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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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Wetzler A, McMillan S, Brewer E, Patel A, Handy S, Wetzler M. No Difference in Pullout Strength Between a Bio-inductive Implant and a Semitendinosus Tendon Graft in a Biomechanical Study of Medial Patellofemoral Ligament Repair Augmentation. Arthrosc Sports Med Rehabil 2024; 6:100827. [PMID: 38313861 PMCID: PMC10834473 DOI: 10.1016/j.asmr.2023.100827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/26/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose To compare the pullout strength of a bio-inductive implant (BI) used to augment a medial patellofemoral ligament (MPFL) repair with the pullout strength of semitendinosus graft in a biomechanical cadaveric model. Methods Six matched pairs of cadavers (12 knees) were used in the biomechanical testing comparing semitendinosus tendon (Semi-T) versus a BI. The Semi-T was harvested from 1 of the matched pairs. A standard double-bundle technique using 2 sockets in the upper two-thirds of the patella 15 mm apart was performed. After docking of the graft into the patella, the patella was dissected free of soft tissues and potted into a fixture to allow mechanical pull parallel to the transverse axis of the patella. The construct was pulled to failure. Results There was no statistically significant difference in pullout strength (P = .77) between the BI group (249.3 ± 36.3 N) and Semi-T group (235.0 ± 113.6 N) double-bundle constructs. In the Semi-T group, 50% of the specimens (3 of 6 knees) failed via anchor pullout and a fourth specimen failed at the suture-anchor interface (16.7%), whereas in the BI group, 16.7% of the specimens (1 of 6 knees) failed by anchor pullout. Although the Semi-T group (49.5 ± 14.1 N/mm) showed significantly greater stiffness than the BI group (13.8 ± 0.6 N/mm, P < .01), pullout strength in the Semi-T group was highly variable: 50% of the specimens (3 of 6 knees) with semitendinosus constructs failed at 5 mm of displacement or less via graft or anchor pullout. Maximum load, displacement at failure, stiffness, and load at 5 mm were compared between the augmented and non-augmented control specimens using a 2-tailed non-equal variance Student t test. For all comparisons, P < .05 was considered to indicate a statistically significant difference. Conclusions In this biomechanical study, augmentation of an MPFL reconstruction using a common double-bundle technique with a BI had the same pullout strength as a semitendinosus graft using the same technique in cadaveric knees. Clinical Relevance MPFL repair after a patellar dislocation may be inadequate to restore the strength of the native MPFL and prevent recurrent patellar instability. Recurrent instability of the patella can result in progressive injury to the soft tissue and articular cartilage of the patella and femur. It is important to study the techniques used for MPFL repair to continually improve patient outcomes. Further testing of these additional techniques and clinical studies are needed to evaluate the implants used to augment MPFL repairs.
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Affiliation(s)
- Austin Wetzler
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, U.S.A
| | - Sean McMillan
- Virtua College of Medicine and Life Sciences, Rowan University, Strafford, New Jersey, U.S.A
| | - Erik Brewer
- Department of Biomedical Engineering, Rowan University, Glassboro, New Jersey, U.S.A
| | - Aakash Patel
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Samuel Handy
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, U.S.A
| | - Merrick Wetzler
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, U.S.A
- Virtua Health, Voorhees, New Jersey, U.S.A
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Jones TJ, Koh JL, Elias JJ. Influence of medial patellofemoral ligament reconstruction on patellar tracking and patellofemoral contact pressures in patella alta. Comput Methods Biomech Biomed Engin 2024; 27:36-44. [PMID: 36645842 DOI: 10.1080/10255842.2023.2168122] [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: 05/13/2022] [Accepted: 01/08/2023] [Indexed: 01/18/2023]
Abstract
Knee squatting was simulated to characterize the influence of medial patellofemoral ligament (MPFL) reconstruction on patellar tracking and contact pressures for knees with mild patella alta (Caton-Deschamps index = 1.3-1.4). Eight computational models represented knees in the pre-operative condition and following MPFL reconstruction. MPFL reconstruction significantly reduced patellar lateral tracking at low flexion angles based on bisect offset index, significantly decreased the maximum lateral pressure in mid-flexion, and significantly increased the maximum medial pressure in mid-flexion. MPFL reconstruction improves patellar stability for knees with mild patella alta and can reduce the pressure applied to lateral cartilage on the patella.
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Affiliation(s)
- Travis J Jones
- Department of Orthopedic Surgery, Cleveland Clinic Akron General, Akron, OH, USA
| | - Jason L Koh
- Department of Orthopedic Surgery, NorthShore University Health System, Evanston, IL, USA
| | - John J Elias
- Department of Health Sciences, Cleveland Clinic Akron General, Akron, OH, USA
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Monaco E, Criseo N, Annibaldi A, Carrozzo A, Pagnotta SM, Cantagalli MR, Orlandi P, Daggett M. Medial Patellofemoral Ligament Reconstruction Using Gracilis Tendon Graft and "All Suture" Knotless Anchors for Patellar Fixation. Arthrosc Tech 2023; 12:e2329-e2334. [PMID: 38196870 PMCID: PMC10773230 DOI: 10.1016/j.eats.2023.08.002] [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: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 01/11/2024] Open
Abstract
Patellar dislocation is a frequent sports-related knee injury. The primary restraint to lateral translation of patella is medial patellofemoral ligament. Several treatments for patella dislocation have been described in the literature. The purpose of this Technical Note is to describe the surgical technique for medial patellofemoral ligament reconstruction using gracilis tendon and 2 knotless soft anchors, avoiding patella tunneling.
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Affiliation(s)
- Edoardo Monaco
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Natale Criseo
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Alessandro Annibaldi
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Alessandro Carrozzo
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Susanna M Pagnotta
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
| | | | - Pierfrancesco Orlandi
- Department of Orthopaedic Surgery, S. Andrea Hospital, "Sapienza" University of Rome, Italy
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Elias JJ, Cosgarea AJ, Tanaka MJ. Adding Tibial Tuberosity Medialization to Medial Patellofemoral Ligament Reconstruction Reduces Lateral Patellar Maltracking During Multidirectional Motion in a Computational Simulation Model. Arthrosc Sports Med Rehabil 2023; 5:100753. [PMID: 37645404 PMCID: PMC10461214 DOI: 10.1016/j.asmr.2023.100753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/29/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To determine whether adding tibial tuberosity medialization to medial patellofemoral ligament (MPFL) reconstruction reduces lateral patellar maltracking during a dynamic multidirectional activity and to investigate when medial patellofemoral contact pressures are elevated during daily activities, such as squatting. Methods Seven computational models representing knees with patellar instability, including lateral patellar maltracking, were evaluated following simulated MPFL reconstruction (bisect offset index > .75). Tibial tuberosity medialization was added to MPFL reconstruction for each model. Patellar tracking during multidirectional motion was evaluated by simulating pivot landing. Analysis of pivoting focused on early flexion (5° to 40°). Patellofemoral contact pressures during daily function were evaluated by simulating knee squatting. Data were analyzed with paired comparisons between MPFL reconstruction with and without tuberosity medialization. Results The patella dislocated during pivoting for 2 models with an isolated MPFL reconstruction and for 1 model including tibial tuberosity medialization. Adding tibial tuberosity medialization to MPFL reconstruction significantly decreased bisect offset index by ∼0.1 from 5° to 40° (P < .03). For knee squatting, medializing the tibial tuberosity significantly increased maximum medial contract pressure by ∼0.5 MPa from 30° to 85° (P < .05) but did not significantly influence maximum lateral pressure. Conclusions In this study of simulated multidirectional motion, MPFL reconstruction did not sufficiently constrain the patella for some knees. Adding tibial tuberosity medialization to MPFL reconstruction in these models reduced lateral patellar maltracking during multidirectional motion but increased pressure applied to medial cartilage during squatting. Clinical Relevance After establishing the influence of tibial tuberosity medialization on patellar maltracking for an idealized population, as was done in the current study, future simulation studies can be performed to better determine the anatomical characteristics of patients for whom tibial tuberosity medialization is needed to reduce the risk of postoperative patellar maltracking.
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Affiliation(s)
- John J. Elias
- Department of Health Sciences, Cleveland Clinic Akron General, Cleveland, Ohio, U.S.A
| | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Miho J. Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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Tayne S, Kim BI, Lau BC. Physeal Sparing Medial Patellofemoral Ligament Reconstruction With Suture Anchor for Femoral Fixation of Graft. VIDEO JOURNAL OF SPORTS MEDICINE 2022. [DOI: 10.1177/26350254221115202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background: Patellar instability is a common problem in the active pediatric population. Physeal sparing medial patellofemoral ligament (MPFL) reconstruction using a soft suture anchor for femoral graft fixation has the proposed advantages of diminishing volumetric bony removal from the epiphysis, increasing the margin of safety with respect to notch, trochlear, and/or physeal damage, as well as reducing the risk of thermal damage to the physis during socket reaming. Indications: MPFL reconstruction is indicated in patients with recurrent patellar instability with MPFL tear or attenuation on magnetic resonance imaging or failure of conservative treatment. Physeal sparing techniques are necessary in the pediatric population to prevent growth disturbance and deformities that can lead to significant long-term disability. Technique Description: The patient was placed in supine position. Following examination under anesthesia, diagnostic arthroscopy was performed to assess for patellofemoral chondral defects. The surgical technique required 6 steps: (1) medial patellar dissection, (2) patellar anchor placement with 1.8-mm suture anchors, (3) medial femoral dissection over Schottle’s point, (4) femoral anchor placement using 2.8-mm double loaded anchor, (5) allograft femoral fixation, and (6) allograft patellar fixation. After skin closure, examination under anesthesia was repeated. Results: The patient was weight-bearing as tolerated immediately after surgery, using a brace for the first 6 weeks. Rehabilitation progressed from regaining range of motion, strengthening of the operative extremity, and returning to sport activities. In the senior author’s experience using this technique, there have been no recurrent patellar dislocations and no evidence of growth disturbance or angulation. One patient did find that the graft was prominent over the femoral epicondyle and returned to the operating room for debulking at 9 months postoperatively. Discussion/Conclusion: In conclusion, we propose that physeal sparing MPFL reconstruction using soft anchors for patellar and femoral fixation offers a simple and safe technique with reproducible anatomic graft placement and favorable clinical outcomes. This technique is technically simple and can be easily learned by surgeons familiar with adult MPFL reconstruction techniques. 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)
- Samantha Tayne
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Billy I. Kim
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian C. Lau
- Department of Orthopaedic Surgery, Duke Sports Sciences Institute, Duke University, Durham, North Carolina, USA
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Vlaic J, Josipovic M, Bohacek I, Pilipovic A, Skavic P, Schauperl Z, Jelic M. Plantaris tendon is valuable graft for the medial patellofemoral ligament reconstruction: A biomechanical study. Knee 2022; 38:212-219. [PMID: 36099662 DOI: 10.1016/j.knee.2022.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 07/03/2022] [Accepted: 08/24/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is a standard treatment option for selected patients with patellar instability. Although frequently performed, the optimal graft source for the procedure has not yet been established. This study aimed to determine whether a two-strand plantaris tendon construct possesses the biomechanical properties needed to act as an MPFL reconstruction graft. METHODS Thirty paired plantaris and gracilis tendons were harvested from 15 cadavers, mean age at death of 42.7 years. All specimens were frozen and maintained at -20 °C until biomechanical testing. Prior to mechanical testing, specimens were thawed at room temperature. The two-strand plantaris tendon and two-strand gracilis tendon constructs were created and secured in a uniaxial tensile testing machine in a triangular-shaped mode. Biomechanical properties for tensile testing to failure were determined using validated method. Results obtained were compared with the previously published data on native MPFL biomechanical properties. RESULTS The mean maximal force was 220.3 ± 108.1 N and 448.1 ± 117 N for the two-strand plantaris tendon construct and two-strand gracilis tendon construct, respectively. Significant differences were observed between all biomechanical properties of two-strand plantaris tendon and two-strand gracilis tendon constructs. The mean maximal force of a two-strand plantaris tendon construct and a two-strand gracilis tendon construct were greater than the mean maximal force of the native MPFL reported in all previous studies. CONCLUSIONS This study suggests that, due to its biomechanical properties, the two-strand plantaris tendon graft is suitable as a graft for MPFL reconstruction.
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Affiliation(s)
- Josip Vlaic
- Division of Pediatric Orthopedic Surgery, Children's Hospital Zagreb, Zagreb, Croatia
| | - Mario Josipovic
- Department of Orthopedic Surgery, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Bohacek
- Department of Orthopedic Surgery, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ana Pilipovic
- Department of Technology, Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Petar Skavic
- Department of Forensic Medicine and Criminology, School of Medicine, University of Zagreb, Croatia
| | - Zdravko Schauperl
- Department of Materials, Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Mislav Jelic
- Department of Orthopedic Surgery, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia.
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Wierer G, Winkler PW, Pomwenger W, Plachel F, Moroder P, Seitlinger G. Transpatellar bone tunnels perforating the lateral or anterior cortex increase the risk of patellar fracture in MPFL reconstruction: a finite element analysis and survey of the International Patellofemoral Study Group. Knee Surg Sports Traumatol Arthrosc 2022; 30:1620-1628. [PMID: 34333671 DOI: 10.1007/s00167-021-06682-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE (1) To determine applied patellar drilling techniques for medial patellofemoral ligament (MPFL) reconstruction among members of the International Patellofemoral Study Group (IPSG) and (2) to evaluate the risk of patellar fracture for various patellar bone tunnel locations based on a finite element analysis (FEA) model. METHODS In the first part of the study, an online survey on current MPFL reconstruction techniques was conducted among members of the IPSG. In the second part of the study, a three-dimensional FEA model of a healthy knee joint was created using a computed tomography scan. Patient-specific bone density was integrated into the patella, and cartilage of 3 mm thickness was modeled for the patellofemoral joint. According to the survey's results, two different types of patellar bone tunnels (bone socket and transpatellar bone tunnel) were simulated. The risk of patellar fracture was evaluated based on the fracture risk volume (FRV) obtained from the FEA. RESULTS Finite element analysis revealed that subchondral bone socket tunnel placement is associated with the lowest FRV but increased with an anterior offset (1-5 mm). Transpatellar bone tunnels violating the lateral or anterior cortex showed a higher FRV compared to bone socket, with the highest values observed when the anterior cortex was penetrated. CONCLUSION Violation of the anterior or lateral patellar cortex using transpatellar bone tunnels increased FRV compared to a subchondral patellar bone socket tunnel. In MPFL reconstruction, subchondral patellar bone socket tunnels should be considered for patellar graft fixation to avoid the risk of postoperative patellar fracture. LEVEL OF EVIDENCE Survey; Descriptive laboratory study/Level V.
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Affiliation(s)
- Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria. .,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT, Eduard-Wallnöfer-Zentrum 1, 6060, Hall in Tirol, Austria.
| | - Philipp W Winkler
- Department for Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Werner Pomwenger
- Department of Information Technology & Systems, Salzburg University of Applied Sciences, Urstein Süd 1, 5412, Puch bei Salzburg, Austria
| | - Fabian Plachel
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria.,Center for Musculoskeletal Surgery, Charité -Universitatsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Charité -Universitatsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Gerd Seitlinger
- Orthofocus, Guggenbichlerstrasse 20, 5026, Salzburg, Austria
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Kheir N, Salvatore G, Berton A, Orsi A, Egan J, Mohamadi A, DeAngelis JP, Ramappa AJ, Longo UG, Denaro V, Nazarian A. Lateral release associated with MPFL reconstruction in patients with acute patellar dislocation. BMC Musculoskelet Disord 2022; 23:139. [PMID: 35148741 PMCID: PMC8832651 DOI: 10.1186/s12891-022-05013-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/10/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Medial patellofemoral ligament (MPFL) injury occurs in the majority of the cases of acute patellar dislocation. The role of concomitant lateral retinaculum release with MPFL reconstruction is not clearly understood. Even though the lateral retinaculum plays a role in both medial and lateral patellofemoral joint stability in MPFL intact knees, studies have shown mixed clinical outcomes following its release during MPFL reconstruction surgery. Better understanding of the biomechanical effects of the release of the lateral retinaculum during MPFL reconstruction is warranted. We hypothesize that performing a lateral release concurrent with MPFL reconstruction will disrupt the patellofemoral joint biomechanics and result in lateral patellar instability. Methods A previously developed and validated finite element (FE) model of the patellofemoral joint was used to understand the effect of lateral retinaculum release following MPFL reconstruction. Contact pressure (CP), contact area (CA) and lateral patellar displacement were recorded. abstract. Results FE modeling and analysis demonstrated that lateral retinacular release following MPFL reconstruction with tibial tuberosity-tibial groove distance (TT-TG) of 12 mm resulted in a 39% decrease in CP, 44% decrease in CA and a 20% increase in lateral patellar displacement when compared to a knee with an intact MPFL. In addition, there was a 45% decrease in CP, 44% decrease in CA and a 21% increase in lateral displacement when compared to a knee that only had an MPFL reconstruction. Conclusion This FE-based analysis exhibits that concomitant lateral retinaculum release with MPFL reconstruction results in decreased PF CA, CP and increased lateral patellar displacement with increased knee flexion, which may increase the risk of patellar instability.
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Affiliation(s)
- Nadim Kheir
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Giuseppe Salvatore
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | | | - Jonathan Egan
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Amin Mohamadi
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joseph P DeAngelis
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Arun J Ramappa
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. .,Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia.
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Cregar WM, Huddleston HP, Shewman EF, Cole BJ, Yanke AB. Lateral Translation of the Patella in MPFC Reconstruction: A Biomechanical Study of Three Approaches. J Knee Surg 2022; 36:622-630. [PMID: 35144302 DOI: 10.1055/s-0041-1741549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to investigate whether differences exist in preventing lateral patellar translation between three distinct medial patellofemoral complex (MPFC) reconstruction procedures at varying knee flexion angles. Six cadaveric knee specimens were dissected, potted, and placed in a customized jig for testing. Lateral patellar displacement was measured at intervals between 0 and 90 degrees of knee flexion using a tensile testing machine with a 20 N lateral force applied to the patella. Each specimen was tested with the MPFC intact, sectioned, and after each of the three reconstruction techniques: MPFL, hybrid, and medial quadriceps-tendon femoral (MQTFL) reconstructions. There was significantly increased lateral patellar displacement following MPFC sectioning when compared with the intact state in early degrees of flexion (10-30 degrees) (p < 0.05). All three reconstruction groups restored patella stability and reduced lateral patellar displacement following sectioning from 0 to 30 degrees of flexion (p < 0.05). When compared with the intact group, all three reconstruction groups demonstrated reduced patella translation at full knee extension, while the MPFL and hybrid reconstruction groups additionally demonstrated significant reduction in patella translation at 10 degrees of flexion (p < 0.05). No significant differences were observed between the three reconstruction groups. This biomechanical study demonstrates the efficacy of three MPFC reconstruction techniques in patella stabilization following sectioning. Our results suggest that MPFL reconstruction may provide the most robust patella stabilization, whereas MQTFL reconstruction may be the most forgiving construct. This study suggests that MQTFL and hybrid reconstructions provide adequate resistance to lateral translation and may be used as an alternative to MPFL reconstruction.
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Affiliation(s)
- William M Cregar
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Hailey P Huddleston
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Elizabeth F Shewman
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brian J Cole
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
| | - Adam B Yanke
- Division of Orthopedic Sports Medicine, Rush University Medical Center, Chicago, Illinois
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11
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Raoulis VA, Zibis A, Chiotelli MD, Kermanidis AT, Banios K, Schuster P, Hantes ME. Biomechanical evaluation of three patellar fixation techniques for MPFL reconstruction: Load to failure did not differ but interference screw stabilization was stiffer than suture anchor and suture-knot fixation. Knee Surg Sports Traumatol Arthrosc 2021; 29:3697-3705. [PMID: 33386885 DOI: 10.1007/s00167-020-06389-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to compare the maximum load to failure and stiffness of three medial patella-femoral ligament (MPFL) reconstruction techniques: (i) suture anchor fixation (SA), (ii) interference screw fixation (SF), and (iii) suture knot (SK) patellar fixation. The null hypothesis was that the comparison between these three different patella fixation techniques would show no difference in the ultimate failure load and stiffness. METHODS Reconstruction of the MPFL with gracilis tendon autograft was performed in 12 pairs of fresh-frozen cadaveric knees (24 knees total; mean age, 63.6 [Formula: see text] 8.0 years). The specimens were randomly distributed into 3 groups of 8 specimens; SA reconstruction was completed with two 3.0-mm metal suture anchors; (SF) fixation was accomplished by two 6-mm bio-composite interference screws; SK fixation at the lateral side of the patella was accomplished after drilling two semi-patellar tunnels with a diameter of 4.5 mm. The reconstructions were subjected to cyclic loading for 10 cycles to 30 N and tested to failure at a constant displacement rate of 15 mm/min using a materials-testing machine (MTS 810 Universal Testing System). The final load of failure (N), stiffness (N / mm) and failure mode was recorded in each specimen and followed by statistical analysis. RESULTS There was no significant difference in mean ultimate failure load among the three groups. The SK group failed at a mean ([Formula: see text] SD) ultimate load of 253.5 [Formula: see text] 38.2 N, the SA group failed at 243 [Formula: see text] 41.9 N and the SF group at 263.2 [Formula: see text] 9.06 N. The SF group had a mean stiffness of 37.8 [Formula: see text] 5.7 N/mm. This was significantly higher (p < 0.05) than the mean stiffness value achieved for the SK group 21.4 [Formula: see text] 9.5 N/mm and the SA group 18.7 [Formula: see text] 3.4 N/mm. The most common mode of failure in the SA group was anchor pullout, and in the SK group was failure at the graft-suture interface. All the reconstructions in the SF group failed due to tendon graft slippage from the tunnel. CONCLUSION Load to failure was not significantly different between the 3 techniques. However, screw fixation was found to be significantly stronger than the anchor and the suture knot fixation in terms of rigidity of the reconstruction. From a clinical point of view, all methods of fixation can be used reliably for MPFL reconstruction, since they were found to be stronger than the native MPFL.
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Affiliation(s)
- Vasilios A Raoulis
- Anatomy Laboratory, Faculty of Medicine, University of Thessaly, Larissa, Greece
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, 41110, Larissa, Greece
| | - Aristidis Zibis
- Anatomy Laboratory, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Maria Dimitra Chiotelli
- Laboratory of Mechanics and Strength of Materials, Department of Mechanical Engineering, University of Thessaly Volos, Volos, Greece
| | - Alexis T Kermanidis
- Laboratory of Mechanics and Strength of Materials, Department of Mechanical Engineering, University of Thessaly Volos, Volos, Greece
| | - Konstantinos Banios
- Anatomy Laboratory, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Philipp Schuster
- Centre of Sports Orthopedics and Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Medical Private University, Clinic Nuremberg, Nuremberg, Germany
| | - Michael E Hantes
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, 41110, Larissa, Greece.
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Zhao X, Zhang H. Biomechanical Comparison of 2 Patellar Fixation Techniques in Medial Patellofemoral Ligament Reconstruction: Transosseous Sutures vs Suture Anchors. Orthop J Sports Med 2021; 9:23259671211041404. [PMID: 34692878 PMCID: PMC8529315 DOI: 10.1177/23259671211041404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background Multiple techniques for fixing a graft to the patella in medial patellofemoral ligament (MPFL) reconstruction have been described; however, no single technique has been shown to be superior to another. Purpose/Hypothesis The purpose of this study was to compare the biomechanical performance of 2 different patellar fixation techniques: suture anchor (SA) and transosseous suture (TS) fixation. The hypothesis was that there would be no significant differences between the groups in ultimate failure load, stiffness, or elongation. Study Design Controlled laboratory study. Methods In this study, a new TS technique was biomechanically compared with the SA technique for MPFL reconstruction using 24 fresh-frozen mature porcine patellae and porcine flexor profundus tendons. The specimens were randomized into 2 groups undergoing MPFL reconstruction using either the SA technique or the TS technique (n = 12 per group). Fixation with TS was completed using 3 No. 2 UltraBraid sutures and three 2-mm transosseous tunnels. SA reconstruction was completed using 2 parallel 3.5-mm titanium SAs with 2 No. 2 UltraBraid sutures. We preconditioned each graft using a force between 5 and 20 N before cyclic loading. Then, the specimens were biomechanically tested (1000 cycles; 5-100 N; 1 Hz) and loaded under tension at 200 mm/min until failure. The ultimate failure load, stiffness, elongation, and failure mode were recorded for each specimen. The Shapiro-Wilk test and independent t tests were used to assess the data. Results The TS technique resulted in a significantly higher mean failure load than did the SA technique (496.18 ± 93.15 vs 399.43 ± 105.35 N; P = .03). The TS technique resulted in less stiffness than did the SA technique (55.42 ± 7.92 vs 72.11 ± 10.64 N/mm; P < .01). There was no significant difference between the groups in elongation. None of the graft fixation/patellar complexes failed during cyclic testing in either group. During the load-to-failure test, the most common mode of failure in the SA group was an anchor being pulled out of the bone, whereas that in the TS group was rupture of the suture material. Conclusion MPFL reconstruction with 3 TSs provided a higher load to failure than did the commonly used fixation method involving SAs.
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Affiliation(s)
- Xin Zhao
- First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hangzhou Zhang
- Department of Orthopedics; Joint Surgery and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, 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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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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Raoulis V, Tsifountoudis I, Fyllos A, Hantes M, Malahias MA, Karantanas A, Zibis A. A computed tomography cadaveric study of the radiological anatomy of the patella: the size of the patella correlates with bone bridge between tunnels and R angles are introduced for safe tunnel drilling during MPFL reconstruction. J Exp Orthop 2021; 8:29. [PMID: 33864169 PMCID: PMC8052390 DOI: 10.1186/s40634-021-00348-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/31/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To measure the safe range of angles during tunnel drilling and map ideal patella tunnel placement with the use of preoperative computed tomography (CT) scan and compare results after medial patellofemoral ligament (MPFL) reconstruction using a hardware-free patellar fixation technique with two semi-patellar tunnels between a) a free-hand technique, and b) its modification with the use of an anterior cruciate ligament (ACL) tibia aiming device. METHODS CT scan was performed on 30 fresh-frozen cadaveric knees a) prior to any intervention and b) after MPFL reconstruction. For MPFL reconstruction, specimens were randomly allocated to 1) Group A, which consisted of knees operated with free-hand, hardware-free patellar fixation technique with two semi-patellar tunnels and 2) Group B, which consisted of knees operated on with a technique modification with the ACL tibia device. PATELLAR MEASUREMENTS L1 was the maximal patellar length. L2 was the minimum possible distance of placement for the upper tunnel from the proximal pole of the patella. The maximum bone bridge between tunnels was calculated as half of L1 minus the L2 distance (L1/2-L2). We also measured R1 and R2 angles at the proximal and distal tunnel that represent safe angles at the entry point during tunnel drilling (without breaching the anterior cortex or articular cartilage). RESULTS Preoperatively, mean L1 was 3.45 cm (range 3.05-4.52). Mean L2 was 0.62 cm (range 0.49-0.89). The mean maximum possible bone bridge between tunnels (L1/2-L2) was 1.1 cm (range 0.77-1.58). R1 was 6.050 (range 4.78-7.44), R2 was 6.640 (range 4.57-9.03), and their difference reached statistical significance (p = 0.03). Postoperatively, in group A, in 4 out of 15 patellas, multiple attempts were made during tunnel drilling in order to avoid anterior cortex or cartilage breaching. In group B, all tunnels were correctly drilled with the first attempt. Bone bridge between tunnels was significantly shorter postoperatively (0.93 cm, p < 0.01). CONCLUSION Small-size patellae correlate with short maximum bone bridge between tunnels, which makes anatomic, double-bundle, hardware-free patella fixation, with two semi-patellar tunnels MPFL reconstruction challenging. Furthermore, R angles create a narrow window to avoid intraoperative breaching, rendering the use of the ACL tibia device an extremely useful instrument. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Vasileios Raoulis
- Department of Orthopaedic Surgery, University Hospital of Larissa, Larissa, Greece.,Department of Anatomy, University Hospital of Larissa, Larissa, Greece
| | | | - Apostolos Fyllos
- Department of Anatomy, University Hospital of Larissa, Larissa, Greece
| | - Michael Hantes
- Department of Orthopaedic Surgery, University Hospital of Larissa, Larissa, Greece
| | - Michael-Alexander Malahias
- Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 East 72nd Street, New York, NY, 10021, USA
| | - Apostolos Karantanas
- Department of Medical Imaging, University Hospital and Radiology, Medical School University of Crete, Heraklion, Greece
| | - Aristeidis Zibis
- Department of Anatomy, University Hospital of Larissa, Larissa, Greece.
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16
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Maestro A, Pipa I, Rodríguez N, Toyos C, Torrontegui-Duarte M, Castaño C. Safety and Performance of Titanium Suture Anchors Used in Knee Ligament Repair Procedures. ACTA ACUST UNITED AC 2021; 57:medicina57030287. [PMID: 33808666 PMCID: PMC8003405 DOI: 10.3390/medicina57030287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022]
Abstract
Injuries to the knee ligaments can be particularly disabling in young patients, given the risk of long-term disability if adequate fixation is not achieved during initial repair. The TWINFIX™ titanium (Ti) suture anchor with ULTRABRAID™ Suture (Smith and Nephew, London, UK) was designed to secure tendon and ligament reconstructions with increased boney ingrowth at the anchor site with minimal invasive technique. This retrospective analysis looked at 33 patients (41 implants) operated with this device between 2015 and 2019 at a single institution. The average age of patients was 33.18 years (standard deviation [SD], 15.26), with an average body mass index of 24.88 (SD, 3.49). The indications were lateral extra-articular tenodesis during anterior cruciate ligament reconstruction, medial patellofemoral ligament reconstruction, quadriceps or patellar tendon repair and medial collateral ligament repair. After an average follow up of 24.3 + 6.53 months, there was no reports of clinical failure or radiographic evidence of implant failure or loosening. One patient experienced a complication unrelated to the study device, requiring manipulation under anesthesia with resolution of symptoms. This case series supports the safety and performance of this implants for the knee procedures in which its use is indicated. Additional follow-up will be required to determine whether these effects are sustained at medium- and long-term durations.
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Affiliation(s)
- Antonio Maestro
- Hospital Begoña, Avda, Pablo Iglesias 92, 33204 Gijón, Spain; (A.M.); (I.P.); (N.R.); (C.T.)
- Real Sporting Gijon SAD, Camino Mareo-Granda, 645, 33390 Gijon, Spain;
| | - Iván Pipa
- Hospital Begoña, Avda, Pablo Iglesias 92, 33204 Gijón, Spain; (A.M.); (I.P.); (N.R.); (C.T.)
| | - Nicolás Rodríguez
- Hospital Begoña, Avda, Pablo Iglesias 92, 33204 Gijón, Spain; (A.M.); (I.P.); (N.R.); (C.T.)
| | - Carmen Toyos
- Hospital Begoña, Avda, Pablo Iglesias 92, 33204 Gijón, Spain; (A.M.); (I.P.); (N.R.); (C.T.)
| | | | - Cesar Castaño
- Real Sporting Gijon SAD, Camino Mareo-Granda, 645, 33390 Gijon, Spain;
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17
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Raoulis V, Zibis A, Fyllos A, Malahias MA, Banios K, Hantes M. Reconstruction of the medial patellofemoral ligament using two blind transverse semi-patella tunnels and an implant-free technique for patellar fixation: a technical note. J Orthop Surg Res 2021; 16:25. [PMID: 33413498 PMCID: PMC7791973 DOI: 10.1186/s13018-020-02161-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/14/2020] [Indexed: 11/26/2022] Open
Abstract
Background The double-bundle technique with two points of patellar fixation in the upper half of the patella replicating the broad attachment site of the native medial patellofemoral ligament (MPFL) is the most commonly performed procedure for MPFL reconstruction. Complete transverse patella tunnels pose a threat to the integrity of the patella. We present an implant-free, double-bundle technique for MPFL reconstruction with gracilis autograft, overcoming the problem of complete patella bone tunnels and over-drilling. Methods After standard gracilis graft harvesting, the anteromedial side of the patella is exposed. With the guidance of an anterior-cruciate-ligament (ACL) tibia-aiming device, two 2-mm parallel guide pins are inserted from medial to lateral at the upper half of the patella. The two guide pins are over-drilled with a cannulated 4.5-mm drill bit 2-cm deep, to create two transverse blind semi-patellar tunnels. For the femoral fixation, a 2.4-mm guide pin with an eyelet is drilled at the Schöttle point and over-reamed with a 6-mm cannulated reamer to a depth of 30 mm. The two free ends of the graft (with two running Krakow sutures placed) are pulled into the two patella tunnels and the graft sutures are tied together with tension for stable graft fixation at the lateral patella rim. With the help of a femoral suture loop (which is inserted in the femoral bone tunnel), the graft-loop is advanced into the femoral bone tunnel and the graft is finally fixed with a 7-mm interference screw at 30° of knee flexion. Results The utilization of blind transverse tunnels (not trans-patellar tunnels) offers the advantage of avoiding stress risers at the patella. Thanks to the ACL tibia aiming device, multiple drilling, and breaching of the anterior patellar cortex or articular surface of the patella is avoided. Conclusions This implant-free, and consequently affordable technique, isolated or combined with bony procedures, minimizes possibilities for perioperative bony complications at the patella fixation site.
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Affiliation(s)
- Vasileios Raoulis
- Department of Orthopaedic Surgery, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece. .,Department of Anatomy, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece.
| | - Aristeidis Zibis
- Department of Anatomy, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece
| | - Apostolos Fyllos
- Department of Orthopaedic Surgery, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece.,Department of Anatomy, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece
| | - Michael-Alexander Malahias
- Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 East 72nd Street, New York, NY, 10021, USA
| | - Konstantinos Banios
- Department of Orthopaedic Surgery, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece.,Department of Anatomy, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece
| | - Michael Hantes
- Department of Orthopaedic Surgery, University Hospital of Larissa, 43, LamprouKatsonis str, 41221, Larissa, Greece
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18
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Liles J, Johnston T, Hu J, Riboh JC. Physeal-Sparing Medial Patellofemoral Ligament Reconstruction With Suture Anchor for Femoral Graft Fixation. Arthrosc Tech 2020; 9:e889-e895. [PMID: 32714795 PMCID: PMC7372287 DOI: 10.1016/j.eats.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/04/2020] [Indexed: 02/03/2023] Open
Abstract
Patellar instability is a common problem in the active pediatric population. When nonoperative treatment of the instability fails, growth-respecting surgical stabilization techniques are required. As the incidence of medial patellofemoral ligament (MPFL) reconstruction has increased, techniques have improved to avoid physeal injury to the distal femur. These techniques are technically demanding because of the small size of the distal femoral epiphysis in children, as well as the relatively large socket size (7-8 mm in diameter, >20 mm in length) required for sound fixation with a tenodesis screw as originally described. The size of the femoral tunnel for interference fixation puts the surrounding structures at risk of damage. We present a modification of the epiphyseal socket technique for anatomic growth-sparing MPFL reconstruction using a small soft anchor for femoral graft fixation. This has the proposed advantages of diminishing volumetric bony removal from the epiphysis; increasing the margin of safety with respect to notch, trochlear, and/or physeal damage; and reducing the risk of thermal damage to the physis during socket reaming. This technique is technically simple and can be easily learned by surgeons familiar with adult MPFL reconstruction techniques.
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Affiliation(s)
- Jordan Liles
- Address correspondence to Jordan Liles, M.D., Duke University Medical Center, Box 104002, Durham, NC 27710, U.S.A.
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Ye M, Zhang H, Liang Q. Clinical Outcomes After Medial Patellofemoral Ligament Reconstruction Using Transosseous Sutures Versus Suture Anchors: A Prospective Nonrandomized Controlled Trial. Orthop J Sports Med 2020; 8:2325967120917112. [PMID: 32490023 PMCID: PMC7238809 DOI: 10.1177/2325967120917112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/22/2020] [Indexed: 11/15/2022] Open
Abstract
Background Patellar instability remains a challenging problem for orthopaedic surgeons. Recurrent patellar instability is traditionally treated with medial patellofemoral ligament (MPFL) reconstruction using a suture anchor or bone tunnel technique. Although the use of transosseous sutures was recently described for MPFL reconstruction, relevant clinical data have not been reported. Purpose/Hypothesis The purpose of this study was to compare a new transosseous suture fixation technique with the suture anchor technique for MPFL reconstruction. The hypothesis was that reconstruction with transosseous sutures would show similar clinical results to reconstruction with suture anchors. Study Design Cohort study; Level of evidence, 2. Methods There were 65 patients with recurrent lateral patellar dislocations from January 2014 to December 2016 who were included in this prospective nonrandomized controlled trial. In total, 31 patients underwent MPFL reconstruction with suture anchors at the patella site (suture anchor group), while the other 34 patients underwent MPFL reconstruction with transosseous sutures (transosseous suture group). The main outcome variable (patellar redislocation) was recorded at follow-up (range, 25-60 months). The International Knee Documentation Committee (IKDC) score, Kujala score, range of motion, congruence angle, patellar tilt, redislocation rate, and complications were collected preoperatively and/or postoperatively. Results No recurrent dislocations or other complications were observed in any of the patients. No significant differences were found at follow-up between the suture anchor and transosseous suture groups for subjective IKDC score, Kujala score, congruence angle, patellar tilt, redislocation rate, or range of motion. Conclusion This short-term study showed that after MPFL reconstruction (suture anchors or transosseous sutures), patellar stability could be restored. With the numbers available, no significant differences in outcome scores were observed between patients in the transosseous suture and suture anchor groups.
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Affiliation(s)
- Mao Ye
- Department of Orthopedics, Joint Surgery, and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hangzhou Zhang
- Department of Orthopedics, Joint Surgery, and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Qingwei Liang
- Department of Orthopedics, Joint Surgery, and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
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Elias JJ, Tanaka MJ, Jones KC, Cosgarea AJ. Tibial tuberosity anteriomedialization vs. medial patellofemoral ligament reconstruction for treatment of patellar instability related to malalignment: Computational simulation. Clin Biomech (Bristol, Avon) 2020; 74:111-117. [PMID: 32171152 PMCID: PMC7225030 DOI: 10.1016/j.clinbiomech.2020.01.019] [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] [Received: 08/28/2019] [Revised: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Medial patellofemoral ligament reconstruction and tibial tuberosity anteromedialization are common treatment options for recurrent lateral patellar instability, although ligament reconstruction is not commonly applied to knees with lateral malalignment. METHODS Multibody dynamic simulation was used to assess knee function following tibial tuberosity anteromedialization and medial patellofemoral ligament reconstruction for knees with lateral malalignment. Dual limb squatting was simulated with six models representing knees being treated for patellar instability with an elevated tibial tuberosity to trochlear groove distance. The patellar tendon attachment on the tibia was shifted medially (10 mm) and anteriorly (5 mm) to represent tibial tuberosity anteromedialization. A hamstrings tendon graft was represented for medial patellofemoral ligament reconstruction. Patellar tracking was quantified based on bisect offset index. The patellofemoral contact pressure distribution was quantified using discrete element analysis. Data were analyzed with repeated measures comparisons with post-hoc tests. FINDINGS Both procedures significantly reduced bisect offset index, primarily at low flexion angles. The decrease was larger for tibial tuberosity anteromedialization, peaking at 0.18. Tibial tuberosity anteromedialization shifted contact pressures medially, significantly increasing the maximum medial contact pressure at multiple flexion angles, with the maximum pressure increasing up to 1 MPa. INTERPRETATION The results indicate tibial tuberosity anteromedialization decreases lateral patellar maltracking more effectively than medial patellofemoral ligament reconstruction, but shifts contact pressure medially. Tibial tuberosity anteromedialization is likely to reduce the risk of post-operative instability compared to medial patellofemoral ligament reconstruction. The medial shift in the pressure distribution should be considered for knees with medial cartilage lesions, however.
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Affiliation(s)
- John J. Elias
- Department of Research, Cleveland Clinic Akron General, 1
Akron General Ave, Akron OH 44302, United States,Corresponding Author:
| | - Miho J. Tanaka
- Department of Orthopaedic Surgery, Johns Hopkins
University, 10803 Falls Road, Suite 2100, Lutherville, MD 21093, United States
| | - Kerwyn C. Jones
- Department of Orthopedic Surgery, Akron Children’s
Hospital, 1 Perkins Square, Akron, Ohio 44308, United States
| | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins
University, 10803 Falls Road, Suite 2100, Lutherville, MD 21093, United States
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21
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Mehl J, Otto A, Comer B, Kia C, Liska F, Obopilwe E, Beitzel K, Imhoff AB, Fulkerson JP, Imhoff FB. Repair of the medial patellofemoral ligament with suture tape augmentation leads to similar primary contact pressures and joint kinematics like reconstruction with a tendon graft: a biomechanical comparison. Knee Surg Sports Traumatol Arthrosc 2020; 28:478-488. [PMID: 31410528 DOI: 10.1007/s00167-019-05668-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare suture tape-augmented MPFL repair with allograft MPFL reconstruction using patellofemoral contact pressure and joint kinematics to assess the risk of patellofemoral over-constrainment at point zero. METHODS A total of ten fresh frozen cadaveric knee specimens were tested in four different conditions of the MPFL: (1) native, (2) cut, (3) reconstructed with tendon graft, and (4) augmented with suture tape. The patellofemoral mean pressure (MP), peak pressure (PP) and contact area (CA) were measured independently for the medial and lateral compartments using pressure-sensitive films. Patellar tilt (PT) and shift (PS) were measured using an optical 3D motion tracking system. Measurements were recorded at 0°, 10°, 20°, 30°, 60° and 90° of flexion. Both the tendon graft and the internal brace were preloaded with 2 N, 5 N, and 10 N. RESULTS There was no significant differences found between surgical methods for medial MP, medial PP, medial CA, lateral MP and PS at any preload or flexion angle. Significant differences were seen for lateral PP at 20° knee flexion and 10 N preload (suture tape vs. reconstruction: 1045.9 ± 168.7 kPa vs. 1003.0 ± 151.9 kPa; p = 0.016), for lateral CA at 10° knee flexion and 10 N preload (101.4 ± 39.5 mm2 vs. 108.7 ± 36.6 mm2; p = 0.040), for PT at 10° knee flexion and 2 N preload (- 1.9 ± 2.5° vs. - 2.5 ± 2.3°; p = 0.033) and for PT at 0° knee flexion and 10 N preload (- 0.8 ± 2.5° vs. - 1.8 ± 3.1°; p = 0.040). A preload of 2 N on the suture tape was the closest in restoring the native joint kinematics. CONCLUSIONS Suture tape augmentation of the MPFL resulted in similar primary contact pressures and joint kinematics in comparison with MPFL reconstruction using a tendon graft. A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics.
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Affiliation(s)
- Julian Mehl
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA.,Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Alexander Otto
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Augsburg, Germany
| | - Brendan Comer
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Cameron Kia
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Franz Liska
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Knut Beitzel
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - John P Fulkerson
- Orthopaedic Associates of Hartford, 499 Farmington Avenue, Farmington, CT, 06032, USA
| | - Florian B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
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Primary Medial Patellofemoral Ligament Repair Versus Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Patient Population. Arthroscopy 2019; 35:2909-2915. [PMID: 31604512 DOI: 10.1016/j.arthro.2019.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 04/09/2019] [Accepted: 05/01/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE To comparatively evaluate the clinical outcomes and rates of recurrent instability in young patients with primary medial patellofemoral ligament (MPFL) repair or reconstruction, as well as to assess for radiologic risk factors for worse outcomes. METHODS A retrospective review identified all patients with lateral patellar instability who underwent either MPFL repair and/or imbrication or MPFL reconstruction without any additional osseous procedures between 2008 and 2015 at a single center. Demographic variables and preoperative magnetic resonance imaging were analyzed, and Kujala scores were obtained at a minimum 2-year follow-up. Risk factors for worse outcomes were assessed, including the Caton-Deschamps Index (CDI) Insall-Salvati Index, tibial tubercle-trochlear groove distance, and tibial tubercle-posterior cruciate ligament distance. RESULTS We identified 51 knees with isolated MPFL surgery (reconstruction in 32 and imbrication and/or repair in 19) at a mean of 59.7 months' follow-up (range, 24-121 months). The overall rate of recurrent dislocations was significantly greater in the repair group (36.9%) versus the reconstruction group (6.3%, P = .01), despite the average CDI being significantly higher in the reconstruction group (1.34 vs 1.23 in repair group, P = .04). No significant difference in the rate of return to baseline activity was found between the groups (77.8% in reconstruction group vs 70% in repair group, P = .62). The average Kujala score showed no significant difference between the repair and reconstruction groups (84.15 ± 14.2 vs 84.83 ± 14.38, P = .72). No imaging measurements were found to be predictive of a worse postoperative Kujala score; however, the average CDI among the MPFL repair failures (1.30 ± 0.05) was significantly higher than among the MPFL repair nonfailures (1.18 ± 0.12, P = .03). CONCLUSIONS MPFL reconstruction may provide improved midterm clinical outcomes and a decreased recurrence rate compared with MPFL repair. Increased patellar height as measured by the CDI may be a risk factor for recurrent patellar instability in patients who undergo isolated MPFL repair. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Vishwanathan K. Simple, Cost-Effective Technique to Create a Double-Loaded Suture Anchor from a Non-loaded Suture Anchor. J Orthop Case Rep 2019; 9:80-83. [PMID: 31534942 PMCID: PMC6727456 DOI: 10.13107/jocr.2250-0685.1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Suture anchors are used in the repair of rotator cuff repair, bankart’s repair, SLAP repair, tendoachilles avulsion type injury, bony avulsion of medial collateral ligament of the knee, etc. The cost of preloaded suture anchors varies from INR 4500 to 10,000. Double-loaded suture anchors are better than single-loaded suture anchors in terms of having more hold in the soft tissues and having multiple anchoring points. Non-loaded screw type suture anchors are available with their inserter devices through which one suture stranded can be passed to create single-loaded suture anchor. However, passing two sutures through the eyelet of the suture anchor and subsequently passing two sutures through the long tubular cannulated suture anchor inserter device can be fiddly, time-consuming and difficult to pass because the sutures can get entangled within this device and not pass inside the inserter device. Hence, a technique was devised to simultaneously pass both sutures through the eyelet of the suture anchor and subsequently through the suture anchor inserter device. This method of loading suture anchors has not been described previously in literature. Technique: A single number 1–0 Ethilon is used to shuttle two sutures of number 2 Ethibond through the suture anchor insertion device after passing the two Ethibond sutures through the eyelet of a 5mm non-loaded suture anchor. This technique saves considerable time during the surgical procedure and can be easily taught to scrub nurses. The greatest cost benefit is seen in cases where more than two suture anchors have to be inserted. The above technique has been used in patients with rotator cuff repair, biceps tenodesis, tendoachilles avulsion repair with great degree of success and no case of failure of suture or suture anchor seen in any of the cases. Conclusion: The cost of a double-loaded suture anchor using our method is INR 1950 which is much cheaper compared to the available preloaded suture anchors. This is a novel, time saving, simple, cheap, and easy and easily replicable method to create an effective twin-loaded suture anchor from a non-loaded suture anchor.
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Affiliation(s)
- Karthik Vishwanathan
- Department of Orthopaedics, Pramukhswami Medical College, Karamsad, Gujarat, India
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24
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Elias JJ, Jones KC, Lalonde MK, Gabra JN, Rezvanifar SC, Cosgarea AJ. Allowing one quadrant of patellar lateral translation during medial patellofemoral ligament reconstruction successfully limits maltracking without overconstraining the patella. Knee Surg Sports Traumatol Arthrosc 2018; 26:2883-2890. [PMID: 29128875 PMCID: PMC5948116 DOI: 10.1007/s00167-017-4799-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/08/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Graft tensioning during medial patellofemoral ligament (MPFL) reconstruction typically allows for lateral patellar translation within the trochlear groove. Computational simulation was performed to relate the allowed patellar translation to patellofemoral kinematics and contact pressures. METHODS Multibody dynamic simulation models were developed to represent nine knees with patellar instability. Dual limb squatting was simulated representing the pre-operative condition and simulated MPFL reconstruction. The graft was tensioned to allow 10, 5, and 0 mm of patellar lateral translation at 30° of knee flexion. The patellofemoral contact pressure distribution was quantified using discrete element analysis. RESULTS For the 5 and 10 mm conditions, patellar lateral shift decreased significantly at 0° and 20°. The 0 mm condition significantly decreased lateral shift for nearly all flexion angles. All graft conditions significantly decreased lateral tilt at 0°, with additional significant decreases for the 5 and 0 mm conditions. The 0 mm condition significantly increased the maximum medial pressure at multiple flexion angles, increasing by 57% at 30°, but did not alter the maximum lateral pressure. CONCLUSIONS Allowing 5 to 10 mm of patellar lateral translation limits lateral maltracking, thereby decreasing the risk of post-operative recurrent instability. Allowing no patellar translation during graft tensioning reduces maltracking further, but can overconstrain the patella, increasing the pressure applied to medial patellar cartilage already fibrillated or eroded from an instability episode.
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Affiliation(s)
- John J. Elias
- Department of Research, Cleveland Clinic Akron General, Akron, OH
| | - Kerwyn C. Jones
- Department of Orthopedic Surgery, Akron Children’s Hospital, Akron, OH
| | - Molly K. Lalonde
- Department of Research, Cleveland Clinic Akron General, Akron, OH
| | - Joseph N. Gabra
- Department of Research, Cleveland Clinic Akron General, Akron, OH
| | | | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Elias JJ, Jones KC, Rezvanifar SC, Gabra JN, Morscher MA, Cosgarea AJ. Dynamic tracking influenced by anatomy following medial patellofemoral ligament reconstruction: Computational simulation. Knee 2018; 25:262-270. [PMID: 29544985 PMCID: PMC5878740 DOI: 10.1016/j.knee.2018.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/29/2017] [Accepted: 02/12/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Continued patellar instability can occur following medial patellofemoral ligament (MPFL) reconstruction. Computational simulation of function was used to investigate the influence of the lateral position of the tibial tuberosity, trochlear dysplasia and patella alta on lateral patellar tracking following MPFL reconstruction. METHODS Multibody dynamic simulation models were developed to represent nine knees being treated for recurrent patellar instability. Knee extension against gravity and dual limb squatting were simulated with and without simulated MPFL reconstruction. Graft resting lengths were set to allow 10mm and five millimeters of patellar lateral translation at 30° of knee flexion. The bisect offset index, lateral tibial tuberosity to posterior cruciate ligament tibial attachment (TT-PCL) distance, lateral trochlear inclination, and Caton-Deschamps index were quantified at every five degrees of knee flexion to characterize lateral tracking, lateral position of the tibial tuberosity, trochlear dysplasia, and patella alta, respectively. For the pre-operative and post-operative conditions and each type of motion, bisect offset index was correlated with the anatomical parameters using stepwise multivariate linear regression. RESULTS For both motions, the pre-operative and post-operative bisect offset indices were significantly correlated with lateral trochlear inclination and lateral TT-PCL distance. For both motions, the adjusted r2 decreased with MPFL reconstruction, but was still approximately 0.5 for MPFL reconstruction allowing five millimeters of lateral translation. CONCLUSION MPFL reconstruction decreases but does not eliminate lateral maltracking related to trochlear dysplasia and a lateralized tibial tuberosity. Patients with these pathologies are likely at the highest risk for instability related to maltracking following MPFL reconstruction.
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Affiliation(s)
- John J. Elias
- Department of Research, Cleveland Clinic Akron General, 1 Akron
General Ave, Akron, OH 44307
| | - Kerwyn C. Jones
- Department of Orthopedic Surgery, Akron Children’s Hospital,
214 W Bowery St, Akron, OH 44308
| | - S. Cyrus Rezvanifar
- Department of Biomedical Engineering, The University of Akron,
Akron, OH 44325
| | - Joseph N. Gabra
- Department of Research, Cleveland Clinic Akron General, 1 Akron
General Ave, Akron, OH 44307
| | - Melanie A. Morscher
- Department of Orthopedic Surgery, Akron Children’s Hospital,
214 W Bowery St, Akron, OH 44308
| | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins University, 10753
Falls Rd., Suite 215, Baltimore, MD, USA 21093
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Medial Patellofemoral Ligament Reconstruction Using All-Soft Suture Anchors for Patellar Fixation. Arthrosc Tech 2018; 7:e231-e237. [PMID: 29881694 PMCID: PMC5989692 DOI: 10.1016/j.eats.2017.08.075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/28/2017] [Indexed: 02/03/2023] Open
Abstract
The medial patellofemoral ligament (MPFL), which is critical for both patellar stability and normal kinematics of the patellofemoral joint, is disrupted in most patellar dislocations. Consequently, MPFL reconstruction is advocated in recurrent dislocations to restore native patellar constraints. Fixation of the MPFL graft to the medial border of the patella can be achieved through various methods, each with its own benefits and drawbacks. We present a technique for MPFL fixation to the patella using all-soft suture anchors, theoretically decreasing the risk of patellar fracture and articular surface violation.
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