. In the second, the mean Kujala score was 78.1 and the mean Lysholm score was 79.7. No significant differences were observed between the groups in relation to the Lysholm (p = 0.296) and Kujala scores (p = 0.181).

CONCLUSION

Isolated medial patellofemoral ligament reconstruction presented similar results in patients with normal patellar height and patella alta.

Reconstruction of the medial patellofemoral ligament using autologous graft from quadriceps tendon to treat recurrent patellar dislocation

OBJECTIVE

The objective of this study was to evaluate the efficacy of the surgical technique using the quadriceps tendon as a graft in static reconstruction of the medial patellofemoral ligament.

METHODS

This was a prospective case series study in which the participants were 22 patients with a diagnosis of recurrent patellar dislocation without any other anatomical alterations that required surgical treatment. The functional results from the technique were evaluated using clinical data and the Lysholm questionnaire, one year after the operation.

RESULTS

It was observed that the patients were predominantly female (86%) and under 21 years of age (73%), just like in the literature. At the first annual return after the surgery, there was no significant pain on medium efforts, no loss of range of motion and a positive apprehension test. According to the questionnaire used, the results were graded as good. The patients who reported having severe pain on greater effort were involved in employment-related legal disputes.

CONCLUSION

This technique showed low morbidity and good functional results over the short term.

Clinical-radiographic correlation of the femoral insertion point of the graft in reconstruction of the medial patellofemoral ligament

OBJECTIVE

To analyze the radiographic positioning of the femoral tunnel and correlate this with the postoperative clinical results among patients undergoing reconstruction of the medial patellofemoral ligament (MPFL) alone.

METHOD

This was a retrospective study in which 30 knees of 26 patients with recurrent dislocation of the patella that underwent MPFL reconstruction were evaluated. The femoral insertion point of the graft and the postoperative clinical condition were analyzed and correlated using the Kujala and Lysholm scales.

RESULTS

22 knees presented a femoral tunnel in the anatomical area (group A) and 8 outside of this location (group B). In group A, the mean score on the Kujala scale was 89.68 points and on the Lysholm scale was 92.45 points. In group B, the mean score on the Kujala scale was 84.75 points and on the Lysholm scale was 92 points. The difference between the means was not significant on either of the two scales.

CONCLUSION

Correlation with the clinical results did not show any difference in relation to the positioning of the femoral insertion of the graft.