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Balcarek P, Zimmerer A, Wassilew GI, Gebhardt S. Implications for Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction Considering the Sagittal Trochlear Groove Curvature in Severe Trochlear Dysplasia Before and After Deepening Trochleoplasty. Am J Sports Med 2024:3635465241271900. [PMID: 39207361 DOI: 10.1177/03635465241271900] [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] [Indexed: 09/04/2024]
Abstract
BACKGROUND Medial patellofemoral ligament reconstruction (MPFL-R) aims to restore proper ligament function with minimal changes in length during range of motion, yet the ideal area for femoral fixation of the graft remains controversial. PURPOSE To determine the region where the isometric circular path of a simulated MPFL graft (best-fit circle) follows the sagittal radius curvature of the trochlea in normal (nontrochlear dysplastic) knees and to evaluate the best-fit circle coverage of different femoral fixation points in knees with severe trochlear dysplasia (TD) and after deepening trochleoplasty. STUDY DESIGN Controlled laboratory study. METHODS Twelve patients (4 male, 8 female; mean age, 24 ± 8 years) who underwent surgical treatment for recurrent lateral patellar instability due to severe TD were prospectively enrolled in this study. Four previously defined reference points for the femoral MPFL-R (Schöttle, Fujino, Stephen, and Oka) were identified, and the best-fit circle was drawn along the sagittal trochlear groove curvature. The divergence between each best-fit circle and the trochlear groove was calculated, with negative values indicating relative slackening and positive values indicating relative tightening of the simulated MPFL graft. Measurements were made on true-lateral fluoroscopic images before and after deepening trochleoplasty and compared with those of a sex-matched control group. RESULTS The best-fit circle of the Schöttle point followed the sagittal curvature of the trochlea most closely in both the control and trochlear dysplastic knees, followed by the Fujino, Stephen, and Oka points. As the radius of the trochlear groove curvature increased, the divergence of all best-fit circles to the trochlear groove became negative (all P < .05). This effect was most pronounced at the Stephen and Oka points, followed by the Fujino and Schöttle points (all P < .05). After deepening trochleoplasty, the divergence of the Schöttle point changed toward positive values (11.6% at 40°; P < .001). Concurrently, the best-fit circle divergence of all other reference points improved toward baseline (all P < .05). CONCLUSION The isometric circle of the Schöttle point provides the best congruence with the sagittal trochlear groove curvature in both the normal trochlea and the dysplastic trochlea. After trochleoplasty, the best-fit circles of more distal femoral fixation points resulted in better congruence with the deepened trochlear groove, whereas the best-fit circle of Schöttle indicated graft tension during flexion. CLINICAL RELEVANCE According to the present study, different femoral fixation points should be considered depending on whether the TD is corrected.
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Affiliation(s)
- Peter Balcarek
- Arcus Sportklinik, Pforzheim, Germany
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Göttingen, Germany
| | - Alexander Zimmerer
- Diakonieklinikum Stuttgart, Department of Orthopaedic and Trauma Surgery, Orthopädische Klinik Paulinenhilfe, Stuttgart, Germany
| | - Georgi I Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Gebhardt
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
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Kaplan DJ. Editorial Commentary: Proper Femoral Tunnel Placement for Medial Patellofemoral Ligament Reconstruction Requires Optimal Radiographic Technique. Arthroscopy 2024; 40:1867-1869. [PMID: 38284957 DOI: 10.1016/j.arthro.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024]
Abstract
Femoral tunnel malposition has been shown to be a risk factor for medial patellofemoral ligament reconstruction failure. Palpation of the "saddle point" between the adductor tubercle and medial epicondyle can be an effective strategy; however, compared to using fluoroscopy, tunnel placement using palpation alone may result in significantly more frequent malposition. Accordingly, use of radiographic landmarks has gained in popularity. However, the technique is not without its pitfalls. The first issue lies with obtaining an adequate x-ray. Deviation from a true lateral x-ray by as little as 5° can result in significant tunnel malposition. Including sufficient visible femoral shaft is also required; a minimum requirement is 4 cm. The literature widely varies as to the anatomic, fluoroscopic position. Schottle's point (1.3 mm anterior to the posterior cortical extension line) is the most well studied.
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Walsh JM, Credille K, Allahabadi S, Kaplan DJ, Darbandi AD, Huddleston HP, Hevesi M, Wang Z, Dandu N, Yanke AB. Biomechanical Properties and Kinematics of Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Orthop J Sports Med 2024; 12:23259671241241537. [PMID: 38855071 PMCID: PMC11159569 DOI: 10.1177/23259671241241537] [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: 08/21/2023] [Accepted: 10/01/2023] [Indexed: 06/11/2024] Open
Abstract
Background While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of MPFL reconstruction (MPFLR). An accurate understanding of the kinematic properties and functional behavior of current techniques used in MPFLR is imperative to restoring native biomechanics and improving outcomes. Purpose To provide a comprehensive review of the biomechanical effects of variations in MPFLR, specifically to determine the effect of graft choice and reconstruction technique. Study Design Systematic review. Methods A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 32 studies met inclusion criteria: (1) using ≥8 human cadaveric specimens, (2) reporting on a component of MPFLR, and (3) having multiple comparison groups. Results Gracilis, semitendinosus, and quadriceps grafts demonstrated an ultimate load to failure (N) of 206.2, 102.8, and 190.0 to 205.0 and stiffness (N/mm) of 20.4, 8.5, and 21.4 to 33.6, respectively. Single-bundle and double-bundle techniques produced an ultimate load to failure (N) of 171 and 213 and stiffness (N/mm) of 13.9 and 17.1, respectively. Anchors placed centrally and superomedially in the patella produced the smallest degree of length changes throughout range of motion in contrast to anchors placed more proximally. Sutures, suture anchors, and transosseous tunnels all produced similar ultimate load to failure, stiffness, and elongation data. Femoral tunnel malpositioning resulted in significant increases in contact pressures, patellar translation, tilt, and graft tightening or loosening. Low tension grafts (2 N) most closely restored the patellofemoral contact pressures, translation, and tilt. Graft fixation angles variably and inconsistently altered contact pressures, and patellar translation and tilt. Conclusion Data demonstrated that placement of the MPFLR femoral tunnel at the Schöttle point is critical to success. Femoral tunnel diameter should be ≥2 mm greater than graft diameter to limit graft advancement and overtensioning. Graft fixation, regardless of graft choice or fixation angle, is optimally performed under minimal tension with patellar fixation at the medial and superomedial patella. However, lower fixation angles may reduce graft strain, and higher fixation angles may exacerbate anisometry and length changes if femoral tunnel placement is nonanatomic.
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Affiliation(s)
| | | | - Sachin Allahabadi
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Daniel J. Kaplan
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Azad D. Darbandi
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Zachary Wang
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Navya Dandu
- University of Illinois Chicago, Chicago, Illinois, USA
| | - Adam B. Yanke
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
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Hiemstra LA, Kerslake S, Sasyniuk TM, Lafave MR. Palpation and fluoroscopy are valid but unreliable for the assessment of femoral tunnel position after medial patellofemoral ligament reconstruction. J ISAKOS 2024; 9:348-352. [PMID: 38492848 DOI: 10.1016/j.jisako.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES The purpose of this study was to evaluate the validity and reliability of two techniques, palpation and fluoroscopy, for assessing medial patellofemoral ligament (MPFL) reconstruction femoral tunnel position accuracy. METHODS Twenty-one fresh frozen cadaveric knees had an MPFL femoral tunnel drilled and filled with a metal screw. Tunnels were created in a nonstandard fashion to ensure the sample included a range of tunnel positions from poor to ideal. Six experienced sport medicine and arthroscopy surgeons evaluated the placement of the femoral tunnel by palpating the screw in relation to anatomic landmarks and by fluoroscopy related to Schöttle's Point. They evaluated 1) the accuracy of femoral tunnel placement, 2) the direction of tunnel error, and 3) the clinical acceptability of the tunnel position. Validity measures included sensitivity, specificity, and correlation to clinical acceptability, which were calculated for the palpation and fluoroscopic assessments. Reliability measures included interrater reliability (ICC 2,k) for femoral tunnel accuracy and percent agreement of the raters' tunnel direction assessment. RESULTS The palpation method demonstrated a sensitivity of 0.79 and specificity of 0.84 for assessing the accuracy of femoral tunnel placement, while the fluoroscopic method showed a sensitivity of 0.83 and specificity of 0.92. Pearson correlation coefficients for clinical acceptability of tunnel position were high, with both techniques ranging from .589 to .854. Interrater reliability for the palpation and fluoroscopic techniques for assessment of tunnel accuracy were 0.31 and 0.55 (ICC 2,k), respectively. Assessment of the direction of tunnel error was good with the fluoroscopic technique slightly more accurate than palpation. CONCLUSION This study demonstrated that both palpation and fluoroscopy are valid techniques for assessing femoral tunnel position after MPFL reconstruction. Despite demonstrating good validity, the accuracy of assessing tunnel position was unreliable in a group of six experienced knee surgeons. Further research into MPFL reconstruction femoral tunnel assessment techniques, including patient-specific reference standards, is warranted. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Laurie A Hiemstra
- Banff Sport Medicine Foundation, PO Box 1300, Banff, Alberta, T1L 1B3, Canada; Department of Surgery, University of Calgary, North Tower Foothills Medicine Centre, 1403 29th St. NW, Calgary, Alberta, T2N 2T9, Canada.
| | - Sarah Kerslake
- Banff Sport Medicine Foundation, PO Box 1300, Banff, Alberta, T1L 1B3, Canada.
| | - Treny M Sasyniuk
- Banff Sport Medicine Foundation, PO Box 1300, Banff, Alberta, T1L 1B3, Canada.
| | - Mark R Lafave
- Department of Health & Physical Education, Mount Royal University, 4825 Mount Royal Gate SW, Calgary, Alberta, T3E 6K6, Canada.
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Bhimani R, Ashkani-Esfahani S, Mirochnik K, Lubberts B, Waryasz G, Tanaka MJ. Radiographic Landmark Measurements for the Femoral Footprint of the Medial Patellofemoral Complex May Be Affected by Visible Femoral Shaft Length on Lateral Knee Radiographs. Arthroscopy 2024; 40:1858-1866. [PMID: 38056724 DOI: 10.1016/j.arthro.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 10/29/2023] [Accepted: 11/19/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE To assess the effect of visible femoral shaft length on the accuracy of radiographic landmarks of the medial patellofemoral complex (MPFC). METHODS In 9 cadaveric knees, the MPFC footprint was exposed on the medial femur, and its proximal and distal boundaries were marked. Lateral fluoroscopic images of the knee were assessed in 1-cm length increments, beginning 1 cm proximal to the medial condyle and continuing proximally to 8 cm. The MPFC midpoint was described on each image relative to the posterior cortical line of the femur and a line perpendicular to this line through the proximal margin of the medial condyle. In addition, the MPFC midpoint was assessed relative to a line from the proximal posterior cortex to the midpoint of Blumensaat line. RESULTS Using the posterior cortical line as a reference, the MPFC radiographic landmark moved anteriorly with decreasing visible femoral shaft on radiographs, particularly at 4 cm and less. However, no proximal-distal change was noted. Linear regression analysis demonstrated a relationship between visible femoral shaft and MPFC position on radiographs (R = 0.461, R2 = 0.212, B = -0.636, P < .001). For every centimeter decrease in the visible femoral shaft, the radiographic MPFC footprint moved anteriorly by 0.636 mm. Receiver operating characteristic curve analysis revealed that a minimum of 4 cm of femoral shaft on lateral radiographs is required for accurate MPFC footprint localization (area under the curve = 0.80; sensitivity = 76.7%; specificity = 69.0%; P < .001). In contrast, no anterior-posterior change was seen when referencing a line from the proximal posterior cortex to the midpoint of Blumensaat line. CONCLUSIONS When using the posterior cortical line to identify the midpoint of the MPFC, at least 4 cm of femoral shaft should be visible for accurate assessment. If less than 4 cm of shaft is visible, a line through the midpoint of Blumensaat line and the proximal posterior cortex can be used as an alternative method to estimate the position of the femoral footprint. CLINICAL RELEVANCE As fluoroscopy is frequently used intraoperatively for MPFC reconstruction, our findings may serve as a guide when assessing femoral tunnel placement on fluoroscopy.
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Affiliation(s)
- Rohan Bhimani
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Soheil Ashkani-Esfahani
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Karina Mirochnik
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Bart Lubberts
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Gregory Waryasz
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Miho J Tanaka
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A..
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Behrendt P, Robinson JR, Herbst E, Gellhaus F, Raschke MJ, Seekamp A, Herbort M, Kurz B, Kittl C. Isometry of anteromedial reconstructions mimicking the deep medial collateral ligament depends on the femoral insertion. Knee Surg Sports Traumatol Arthrosc 2024; 32:978-986. [PMID: 38431913 DOI: 10.1002/ksa.12111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE This study aimed to investigate the length change patterns of the native deep medial collateral ligament (dMCL) and potential anteromedial reconstructions (AMs) that might be added to a reconstruction of the superficial MCL (sMCL) to better understand the control of anteromedial rotatory instability (AMRI). METHODS Insertion points of the dMCL and potential AM reconstructions were marked with pins (tibial) and eyelets (femoral) in 11 cadaveric knee specimens. Length changes between the pins and eyelets were then tested using threads in a validated kinematics rig with muscle loading of the quadriceps and iliotibial tract. Between 0° and 100° knee flexion, length change pattern of the anterior, middle and posterior part of the dMCL and simulated AM reconstructions were analysed using a rotary encoder. Isometry was tested using the total strain range (TSR). RESULTS The tibiofemoral distance of the anterior dMCL part lengthened with flexion (+12.7% at 100°), whereas the posterior part slackened with flexion (-12.9% at 100°). The middle part behaved almost isometrically (maximum length: +2.8% at 100°). Depending on the femoral position within the sMCL footprint, AM reconstructions resulted in an increase in length as the knee flexed when a more centred position was used, irrespective of the tibial attachment position. Femoral positioning in the posterior aspect of the sMCL footprint exhibited <4% length change and was slightly less tight in flexion (min TSR = 3.6 ± 1.5%), irrespective of the tibial attachment position. CONCLUSION The length change behaviour of potential AM reconstructions in a functionally intact knee is mainly influenced by the position of the femoral attachment, with different tibial attachments having a minimal effect on length change. Surgeons performing AM reconstructions to control AMRI would be advised to choose a femoral graft position in the posterior part of the native sMCL attachment to optimise graft length change behaviour. Given the high frequency of MCL injuries, sufficient restoration of AMRI is essential in isolated and combined ligamentous knee injuries. LEVEL OF EVIDENCE There is no level of evidence as this study was an experimental laboratory study.
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Affiliation(s)
- Peter Behrendt
- Department of Orthopedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
- Department of Trauma and Orthopedic Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Florian Gellhaus
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Andreas Seekamp
- Department of Trauma and Orthopedic Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Mirco Herbort
- OCM Orthopedic Surgery Munich Clinic, Munich, Germany
| | - Bodo Kurz
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
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Emre TY, Cetin H, Selcuk H, Kilic KK, Aykanat F, Sarikcioglu L, Kose O. Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint. Arch Orthop Trauma Surg 2024; 144:1675-1684. [PMID: 38400901 PMCID: PMC10965741 DOI: 10.1007/s00402-024-05213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/24/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE The success of medial patellofemoral ligament (MPFL) reconstruction is closely linked to the precise positioning of the femoral tunnel. Intraoperative fluoroscopy is commonly utilized to identify the MPFL footprint. This study aimed to ascertain the most accurate fluoroscopic method among the five previously described methods used to determine the MPFL femoral footprint. MATERIALS AND METHODS Using 44 well-preserved dry femur bones, the MPFL femoral insertion site was demarcated using anatomical bony landmarks, namely the center of the saddle sulcus between the medial epicondyle, adductor tubercle and gastrocnemius tubercle. Fluoroscopic true lateral knee images were acquired and measurements taken, referencing established methods by Schottle et al., Redfern et al., Wijdicks et al., Barnett et al., and Kaipel et al. The distance between anatomic and fluoroscopic MPFL footprints was then measured on digital fluoroscopic images. The accuracy of the locations was compared using a margin of error of 5 and 7 mm. RESULTS The Schottle method consistently emerged superior, showcasing the smallest mean distance (3.2 ± 1.2 mm) between the anatomic and radiographic MPFL footprints and a high in-point detection rate of 90.9% under 5 mm criteria. While the Redfern method displayed perfect accuracy (100%) within the 7 mm criteria, the Schottle method also performed 97.7% accuracy. CONCLUSIONS For intraoperative identification of the MPFL footprint using fluoroscopy, the Schottle method is the most consistent and accurate among the assessed methods. Thus, its accuracy in detecting the MPFL footprint makes it recommended for MPFLR to ensure optimal outcomes. LEVEL OF EVIDENCE Level IV, cadaveric study.
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Affiliation(s)
- Tuluhan Yunus Emre
- Department of Orthopaedics and Traumatology, Kadikoy Hospital, Acıbadem University, Istanbul, Turkey
| | - Hakan Cetin
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey
| | - Koray Kaya Kilic
- Department of Radiology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Faruk Aykanat
- Medical Faculty Department of Orthopaedics and Traumatology, Sanko University, Gaziantep, Turkey
| | - Levent Sarikcioglu
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd., Muratpasa, 07100, Antalya, Turkey.
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey.
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Mostowy M, Puzio T, Matera K, Kozieł M, Stanek J, Bawor M, Grzelak P, Domżalski ME. Quadriceps muscle contraction causes medial patellofemoral ligament elongation by intermeshed fibers of vastus medialis oblique muscle. J Anat 2024; 244:325-332. [PMID: 37737508 PMCID: PMC10780142 DOI: 10.1111/joa.13954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023] Open
Abstract
The first aim of this study was to compare the medial patellofemoral length between contracted and relaxed quadriceps muscle and second to assess the importance of the intermeshed vastus medialis oblique fibers. After a priori power analysis (α = 0.05, power [1-β] = 0.95), 35 healthy males aged 18-30 were prospectively examined with a 3.0-T magnetic resonance imaging (MRI) scanner in 10-15° of knee flexion. Two axial MRI sequences (25 s each) were made with relaxed and contracted quadriceps. Two blinded, independent raters measured twice medial patellofemoral ligament length (curved line) and attachment-to-attachment length (straight line). Mean medial patellofemoral ligament length and attachment-to-attachment length with relaxed quadriceps was: 65.5 mm (SD = 3.7), 59.7 mm (SD = 3.6), and after contraction, it increased to 68.7 mm (SD = 5.3), 61.2 mm (SD = 4.7); p < 0.01 and <0.001, respectively. Intraclass correlation coefficients for intra- and inter-rater reliabilities ranged from 0.55 (moderate) to 0.97 (excellent). Mean medial patellofemoral ligament length elongation after quadriceps contraction was significantly greater (3.2 mm, SD = 3.9) than mean attachment-to-attachment length elongation (1.6 mm, SD = 2.8); p < 0.001. Contraction of quadriceps muscle causes elongation of the medial patellofemoral ligament to the extent greater than the elongation of distance between its attachments. This confirms that medial patellofemoral ligament elongation after quadriceps contraction results not only from movement of its patellar attachment but also directly from intermeshed vastus medialis oblique fibers pulling medial patellofemoral ligament in a different direction creating a bow-like construct in agreement with the "pull-and-guide mechanism" proposed in the literature.
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Affiliation(s)
- Marcin Mostowy
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Tomasz Puzio
- Department of Diagnostic Imaging, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Katarzyna Matera
- Department of Diagnostic Imaging, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Michał Kozieł
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Jakub Stanek
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Michalina Bawor
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Piotr Grzelak
- Department of Diagnostic Imaging, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Marcin E Domżalski
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
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Kader DF, Jones S, Haddad FS. Towards a better understanding of patellofemoral instability. Bone Joint J 2023; 105-B:1235-1238. [PMID: 38035592 DOI: 10.1302/0301-620x.105b12.bjj-2023-1026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Deiary F Kader
- South West London Elective Orthopaedic Centre, Epsom, UK
- University of Kurdistan Hewlêr, Erbil, Iraq
| | - Samantha Jones
- South West London Elective Orthopaedic Centre, Epsom, UK
- Institute of Medical and Biomedical Education, St George's, University of London, London, UK
| | - Fares S Haddad
- University College London Hospitals, London, UK
- The Princess Grace Hospital, London, UK
- The NIHR Biomedical Research Centre, London, UK
- The Bone & Joint Journal , London, UK
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Boot MR, van de Groes SA, Dunning H, Tanck E, Janssen D. Length Changes of the Medial Patellofemoral Ligament During In Vivo Knee Motion: An Evaluation Using Dynamic Computed Tomography. Am J Sports Med 2023; 51:3724-3731. [PMID: 37960850 PMCID: PMC10691293 DOI: 10.1177/03635465231205597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/23/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is associated with high complication rates because of graft overloading from incorrect graft positioning. To improve clinical outcomes, it is crucial to gain a better understanding of MPFL elongation patterns. PURPOSE To assess MPFL length changes in healthy knees from 0° to 90° of dynamic flexion and their relationship with anatomic parameters of the patellofemoral joint. STUDY DESIGN Descriptive laboratory study. METHODS Dynamic computed tomography scans of an active flexion-extension-flexion movement in 115 knees from 63 healthy participants were evaluated to construct knee joint models. Using these models, the MPFL length was measured as the shortest wrapping path from the Schöttle point on the femur to 3 insertion points on the superomedial border of the patella (proximal, central, and distal). MPFL length changes (%) relative to the length in full extension were calculated, and their correlations with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination were analyzed. RESULTS The proximal fiber was the longest in full extension and progressively decreased to a median length of -6.0% at 90° of flexion. The central fiber exhibited the most isometric pattern during knee flexion, showing a median maximal decrease of 2.8% relative to the full extension length and no evident elongation. The distal fiber first slightly decreased in length but increased at deeper flexion angles. The median overall length changes were 4.6, 4.7, and 5.7 mm for the proximal, central, and distal patellar insertion, respectively. These values were either not or very weakly correlated with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination when the anatomic parameters were within the healthy range. CONCLUSION The median MPFL length changed by approximately 5 mm between 0° and 90° of flexion. Proximally, the length continuously decreased, indicating slackening behavior. Distally, the length increased at deeper flexion angles, indicating tightening behavior. CLINICAL RELEVANCE In MPFL reconstruction techniques utilizing the Schöttle point to establish the femoral insertion, one should avoid distal patellar insertion, as it causes elongation of the ligament, which may increase the risk for complications due to overloading.
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Affiliation(s)
- Miriam R. Boot
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Hans Dunning
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dennis Janssen
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
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11
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Uso MB, Thürig G, Heimann AF, Schwab JM, Panadero-Morales R, Peris JL, Tannast M, Petek D. Patient-Individualized Identification of Medial Patellofemoral Ligament Attachment Site to Femur Using "CLASS" MRI Sequences. JB JS Open Access 2023; 8:e23.00097. [PMID: 37790196 PMCID: PMC10545411 DOI: 10.2106/jbjs.oa.23.00097] [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] [Indexed: 10/05/2023] Open
Abstract
Background Malposition of the femoral tunnel during medial patellofemoral ligament (MPFL) reconstruction may increase the risk of recurrence of patellar dislocation due to isometric changes during flexion and extension. Different methods have been described to identify the MPFL isometric point using fluoroscopy. However, femoral tunnel malposition was found to be the cause of 38.1% of revisions due to patellar redislocation. This high rate of malposition has raised the question of individual anatomical variability. Methods Magnetic resonance imaging (MRI) was performed on 80 native knees using the CLASS (MRI-generated Compressed Lateral and anteroposterior Anatomical Systematic Sequence) algorithm to identify the femoral MPFL insertion. The insertions were identified on the MRI views by 2 senior orthopaedic surgeons in order to assess the reliability and reproducibility of the method. The distribution of the MPFL insertion locations was then described in a 2-plane coordinate system and compared with MPFL insertion locations identified with other methods in previously published studies. Results The CLASS MPFL footprint was located 0.83 mm anterior to the posterior cortex (line 1) and 3.66 mm proximal to the Blumensaat line (line 2). Analysis demonstrated 0.90 and 0.89 reproducibility and 0.89 and 0.80 reliability of the CLASS method to identify the anatomical femoral MPFL insertion point. The distribution did not correlate with previously published data obtained with other methods. The definitions of the MPFL insertion point in the studies by Schöttle et al. and Fujino et al. most closely approximated the CLASS location in relation to the posterior femoral cortex, but there were significant differences between the CLASS method and all 4 previously published methods in relation to the proximal-distal location. When we averaged the distances from line 1 and line 2, the method that came closest to the CLASS method was that of Stephen et al., followed by the method of Schöttle et al. Conclusions The CLASS algorithm is a reliable and reproducible method to identify the MPFL femoral insertion from MRI views. Measurement using the CLASS algorithm shows substantial individual anatomical variation that may not be adequately captured with existing measurement methods. While further research must target translation of this method to clinical use, we believe that this method has the potential to create a safe template for sagittal fluoroscopic identification of the femoral tunnel during MPFL surgical reconstruction. Level of Evidence Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Marc Barrera Uso
- Department of Orthopaedic Surgery and Traumatology, Hospital and University of Fribourg, Fribourg, Switzerland
| | - Grégoire Thürig
- Department of Orthopaedic Surgery and Traumatology, Hospital and University of Fribourg, Fribourg, Switzerland
| | - Alexander Frank Heimann
- Department of Orthopaedic Surgery and Traumatology, Hospital and University of Fribourg, Fribourg, Switzerland
| | - Joseph M. Schwab
- Department of Orthopaedic Surgery and Traumatology, Hospital and University of Fribourg, Fribourg, Switzerland
| | - Raul Panadero-Morales
- Biomechanics Institute of Valencia, Universitat Politècnica de València, Valencia, Spain
| | - José Luis Peris
- Biomechanics Institute of Valencia, Universitat Politècnica de València, Valencia, Spain
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Hospital and University of Fribourg, Fribourg, Switzerland
| | - Daniel Petek
- Department of Orthopaedic Surgery and Traumatology, Hospital and University of Fribourg, Fribourg, Switzerland
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12
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Drapeau-Zgoralski V, Swift B, Caines A, Kerrigan A, Carsen S, Pickell M. Lateral Patellar Instability. J Bone Joint Surg Am 2023; 105:397-409. [PMID: 36728086 DOI: 10.2106/jbjs.22.00756] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
➤ Patellar instability represents a common problem with an evolving understanding and multifactorial pathoetiology. Treatment plans should be based on the identification of contributing anatomical factors and tailored to each individual patient. ➤ Risks for recurrent instability are dependent on several patient-specific factors including patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, trochlear dysplasia, younger skeletal age, and ligamentous laxity. ➤ Cartilage or osteochondral lesions and/or fractures are commonly observed in first-time patellar dislocation, and magnetic resonance imaging (MRI) should be strongly considered. Advanced imaging modalities, such as computed tomography (CT) or MRI, should also be obtained preoperatively to identify predisposing factors and guide surgical treatment. ➤ Medial patellofemoral ligament (MPFL) reconstruction with anatomical femoral tunnel positioning is associated with lower recurrence rates compared with MPFL repair and has become a common and successful reconstructive surgical option in cases of instability. ➤ Lateral retinacular tightness can be addressed with lateral retinacular release or lengthening, but these procedures should not be performed in isolation. ➤ Tibial tubercle osteotomy is a powerful reconstructive tool in the setting of underlying skeletal risk factors for instability and can be of particular benefit in the presence of increased TT-TG distance (>20 mm), and/or in the setting of patella alta. ➤ The indications for trochleoplasty are still developing along with the clinical evidence, but trochleoplasty may be indicated in some cases of severe trochlear dysplasia. Several surgical techniques have indications in specific clinical scenarios and populations, and indications, risks, and benefits to each are progressing with our understanding. ➤ Combined femoral derotational osteotomy and MPFL reconstruction can be considered for patients with a femoral anteversion angle of >30° to improve patient outcomes and reduce recurrence rates.
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Affiliation(s)
| | - Brendan Swift
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew Caines
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alicia Kerrigan
- Division of Orthopaedic Surgery, The Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, The Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Michael Pickell
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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13
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Masquijo J, Parikh SN, Kothari A. Evaluation of the Optimal Femoral Fixation Site for Medial Patellofemoral Ligament Reconstruction in the Skeletally Immature Patient. Orthopedics 2023; 46:108-113. [PMID: 36343644 DOI: 10.3928/01477447-20221031-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of this study was to assess which femoral fixation site, distal to the physis, most closely emulates the native medial patellofemoral ligament (nMPFL) length relationship in the pediatric knee. Lateral knee radiographs were taken incrementally, from 0° to 120° of flexion. The femoral origin of the nMPFL and 3 other MPFL femoral fixation sites distal to the physis were identified (P1, 1 cm distal to physis along the posterior femoral cortex; P2, 2 cm distal to physis along the posterior femoral cortex; P3, 1 cm distal and 1 cm anterior). Virtual MPFL lengths were measured from all sites. Measurement reliability was assessed using intraclass correlation coefficients. Primary comparison between simulated MPFL length at native and femoral fixation sites was made using a repeated measures analysis of variance at 30° flexion. Bivariate Pearson correlation was used to assess the relationship between fixation sites and nMPFL through the range of motion (alpha=0.05). The intra-class correlation coefficient for intraobserver reliability of MPFL length measurement was excellent. Analysis of variance showed virtual MPFL lengths from proposed femoral fixation sites at 30° were significantly different from nMPFL length (P<.01). The P1 MPFL had the least difference in means compared with nMPFL (-2.6±1.8 mm). Correlational analysis showed that P1 MPFL had the closest relationship with nMPFL compared with other femoral fixation sites (R=0.91, P<.01). The P1 MPFL had the length change most comparable to that of nMPFL (23.9±3.1 mm vs 13.3±2.85 mm) compared with the other simulated MPFLs. Femoral graft fixation site 1 cm distal to the physis in the lateral view along the posterior femoral cortex closely represents the length relationship of the nMPFL. [Orthopedics. 2023;46(2):108-113.].
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14
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Zhang W, Mou L, Zhang S, Liu W, Remila A, Han M, Xiang W, Fang R. 3D-printed individualized navigation template versus the fluoroscopic guide to defining the femoral tunnel for medial patellofemoral ligament reconstruction: A retrospective study. Medicine (Baltimore) 2023; 102:e32729. [PMID: 36705383 PMCID: PMC9876018 DOI: 10.1097/md.0000000000032729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
During medial patellofemoral ligament (MPFL) reconstruction, fluoroscopic determination of the femoral tunnel point is the most common method. However, there is a decrease in tunnel position accuracy due to rotation of the femur during fluoroscopy, as well as the damage to the operator from multiple fluoroscopies, whereas the 3D-printed individualized navigation template is not affected by this factor. This study focuses on the accuracy and early clinical efficacy of 2 different ways to determine the femoral tunnel (Schöttle point) for double-bundle isometric MPFL reconstruction. This is a retrospective study, conducted between 2016 and 2019, in which 60 patients with recurrent patellar dislocation were divided into 2 groups: 30 with MPFL reconstruction at the Schöttle point determined by 3D-printed individualized navigation template (group A) and 30 with MPFL reconstruction at the Schöttle point determined by fluoroscopic guidance (group B). The changes in patella congruence angle and patella tilt angle before and after surgery were assessed using computed tomography scans of the knee, knee function was assessed using the Kujala knee score and the international knee documentation committee (IKDC) score, and the 2 approaches were compared for the intraoperative establishment of the femoral tunnel position at a distance from Schöttle point. At a minimum of 3 years follow-up, patella tilt angle and patella congruence angle returned to normal levels and were statistically different from the preoperative range, with no significant differences between the 2 groups at the same period, and Kujala and IKDC scores of knee function were significantly improved in both groups after surgery. The mean Kujala and IKDC scores were statistically different between groups A and B at 3 and 6 months postoperatively. No statistically significant differences were seen between the 2 groups at the final follow-up. Both femoral tunnel localization approaches for double-bundle isometric MPFL reconstruction resulted in good knee function. At no < 3 years of follow-up, the use of a 3D-printed individualized navigation template did result in more accurate isometric points and higher knee function scores in the early postoperative period.
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Affiliation(s)
- Wenhao Zhang
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Limin Mou
- Emergency Trauma Surgery, Yichang Central Hospital, affiliated with Three Gorges University, Yicang, Hubei Province
| | - Shiping Zhang
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Wei Liu
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Aimaiti Remila
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Mingzhan Han
- Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Wenyuan Xiang
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
| | - Rui Fang
- Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province, China
- * Correspondence: Rui Fang, Department of Orthopedics, The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province 830054, China (e-mail: )
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15
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Hu F, Shi W, Wang H, Wang C. A Novel Technique of Arthroscopic Femoral Tunnel Placement during Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation. J Clin Med 2023; 12:jcm12020680. [PMID: 36675609 PMCID: PMC9860788 DOI: 10.3390/jcm12020680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Recurrent patellar dislocation is a commonly encountered patellofemoral disease. Prompt surgical intervention is indicated for recurrent dislocation to restore patellofemoral stability. As one of the most preferred procedures, medial patellofemoral ligament (MPFL) reconstruction has been implemented on a large scale. Femoral tunnel placement remains a crucial technical issue during MPFL reconstruction and is critical to ensure the isometry and proper tension of the graft. Currently, visual-palpatory anatomic landmarks and fluoroscopy-guided radiographic landmarks comprise the main approaches to intraoperative femoral tunnel positioning. However, the accuracy of both methods has been questioned. This article introduces an arthroscopic femoral tunnel placement technique. Apart from traditional anteromedial and anterolateral portals, two auxiliary arthroscopic portals are specially designed. The adductor tubercle, the medial epicondyle and the posterior edge are selected as main anatomic landmarks and are directly visualized in sequence under arthroscope. The relative position between the femoral attachment of the MPFL and the three landmarks is measured on preoperative three-dimensional computed tomography, providing semi-quantified reference for intraoperative localization. This technique achieves minimally invasive tunnel placement without X-ray exposure, and especially suits obese patients for whom palpatory methods are difficult to perform.
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Deroche E, Erasmus P, Roberts C. MPFL Reconstruction With a Double-Loop Gracilis: The Concept of “Favorable Anisometry”. VIDEO JOURNAL OF SPORTS MEDICINE 2022. [DOI: 10.1177/26350254221128039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Medial patellofemoral ligament (MPFL) reconstruction has shown very good results in patella dislocation and patient satisfaction. However, correct positioning and tensioning of the graft can be difficult to achieve and can lead to complications. Indications: Medial patellofemoral ligament reconstruction is always indicated for recurrent patellar instability with dislocation in extension, with or without other procedures that aim to correct predisposing factors of instability. Technique Description: An arthroscopic examination is first done to assess chondral lesions. The gracilis tendon is detached from the tibia and prepared to pass through 3-mm drill holes. The medial edge of the patella is exposed, and two 3-mm drill holes are made. Dissection is performed with a scissors between the second and third layers toward the medial epicondyle, where a small skin incision is made. A guidewire is placed just anterior and distal to the adductor tubercle. A suture is used to test the isometry of the femoral drill hole. If correct tension or “favorable anisometry” is achieved, a 5-mm bone anchor is placed. The graft is looped and pulled into the femoral hole with sliding sutures. The 2 free ends of the graft are pulled through the patellar drill holes and looped back onto themselves. The graft is tensioned with the knee in maximum extension while pulling the patella proximally with a bone hook as hard as possible in the direction of the femoral shaft. The principle is that with maximum quads contraction, the tension in the patella tendon should be more than in the reconstructed MPFL. Results: Immediate full range of motion, intensive isomeric quads contraction exercises, and full weight-bearing with crutches for 2 to 4 weeks are recommended. Sport can be resumed after 3 months, but it usually takes 6 months to play at the same level as before. Discussion/Conclusion: The technique of “favorable anisometry” of the MPFL has shown a very low rate of recurrence of patella dislocation. Complications are rare and extensor lag is very uncommon, thanks to the specificity of tensioning the graft. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Affiliation(s)
- Etienne Deroche
- Knee Clinic, G3 Medi Clinic, Stellenbosch, South Africa
- Department of Orthopaedics Surgery and Sports Medicine, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
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17
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Landmarks Used in Medial Patellofemoral Ligament Reconstruction Have Variable Topography. Arthrosc Sports Med Rehabil 2022; 4:e2043-e2050. [PMID: 36579037 PMCID: PMC9791883 DOI: 10.1016/j.asmr.2022.09.003] [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: 03/03/2022] [Accepted: 09/15/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose To describe the morphology of the adductor tubercle (AT), medial epicondyle (ME), and gastrocnemius tubercle (GT); to quantify their relationships to the medial patellofemoral ligament (MPFL) footprint location; and to classify the reliability of each landmark based on measurement variability. Methods Eight cadaveric specimens were dissected to expose the following landmarks on the femur: MPFL footprint, AT, ME, and GT. Using the MicroScribe 3D digitizer, each landmark was projected into a 3-dimensional coordinate system and reconstructed into a complex, closed polygon. For each specimen tubercle, the base surface area, volume, height, base:height ratio, sulcus point, and distance from the MPFL footprint center were calculated. Levene's test was performed to evaluate differences in variance of the morphologic parameters between the three osseous structures. Results The ME had significantly greater variance in volume than the GT (P = .032), and the AT (17.5 ± 3.9) and GT (19.5 ± 3.6) were significantly less variable in base:height ratio than the ME (95.3 ± 19.2; P < .001). The GT was the closest to the MPFL footprint center (7.1 ± 3.1 mm) compared with the AT (13.4 ± 3.6 mm, P = .002) and ME (13.2 ± 2.7 mm, P = .003). However, the tubercles were equally variable in terms of distance to the MPFL footprint center (P = .86). Lastly, the sulcus point was estimated to be on average 1.9 ± 2.9 mm distal and 2.0 ± 2.0 mm posterior to the MPFL center point. Conclusions The 3 major osseous landmarks of the medial femur have significantly different variances in volume and base:height ratio. Specifically, the variability and elongated morphology of the ME differentiated this landmark from the AT and GT, which demonstrated the most consistent morphology. Clinical Relevance The results of this study may be useful to accurately locate landmarks for femoral tunnel placement and determine the isometric MPFL point during reconstruction.
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18
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A Simple Instrument for Intraoperative Fluoroscopic Localization of Anatomic Insertions in Medial Patellofemoral Ligament Reconstruction. Arthrosc Tech 2022; 11:e1431-e1433. [PMID: 36061458 PMCID: PMC9437445 DOI: 10.1016/j.eats.2022.03.033] [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: 02/05/2022] [Accepted: 03/17/2022] [Indexed: 02/03/2023] Open
Abstract
Medial patellofemoral ligament (MPFL) reconstruction is the most common operation for treating patellofemoral joint instability. Accurately identifying the fluoroscopic location of the MPFL anatomical insertion point is critical in this procedure. However, current radiographic localization has some limitations, such as inaccuracy and radiation exposure. We recommend a simpler and more accurate instrument for intraoperative fluoroscopic positioning.
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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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20
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Xu J, Ye Z, Qiao Y, Xu C, Han K, Chen J, Dong S, Zhao J. Medial Patellofemoral Ligament Reconstruction Using Adductor-Transfer and Adductor-Sling at Nonanatomic Femoral Attachment Sites Leads to Unfavorable Graft-Length Change Patterns: A Descriptive Biomechanical Study. Arthroscopy 2022; 38:1557-1567. [PMID: 34767953 DOI: 10.1016/j.arthro.2021.10.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the graft length change patterns in nonanatomic adductor-transfer (AT) and adductor-sling (AS) medial patellofemoral ligament (MPFL) reconstruction with those in anatomic MPFL reconstruction (MPFLR) and to investigate the favorable isometric ranges (FIRs) of knee flexion. METHODS Eight small fresh-frozen cadaveric knees were mounted in a knee-customized jig with tensioned muscles to measure graft length changes from two patellar points to four femoral attachments using a linear variable displacement transducer. Femoral attachments were at the MPFL footprint center (MPFL-C) in anatomic MPFLR, adductor magnus (AM) footprint center (AM-C) in AT, and at 5-mm (AM-5) or 10-mm (AM-10) points proximal to AM-C in AS. The FIRs of these femoral attachments were determined after zeroing the graft length changes at different initial fixation angles. RESULTS Anatomic MPFL-C resulted in almost isometric graft length changes from 0° to 90°. At AM-C, the graft length changes displayed an increase from 0° to 45° and significantly greater length changes than those at MPFL-C from 60° to 90°. The graft length changes at both AM-5 and at AM-10 continuously increased with knee flexion angles and presented significantly larger graft length changes than those at MPFL-C and at AM-C from 30° to 90° and 60° to 90°, respectively. After zeroing graft length changes at different fixation angles, the FIRs of the MPFL-C covered all knee flexion angles, regardless of the patellar attachments and initial fixation angles. Moreover, with the smaller FIRs of AM-C observed at any fixation angle when compared with MPFL-C, fixing the graft at 0° to 30° in AT allowed the FIRs to cover the whole functional flexion range. However, the significantly larger graft length changes of both AM-5 and AM-10 resulted in extremely limited FIRs at any fixation angle. CONCLUSION Anatomic MPFL-C resulted in a favorable graft length change range (less than 2 mm) at 0° to 90° of knee flexion, which was close to the isometric graft behavior. However, nonanatomic attachments of AM-C in AT, and both AM-5 and AM-10 in AS caused significant anisometric graft length change patterns and limited FIRs. Moreover, AT had a smaller range of graft length change but wider FIRs compared to AS, indicating superior graft behavior for MPFLR. CLINICAL RELEVANCE Anatomic MPFLR is preferable for the treatment of in skeletally immature patients, followed in preference by nonanatomic AT. Nonanatomic AS should be performed cautiously.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Qiao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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21
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Duchman KR. Editorial Commentary: The Medial Patellofemoral Ligament Is Not Isometric and Anatomic Reconstruction Is Important, But Just a Small Piece of the Patellar Instability Puzzle. Arthroscopy 2022; 38:1568-1570. [PMID: 35501021 DOI: 10.1016/j.arthro.2021.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 11/16/2021] [Indexed: 02/02/2023]
Abstract
Medial patellofemoral ligament (MPFL) reconstruction has proven to be a reliable procedure to reduce patellar instability events in patients with recurrent patellar instability. As our reconstruction techniques have evolved to address pathology in a diverse patient population, there continues to be an obsessive focus on the precise anatomy of the MPFL origin on the medial knee, due in large part to concerns that improper femoral tunnel position may result in excessive graft anisometry and failure. However, recurrent patellar instability involves many complexities and should not be simply reduced to a single point on the medial knee.
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22
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Dandridge O, Garner A, Amis AA, Cobb JP, van Arkel RJ. Variation in the patellar tendon moment arm identified with an improved measurement framework. J Orthop Res 2022; 40:799-807. [PMID: 34191354 DOI: 10.1002/jor.25124] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/08/2021] [Accepted: 06/09/2021] [Indexed: 02/04/2023]
Abstract
The mechanical advantage of the knee extensor mechanism depends heavily on the patellar tendon moment arm (PTMA). Understanding which factors contribute to its variation may help improve functional outcomes following arthroplasty. This study optimized PTMA measurement, allowing us to quantify the contribution of different variables. The PTMA was calculated about the instantaneous helical axis of tibiofemoral rotation from optical tracked kinematics. A fabricated knee model facilitated calculation optimization, comparing four data smoothing techniques (raw, Butterworth filtering, generalized cross-validated cubic spline-interpolation and combined filtering/interpolation). The PTMA was then measured for 24 fresh-frozen cadaveric knees, under physiologically based loading and extension rates. Combined filtering/interpolation enabled sub-mm PTMA calculation accuracy throughout the range of motion (root-mean-squared error 0.2 mm, max error 0.4 mm), whereas large errors were measured for raw, filtered-only and interpolated-only techniques at terminal flexion/extension. Before scaling, the mean PTMA was 46 mm; PTMA magnitude was consistently larger in males (mean differences: 5 to 10 mm, p < .05) and was strongly related to knee size: larger knees have a larger PTMA. However, while scaling eliminated sex differences in PTMA magnitude, the peak PTMA occurred closer to terminal extension in females (female 15°, male 29°, p = .01). Knee size accounted for two-thirds of the variation in PTMA magnitude, but not the flexion angle where peak PTMA occurred. This substantial variation in angle of peak PTMA has implications for the design of musculoskeletal models and morphotype-specific arthroplasty. The developed calculation framework is applicable both in vivo and vitro for accurate PTMA measurement.
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Affiliation(s)
- Oliver Dandridge
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Amy Garner
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK.,MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK.,Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship. Royal College of Surgeons of England, London, UK.,Health Education Kent, Surrey and Sussex, Stewart House, London, UK
| | - Andrew A Amis
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Justin P Cobb
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Richard J van Arkel
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
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Chen J, Xiong Y, Han K, Xu C, Cai J, Wu C, Ye Z, Zhao J, Xie G. Computed Tomography Imaging Analysis of the MPFL Femoral Footprint Morphology and the Saddle Sulcus: Evaluation of 1094 Knees. Orthop J Sports Med 2022; 10:23259671211073608. [PMID: 35155709 PMCID: PMC8829748 DOI: 10.1177/23259671211073608] [Citation(s) in RCA: 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: 10/08/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The medial patellofemoral ligament (MPFL) has been reported to be anatomically attached from an osseous saddle region (saddle sulcus) between neighboring landmarks on the femur, including the adductor tubercle (AT), medial epicondyle (ME), and medial gastrocnemius tubercle (MGT). However, the position and prevalence of the saddle sulcus remain unknown. Purpose: To study the femoral footprint of MPFL and the prevalence of the saddle sulcus with computed tomography (CT) imaging; quantify the position of the saddle sulcus; and determine the relevant factors of the identified position and measuring distances. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1094 knees in 753 patients were studied. Knees were organized into an anterior cruciate ligament reconstruction (ACLR) group (controls) and a recurrent patellar dislocation (RPD) group. Using 3-dimensionally reconstructed CT images, the authors determined the prevalence of the saddle sulcus and its position relative to the AT, the ME, the Schöttle point (1.3 mm anterior to the distal posterior cortex and 2.5 mm distal to the posterior origin of the medial femoral condyle), and the Fujino point (approximately 10 mm distal to the AT). Analysis of covariance was used to adjust for age, sex, side, and body mass index on the measurements. Results: There were 555 knees in the control group and 539 knees in the RPD group. The MPFL femoral footprint presented as an oblique, oblong, osseous region (saddle sulcus) in 75.7% of knees (75.0%, ACLR group vs 76.4%, RPD group; P < .001). The saddle sulcus was located a mean of 12.2 mm (95% CI, 12.0-12.4 mm) from a line connecting the apex of the AT to the ME (AT-ME) and a mean of 7.6 mm (95% CI, 7.5-7.8 mm) posteriorly perpendicular to that line. The location as a proportion of the AT-ME distance was 63.1% (95% CI, 62.6%-63.7%) in the X direction and 39.8% (95% CI, 39.1%-40.5%) in the Y direction. The Schöttle and Fujino points lay anterior and proximal to the saddle sulcus more than 5 mm away from the center of the saddle sulcus. Women had a higher prevalence of saddle sulcus (odds ratio [OR], 1.33 [95% CI, 1.00-1.75]; P = .046) compared with men. Conclusion: The saddle sulcus was identified in 75.7% of knees from the medial femoral aspect, with its center located consistently between the AT and ME.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yijia Xiong
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jiangyu Cai
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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24
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Zhang YQ, Zhang Z, Wu M, Zhou YD, Tao SL, Yang YL, Li Y, Liu JL, Li P, Teng YS, Guo YM. Medial patellofemoral ligament reconstruction: A review. Medicine (Baltimore) 2022; 101:e28511. [PMID: 35029909 PMCID: PMC8735765 DOI: 10.1097/md.0000000000028511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/09/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Reconstruction of the medial patellofemoral ligament (MPFL) is an effective surgical method for the treatment of lateral patellar instability. At present, there is not much controversies regarding the femoral attachment, however, the controversies regarding patellar attachment versus attachment, number of graft strands, tension, isometry and so on. The following electronic databases will be searched: PubMed, the Cochrane Library, Embase, Web of Science, Medline. We will consider articles published between database initiation and March 2021. MPFL in the subject heading will be included in the study. Language is limited to English. Research selection, data extraction, and research quality assessment were independently completed by 2 researchers. CONCLUSIONS MPFL reconstruction is a reliable technique for the treatment of patellofemoral instability. The Schöttle point is still the mainstream method for locating the femoral attachment, the patellar attachment for single-bundle is located at the junction of the proximal one third and the distal two third of the longitudinal axis of the patella. For double-bundles, one is located in the proximal one third of the medial patellar edge and another is in the center of the patellar edge. Meanwhile, the adjustment of graft tension during operation is very important.
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25
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Medial patellofemoral ligament reconstruction with autologous gracilis tendon: Clinical and radiological outcomes at a mean 6 years of follow up. Knee 2021; 33:252-259. [PMID: 34739956 DOI: 10.1016/j.knee.2021.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 08/23/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The medial patellofemoral ligament (MPFL) is considered the primary soft tissue restrain to lateral translation of the patella during the first 15-30 degrees of knee flexion. The primary restraint thereafter is the slope of the lateral wall of the trochlea. A plenty of procedures are described in literature for MPFL reconstruction with different types of graft, angle of knee flexion for fixation and rehabilitation protocols. In this study we used MPFL reconstruction with doubled autologous gracilis tendon with the Schottle's technique. The aim of our study is to evaluate outcomes at medium-long term follow up of MPFL reconstruction. METHODS Patients who underwent arthroscopic MPFL reconstruction for recurrent patellar dislocation were followed up for a minimum of 2 to 10 years. Patient-reported outcomes including the Kujala, Visual Analogue Scale (VAS) score were collected preoperatively and postoperatively. Clinical complications such as loss of ROM, recurrent sub-luxation or dislocation were recorded. RESULTS A total of 38 patients with recurrent patellar dislocation were treated with MPFL reconstruction and data were available for final follow up (mean 72.3 months, SD 33.6). Mean age at time of surgery was 23.4 (SD 7.8). Mean number of dislocations before surgery was 7.1 (SD 10.5). Recurrent dislocations were not observed in any of the patients treated at last follow-up. Significant clinical improvements were also noted with Kujala and VAS score. Patellar tilt angle decreased significantly from pre to post-operative. CONCLUSION Our study demonstrated that MPFL reconstruction with patellar suture anchors fixation using autologous gracilis tendon is an effective, safe and reliable method for treating recurrent patellar dislocation.
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Abstract
Patellar instability is one of the most prevalent knee disorders, with dislocations occurring in 5 to 43 cases per 10,000 annually. Traumatic patellar dislocation can result in significant morbidity and is associated with patellofemoral chondral injuries and fractures, medial soft tissue disruption, pain, and reduced function, and can lead to patellofemoral osteoarthritis. Chronic and recurrent instability can lead to deformation and incompetence of the medial soft tissue stabilizers. Despite recent gains in understanding the pathoanatomy of this disorder, the management of patients with this condition is complex and remains enigmatic.
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27
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Anderson G, Diduch DR. Medial Patellofemoral Ligament Reconstruction: Tips and Tricks to Get It Right. Clin Sports Med 2021; 41:89-96. [PMID: 34782078 DOI: 10.1016/j.csm.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Medial patellofemoral ligament reconstruction is used increasingly to treat patellar instability. A number of different techniques have been described to perform this procedure. In this article, we review common pearls and pitfalls to medial patellofemoral ligament reconstruction, as well as tips for troubleshooting the procedure. A special emphasis is placed on femoral tunnel position and intraoperative adjustments that can be made to improve outcomes.
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Affiliation(s)
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA 22903, USA
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28
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Zhang YQ, Zhang Z, Wu M, Zhou YD, Li P, Tao SL, Yang YL, Li Y, Liu JL, Teng YS, Guo YM. Medial patellofemoral ligament reconstruction: A protocol for systematic review and meta-analysis. J Orthop 2021. [DOI: 10.1016/j.jor.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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29
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Ishikawa M, Hoo C, Ishifuro M, Kamei G, Omoto T, Kano T, Nakata K, Nekomoto A, Nakamae A, Adachi N. Application of a true lateral virtual radiograph from 3D-CT to identify the femoral reference point of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2021; 29:3809-3817. [PMID: 33459830 DOI: 10.1007/s00167-020-06403-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study is two-fold: (1) to describe the femoral reference point of the medial patellofemoral ligament (MPFL) on a virtual true lateral radiograph reconstructed from a three-dimensional computed tomography (3D-CT) image and (2) to compare this point with that of patients without patellofemoral instability and with Schöttle's point. METHODS A total of 26 consecutive patients (29 affected knees) with recurrent patellar dislocation (RPD), who underwent MPFL reconstruction were included in this study (4 males; 22 females; mean age, 24.0 years old). Using a true lateral 3DCT image, the MPFL femoral insertion was identified and marked with a 2-mm circle, and this image was reconstructed as a virtual true lateral radiograph. Following Schöttle's method, the point of intersection was described by their anterior-posterior and proximal-distal positions. As a control population, 29 age- and gender-matched patients with anterior cruciate ligament (ACL) injuries were also analysed. RESULTS The points in RPD patients were located significantly posterior (-2.5 ± 2.3 mm, p < 0.01) to the line representing an extension of the posterior cortex of the femur and distal (- 6.9 ± 2.4 mm, p < 0.01) to the posterior origin of the medial femoral condyle compared with those in the control population. The mean reference point of RPD patients was located in a 3.8-mm posterior and 4.4-mm distal position compared with Schöttle's point. CONCLUSIONS An anatomical and radiographic femoral reference point of the MPFL on a true lateral virtual radiograph was described with our method. In patients with RPD, this reference point was identified to be more posterior and distal to Schöttle's point. More anatomical and individualized MPFL reconstruction will be secured using our method. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Masakazu Ishikawa
- Department of Artificial Joints and Biomaterials, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Charles Hoo
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Minoru Ishifuro
- Department of Medical Imaging, Hiroshima University Hospital Clinical Support, Hiroshima, Japan
| | - Goki Kamei
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takenori Omoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshiya Kano
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kyohei Nakata
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Atsuo Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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30
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Kittl C, Robinson J, Raschke MJ, Olbrich A, Frank A, Glasbrenner J, Herbst E, Domnick C, Herbort M. Medial collateral ligament reconstruction graft isometry is effected by femoral position more than tibial position. Knee Surg Sports Traumatol Arthrosc 2021; 29:3800-3808. [PMID: 33454831 PMCID: PMC8514388 DOI: 10.1007/s00167-020-06420-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/14/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this study was to examine the length change patterns of the native medial structures of the knee and determine the effect on graft length change patterns for different tibial and femoral attachment points for previously described medial reconstructions. METHODS Eight cadaveric knee specimens were prepared by removing the skin and subcutaneous fat. The sartorius fascia was divided to allow clear identification of the medial ligamentous structures. Knees were then mounted in a custom-made rig and the quadriceps muscle and the iliotibial tract were loaded, using cables and hanging weights. Threads were mounted between tibial and femoral pins positioned in the anterior, middle, and posterior parts of the attachment sites of the native superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). Pins were also placed at the attachment sites relating to two commonly used medial reconstructions (Bosworth/Lind and LaPrade). Length changes between the tibiofemoral pin combinations were measured using a rotary encoder as the knee was flexed through an arc of 0-120°. RESULTS With knee flexion, the anterior fibres of the sMCL tightened (increased in length 7.4% ± 2.9%) whilst the posterior fibres slackened (decreased in length 8.3% ± 3.1%). All fibre regions of the POL displayed a uniform lengthening of approximately 25% between 0 and 120° knee flexion. The most isometric tibiofemoral combination was between pins placed representing the middle fibres of the sMCL (Length change = 5.4% ± 2.1% with knee flexion). The simulated sMCL reconstruction that produced the least length change was the Lind/Bosworth reconstruction with the tibial attachment at the insertion of the semitendinosus and the femoral attachment in the posterior part of the native sMCL attachment side (5.4 ± 2.2%). This appeared more isometric than using the attachment positions described for the LaPrade reconstruction (10.0 ± 4.8%). CONCLUSION The complex behaviour of the native MCL could not be imitated by a single point-to-point combination and surgeons should be aware that small changes in the femoral MCL graft attachment position will significantly effect graft length change patterns. Reconstructing the sMCL with a semitendinosus autograft, left attached distally to its tibial insertion, would appear to have a minimal effect on length change compared to detaching it and using the native tibial attachment site. A POL graft must always be tensioned near extension to avoid capturing the knee or graft failure.
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Affiliation(s)
- Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany.
| | | | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Arne Olbrich
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Andre Frank
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Christoph Domnick
- Department of Trauma and Hand Surgery, Euregio Klinik Nordhorn, Nordhorn, Deutschland
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Femoral interference screw insertion significantly increases graft tension in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:2851-2856. [PMID: 32734332 DOI: 10.1007/s00167-020-06186-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 07/24/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE This study aimed to quantify the effect of interference screw insertion on MPFL graft tension when securing the femoral attachment after patellar fixation. It was hypothesized that interference screw insertion significantly increases graft tension. METHODS Ten fresh frozen human cadaveric femurs were utilized to compare graft tension at three different preloading conditions (2 N, 5 N, 10 N) using a tensile testing machine (Admet Inc., Norwood, MA). Each preloading condition was analyzed with varying graft sizes (5-8 mm), tunnel diameters (7-9 mm), and interference screw sizes (7-9 mm). Non-parametric statistical analysis was utilized to compare testing conditions among each other. RESULTS Graft tension significantly increased after interference screw insertion by 100% to 552%, with 2 N preload showing the greatest increase (p < 0.001). Grafts with a larger diameter (7-8 mm) had a significantly greater increase in tension than smaller grafts (5-6 mm), regardless of preloading conditions (p < 0.001). Interference screw size had no influence on graft tension (n.s.). A graft-tunnel interference (tunnel diameter-graft diameter) fit of 0 mm and 1 mm significantly increased graft tension for each preloading condition when compared to a slightly looser fit of ≥ 2 mm (p < 0.05). CONCLUSION Femoral interference screw insertion significantly increases graft tension in MPFL reconstruction even in low preloading conditions, with graft size and graft-tunnel interference fit having a considerably effect on graft tension. Surgeons should be aware of the inadvertent increases in graft tension even in low preloading conditions to mitigate the risk of graft overtensioning.
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32
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Wang C, Kernkamp WA, Li C, Hu H, Li P, Tsai TY. Elongation and orientation pattern of the medial patellofemoral ligament during lunging. J Orthop Res 2021; 39:2036-2047. [PMID: 33002242 DOI: 10.1002/jor.24872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 09/18/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
Unfavorable clinical outcomes after medial patellofemoral ligament (MPFL) reconstruction, such as early osteoarthritis of the patellofemoral joint, were considered to be associate with tunnel malpositioning. Length change studies have found that small changes in the femoral position can cause great changes in elongation trends. Further studying the MPFL kinematics may help us to understand the consequences of tunnel malpositioning and optimize the reconstruction techniques. Fifteen healthy subjects were studied with a combined computed tomography and biplane fluoroscopic imaging technique during a lunge motion. Five femoral and three patellar attachments were used to simulate different MPFL bundles. Kinematics of MPFL was defined as elongation and orientation changes (i.e., deviation angle and elevation angle). The mean deviation angle was 28.7° (95% confidence interval, 28.0°-29.4°) at full extension and remained nearly unchanged up to 60° of flexion, and increased to 56.5° (54.1°-58.9°) at 110°. The elevation angle decreased linearly from 12.6° (9.3°-15.9°) at full extension to -86.2° (-92.7-79.7°) at 110° of flexion. The MPFL was most stretched anteriorly and laterally relative to femur from full extension to 30° of flexion and remained near isometric beyond 30°. The current study found that proximal and anterior femoral attachments caused excessive lateral stretching of the MPFL at deeper flexion angles. Such abnormal MPFL kinematics may subsequently cause overconstraint and increased cartilage pressures of the medial patellofemoral joint.
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Affiliation(s)
- Cong Wang
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, China.,Department of Orthopaedic Surgery, Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translational R&D Center of 3D Printing Technology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Willem A Kernkamp
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Changzhao Li
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Hai Hu
- Department of Orthopaedic Surgery, Orthopaedic Biomechanical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Pingyue Li
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, China.,Department of Orthopaedic Surgery, Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translational R&D Center of 3D Printing Technology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Tanaka MJ, Cosgarea AJ, Forman JM, Elias JJ. Factors Influencing Graft Function following MPFL Reconstruction: A Dynamic Simulation Study. J Knee Surg 2021; 34:1162-1169. [PMID: 32143217 PMCID: PMC7483749 DOI: 10.1055/s-0040-1702185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Medial patellofemoral ligament (MPFL) reconstruction is currently the primary surgical procedure for treating recurrent lateral patellar instability. The understanding of graft function has largely been based on studies performed with normal knees. The current study was performed to characterize graft function following MPFL reconstruction, focusing on the influence of pathologic anatomy on graft tension, variations with knee flexion, and the influence on patellar tracking. Knee squatting was simulated with 15 multibody dynamic simulation models representing knees being treated for recurrent lateral patellar instability. Squatting was simulated in a preoperative condition and following MPFL reconstruction with a hamstrings tendon graft set to allow 0.5 quadrants of lateral patellar translation with the knee at 30 degrees of flexion. Linear regressions were performed to relate maximum tension in the graft to parameters of knee anatomy. Repeated measures comparisons evaluated variations in patellar tracking at 5-degree increments of knee flexion. Maximum graft tension was significantly correlated with a parameter characterizing lateral position of the tibial tuberosity (maximum lateral tibial tuberosity to posterior cruciate ligament attachment distance, r 2 = 0.73, p < 0.001). No significant correlations were identified for parameters related to trochlear dysplasia (lateral trochlear inclination) or patella alta (Caton-Deschamps index and patellotrochlear index). Graft tension peaked at low flexion angles and was minimal by 30 degrees of flexion. MPFL reconstruction decreased lateral patellar shift (bisect offset index) compared with preoperative tracking at all flexion angles from 0 to 50 degrees of flexion, except 45 degrees. At 0 degrees, the average bisect offset index decreased from 0.81 for the preoperative condition to 0.71. The results indicate that tension within an MPFL graft increases with the lateral position of the tibial tuberosity. The graft tension peaks at low flexion angles and decreases lateral patellar maltracking. The factors that influence graft function following MPFL reconstruction need to be understood to limit patellar maltracking without overloading the graft or over constraining the patella.
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Affiliation(s)
- Miho J. Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Jared M. Forman
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - John J. Elias
- Department of Research, Cleveland Clinic Akron General, Akron, OH
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Anterior and distal tunnel orientation for anatomic reconstruction of the medial patellofemoral ligament is safer in patients with open growth plates. Knee Surg Sports Traumatol Arthrosc 2021; 29:1822-1829. [PMID: 32809118 DOI: 10.1007/s00167-020-06229-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE In patients with open growth plates, the direction of tunneling that avoids distal femoral physis (DFP) damage in anatomic reconstructions of the medial patellofemoral ligament (MPFL) has been a topic of discussion. The objective of this study was to determine the ideal orientation for anatomic reconstructions of MPFL tunneling that minimized DFP damage while avoiding breaching the intercondylar notch. METHODS Eighty magnetic resonance images of patients aged 10 through 17 were obtained, randomly sampled from the institutional database. A de novo software was developed to obtain 3D models of the distal femur and DFP. In each model, the anatomical insertion point of the MPFL was determined as defined by Stephen. A 20-mm-depth drilling was simulated, starting from the insertion point at every possible angle within a 90° cone using 5-, 6- and 7-mm drills. Physeal damage for each pair of angles and each drill size was determined. Damage was expressed as a percentage of total physis volume. Statistical analysis was conducted using Student's t test and one-way ANOVA. RESULTS Maximum physeal damage (5.35% [4.47-6.24]) was obtained with the 7-mm drill when drilling 3° cephalic and 15° posterior from insertion without differences between sexes (n.s.). Minimal physeal damage (0.22% [0.07-0.37]) was obtained using the 5-mm drill aimed 45° distal and 0° anteroposterior, not affected by sex (n.s.). Considering intra-articular drilling avoidance, the safest zone was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. CONCLUSION Ideal femoral tunnel orientation, avoiding physeal damage and breaching of the intercondylar notch, was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. This area is a safe zone that allows anatomic MPFL reconstruction of patients with an open physis.
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35
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Wang HJ, Song YF, Yan X, Wang F, Wang J, Wang YJ, Lin L, Liu Y, Han SB, Yu JK. Using Anatomic Landmarks to Locate Schöttle's Point Was Accurate Without Fluoroscopy During Medial Patellofemoral Ligament Reconstruction. Arthroscopy 2021; 37:1902-1908. [PMID: 33539982 DOI: 10.1016/j.arthro.2021.01.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/10/2021] [Accepted: 01/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of the present study was to analyze the anatomic landmarks of Schöttle's point and establish a locating method for identification. METHODS From 2013 to 2016, patients undergoing medial patellofemoral ligament (MPFL) reconstruction for patellofemoral instability were enrolled. INCLUSION CRITERIA at least 2 episodes of patellar dislocation. EXCLUSION CRITERIA previous knee surgeries, open physes, severe trochlear dysplasia, tibial tuberosity lateralization, or patella alta. Group A: From January 2013 to December 2013, preoperative 3-dimensional computed tomography (3D-CT) images were obtained. Anatomic features of Schöttle's point were measured on the 3D-CT images. A Schöttle's point locating method with 2 distinct landmarks was established. Group B: From January 2014 to January 2016, consecutive MPFL reconstructions were performed. The placement of Schöttle's point was following the established method without fluoroscopy. The accuracy of femoral tunnel positions was assessed on the 3D-CT images postoperatively. RESULTS CT images of 53 knees were obtained in group A. Forty-seven MPFL reconstructions were performed in group B. No significant difference was found between the 2 groups regarding to demographic characteristics. The intraclass correlation coefficients were excellent for all measures (r = 0.97). In group A, Schöttle's point was 8.1 ± 0.2 mm (95% confidence interval [CI], 7.7-8.5) distal to the apex of the adductor tubercle and 8.0 ± 0.3 mm (95% CI, 7.4-8.6) anterior to the posterior edge. Apex of the adductor tubercle was defined as the most convex point, and posterior edge was defined as the edge of the posteromedial cortex in the transition area between the medial condyle and femoral shaft. In group B, 44 of 47 femoral tunnels (93.6%) were considered localized in the proper zone. CONCLUSIONS Schöttle's point was approximately 8 mm distal to the apex of the adductor tubercle and 8 mm from the posterior edge. Schöttle's point locating method without fluoroscopy had high accuracy. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Hai-Jun Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China
| | - Yi-Fan Song
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China
| | - Xin Yan
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China
| | - Fei Wang
- Department of Joint Surgery, The Third Hospital of Heibei Medical University, Shijiazhuang, China
| | - Jian Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China
| | - Yong-Jian Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China
| | - Lin Lin
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China
| | - Yang Liu
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China
| | - Song-Bo Han
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Jia-Kuo Yu
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China. Institute of Sports Medicine of Peking University, Beijing, China.
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Megremis P, Megremis O. Evaluation of recurrent dislocation of the patella in children with MRI: Goldthwait technique combined with lateral release, and VMO advancement-a retrospective study of 85 knees. Musculoskelet Surg 2021; 106:397-406. [PMID: 34027575 DOI: 10.1007/s12306-021-00713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE There are certain risk factors responsible for patella instability that should be identified before choosing the most appropriate treatment. METHODS We evaluated 83 skeletally immature patients who, after two or more patellar dislocation episodes, underwent surgical treatment to address the condition of patellar instability. Each patient was evaluated for patellar instability risk factors using the Balcarek patellar instability severity score. Evaluation of patellar instability included knee MRI to systematically identify anatomical risk factors. The preoperative and postoperative clinical evaluation included the modified Cincinnati score and the Kujala score. The Roux-Goldthwait technique combined with lateral retinaculum release and the advancement of the vastus medialis oblique (VMO) was performed on all knees. RESULTS The mean patient age at the time of surgery was 12.2 ± 1.59 years (range 8-14 years). The average follow-up was 4.72 ± 1.37 (range 3-8) years. Trochlear dysplasia (decreased trochlear depth), the most common anatomical risk factor, was identified in 71 knees (83.5%). The modified Cincinnati score increased from 58.46 ± 8.75 (range 49-76) points to 94.07 ± 2.88 (range 88-98) postoperatively. The mean Kujala scores increased from 58.51 ± 8.94 (range 49-76) points to 93.66 ± 2.65 (range 87-98) postoperatively. The two-tailed P value was less than 0.0001. The patients were followed until their skeletal maturation, without reporting any incidents of patella dislocation, except one. CONCLUSION The Roux-Goldthwait technique combined with lateral retinaculum release, and the advancement of VMO, can restore patellar tracking and can decrease the probability of another dislocation. It was an effective treatment in skeletally immature patients who had two or more episodes of patellar dislocation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- P Megremis
- Consultant Pediatric Orthopaedic Surgeon, A' Orthopaedic Department, Athens Children's Hospital «P. & A. Kyriakou», Megalou Alexandrou 6, Mati Attiki, Athens, Greece.
| | - O Megremis
- A' Surgical Department, Sismanogleio General Hospital, Athens, Greece
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Wong TT, Denning J, Moy MP, Rasiej MJ, Redler LH, Ahmad CS, Popkin CA. MRI following medial patellofemoral ligament reconstruction: assessment of imaging features found with post-operative pain, arthritis, and graft failure. Skeletal Radiol 2021; 50:981-991. [PMID: 33083857 DOI: 10.1007/s00256-020-03655-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/30/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess MR features following MPFL reconstruction and determine their influence on post-operative pain, progressive arthritis, or graft failure. MATERIALS AND METHODS Retrospective study on 38 patients with MPFL reconstruction and a post-operative MRI between January 2010 and June 2019. Two radiologists assessed MPFL graft signal, graft thickness, femoral screw, femoral tunnel widening, and patellofemoral cartilage damage. The third performed patellofemoral instability measurements. All three assessed femoral tunnel position with final result determined by majority consensus. Imaging findings were evaluated in the setting of post-operative pain, patellofemoral arthritis, and MPFL graft failure including need for MPFL revision. Statistics included chi-square, Fisher's exact test, t test, and kappa. RESULTS Mean graft thickness was 6.0 ± 1.8 mm; 24% of the grafts were diffusely hypointense. Mean femoral tunnel widening was 2.5 ± 1.8 mm; 34% of the femoral screws were broken or extruded. Fifty-two percent of the patients had no interval cartilage change. Non-anatomic femoral tunnels were found in 66% of patients, including in all 9 patients requiring revision MPFL reconstruction (p = 0.013). Revised MPFL grafts had more abnormal femoral screws compared to those that did not (67% vs. 24%) (p = 0.019). Other MR features did not significantly influence the evaluated outcomes. CONCLUSION The need for revision MPFL reconstruction occurs more frequently when there is a non-anatomic femoral tunnel and broken or extruded femoral screws. The appearance of the MPFL graft itself is not an influencing factor for post-operative pain, progression of patellofemoral arthritis, or graft failure.
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Affiliation(s)
- Tony T Wong
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA.
| | - John Denning
- New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, New York, NY, 10032, USA
| | - Matthew P Moy
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA
| | - Michael J Rasiej
- Department of Radiology, Division of Musculoskeletal Radiology, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 W 168th Street, MC-28, New York, NY, 10032, USA
| | - Lauren H Redler
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
| | - Charles A Popkin
- Department of Orthopedic Surgery, The Center for Shoulder, Elbow, and Sports Medicine, New York Presbyterian Hospital - Columbia University Irving Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA
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Sarikaya B, Bozkurt C, Sipahioglu S, Çetin BV, Altay MA. Patellar Fixation With Suspensory Fixation Device in Single-Tunnel Medial Patellofemoral Ligament Reconstruction. Arthrosc Tech 2021; 10:e1109-e1116. [PMID: 33981558 PMCID: PMC8085437 DOI: 10.1016/j.eats.2021.01.001] [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: 10/21/2020] [Accepted: 01/08/2021] [Indexed: 02/03/2023] Open
Abstract
The medial patellofemoral ligament (MPFL) is the primary soft-tissue stabilizer of the patellofemoral joint. Among the patellofemoral instability surgery options, MPFL reconstruction is the most preferred soft-tissue procedure. There is no gold-standard surgical treatment method in MPFL reconstruction, and many surgical methods have been described. We describe our surgical technique for MPFL reconstruction wherein the semitendinosus autograft is fixed to a single tunnel opened in the patella with a suspensory fixation device and only a single interference screw on the femoral side.
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Affiliation(s)
- Baran Sarikaya
- Address correspondence to Baran Sarikaya, M.D., Osmanbey Kampusu, Ortopedi ve Travmatoloji Anabilim Dali, Sanliurfa-Mardin Karayolu Uzeri, 18 Km, 63100, Sanliurfa, Turkey.
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Ambra LF, Franciozi CE, Phan A, Faloppa F, Gomoll AH. Isolated MPTL reconstruction fails to restore lateral patellar stability when compared to MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:793-799. [PMID: 32347346 DOI: 10.1007/s00167-020-06015-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To biomechanically evaluate MPTL reconstruction and compare it with two techniques for MPFL reconstruction in regard to changes in patellofemoral contact pressures and restoration of patellar stability. METHODS This is an experimental laboratory study in eight human cadaveric knees. None had patellofemoral cartilage lesions or trochlear dysplasia as evaluated by conventional radiographs and MRI examinations. The specimens were secured in a testing apparatus, and the quadriceps was tensioned in line with the femoral shaft. Contact pressures were measured using the TekScan sensor at 30°, 60° and 90°. The sensor was placed in the patellofemoral joint through a proximal approach between femoral shaft and quadriceps tendon to not violate the medial and lateral patellofemoral complex. TekScan data were analysed to determine mean contact pressures on the medial and lateral patellar facets. Patellar lateral displacement was evaluated with the knee positioned at 30° of flexion and 9 N of quadriceps load, then a lateral force of 22 N was applied. The same protocol was used for each condition: native, medial patellofemoral complex lesion, medial patellofemoral ligament reconstruction (MPFL-R) using gracilis tendon, MPFL-R using quadriceps tendon transfer, and medial patellotibial ligament reconstruction (MPTL-R) using patellar tendon transfer. RESULTS No statistical differences were found for mean and peak contact pressures, medial or lateral, among all three techniques. However, while both techniques of MPFL-R were able to restore the medial restraint, MPTL-R failed to restore resistance to lateral patellar translation to the native state (mean lateralization of the patella [mm]: native: 9.4; lesion: 22; gracilis MPFL-R: 8.1; quadriceps MPFL-R: 11.3; MPTL-R: 23.4 (p < 0.001). CONCLUSION MPTL-R and both techniques for MPFL-R did not increase patellofemoral contact pressures; however, MPTL-R failed to provide a sufficient restraint against lateral patellar translation lateral translation in 30° of flexion. It, therefore, cannot be recommended as an isolated procedure for the treatment of patellar instability.
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Affiliation(s)
- Luiz Felipe Ambra
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 1o.andar, Vila Clementino, São Paulo, Brazil. .,Center for Regenerative Medicine and Cartilage Repair Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA.
| | - Carlos Eduardo Franciozi
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 1o.andar, Vila Clementino, São Paulo, Brazil.,Knee Institute, Hospital do Coração, São Paulo, SP, Brazil.,Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Amy Phan
- Center for Regenerative Medicine and Cartilage Repair Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Flavio Faloppa
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 1o.andar, Vila Clementino, São Paulo, Brazil
| | - Andreas H Gomoll
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Huddleston HP, Campbell KJ, Madden BT, Christian DR, Chahla J, Farr J, Cole BJ, Yanke AB. The quadriceps insertion of the medial patellofemoral complex demonstrates the greatest anisometry through flexion. Knee Surg Sports Traumatol Arthrosc 2021; 29:757-763. [PMID: 32361929 DOI: 10.1007/s00167-020-05999-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 04/15/2020] [Indexed: 01/23/2023]
Abstract
PURPOSE A comprehensive understanding of the biomechanical properties of the medial patellofemoral complex (MPFC) is necessary when performing an MPFC reconstruction. How components of the MPFC change over the course of flexion can influence the surgeon's choice of location for graft fixation along the extensor mechanism. The purpose of this study was to (1) determine native MPFC length changes throughout a 90° arc using an anatomically based attachment and using Schöttle's point, and (2) compare native MPFC length changes with different MPFC attachment sites along the extensor mechanism. METHODS Eight fresh-frozen (n = 8), cadaveric knees were dissected of all soft tissue structures except the MPFC. The distance between the femoral footprint (identified through anatomical landmarks and Schottle's point) and the MPFC was calculated at four attachment sites along the extensor mechanism [midpoint of the patella [MP], the center of the osseous footprint of the MPFC (FC), the superomedial corner of the patella at the quadriceps insertion (SM), and the proximal extent of the MPFC along the quadriceps tendon (QT)] at 0°, 20°, 40°, 60°, and 90° of flexion. RESULTS Length changes were investigated between the MPFL femoral attachment site and the radiographic surrogate of the MPFL attachment site, Schottle's Point (SP). Paired t tests at each of the four components showed no differences in length change from 0° to 90° when comparing SP to the anatomic MPFC insertion. MPFL length changes from 0° to 90° were greatest at the QT point (13.9 ± 3.0 mm) and smallest at the MP point (2.7 ± 4.4 mm). The FC and SM points had a length change of 6.6 ± 4.2 and 9.0 ± 3.8, respectively. Finally, when examining how the length of the MPFC components changed through flexion, the greatest differences were seen at QT where all comparisons were significant (p < 0.01) except when comparing 0° vs 20° (n.s.). CONCLUSION The MPFC demonstrates the most significant length changes between 0° and 20° of flexion, while more isometric behavior was seen during 20°-90°. The attachment points along the extensor mechanism demonstrate different length behaviors, where the more proximal components of the MPFC display greater anisometry through the arc of motion. When performing a proximal MPFC reconstruction, surgeons should expect increased length changes compared to reconstructions utilizing distal attachment sites.
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Affiliation(s)
- Hailey P Huddleston
- Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL, 60612, USA
| | - Kevin J Campbell
- Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL, 60612, USA
| | - Brett T Madden
- Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL, 60612, USA
| | - David R Christian
- McGaw Medical Center at Northwestern University, Chicago, IL, 60611, USA
| | - Jorge Chahla
- Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL, 60612, USA
| | - Jack Farr
- OrthoIndy, Greenwood, IN, 46143, USA
| | - Brian J Cole
- Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL, 60612, USA
| | - Adam B Yanke
- Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St., Ste 300, Chicago, IL, 60612, USA.
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Zhang Y, Li Y, Liu D, Wang G. [Research progress in femoral tunnel positioning points of medial patellofemoral ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:258-264. [PMID: 33624484 DOI: 10.7507/1002-1892.202006059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress of location methods and the best femoral insertion position of medial patellofemoral ligament (MPFL) reconstruction of femoral tunnel, and provide reference for surgical treatment. Methods The literature about femoral insertion position of the MPFL reconstruction in recent years was extensively reviewed, and the anatomical and biomechanical characteristics of MPFL, as well as the advantages and disadvantages of femoral tunnel positioning methods were summarized. Results The accurate establishment of the femoral anatomical tunnel is crucial to the success of MPFL reconstruction. At present, there are mainly two kinds of methods for femoral insertion: radiographic landmark positioning method and anatomical landmark positioning method. Radiographic landmark positioning method has such advantages as small incision and simple operation, but it can not be accurately positioned for patients with severe femoral trochlear dysplasia. It is suggested to combine with the anatomical landmark positioning method. These methods have their own advantages and disadvantages, and there is no unified positioning standard. In recent years, the use of three-dimensional design software can accurately assist in the MPFL reconstruction, which has become a new trend. Conclusion Femoral tunnel positioning of the MPFL reconstruction is very important. The current positioning methods have their own advantages and disadvantages. Personalized positioning is a new trend and has not been widely used in clinic, its effectiveness needs further research and clinical practice and verification.
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Affiliation(s)
- Yan Zhang
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
| | - Yanlin Li
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
| | - Dejian Liu
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
| | - Guoliang Wang
- Kunming Medical University, Kunming Yunnan, 650000, P.R.China;Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China
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Hartanto J, Leow WK, Yew AKS, Koh JSB, Howe TS. Studies of the criteria for determining optimal location of medial patellofemoral ligament attachment sites. Med Biol Eng Comput 2021; 59:693-702. [PMID: 33598884 DOI: 10.1007/s11517-021-02330-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 01/29/2021] [Indexed: 11/30/2022]
Abstract
Identifying appropriate attachment sites is important in the planning of medial patellofemoral ligament (MPFL) reconstruction. Two criteria are advanced to describe normal MPFL function, namely isometric criterion and desired pattern criterion. Subsequently, computational methods have applied these criteria to determine optimal attachment sites. So far, there is no study that compares the outcomes of these two criteria. For five subjects' 3D models of the patella and femur, three patellar sites and many femoral sites were identified as pairs of candidate attachment sites. For each patellar site, the criteria were applied to identify the matching femoral sites that satisfy them. The matching femoral site with the smallest length change was identified as the optimal femoral site. The desired pattern criterion finds fewer matching sites compared to the isometric criterion. In contrast, the isometric criterion can always find matching sites. The optimal femoral sites obtained vary significantly across different subjects. For most subjects, the optimal sites obtained using the isometric criterion are closer to known anatomical sites than those obtained using the desired pattern criterion. This study reaffirms that MPFL reconstruction is subject specific. The isometric criterion may be more reliable than the desired pattern criterion for determining optimal attachment sites. Graphical Abstract. Highlight of the paper. The location of the patella site significantly affects the location of the optimal femoral site. The isometric criterion option 1, with length at 0° regarded as MPFL's natural length, may be more reliable than other criteria or options for the planning of MPFL surgery because the optimal sites that it finds are closest to known anatomical sites.ᅟ.
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Affiliation(s)
- Jeffry Hartanto
- Department of Computer Science, National University of Singapore, Singapore, Singapore.
| | - Wee Kheng Leow
- Department of Computer Science, National University of Singapore, Singapore, Singapore
| | - Andy Khye Soon Yew
- Department of Orthopaedics, Singapore General Hospital, Singapore, Singapore
| | - Joyce Suang Bee Koh
- Department of Orthopaedics, Singapore General Hospital, Singapore, Singapore
| | - Tet Sen Howe
- Department of Orthopaedics, Singapore General Hospital, Singapore, Singapore
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Jha V, Jain P. Medial Patellofemoral Complex Advancement for Recurrent Lateral Patellar Instability and Selective Acute Primary Patellar Dislocations. Arthrosc Tech 2021; 10:e767-e774. [PMID: 33738213 PMCID: PMC7953354 DOI: 10.1016/j.eats.2020.10.081] [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: 08/14/2020] [Accepted: 10/28/2020] [Indexed: 02/03/2023] Open
Abstract
Medial patellofemoral complex (MPFC) is considered as the primary medial patellar restraint and has a static, as well as dynamic, component. MPFL reconstruction (MPFL-R) restores only the static component of MPFC, is associated with multiple technical concerns, and has a steep learning curve. Need for physeal sparing techniques and relatively high rates of complications including patella fracture are some other concerns with MPFL-R. We propose a simple procedure for advancement of MPFC onto patella, which is indicated in most of the recurrent lateral instabilities (with a positive lateral glide test result and an intact MPFL on magnetic resonance imaging). The procedure is also indicated in selective acute primary dislocations-those with associated chondral lesions and magnetic resonance imaging-documented isolated patellar side avulsion/injury. MPFC advancement is a more anatomical procedure that also restores dynamic medial checkrein of patella and can be performed even by a novice surgeon. MPFC advancement is devoid of the multiple technicalities of MPFL-R, does not require intraoperative imaging or any postoperative immobilization, and renders complications like donor graft-site morbidity and patella fractures irrelevant. It requires no modifications in patients with open physes and can be performed in isolation or with other procedures as per à la carte principle.
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Affiliation(s)
- Vivek Jha
- Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
- Address correspondence to Vivek Jha, M.S., Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan, Himachal Pradesh, India.
| | - Prathmesh Jain
- Advance Knee and Shoulder Hospital, Ahmedabad, Gujarat, India
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Chen J, Han K, Jiang J, Huangfu X, Zhao S, Zhao J, Xie G. Radiographic Reference Points Do Not Ensure Anatomic Femoral Fixation Sites in Medial Patellofemoral Ligament Reconstruction: A Quantified Anatomic Localization Method Based on the Saddle Sulcus. Am J Sports Med 2021; 49:435-441. [PMID: 33175561 DOI: 10.1177/0363546520972420] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is one of the main treatments for lateral patellar translation. Based on intraoperative true lateral radiographs, the accepted methods for femoral MPFL tunnel location are potentially inaccurate. Direct assessment of anatomic characteristics during surgery through palpation of the anatomic landmarks involving the saddle sulcus might help eliminate tunnel malposition. HYPOTHESIS The saddle sulcus is a reliable osseous landmark where the MPFL attaches for tunnel placement. STUDY DESIGN Descriptive laboratory study. METHODS A total of 9 fresh-frozen unpaired human cadaveric knees were dissected; MPFL insertion point and relative osseous structures were marked. Three-dimensional images and transformed true lateral radiographs were obtained for analysis; 3 previously reported radiographic reference points for MPFL femoral tunnel placement were determined on all images and compared with the anatomic insertion. RESULTS A saddle sulcus consistently existed where the MPFL was attached, located at 11.7 ± 5.9 mm from the apex of the adductor tubercle (AT) to the medial epicondyle (ME), 62.8% of the average distance between the apexes of the AT and ME, and 5.6 ± 2.8 mm perpendicular-posterior to the border connecting the AT and ME. The reported radiographic reference points were located at average distances of 6.2 ± 3.2 mm (Schöttle method), 5.9 ± 2.3 mm (Redfern method), and 7.3 ± 6.6 mm (Fujino method) from the saddle sulcus center on the true lateral radiographs. CONCLUSION The saddle sulcus was a reliable landmark where the MPFL was anatomically attached, located approximately 12 mm from the AT to the ME (approximately 60% along a line from the AT to the ME) and 6 mm perpendicular-posterior to the border connecting the apexes of the AT and ME. Additionally, the saddle sulcus position presented variability on the femoral aspect of different knees. All of the average direct distances from the sulcus to the reference radiographic points exceeded 5 mm, and tunnel localizations on a true lateral radiograph were inaccurate. CLINICAL RELEVANCE This study demonstrates the potential precise position of the saddle sulcus, according to the ME and AT, as a reliable anatomic landmark for MPFL femoral tunnel location. Radiographic reference points were not accurate during MPFL reconstruction. Direct palpation of the landmarks might be effective for femoral MPFL tunnel placement.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoqiao Huangfu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Song Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Belkin NS, Meyers KN, Redler LH, Maher S, Nguyen JT, Shubin Stein BE. Medial Patellofemoral Ligament Isometry in the Setting of Patella Alta. Arthroscopy 2020; 36:3031-3036. [PMID: 32035170 DOI: 10.1016/j.arthro.2020.01.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate alterations in technique for medial patellofemoral ligament (MPFL) reconstruction in the setting of patella alta and describe the effect of these alterations on MPFL anatomometry. METHODS Ten cadaveric knees were used. Four candidate femoral attachment sites of MPFL were tested. The attachment sites were Schottle's point (SP), 5 mm distal to SP, 5 mm proximal to SP, and 10 mm proximal to SP. A suture anchor was placed at the upper 40% of the medial border of the patella with the emanating suture used to simulate the reconstructed ligament. MPFL maximum length change was calculated through a range of motion between 0° and 110°. Recordings at all 4 candidate femoral attachments sites were repeated after a flat tibial tubercle osteotomy and transfer to achieve alta as measured by the Caton-Deschamps Index (CDI) of 1.3, 1.4, and 1.5. RESULTS The 10 specimens had an average CDI of 0.99, range 0.87 to 1.16. In the native tibial tubercle condition, SP was more isometric through 20° to 70° range of motion, or anatomometric, than any other candidate femoral attachment location. With patella alta with a CDI of 1.3 and 1.4, attachment site 5 mm proximal to SP exhibited more anatomometry than SP. With patella alta with a CDI of 1.5, attachment site 10 mm proximal to SP exhibited more anatomometry than SP. CONCLUSIONS Increased patella alta significantly alters MPFL anatomometry. With increasing degrees of patella alta, more proximal candidate femoral attachment sites demonstrate decreased change in length compared with SP. None of the varied femoral attachments produced anatomometry over the entirety of the flexion range from 20° to 70°, suggesting that in cases of significant patella alta, proximalization the femoral attachment site of MPFL reconstruction may be necessary to achieve an anatomometric MPFL reconstruction. CLINICAL RELEVANCE A standardized, isolated MPFL reconstruction may be prone to failure in the setting of patella alta, given the anisometry demonstrated. Alternative femoral attachment sites for MPFL reconstruction should be considered in these patients.
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Affiliation(s)
- Nicole S Belkin
- Sports Medicine and Shoulder Service, Columbia University Orthopedics, New York, New York, U.S.A..
| | - Kathleen N Meyers
- Department of Biomechanics, New York, New York, U.S.A.; Hospital for Special Surgery, New York, New York, U.S.A
| | - Lauren H Redler
- Sports Medicine and Shoulder Service, Columbia University Orthopedics, New York, New York, U.S.A
| | - Suzanne Maher
- Hospital for Special Surgery Research Institute, New York, New York, U.S.A
| | | | - Beth E Shubin Stein
- Sports Medicine and Shoulder Service, New York, New York, U.S.A.; Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, U.S.A
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Tanaka MJ. Femoral Origin Anatomy of the Medial Patellofemoral Complex: Implications for Reconstruction. Arthroscopy 2020; 36:3010-3015. [PMID: 32569722 DOI: 10.1016/j.arthro.2020.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the shape and orientation of the medial patellofemoral complex (MPFC) footprint on the medial femur and describe the difference between the proximal (medial quadriceps tendon femoral ligament, MQTFL) and distal (medial patellofemoral ligament, MPFL) fibers. METHODS In 20 cadaveric knees, the MPFC footprint on the medial femur was exposed. Images of the medial femur were analyzed using ImageJ software. The length and width of the MPFC footprint were described to the nearest 0.1 mm; the angle of its long axis was described relative to the axis of the femoral shaft (0.1°). The footprint's most proximal and distal margins were described in relation to the adductor tubercle and medial epicondyle. The differences between each were compared using paired t tests. RESULTS 17 knees from 10 cadavers were included in this study. The MPFC footprint had a length of 11.7 ± 1.8 mm and a width of 1.7 ± 0.4 mm. The long axis of the footprint was at an angle 14.6° ± 16.6° anterior to the axis of the femoral shaft. The most proximal (MQTFL) fibers originated 7.4 ± 3.8 mm anterior and 1.8 ± 4.7 mm distal to the adductor tubercle and 4.1 ± 2.9 mm posterior and 8.4 ± 5.6 mm proximal to the medial epicondyle. The most distal (MPFL) fibers originated 4.9 ± 4.2 mm anterior and 12.7 ± 4.3 mm distal to the adductor tubercle, as well as 7.1 ± 2.4 mm posterior and 0.5 ± 5.6 mm distal to the medial epicondyle. The distal margin of the femoral MPFC footprint was 10.9 ± 1.7 mm distal (p < .001) and 2.6 ± 3.2 mm more posterior (p = .005) than the proximal margin. CONCLUSIONS The femoral footprint of the MPFC has a length almost 7 times greater than its width, with the distal margin being 10.9 mm distal and 2.6 mm posterior to the proximal margin. CLINICAL RELEVANCE This differential anatomy within the femoral origin suggests that MPFL and MQTFL reconstruction may require separate positions of femoral fixation to recreate the anatomy of these fibers.
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Affiliation(s)
- Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A..
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张 勇, 程 飚, 杨 林. [Optimization location of femoral attachment in medial patellofemoral ligament reconstruction assisted with arthroscopy for patellar dislocation]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1233-1237. [PMID: 33063485 PMCID: PMC8171885 DOI: 10.7507/1002-1892.202003050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/06/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the technique of optimizing the location of femoral attachment in medial patellofemoral ligament (MPFL) reconstruction assisted with arthroscopy and evaluate the effectiveness. METHODS Between January 2014 and September 2018, 35 patients with patellar dislocation were admitted. There were 14 males and 21 females with an average age of 22.6 years (range, 16-38 years). All patients had a history of knee sprain. The disease duration ranged from 1 to 7 days (mean, 2.8 days). Patellar dislocation occurred 2-4 times (mean, 2.5 times). The preoperative Lysholm score and Kujala score were 47.60±11.24 and 48.37±9.79, respectively. The patellar congruence angle was (31.40±6.81)°, the patellar tilt angle was (29.95±5.44)°, the lateral patellofemoral angle was (-11.46±5.18)°, and the tibial tubercle-trochlear groove distance was (16.66±1.28) mm. All patients were treated by MPFL reconstruction with the semitendinosus tendon under arthroscopy. During operation, the suture anchors were inserted into the midpoint and the 1/3 point of superomedial edge of the patella. Then, the femoral tunnels were created in medial femoral condyle through limited excision. For tendon fixation, the Kirschner wires were inserted into adductor tubercle, medial epicondyle of femur, and the midpoint between the two points, as well as the anteriorly and posteriorly. Afterwards, the changes of ligament length and tension, patellar tracking, and the relationship of patella and femoral trochlea were evaluated, thereby determining the optimized femoral attachment for MPFL reconstruction. Finally, the patellar congruence angle, patellar tilt angle, and lateral patellofemoral angle were measured by imaging to assess the relationship of patella and femoral trochlea. Moreover, Lysholm score and Kujala score were used to evaluate the knee joint function. RESULTS All incisions healed by first intention without infection. All patients were followed up 12-18 months (mean, 15.4 months). At 12 months, the Lysholm score was 94.40±3.99 and the Kujala score was 92.28±4.13, which were significant higher than those before operation ( P<0.05). No patellar dislocation occurred during follow-up. At 12 months, the patellar congruence angle was (6.57±4.59)°, the patellar tilt angle was (9.73±2.82)°, the lateral patellofemoral angle was (7.14±4.63)°, which were superior to those before operation ( P<0.05). CONCLUSION During the MPFL reconstruction under arthroscopy, a higher positioning accuracy for the femoral attachment and satisfactory effectiveness can be obtained by evaluating MPFL length and tension, patellofemoral joint kinematics, and patellar tracking.
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Affiliation(s)
- 勇 张
- 南京医科大学临床学院上海第十人民医院骨科(上海 201700)Department of Orthopedics, Shanghai Tenth People’s Hospital, Clinical College of Nanjing Medical University, Shanghai, 201700, P.R.China
- 平煤神马医疗集团总医院骨科(河南平顶山 467000)Department of Orthopedics, General Hospital of Ping Mei Shen Ma Medical Group, Pingdingshan Henan, 467000, P.R.China
| | - 飚 程
- 南京医科大学临床学院上海第十人民医院骨科(上海 201700)Department of Orthopedics, Shanghai Tenth People’s Hospital, Clinical College of Nanjing Medical University, Shanghai, 201700, P.R.China
| | - 林 杨
- 南京医科大学临床学院上海第十人民医院骨科(上海 201700)Department of Orthopedics, Shanghai Tenth People’s Hospital, Clinical College of Nanjing Medical University, Shanghai, 201700, P.R.China
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Willinger L, Shinohara S, Athwal KK, Ball S, Williams A, Amis AA. Längenänderung der passiven medialen Kniestabilisatoren über den Bewegungsradius. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Feucht MJ, Mehl J, Forkel P, Achtnich A, Schmitt A, Izadpanah K, Imhoff AB, Berthold DP. Failure Analysis in Patients With Patellar Redislocation After Primary Isolated Medial Patellofemoral Ligament Reconstruction. Orthop J Sports Med 2020; 8:2325967120926178. [PMID: 32613021 PMCID: PMC7309400 DOI: 10.1177/2325967120926178] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/13/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Reconstruction of the medial patellofemoral ligament (MPFL) has become a popular surgical procedure to address patellofemoral instability. As a consequence of the growing number of MPFL reconstructions performed, a higher rate of failures and revision procedures has been seen. Purpose: To perform a failure analysis in patients with patellar redislocation after primary isolated MPFL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing revision surgery for reinstability after primary isolated MPFL reconstruction were included. Clinical notes were reviewed to collect demographic data, information on the primary surgery, and the mechanism of patellar redislocation (traumatic vs nontraumatic). Preoperative imaging was analyzed regarding femoral tunnel position and the prevalence of anatomic risk factors (ARFs) associated with patellofemoral instability: trochlear dysplasia (types B through D), patella alta (Caton-Deschamps index >1.2, patellotrochlear index <0.28), lateralization of the tibial tuberosity (tibial tuberosity–trochlear groove distance >20 mm, tibial tuberosity–posterior cruciate ligament [TT-PCL] distance >24 mm), valgus malalignment (mechanical valgus axis >5°), and torsional deformity (internal femoral torsion >25°, external tibial torsion >35°). The prevalence of ARF was compared between patients with traumatic and nontraumatic redislocations and between patients with anatomic and nonanatomic femoral tunnel position. Results: A total of 26 patients (69% female) with a mean age of 25 ± 7 years were included. The cause of redislocation was traumatic in 31% and nontraumatic in 69%. Position of the femoral tunnel was considered nonanatomic in 50% of patients. Trochlear dysplasia was the most common ARF with a prevalence of 50%, followed by elevated TT-PCL distance (36%) and valgus malalignment (35%). The median number of ARFs per patient was 3 (range, 0-6), and 65% of patients had 2 or more ARFs. Patients with nontraumatic redislocations showed significantly more ARFs per patient, and the presence of 2 or more ARFs was significantly more common in this group. No significant difference was observed between patients with anatomic versus nonanatomic femoral tunnel position. Conclusion: Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction. Before revision surgery, a focused clinical examination and adequate imaging including radiographs, magnetic resonance imaging (MRI), standing full-leg radiographs, and torsional measurement with computed tomography or MRI are recommended to assess all relevant anatomic parameters to understand an individual patient’s risk profile. During revision surgery, care must be taken to ensure anatomic placement of the femoral tunnel through use of anatomic and/or radiographic landmarks.
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Affiliation(s)
- Matthias J Feucht
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany.,Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Julian Mehl
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Philipp Forkel
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Andrea Achtnich
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Andreas Schmitt
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Kaywan Izadpanah
- Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Andreas B Imhoff
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel P Berthold
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
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Yanke AB, Huddleston HP, Campbell K, Redondo ML, Espinoza A, Chahla J, Cole BJ, Farr J. Effect of Patella Alta on the Native Anatomometricity of the Medial Patellofemoral Complex: A Cadaveric Study. Am J Sports Med 2020; 48:1398-1405. [PMID: 32352333 DOI: 10.1177/0363546520916435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patella alta has been identified as an important risk factor for lateral patellar instability and medial patellofemoral complex (MPFC) reconstruction failure. PURPOSE To evaluate the length changes of the MPFC at multiple possible reconstruction locations along the extensor mechanism in varying degrees of patella alta throughout knee motion. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen cadaveric knees were used in this study. The MPFC was identified and dissected with the patellar tendon and quadriceps tendon. A custom-made jig was utilized to evaluate lengths from 0° to 90° of flexion with physiological quadriceps loading. Length was measured with a 3-dimensional robotic arm at 4 possible reconstruction locations along the extensor mechanism: the midpoint patella (MP), the MPFC osseous center (FC), the superior medial pole of the patella (SM) at the level of the quadriceps insertion, and 1 cm proximal to the SM point along the quadriceps tendon (QT). These measurements were repeated at 0°, 20°, 40°, 60° and 90° of flexion. Degrees of increasing severity of patella alta at Caton-Deschamps index (CDI) ratios of 1.0, 1.2, 1.4, and 1.6 were then investigated. RESULTS Patella alta and MPFC attachment site location significantly affected changes in MPFC length from 0° to 90° of flexion (P< .0005). Length changes at attachment MP showed no difference when CDI 1.0 was compared with all patella alta values (CDI 1.2, 1.4, 1.6; P > .05). Similarly, FC showed no difference in length change from 0° to 90° until CDI 1.6, in contrast to proximal attachments (SM, QT), which demonstrated significant changes at CDI 1.4 and 1.6. When length changes were analyzed at each degree of flexion (0°, 20°, 40°, 60°, 90°), Spearman correlation analysis showed a moderate negative linear correlation for QT at CDI 1.0 (r= -0.484; P = .002) and 1.6 (r = -0.692; P < .0005), demonstrating constant loosening at the QT point at normal and elevated patellar height. In contrast, no differences in length were observed for MP at CDI 1.0 throughout flexion, and at CDI 1.6, there was a difference only at 0° (P < .05). Points FC and MP at CDI 1.6 had similar length change properties to points SM and QT at CDI 1.0 (P > .05), suggesting that distal attachments in the setting of patella alta may provide similar length changes to proximal attachmentswith normal height. CONCLUSION Anisometry of the MPFC varies not only with attachment location on the extensor mechanism but also with patellar height. Increased patellar height leads to more significant changes in anisometry in the proximal MPFC attachment point as compared with the distal component. In the setting of patella alta, including a CD ratio of 1.6, the osseous attachments of the MPFC remain nearly isometric wheras the proximal half length changes increase significantly. CLINICAL SIGNIFICANCE The results of this study support the idea that the MPFC should be considered as 2 separate entities (proximal medial quadriceps tendon femoral ligament and distal medial patellofemoral ligament) owing to their unique length change properties.
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Affiliation(s)
- Adam B Yanke
- Rush University Medical Center, Chicago, Illinois, USA
| | | | | | | | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Rush University Medical Center, Chicago, Illinois, USA
| | - Jack Farr
- OrthoIndy, Indianapolis, Indiana, USA
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