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Hinckel BB, Dean RS, Ahlgren CD, Cavinatto LM. Combined Medial Patellofemoral Ligament, Medial Quadriceps Tendon-Femoral Ligament, and Medial Patellotibial Ligament Reconstruction for Patellar Instability: A Technical Note. Arthrosc Tech 2023; 12:e329-e335. [PMID: 37013008 PMCID: PMC10066251 DOI: 10.1016/j.eats.2022.11.011] [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] [Received: 08/12/2022] [Accepted: 11/03/2022] [Indexed: 04/05/2023] Open
Abstract
Lateral patellar dislocations often occur in a young, athletic population of recurrent dislocators with generalized laxity and an interest in returning to an active lifestyle. A recent appreciation for the distal patellotibial complex has directed surgeons toward attempting to re-create the native anatomy and knee biomechanics during medial patellar reconstructive procedures. By reconstructing the medial patellotibial ligament (MPTL) in addition to the medial patella-femoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL), the current article describes a potentially more stable construct that can be utilized in patients with subluxation with the knee in full extension, patellar instability with the knee in deep flexion, genu recurvatum, and generalized hyperlaxity. Additionally, the current technique utilizes a tibialis anterior allograft. The purpose of this Technical Note is to describe, in detail, the current authors' technique for a combined MPFL, MQTFL, and MPTL reconstruction.
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Affiliation(s)
- Betina B. Hinckel
- Address correspondence to Betina B. Hinckel, M.D., Ph.D., 3601 W 13 Mile Rd, Royal Oak, MI, 48073, U.S.A.
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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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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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Nha KW, Kim HS, Cho ST, Bae JH, Jang KM, Kim SG. Arthroscopy-controlled medial reefing and lateral release for recurrent patellar dislocation: clinical, radiologic outcomes and complications. BMC Musculoskelet Disord 2021; 22:430. [PMID: 33971864 PMCID: PMC8111772 DOI: 10.1186/s12891-021-04300-x] [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: 01/04/2021] [Accepted: 04/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background Few studies have reported the clinical outcomes of the medial reefing procedure and lateral release with arthroscopic control of medial retinacular tension in patients with recurrent patellar dislocation. The purpose of this study was to investigate the clinical, radiologic outcomes and complications of arthroscopy-controlled medial reefing and lateral release. Methods Patients who underwent arthroscopy-controlled medial reefing and lateral release for recurrent patellar dislocation between November 2007 and June 2017 were retrospectively evaluated. The clinical outcome (Kujala score), radiologic outcome (congruence and patellar tilt angles), and complications were evaluated at final follow-up. The results were also compared with literature-reported outcomes of other surgical procedures for patellar dislocation. Results Twenty-five patients (mean age, 18.3 ± 4.8 years) were included in the study. The mean clinical follow-up period was 7.0 ± 2.5 (range, 3.8–12.2) years. The mean Kujala score was significantly improved from 54.7 ± 14.0 (range, 37–86) preoperatively to 91.0 ± 7.6 (range, 63–99) at a mean follow-up period of 7 years (P < 0.001). The radiologic results also significantly improved from 17.8° ± 5.9° to 6.8° ± 2.4° (P < 0.001) in the congruence angle and from 17.5° ± 8.2° to 5.6° ± 3.1° (P < 0.001) in the patella tilt angle at a mean follow-up period of 3.6 years. One patient developed a redislocation after a traumatic event, and two patients showed patellofemoral osteoarthritis progression. Conclusions Arthroscopy-controlled medial reefing and lateral release significantly improved the clinical and radiologic outcomes of the patients with recurrent patellar dislocation at a mean follow-up period of 7 years. The results of this study are comparable with the literature-reported outcomes of other surgical procedures for patellar dislocation. Level of evidence Level IV, retrospective therapeutic case series.
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Affiliation(s)
- Kyung Wook Nha
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Gyeonggi-do, Goyang-si, 10380, Republic of Korea
| | - Hyung Suh Kim
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Gyeonggi-do, Goyang-si, 10380, Republic of Korea
| | - Sung Tan Cho
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Gyeonggi-do, Goyang-si, 10380, Republic of Korea
| | - Ji Hoon Bae
- Department of Orthopaedic Surgery, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Gyeongki-do, Ansan-si, 15355, Republic of Korea.
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Fujii Y, Nakagawa S, Arai Y, Inoue H, Kan H, Hino M, Kaihara K, Mikami Y. Clinical outcomes after medial patellofemoral ligament reconstruction: an analysis of changes in the patellofemoral joint alignment. INTERNATIONAL ORTHOPAEDICS 2020; 45:1215-1222. [PMID: 32770307 DOI: 10.1007/s00264-020-04765-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/28/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE Medial patellofemoral ligament (MPFL) reconstruction using the hamstring tendon is widely performed to treat recurrent patellar dislocation. MPFL reconstruction includes a post-operative process of necrosis and reperfusion of the hamstring tendon graft. We hypothesise that the patella gradually shifts laterally because of this process, ultimately affecting the patellofemoral joint alignment. This study aimed to analyse the chronological changes in the patellofemoral joint alignment and the outcomes of MPFL reconstruction. METHODS In this retrospective case-series study, the Knee Society, Lysholm, and Kujala scores were evaluated in 24 consecutive patients (27 knees). To evaluate patellar tracking defects, radiographic indices including the tilting angle, the lateral shift ratio, and the congruence angle were measured before, immediately after, and three, 12, and 36 months after MPFL reconstruction. RESULTS Post-operative Kujala, Knee Society, and Lysholm scores for the study population significantly improved relative to the pre-operative scores. The tilting and congruence angles at three months after the operation significantly increased relative to those recorded immediately after the operation. The tilting and congruence angles were not significantly different at three, 12, and 36 months after the operation. CONCLUSIONS The post-operative outcomes of MPFL reconstruction for recurrent patellar dislocation were favourable. Insufficient union between the bone tunnel and tendon graft, along with an elongation of the necrotic tendon graft, may change the alignment of the patellofemoral joint within three months after the operation. Therefore, we believe it is necessary to refrain from knee rotation that places lateral stress on the patella until three months after the operation.
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Affiliation(s)
- Yuta Fujii
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shuji Nakagawa
- Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Yuji Arai
- Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Hiroaki Inoue
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroyuki Kan
- Department of Orthopaedics, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Japan
| | - Manabu Hino
- Department of Orthopaedics, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Japan
| | - Kenta Kaihara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuo Mikami
- Department of Rehabilitation Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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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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Zhang H. A Novel Technique for Patellar Fracture Fixation With Simultaneous Medial Patellofemoral Ligament Reconstruction: A Rare Case of Patellar Dislocation Combined With a Patellar Fracture. Orthop J Sports Med 2019; 7:2325967119885358. [PMID: 31799332 PMCID: PMC6864037 DOI: 10.1177/2325967119885358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Hangzhou Zhang
- Department of Orthopaedics, Joint Surgery and Sports Medicine, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
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Waterman BR. Editorial Commentary: The "F" in MPFL (Medial Patellofemoral Ligament) Reconstruction-How Should We Fix It and Does It Matter? Arthroscopy 2019; 35:1138-1140. [PMID: 30954107 DOI: 10.1016/j.arthro.2019.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 02/02/2023]
Abstract
Our understanding of the medial patellofemoral complex anatomy has evolved significantly over the past several decades, and this has informed our current surgical approach to management of lateral patellar instability. Medial patellofemoral ligament reconstruction remains the gold standard for decreasing the risk of secondary patellar dislocation and returning patients to active physical function. However, concerns about isometry, overconstraint, secondary arthrosis, and surgical-site morbidity remain with femoral socket fixation, particularly when patella alta, rotational malalignment, or hypermobility is present. Medial patellofemoral ligament reconstruction with soft-tissue fixation, on either the patellar or femoral side, may mitigate some of these risks by offering a more dynamic checkrein to lateral translation. However, longer-term studies are required to determine comparative efficacy with varying surgical techniques, and the ideal graft tension and degree of knee flexion during fixation have not yet been determined.
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