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Hinckel B, Smith J, Tanaka MJ, Matsushita T, Martinez-Cano JP. Patellofemoral instability part 1 (When to operate and soft tissue procedures): State of the art. J ISAKOS 2024:S2059-7754(24)00100-7. [PMID: 38795864 DOI: 10.1016/j.jisako.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/29/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
Patellofemoral instability is usually initially treated non-operatively. Surgery is considered in patients with recurrent patellar dislocation and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence. Stratifying the risk of recurrence includes evaluating risk factors such as age, trochlear dysplasia, contralateral dislocation, and patellar height. Surgery with soft tissue procedures includes restoring the medial patellar restraints and balancing the lateral side of the joint. Reconstruction of the medial patellofemoral ligament is the most frequent way of addressing the medial soft tissues in patients with patellofemoral instability. Meanwhile, lateral tightness can be achieved by lateral retinaculum lengthening or release. Approaching patellofemoral instability in a patient-specific approach, combined with a shared decision-making process with the patient/family, will guide surgeons to the deliver optimal care for the patellar instability patient.
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Affiliation(s)
- Betina Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Justin Smith
- Atrium Health Musculoskeletal Institute & Sports Medicine, Rock Hill, SC, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Camanho GL, Gobbi RG, Helito CP, Moreira da Silva AG, Machado de Oliveira G. Medial Patellofemoral Ligament Reconstruction Using the Medial Third of the Patellar Tendon: Camanho's Technique. Arthrosc Tech 2024; 13:102913. [PMID: 38690355 PMCID: PMC11056719 DOI: 10.1016/j.eats.2024.102913] [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: 09/24/2023] [Accepted: 12/08/2023] [Indexed: 05/02/2024] Open
Abstract
The reconstruction of the medial patellofemoral ligament (MPFL) is an essential procedure in the surgical treatment of patellar instability. The medial third of the patellar tendon is a good graft option for this reconstruction, maintaining the insertion of the graft in the patella, with no need for hardware for patellar fixation. The objective of this article is to describe the MPFL reconstruction technique with the patellar tendon graft.
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Affiliation(s)
- Gilberto Luis Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Andre Giardino Moreira da Silva
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gabriel Machado de Oliveira
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Hu F, Shi W, Wang H, Gong X, Yang Y, Ma Y, Wang C, Liu P. Arthroscopically Assisted Double-Bundle Medial Patellofemoral Ligament Augmentation With Physeal-Sparing Suture Fixation for Recurrent Patellar Dislocation in Skeletally Immature Patients. Arthrosc Tech 2024; 13:102853. [PMID: 38435249 PMCID: PMC10907910 DOI: 10.1016/j.eats.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/24/2023] [Indexed: 03/05/2024] Open
Abstract
Recurrent patellar dislocation is a common patellofemoral disease that affects active adolescents. The optimal surgical treatment of recurrent patellar dislocation in skeletally immature patients remains controversial. This Technical Note describes an arthroscopically assisted double-bundle medial patellofemoral ligament (MPFL) augmentation. Orthocord suture, with ideal strength and partial bioabsorbable characteristics, is used as the stabilizer to augment and protect the native MPFL during its biological healing. Under an arthroscope, patellar tunnels are created with Kirshner wire at the upper third point of the medial articular margin and the midpoint of the proximal articular margin. A physeal-sparing transosseous suture fixation technique is applied at the femoral attachment. Two femoral tunnels are made with half-circle cutting needle, which is pierced into the femoral origin of the MPFL and exits the posterior femoral cortex. After dynamic assessments of knee range of motion and patellofemoral congruence, free ends of the Orthocord suture bundle are tied together at the external opening of the femoral tunnel. Transosseous suture fixation balances the requirements of anatomic restoration, reliable fixation, and physeal preservation, and thus may provide a promising alternative to current algorithm of addressing recurrent patellar dislocation in pediatric population.
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Affiliation(s)
- Fengyi Hu
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Weili Shi
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Haijun Wang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Xi Gong
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yuping Yang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yong Ma
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Cheng Wang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Ping Liu
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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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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Geers BA, Bishai SK. Chronic Midsubstance Patellar Tendon and Retinacular Rupture: Primary Repair Enhancement Using Bioinductive Implant Augmentation. Arthrosc Tech 2023; 12:e1595-e1600. [PMID: 37780659 PMCID: PMC10533941 DOI: 10.1016/j.eats.2023.05.009] [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: 03/08/2023] [Accepted: 05/03/2023] [Indexed: 10/03/2023] Open
Abstract
Midsubstance tears of the patellar tendon are uncommon and present a difficult injury to treat. If left untreated, these can be debilitating injuries for patients and leave them with an overall lack of function in the injured extremity. Compared to a proximal or distal patellar tendon rupture, midsubstance tears rely on tendon-to-tendon healing instead of bone to tendon healing. Given this situation, specific preoperative planning and the use of a bioinductive scaffolding allows surgeons to enhance the overall construct, while promoting a beneficial healing environment. Although the addition of bioinductive implants has grown in popularity for upper extremity injuries, few cases describe its use in the lower extremity setting. Here, we present a case of midsubstance patellar tendon repair, as well as a medial and lateral retinacular repair using a structural biological implant with Type I collagen for augmentation to enhance our overall final construct.
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Leite CBG, Hinckel BB, Ribeiro GF, Giglio PN, Santos TP, Bonadio MB, Arendt E, Gobbi RG. Medial patellofemoral ligament reconstruction in skeletally immature patients without correction of bony risk factors leads to acceptable outcomes but higher failure rates. J ISAKOS 2023; 8:189-196. [PMID: 36924824 DOI: 10.1016/j.jisako.2023.02.003] [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: 10/26/2022] [Revised: 01/29/2023] [Accepted: 02/25/2023] [Indexed: 03/15/2023]
Abstract
OBJECTIVES To report outcomes and re-dislocation rates of medial patellar stabilizers reconstruction without bone procedures for correction of anatomical risk factors for patellar instability in skeletally immature patients; to compare isolated medial patellofemoral ligament (MPFL) reconstruction to combined MPFL and medial patellotibial ligament (MPTL) reconstruction in this population. METHODS Patients with open physis and bone abnormalities including patella alta and/or increased tibial tubercle-trochlear groove (TT-TG) distance and/or trochlear dysplasia underwent MPFL reconstruction, either isolated or associated with MPTL reconstruction. Preoperative, 1-year follow-up and the latest follow-up (5 years minimum) data were collected. Radiological and clinical evaluations were conducted, with special attention to failure rate. Comparison of results from isolated MPFL and combined MPFL/MPTL reconstructions was performed. RESULTS Twenty-nine patients were included, 19 in the isolated MPFL group (median 14 years old; follow-up 5.8 ± 1.7 years) and 10 in the combined MPFL/MPTL group (median 13.5 years old; follow-up 5.2 ± 1.4 years). Kujala and Tegner scores increased over time, although without statistically significant differences between the two groups at the latest follow-up (p = 0.840 and p > 0.999, respectively). During follow-up, 5 of 19 (26.3%) isolated MPFL and 2 of 10 (20%) MPFL/MPTL reconstructions experienced recurrence of patellar dislocation (p > 0.999). Trochlear dysplasia type D (p = 0.028), knee rotation (p = 0.009) and lateral patellar tilt angle (p = 0.003) were associated with patellar instability recurrence. The isolated MPFL group showed increased laxity on physical exam at the latest follow-up compared to the 1-year follow-up (patellar glide test (p = 0.002), patellar tilt test (p = 0.042) and subluxation in extension (p = 0.019). This increased laxity was not observed in the MPFL/MPTL group (p > 0.999). Comparing both groups, the glide test was significantly better in the combined MPFL/MPTL group in comparison to the isolated MPFL reconstruction group at the latest follow-up (p = 0.021). CONCLUSION MPFL reconstruction in isolation or combined with MPTL reconstruction in skeletally immature patients with additional uncorrected anatomical patellofemoral abnormalities leads to acceptable clinical outcomes within a minimum of 5 years follow-up, although has a high failure rate of 24.1%. Addition of a MPTL reconstruction to the MPFL may result in decreased patellar laxity on physical exams, as demonstrated by better patellar glide test, patellar tilt test and subluxation in extension. LEVEL OF EVIDENCE Level III; retrospective cohort study.
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Affiliation(s)
- Chilan Bou Ghosson Leite
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Betina Bremer Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI 48180, USA.
| | - Gabriel Fernandes Ribeiro
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Pedro Nogueira Giglio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Tarsis Padula Santos
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Marcelo Batista Bonadio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Elizabeth Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN 55454, USA
| | - Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
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Drapeau-Zgoralski V, Swift B, Caines A, Kerrigan A, Carsen S, Pickell M. Lateral Patellar Instability. J Bone Joint Surg Am 2023; 105:397-409. [PMID: 36728086 DOI: 10.2106/jbjs.22.00756] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
➤ Patellar instability represents a common problem with an evolving understanding and multifactorial pathoetiology. Treatment plans should be based on the identification of contributing anatomical factors and tailored to each individual patient. ➤ Risks for recurrent instability are dependent on several patient-specific factors including patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, trochlear dysplasia, younger skeletal age, and ligamentous laxity. ➤ Cartilage or osteochondral lesions and/or fractures are commonly observed in first-time patellar dislocation, and magnetic resonance imaging (MRI) should be strongly considered. Advanced imaging modalities, such as computed tomography (CT) or MRI, should also be obtained preoperatively to identify predisposing factors and guide surgical treatment. ➤ Medial patellofemoral ligament (MPFL) reconstruction with anatomical femoral tunnel positioning is associated with lower recurrence rates compared with MPFL repair and has become a common and successful reconstructive surgical option in cases of instability. ➤ Lateral retinacular tightness can be addressed with lateral retinacular release or lengthening, but these procedures should not be performed in isolation. ➤ Tibial tubercle osteotomy is a powerful reconstructive tool in the setting of underlying skeletal risk factors for instability and can be of particular benefit in the presence of increased TT-TG distance (>20 mm), and/or in the setting of patella alta. ➤ The indications for trochleoplasty are still developing along with the clinical evidence, but trochleoplasty may be indicated in some cases of severe trochlear dysplasia. Several surgical techniques have indications in specific clinical scenarios and populations, and indications, risks, and benefits to each are progressing with our understanding. ➤ Combined femoral derotational osteotomy and MPFL reconstruction can be considered for patients with a femoral anteversion angle of >30° to improve patient outcomes and reduce recurrence rates.
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Affiliation(s)
| | - Brendan Swift
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew Caines
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alicia Kerrigan
- Division of Orthopaedic Surgery, The Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, The Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Michael Pickell
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Frodl A, Lange T, Siegel M, Meine H, Taghizadeh E, Schmal H, Izadpanah K. Individual Influence of Trochlear Dysplasia on Patellofemoral Kinematics after Isolated MPFL Reconstruction. J Pers Med 2022; 12:jpm12122049. [PMID: 36556269 PMCID: PMC9786691 DOI: 10.3390/jpm12122049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The influence of the MPFL graft in cases of patella instability with dysplastic trochlea is a controversial topic. The effect of the MPFL reconstruction as single therapy is under investigation, especially with severely dysplastic trochlea (Dejour types C and D). The purpose of this study was to evaluate the impact of trochlear dysplasia on patellar kinematics in patients suffering from low flexion patellar instability under weight-bearing conditions after isolated MPFL reconstruction. MATERIAL AND METHODS Thirteen patients were included in this study, among them were eight patients with mild dysplasia (Dejour type A and B) and five patients with severe dysplasia (Dejour type C and D). By performing a knee MRI with in situ loading, patella kinematics and the patellofemoral cartilage contact area could be measured under the activation of the quadriceps musculature in knee flexion angles of 0°, 15° and 30°. To mitigate MRI motion artefacts, prospective motion correction based on optical tracking was applied. Bone and cartilage segmentation were performed semi-automatically for further data analysis. Cartilage contact area (CCA) and patella tilt were the main outcome measures for this study. Pre- and post-surgery measures were compared for each group. RESULTS Data visualized a trending lower patella tilt after MPFL graft installation in both groups and flexion angles of the knee. There were no significant changes in patella tilt at 0° (unloaded pre-surgery: 22.6 ± 15.2; post-surgery: 17.7 ± 14.3; p = 0.110) and unloaded 15° flexion (pre-surgery: 18.9 ± 12.7; post-surgery: 12.2 ± 13.0; p = 0.052) of the knee in patients with mild dysplasia, whereas in patients with severe dysplasia of the trochlea the results happened not to be significant in the same angles with loading of 5 kg (0° flexion pre-surgery: 34.4 ± 12.1; post-surgery: 31.2 ± 16.1; p = 0.5; 15° flexion pre-surgery: 33.3 ± 6.1; post-surgery: 23.4 ± 8.6; p = 0.068). CCA increased in every flexion angle and group, but significant increase was seen only between 0°-15° (unloaded and loaded) in mild dysplasia of the trochlea, where significant increase in Dejour type C and D group was seen with unloaded full extension of the knee (0° flexion) and 30° flexion (unloaded and loaded). CONCLUSION This study proves a significant effect of the MPFL graft to cartilage contact area, as well as an improvement of the patella tilt in patients with mild dysplasia of the trochlea. Thus, the MPFL can be used as a single treatment for patient with Dejour type A and B dysplasia. However, in patients with severe dysplasia the MPFL graft alone does not significantly increase CCA.
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Affiliation(s)
- Andreas Frodl
- Department of Orthopedics and Traumatology, Freiburg University Hospital, 79106 Freiburg, Germany
- Correspondence:
| | - Thomas Lange
- Department of Radiology, Medical Physics, Freiburg University Hospital, 79106 Freiburg, Germany
| | - Markus Siegel
- Department of Orthopedics and Traumatology, Freiburg University Hospital, 79106 Freiburg, Germany
| | - Hans Meine
- Fraunhofer Institute for Digital Medicine, 28359 Freiburg, Germany
| | - Elham Taghizadeh
- Fraunhofer Institute for Digital Medicine, 28359 Freiburg, Germany
| | - Hagen Schmal
- Department of Orthopedic Surgery, University Hospital Odense, Sdr. Boulevard 29, 5000 Odense, Denmark
| | - Kaywan Izadpanah
- Department of Orthopedics and Traumatology, Freiburg University Hospital, 79106 Freiburg, Germany
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9
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Perry AK, Maheshwer B, DeFroda SF, Hevesi M, Gursoy S, Chahla J, Yanke A. Patellar Instability. JBJS Rev 2022; 10:01874474-202211000-00008. [PMID: 36441831 DOI: 10.2106/jbjs.rvw.22.00054] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
➢ Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. ➢ The presence of a preoperative J-sign is predictive of recurrent instability after operative management. ➢ Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. ➢ More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.
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Affiliation(s)
- Allison K Perry
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | | | - Steven F DeFroda
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Mario Hevesi
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Adam Yanke
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
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10
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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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11
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Full thickness quadriceps tendon grafts with bone had similar material properties to bone-patellar tendon-bone and a four-strand semitendinosus grafts: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 2022; 30:1786-1794. [PMID: 34591124 DOI: 10.1007/s00167-021-06738-x] [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: 03/10/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Despite increasing interest in utilizing quadriceps tendon (QT) grafts in anterior cruciate ligament reconstruction (ACLR), data on the optimal quadriceps graft thickness are limited. The purpose of this study was to characterize the mechanical properties for the quadriceps tendon, comparing full-thickness (FT) QT grafts with and without bone to a partial-thickness (PT) QT graft, and comparing the three QT grafts to four-stranded semitendinosus (4-SST) and bone-patellar tendon-bone (BTB) grafts and one experimental graft, the two-stranded rectus femoris (RF). METHODS Forty-eight (n = 48) young cadaveric grafts (mean age 32 ± 6 years) were utilized for testing with N = 8 specimens in each of the following groups; (1) FT QT with bone, (2) FT QT without bone, (3) PT QT without bone, (4) BTB, (5) RF, and (6) 4-SST. Each specimen was harvested and rigidly fixed in custom clamps to a dynamic tensile testing machine for biomechanical evaluation. Graft ultimate load and stiffness were recorded. Independent groups one-factor ANOVAs and Tukey's pairwise comparisons were performed for statistical analyses. RESULTS FT QT with bone and 4-SST grafts demonstrated similar ultimate loads to BTB grafts (both n.s), whereas PT QT demonstrate statistically significantly lower ultimate loads to BTB grafts (n.s) and 4-SST grafts (n.s). Furthermore, no statistically significant differences were observed between the ultimate loads of FT QT vs. PT QT grafts without bone (n.s) or between FT QT with vs. without bone (n.s). FT QT grafts with bone did not demonstrate statistically significantly greater ultimate loads than PT QT grafts without bone (n.s). The RF graft demonstrated statistically significantly lower ultimate loads to BTB grafts (p < 0.005) and 4-SST grafts (p < 0.014). CONCLUSIONS Full thickness QT grafts with bone had similar material properties to BTB and a 4-SST grafts, while Partial thickness QT graft without bone had significantly lower material properties than BTB and 4-SST, in a biomechanical setting.
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Elyasi E, Perrier A, Bailet M, Payan Y. Biomechanical lower limb model to predict patellar position alteration after medial open wedge high tibial osteotomy. J Biomech 2022; 136:111062. [DOI: 10.1016/j.jbiomech.2022.111062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/07/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
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Zhou MAJL, Cruz CPTCA, Johnson MAJZA, Bottoni CR. Outcomes of Patellar Stabilization Utilizing a Combined Arthroscopic and Open Technique: A Retrospective Review With 5-Year Follow-up. Orthop J Sports Med 2022; 10:23259671211068404. [PMID: 35237696 PMCID: PMC8883305 DOI: 10.1177/23259671211068404] [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: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Few studies have reported the long-term outcomes of patellar stabilization surgery in an active duty military cohort. Purpose: To evaluate the long-term results of a combined open and arthroscopic patellar stabilization technique for the treatment of recurrent lateral patellar instability in members of a military population. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective review of a consecutive series of 63 patients who underwent operative management for patellar instability at a tertiary military medical center between 2003 and 2017. All cases were performed by a single sports medicine fellowship–trained orthopaedic surgeon. Patients with recurrent lateral patellar instability whose nonoperative management failed were included. All patients underwent arthroscopic imbrication of the medial patellar retinaculum, an open lateral retinacular release, and an Elmslie-Trillat tibial tubercle osteotomy. Outcome measures at final follow-up included recurrent instability, need for surgical revision, subjective assessments, and military-specific metrics. We also analyzed anatomic risk factors for failure: patella alta, coronal plane alignment, trochlear dysplasia, and tibial tubercle–trochlear groove distance. Results: A total of 51 patients were included (34 men, 17 women; mean ± SD age at surgery, 27.2 ± 5.8 years; mean follow-up, 5.3 years). The mean postoperative SANE score (Single Assessment Numeric Evaluation) was 75.0 ± 17.7, and the mean visual analog scale pain score was 2.5 ± 2.1. Four patients (7.8%) reported redislocation events, and 4 underwent revision surgery. Twenty-five patients (49.0%) reported a decrease in activity level as compared with preinjury, while 10 (19.6%) cited restrictions in activities of daily living. Of the 21 patients remaining on active duty, 6 (28.6%) required an activity-limiting medical profile. Of the 48 active duty patients, 12 (25.0%) underwent evaluation by a medical board for separation from the military. Differences in the Caton-Deschamps Index and tibial tubercle–trochlear groove distance between surgical success and failure were not statistically significant. Conclusion: Surgical management of patellar instability utilizing a multifaceted technique resulted in low recurrence rates and may be independent of predisposing anatomic risk factors for instability. At 5-year follow-up, most patients retained their active duty status, although nearly half experienced a decrease in activity level.
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Affiliation(s)
- MAJ Liang Zhou
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - CPT Christian A. Cruz
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | | | - Craig R. Bottoni
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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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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15
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Zhang YQ, Zhang Z, Wu M, Zhou YD, Tao SL, Yang YL, Li Y, Liu JL, Li P, Teng YS, Guo YM. Medial patellofemoral ligament reconstruction: A review. Medicine (Baltimore) 2022; 101:e28511. [PMID: 35029909 PMCID: PMC8735765 DOI: 10.1097/md.0000000000028511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/09/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Reconstruction of the medial patellofemoral ligament (MPFL) is an effective surgical method for the treatment of lateral patellar instability. At present, there is not much controversies regarding the femoral attachment, however, the controversies regarding patellar attachment versus attachment, number of graft strands, tension, isometry and so on. The following electronic databases will be searched: PubMed, the Cochrane Library, Embase, Web of Science, Medline. We will consider articles published between database initiation and March 2021. MPFL in the subject heading will be included in the study. Language is limited to English. Research selection, data extraction, and research quality assessment were independently completed by 2 researchers. CONCLUSIONS MPFL reconstruction is a reliable technique for the treatment of patellofemoral instability. The Schöttle point is still the mainstream method for locating the femoral attachment, the patellar attachment for single-bundle is located at the junction of the proximal one third and the distal two third of the longitudinal axis of the patella. For double-bundles, one is located in the proximal one third of the medial patellar edge and another is in the center of the patellar edge. Meanwhile, the adjustment of graft tension during operation is very important.
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Biomechanical comparison of two medial patellofemoral ligament reconstruction techniques: Quadriceps tendon fixation versus single-tunnel patella fixation with gracilis autograft did not differ in load to failure and stiffness. Knee 2021; 33:169-175. [PMID: 34626887 DOI: 10.1016/j.knee.2021.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/08/2021] [Accepted: 09/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the ultimate failure load and stiffness of two patellar fixation techniques for medial patellofemoral ligament (MPFL) reconstruction: (1) quadriceps tendon fixation (QT), (2) single tunnel (STG) patella fixation with gracilis autograft. METHODS A total of 16 fresh-frozen cadaveric knees (eight matched pairs) were randomized into two groups (QT vs. STG). The MPFL reconstructions were subjected to cyclic loading for 10 cycles to 30 N and then tested to failure at a constant displacement rate of 15 mm/min using a materials-testing machine (MTS 810 Universal Testing System). Failure mode, ultimate failure load and stiffness were recorded for each cadaveric specimen. RESULTS There was no significant difference in mean ultimate failure load among groups (P = 0.35). The STG group failed at a mean ultimate load of 190.04 N [standard deviation (SD) 23.18] and the QT group failed at 206.24 N (SD 37.99). The STG group had a mean stiffness of 21.38 N/mm (SD 1.44). This was not significantly higher than the mean stiffness value achieved for the QT group at 20.36 N/mm (SD 1.3) (P = 0.19). In the QT group all reconstructions failed due to tendon rupture at the patella attachment. The reason for failure in the STG group was the graft-suture connection. CONCLUSIONS This cadaver study showed no statistically significant difference in biomechanical performance of the evaluated patella fixation techniques, in terms of maximum load to failure and stiffness. Both techniques are reliable in terms of biomechanical properties and could offer additional surgical solutions.
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17
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Zhang YQ, Zhang Z, Wu M, Zhou YD, Li P, Tao SL, Yang YL, Li Y, Liu JL, Teng YS, Guo YM. Medial patellofemoral ligament reconstruction: A protocol for systematic review and meta-analysis. J Orthop 2021. [DOI: 10.1016/j.jor.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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18
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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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Aliberti GM, Kraeutler MJ, Miskimin C, Scillia AJ, Belk JW, Mulcahey MK. Autograft Versus Allograft for Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211046639. [PMID: 34692883 PMCID: PMC8529317 DOI: 10.1177/23259671211046639] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Patients with recurrent lateral patellar dislocations are often treated with
reconstruction of the medial patellofemoral ligament (MPFL). Purpose: To perform a systematic review to evaluate clinical outcomes and the risk of
recurrent patellar dislocation after MPFL reconstruction (MPFLR) with
autograft versus allograft. Study Design: Systematic review; Level of evidence, 4. Methods: The authors conducted a search of PubMed, the Cochrane Library, and Embase to
identify studies comparing outcomes of MPFLR with autograft versus
allograft. The inclusion criteria were full-text studies that directly
compared clinical outcomes and/or risk of recurrent patellar instability
between patients undergoing MPFLR with autograft versus allograft. A quality
assessment was performed using the modified Coleman Methodology Score, and
risk-of-bias assessment was performed using the Risk Of Bias In
Non-randomized Studies–of Interventions and the Cochrane Collaboration
tools. Results: Seven studies (1 evidence level 2, 3 level 3, 3 level 4) that met inclusion
criteria were identified and included a total of 150 patients who underwent
MPFLR with autograft and 193 with MPFLR with allograft. One study found a
significantly higher failure rate among patients with autograft, and another
study found a trend toward a significantly higher failure rate among
patients with autograft. One study demonstrated no significant difference
between postoperative tibial tubercle–trochlear groove distance (measured on
magnetic resonance imaging scans) in failed versus successful grafts. One
study found that patellar tilt angle improved significantly from
preoperatively to postoperatively (P < .001) but there
was no difference between the groups. Kujala scores significantly improved
for both autograft and allograft groups across studies. Two studies found
significant differences in postoperative Kujala scores between the 2 groups,
1 of which found better scores in the allograft group (P =
.0032) and another in which scores were better in the autograft group
(P = .02). Conclusion: Patients undergoing MPFLR with either autograft or allograft can expect to
experience improvement in clinical outcomes. Subjective outcomes improved to
a similar degree in both groups. Graft failure was more frequently observed
in patients with autograft. Allograft may be a better option for MPFLR owing
to lower failure rate.
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Affiliation(s)
| | - Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, USA
| | - Cadence Miskimin
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, USA.,New Jersey Orthopaedic Institute, Wayne, New Jersey, USA
| | - John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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20
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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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21
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Geeslin AG, Lemos DF, Geeslin MG. Knee Ligament Imaging: Preoperative and Postoperative Evaluation. Clin Sports Med 2021; 40:657-675. [PMID: 34509204 DOI: 10.1016/j.csm.2021.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Preoperative and postoperative imaging of knee ligament injury hinges on the appropriate use of available modalities. Knowledge of injury patterns as well as the surgical significance of certain image findings enhances injury detection and supports appropriate preoperative planning. The radiologist must be familiar with the strengths and weaknesses of each modality for evaluating specific aspects of ligamentous pathology. This article focuses on preoperative and postoperative imaging of knee ligament injury. Basic topics pertaining to preoperative image modality selection and isolated injury detection are addressed. More advanced areas including ligamentous injury patterns, surgical indications, and postoperative imaging are also discussed.
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Affiliation(s)
- Andrew G Geeslin
- Department of Orthopedic Surgery, University of Vermont Medical Center, 192 Tilley Drive, South Burlington, VT 05403, USA
| | - Diego F Lemos
- Radiology and Orthopedic Surgery, University of Vermont Medical Center, Burlington, VT, USA; Department of Radiology, 111 Colchester Avenue, Burlington, VT 05401, USA
| | - Matthew G Geeslin
- Department of Radiology, University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA.
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22
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Wang C, Kernkamp WA, Li C, Hu H, Li P, Tsai TY. Elongation and orientation pattern of the medial patellofemoral ligament during lunging. J Orthop Res 2021; 39:2036-2047. [PMID: 33002242 DOI: 10.1002/jor.24872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 09/18/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
Unfavorable clinical outcomes after medial patellofemoral ligament (MPFL) reconstruction, such as early osteoarthritis of the patellofemoral joint, were considered to be associate with tunnel malpositioning. Length change studies have found that small changes in the femoral position can cause great changes in elongation trends. Further studying the MPFL kinematics may help us to understand the consequences of tunnel malpositioning and optimize the reconstruction techniques. Fifteen healthy subjects were studied with a combined computed tomography and biplane fluoroscopic imaging technique during a lunge motion. Five femoral and three patellar attachments were used to simulate different MPFL bundles. Kinematics of MPFL was defined as elongation and orientation changes (i.e., deviation angle and elevation angle). The mean deviation angle was 28.7° (95% confidence interval, 28.0°-29.4°) at full extension and remained nearly unchanged up to 60° of flexion, and increased to 56.5° (54.1°-58.9°) at 110°. The elevation angle decreased linearly from 12.6° (9.3°-15.9°) at full extension to -86.2° (-92.7-79.7°) at 110° of flexion. The MPFL was most stretched anteriorly and laterally relative to femur from full extension to 30° of flexion and remained near isometric beyond 30°. The current study found that proximal and anterior femoral attachments caused excessive lateral stretching of the MPFL at deeper flexion angles. Such abnormal MPFL kinematics may subsequently cause overconstraint and increased cartilage pressures of the medial patellofemoral joint.
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Affiliation(s)
- Cong Wang
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, China.,Department of Orthopaedic Surgery, Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translational R&D Center of 3D Printing Technology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Willem A Kernkamp
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Changzhao Li
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Hai Hu
- Department of Orthopaedic Surgery, Orthopaedic Biomechanical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Pingyue Li
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, China.,Department of Orthopaedic Surgery, Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translational R&D Center of 3D Printing Technology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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23
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Milinkovic DD, Fink C, Kittl C, Sillanpää P, Herbst E, Raschke MJ, Herbort M. Anatomic and Biomechanical Properties of Flat Medial Patellofemoral Ligament Reconstruction Using an Adductor Magnus Tendon Graft: A Human Cadaveric Study. Am J Sports Med 2021; 49:1827-1838. [PMID: 33960859 DOI: 10.1177/03635465211009540] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In contrast to the majority of existing techniques for reconstruction of the medial patellofemoral ligament (MPFL), the technique described in this article uses the adductor magnus muscle tendon to gain a flat, broad graft, leaving its distal femoral insertion intact, and does not require drilling within or near the femoral physis. It also allows for soft tissue patellar fixation and could facilitate anatomic MPFL reconstruction in skeletally immature patients. PURPOSE To evaluate the anatomic and structural properties of the native MPFL and the adductor tendon (AT), followed by biomechanical evaluation of the proposed reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS The morphological and topographical features of the AT and MPFL were evaluated in 12 fresh-frozen cadaveric knees. The distance between the distal insertion of the AT on the adductor tubercle and the adductor hiatus, as well as the desired length of the graft, was measured to evaluate this graft's application potential. Load-to-failure tests were performed to determine the biomechanical properties of the proposed reconstruction construct. The construct was placed in a uniaxial testing machine and cyclically loaded 500 times between 5 and 50 N, followed by load to failure, to measure the maximum elongation, stiffness, and maximum load. RESULTS The mean ± SD length of the AT was 12.6 ± 1.5 cm, and the mean distance between the insertion on the adductor tubercle and adductor hiatus was 10.8 ± 1.3 cm, exceeding the mean desired length of the graft (7.5 ± 0.5 cm) by 3.3 ± 0.7 cm. The distal insertion of the AT was slightly proximal and posterior to the insertion of the MPFL. The maximum elongation after cyclical loading was 1.9 ± 0.4 mm. Ultimately, the mean stiffness and load to failure were 26.2 ± 7.6 N/mm and 169.7 ± 19.2 N, respectively. The AT graft failed at patellar fixation in 2 of the initially tested specimens and at the femoral insertion in the remaining 10. CONCLUSION The described reconstruction using the AT has potential for MPFL reconstruction. The AT graft presents a graft of significant volume, beneficial anatomic topography, and adequate tensile properties in comparison with the native MPFL following the data from previously published studies. CLINICAL RELEVANCE Given its advantageous anatomic relationship as an application that avoids femoral drilling and osseous patellar fixation, the AT may be considered a graft for MPFL reconstruction in skeletally immature patients.
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Affiliation(s)
| | - Christian Fink
- Gelenkpunk-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | | | - Petri Sillanpää
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Pihlajalinna Koskisairaala Hospital, Tampere, Finland
| | | | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.,OCM Orthopedic Surgery Munich Clinic, Munich, Germany
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Megremis P, Megremis O. Evaluation of recurrent dislocation of the patella in children with MRI: Goldthwait technique combined with lateral release, and VMO advancement-a retrospective study of 85 knees. Musculoskelet Surg 2021; 106:397-406. [PMID: 34027575 DOI: 10.1007/s12306-021-00713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE There are certain risk factors responsible for patella instability that should be identified before choosing the most appropriate treatment. METHODS We evaluated 83 skeletally immature patients who, after two or more patellar dislocation episodes, underwent surgical treatment to address the condition of patellar instability. Each patient was evaluated for patellar instability risk factors using the Balcarek patellar instability severity score. Evaluation of patellar instability included knee MRI to systematically identify anatomical risk factors. The preoperative and postoperative clinical evaluation included the modified Cincinnati score and the Kujala score. The Roux-Goldthwait technique combined with lateral retinaculum release and the advancement of the vastus medialis oblique (VMO) was performed on all knees. RESULTS The mean patient age at the time of surgery was 12.2 ± 1.59 years (range 8-14 years). The average follow-up was 4.72 ± 1.37 (range 3-8) years. Trochlear dysplasia (decreased trochlear depth), the most common anatomical risk factor, was identified in 71 knees (83.5%). The modified Cincinnati score increased from 58.46 ± 8.75 (range 49-76) points to 94.07 ± 2.88 (range 88-98) postoperatively. The mean Kujala scores increased from 58.51 ± 8.94 (range 49-76) points to 93.66 ± 2.65 (range 87-98) postoperatively. The two-tailed P value was less than 0.0001. The patients were followed until their skeletal maturation, without reporting any incidents of patella dislocation, except one. CONCLUSION The Roux-Goldthwait technique combined with lateral retinaculum release, and the advancement of VMO, can restore patellar tracking and can decrease the probability of another dislocation. It was an effective treatment in skeletally immature patients who had two or more episodes of patellar dislocation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- P Megremis
- Consultant Pediatric Orthopaedic Surgeon, A' Orthopaedic Department, Athens Children's Hospital «P. & A. Kyriakou», Megalou Alexandrou 6, Mati Attiki, Athens, Greece.
| | - O Megremis
- A' Surgical Department, Sismanogleio General Hospital, Athens, Greece
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25
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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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Abstract
Optimal treatment of patients with patellofemoral trochlear dysplasia and recurrent patellar instability requires in-depth understanding of this complex structural anomaly. An extensive review of the literature suggests that dysplasia occurs as a result of aberrant forces applied to the patellofemoral joint in the majority of cases. Evidence supports surgical stabilization that reconstructs the medial patellofemoral and/or medial quadriceps tendon-femoral ligament without added trochleoplasty in the majority of patients with trochlear dysplasia and recurrent patellar instability. Adding tibial tubercle transfer distally, medially, or anteromedially in those who need it to treat specific deficits in alignment or articular cartilage can be beneficial in selected patients with trochlear dysplasia and recurrent patellar instability. Trochleoplasty may be appropriate in those few cases in which permanent stable patellofemoral tracking cannot be restored otherwise, but the indications are not yet clear, particularly as trochleoplasty adds risk to the articular cartilage. Improved understanding of imaging techniques and 3-dimensional reproductions of dysplastic patellofemoral joints are useful in surgical planning for patients with recurrent patellar instability and trochlear dysplasia.
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Affiliation(s)
- Benjamin J Levy
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Surgery, UConn Health, Farmington, Connecticut, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John P Fulkerson
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Surgery, Yale University, New Haven, Connecticut, USA
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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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Floyd ER, Ebert NJ, Carlson GB, Monson JK, LaPrade RF. Medial Patellofemoral Reconstruction Using Quadriceps Tendon Autograft, Tibial Tubercle Osteotomy, and Sulcus-Deepening Trochleoplasty for Patellar Instability. Arthrosc Tech 2021; 10:e1249-e1256. [PMID: 34141539 PMCID: PMC8185575 DOI: 10.1016/j.eats.2021.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023] Open
Abstract
Recurrent patellar dislocations have been correlated with an elevated risk of further patellar dislocations, often requiring surgical treatment. Risk factors include medial patellofemoral ligament (MPFL) tears, patella alta, trochlear dysplasia, and an increased tibial tubercle-trochlear groove distance. Surgical management must be based on a patient's unique joint pathoanatomy and may require MPFL reconstruction with tibial tubercle osteotomy or trochleoplasty either alone or in combination. This article discusses our preferred technique for surgical treatment of recurrent patellar instability with MPFL reconstruction using a quadriceps tendon autograft, an open trochleoplasty, and a tibial tubercle osteotomy for patients with patella alta, trochlear dysplasia, and an increased tibial tubercle-trochlear groove distance.
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Affiliation(s)
- Edward R. Floyd
- Twin Cities Orthopedics, Edina-Crosstown, Edina, Minnesota, U.S.A.,Georgetown University School of Medicine, Washington, DC, U.S.A
| | - Nicholas J. Ebert
- University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | | | - Jill K. Monson
- Twin Cities Orthopedics, Edina-Crosstown, Edina, Minnesota, U.S.A
| | - Robert F. LaPrade
- Twin Cities Orthopedics, Edina-Crosstown, Edina, Minnesota, U.S.A.,Address correspondence to Robert F. LaPrade, M.D., Ph.D., Twin Cities Orthopedics, Edina-Crosstown, 4010 W 65th St, Edina, MN 55435 U.S.A.
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29
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Gould HP, Delaney NR, Parks BG, Melvani RT, Hinton RY. Interference Screw Versus Suture Anchors for Femoral Fixation in Medial Patellofemoral Ligament Reconstruction: A Biomechanical Study. Orthop J Sports Med 2021; 9:2325967121989282. [PMID: 33763498 PMCID: PMC7944534 DOI: 10.1177/2325967121989282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Femoral-sided graft fixation in medial patellofemoral ligament (MPFL) reconstruction is commonly performed using an interference screw (IS). However, the IS method is associated with several clinical disadvantages that may be ameliorated by the use of suture anchors (SAs) for femoral fixation. Purpose: To compare the load to failure and stiffness of SAs versus an IS for the femoral fixation of a semitendinosus autograft in MPFL reconstruction. Study Design: Controlled laboratory study. Methods: Based on a priori power analysis, a total of 6 matched pairs of cadaveric knees were included. Specimens in each pair were randomly assigned to receive either SA or IS fixation. After an appropriate reconstruction procedure, the looped end of the MPFL graft was pulled laterally at a rate of 6 mm/s until construct failure. The best-fit slope of the load-displacement curve was then used to calculate the stiffness (N/mm) in a post hoc fashion. A paired t test was used to compare the mean load to failure and the mean stiffness between groups. Results: No significant difference in load to failure was observed between the IS and the SA fixation groups (294.0 ± 61.1 vs 250.0 ± 55.9; P = .352), although the mean stiffness was significantly higher in IS specimens (34.5 ± 9.6 vs 14.7 ± 1.2; P = .004). All IS reconstructions failed by graft pullout from the femoral tunnel, whereas 5 of the 6 SA reconstructions failed by anchor pullout. Conclusion: In this biomechanical study using a cadaveric model of MPFL reconstruction, SA femoral fixation was not significantly different from IS fixation in terms of load to failure. The mean load-to-failure values for both reconstruction techniques were greater than the literature-reported values for the native MPFL. Clinical Relevance: These results suggest that SAs are a biomechanically viable alternative for femoral-sided graft fixation in MPFL reconstruction.
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Affiliation(s)
- Heath P Gould
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Nicholas R Delaney
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Brent G Parks
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Roshan T Melvani
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Richard Y Hinton
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
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Abdelrahman T, Moatshe G, Arendt E, Feller J, Getgood A. Combined Medial Patellofemoral Ligament and Medial Patellotibial Ligament Reconstruction for Recurrent Lateral Patellar Dislocation in Flexion. Arthrosc Tech 2021; 10:e385-e395. [PMID: 33680770 PMCID: PMC7917088 DOI: 10.1016/j.eats.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023] Open
Abstract
Recurrent lateral patellar dislocation can be a challenging entity to manage. It results from an imbalance between the restraints to lateralization of the patella and the forces applied to the patella within the biomechanical environment of the knee. The medial patellofemoral ligament has been recognized as the most important static soft-tissue restraint. However, the medial patellotibial ligament and medial patellomeniscal ligament are important for patellar stability at higher degrees of knee flexion. Lateral patellar dislocation in flexion poses a particularly challenging clinical entity with a combination of unique characteristics that need to be addressed to achieve optimal patellar tracking and stability. In this technical note, we describe a combined medial patellofemoral ligament and medial patellotibial ligament reconstruction technique to address lateral patellar dislocation in flexion.
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Affiliation(s)
- Taher Abdelrahman
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada
| | - Gilbert Moatshe
- Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, Oslo University Hospital, Orthopaedic Clinic, Oslo, Norway
| | | | | | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Robarts Research Institute, Western University, London, Canada,Address correspondence to Alan Getgood, M.Phil., M.D., F.R.C.S.(Tr&Orth), Fowler Kennedy Sport Medicine Clinic, Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Robarts Research Institute, Western University, London, Ontario, Canada N6A 3K7.
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31
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Winkler PW, Lutz PM, Rupp MC, Imhoff FB, Izadpanah K, Imhoff AB, Feucht MJ. Increased external tibial torsion is an infratuberositary deformity and is not correlated with a lateralized position of the tibial tuberosity. Knee Surg Sports Traumatol Arthrosc 2021; 29:1678-1685. [PMID: 32975625 PMCID: PMC8038952 DOI: 10.1007/s00167-020-06291-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/14/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE To perform a segmental analysis of tibial torsion in patients, with normal and increased external tibial torsion, suffering from chronic patellofemoral instability (PFI) and to investigate a possible correlation between tibial torsion and the position of the tibial tuberosity. METHODS Patients with chronic PFI who underwent torsional analysis of the lower limb using a standardized hip-knee-ankle MRI between 2016 and 2018 were included. For segmental analysis of tibial torsion, three axial levels were defined which divided the tibia into two segments: a distal, infratuberositary segment and a proximal, supratuberositary segment. Torsion was measured for the entire tibia (total tibial torsion, TTT), the proximal segment (proximal tibial torsion, PTT), and the distal segment (distal tibial torsion, DTT). Based on TTT, patients were assigned to one of two groups: Normal TTT (< 35°) or increased external TTT (> 35°). Position of the tibial tuberosity was assessed on conventional MRI scans by measuring the tibial tuberosity-trochlea groove (TT-TG) and the tibial tuberosity-posterior cruciate ligament (TT-PCL) distances. RESULTS Ninety-one patients (24 ± 6 years; 78% female) were included. Mean external TTT was 29.6° ± 9.1° and 24 patients (26%) had increased external TTT. Compared to patients with normal TTT, patients with increased external TTT demonstrated significantly higher values for DTT (38° ± 8° vs. 52° ± 9°; p < 0.001), whereas no difference was found for PTT ( - 13° ± 6° vs. - 12° ± 6°; n.s.). Furthermore, a significant correlation was found between TTT and DTT (p < 0.001), whereas no correlation was found between TTT and PTT (n.s). With regard to TT-TG and TT-PCL distances, no significant differences were observed between the two groups (TT-TG: 15 ± 6 vs. 14 ± 4 mm, n.s.; TT-PCL: 22 ± 4 vs. 21 ± 5 mm, n.s.) and no correlation was found with TTT, DTT, or PTT (n.s.). CONCLUSION In patients with chronic PFI, increased external TTT of greater than 35° is an infratuberositary deformity and does not correlate with a lateralized position of the tibial tuberosity. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Philipp W Winkler
- Department for Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Patricia M Lutz
- Department for Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Marco C Rupp
- Department for Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Florian B Imhoff
- Department for Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Kaywan Izadpanah
- Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Andreas B Imhoff
- Department for Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias J Feucht
- Department for Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.
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Felli L, Alessio-Mazzola M, Lovisolo S, Capello AG, Formica M, Maffulli N. Anatomy and biomechanics of the medial patellotibial ligament: A systematic review. Surgeon 2020; 19:e168-e174. [PMID: 33121878 DOI: 10.1016/j.surge.2020.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/27/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The knowledge of the anatomy and biomechanics of patellar stabilizers is mandatory to achieve good clinical results with surgical reconstructive procedures. Few articles provide clear anatomical and biomechanical picture of medial patello-tibial ligament (MPTL). METHODS After a systematic review of the literature we selected in vivo or ex vivo studies providing anatomical or biomechanical measurements. We included 7 studies about MPTL anatomy for a total of 96 knees and 4 biomechanical studies. RESULTS The MPTL is a true ligament and important component of the medial patellar stabilizers, together with the medial patello-femoral ligament (MPFL) and medial patello-meniscal ligament. The contribution of MPTL on restriction forces of the patello-femoral joint is still unclear. Quadriceps, patellar, semitendinous and gracilis tendons are adequate grafts for surgical MPTL reconstruction. CONCLUSIONS MPTL is a well defined anathomical structure and histologically can be considered a ligament. It plays an important role in patellar stability especially it has a main role on patellar rotation and tilt instead on shift.
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Affiliation(s)
- Lamberto Felli
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy; Department of Surgical Sciences (DISC), University of Genova, Viale Benedetto XV 8, Genova, 16132, Italy.
| | - Mattia Alessio-Mazzola
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy; Department of Surgical Sciences (DISC), University of Genova, Viale Benedetto XV 8, Genova, 16132, Italy.
| | - Stefano Lovisolo
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy.
| | - Andrea Giorgio Capello
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy.
| | - Matteo Formica
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy; Department of Surgical Sciences (DISC), University of Genova, Viale Benedetto XV 8, Genova, 16132, Italy.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Via Salvator Allende 23, Baronissi, 89100, Salerno, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Largo Città di Ippocrate, Salerno, 84131, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, UK; School of Pharmacy and Bioengineering, Keele University of School of Medicine, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, UK.
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Medial Patellotibial Ligament Reconstruction Improves Patella Tracking When Combined With Medial Patellofemoral Reconstruction: An In Vitro Kinematic Study. Arthroscopy 2020; 36:2501-2509. [PMID: 32442704 DOI: 10.1016/j.arthro.2020.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the isolated and combined effects of medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) deficiency and reconstruction on patellofemoral kinematics. METHODS Sixteen matched-paired female cadaveric knee specimens with a mean age of 53.5 years (range, 26-65) were tested in 5 conditions: (1) intact, (2) MPFL or MPTL cut, (3) MPFL and MPTL combined cut, (4) MPFL or MPTL reconstruction, and (5) MPFL and MPTL combined reconstruction. Dynamic testing allowed continuous analysis of kinematics from 0° to 90° of knee flexion. Knees were also tested statically using a lateral load of 45 N at 0°, 30°, 60°, and 90° of flexion. In both dynamic and static loading tests, a motion capture system detected patellar position for each testing state to distinguish changes in patellar kinematics. Random-intercepts linear mixed-effects models were used to compare patellar kinematics. RESULTS The MPFL is the primary restraint to lateral translation of the patella at all knee flexion angles. MPTL deficiency alone did not create significant patella instability, but further increased instability when the MPFL was deficient. Isolated MPFL and combined reconstruction provided improved stability. Through full range of motion native patella tracking was best recreated with combined ligament reconstruction. CONCLUSIONS The MPFL plays the greatest role in medial patellar stability, but the MPTL appears to have an influence on patella tracking. This study provides further understanding to the impact of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking. CLINICAL RELEVANCE This study provides further understanding of the role of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking.
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Regarding "Primary Medial Patellofemoral Ligament Repair Versus Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active Patient Population". Arthroscopy 2020; 36:1495-1496. [PMID: 32503765 DOI: 10.1016/j.arthro.2020.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
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Dall'Oca C, Elena N, Lunardelli E, Ulgelmo M, Magnan B. MPFL reconstruction: indications and results. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:128-135. [PMID: 32555079 PMCID: PMC7944812 DOI: 10.23750/abm.v91i4-s.9669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM The medial patellofemoral ligament (MPFL) is the most important structure commonly injured during lateral patellar dislocation and its rupture accounts for 3% of total knee injuries. MPFL reconstruction (MPFLR) is a reliable procedure with good results but variable rates of recurrent instability. The aim of this study is to underline the proper indications for the MPFLR reconstruction and to explain all the pearls and pitfalls regarding the MPFLR both in our experience and found in the latest literature. METHODS A comprehensive search in the latest literature using various combinations of the keywords MPFL, MPFLR, dislocation, treatment was performed. The following data were extracted: diagnosis methods, indications and contraindications for isolated MPFLR, type of management, recurrence of instability, outcomes and complications. RESULTS History of multiple patellar dislocations is the most relevant indication for ligament reconstruction especially after a failed course of conservative treatment in presence of persistent patello-femoral instability. Gold standard technique for MPFLR has not been clearly defined yet. CONCLUSIONS There is still poor literature about outcome comparisons, therefore it is challenging to decide which technique is the most appropriate as surgical procedures are continuously developing. The ideal candidates for MPFLR have to be decided after a throughout evaluation and careful planning and, with nowadays knowledge, it is possible to put indication for a reconstruction exposing the patient to minimal risks.
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Leal A, Andrade R, Hinckel B, Tompkins M, Bastos R, Flores P, Samuel F, Espregueira-Mendes J, Arendt E. Patients with different patellofemoral disorders display a distinct ligament stiffness pattern under instrumented stress testing. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Huber C, Zhang Q, Taylor WR, Amis AA, Smith C, Hosseini Nasab SH. Properties and Function of the Medial Patellofemoral Ligament: A Systematic Review. Am J Sports Med 2020; 48:754-766. [PMID: 31091114 DOI: 10.1177/0363546519841304] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND As the main passive structure preventing patellar lateral subluxation, accurate knowledge of the anatomy, material properties, and functional behavior of the medial patellofemoral ligament (MPFL) is critical for improving its reconstruction. PURPOSE To provide a state-of-the-art understanding of the properties and function of the MPFL by undertaking a systematic review and statistical analysis of the literature. STUDY DESIGN Systematic review. METHODS On June 26, 2018, data for this systematic review were obtained by searching PubMed and Scopus. Articles containing numerical information regarding the anatomy, mechanical properties, and/or functional behavior of the MPFL that met the inclusion criteria were reviewed, recorded, and statistically evaluated. RESULTS A total of 55 articles met the inclusion criteria for this review. The MPFL presented as a fanlike structure spanning from the medial femoral epicondyle to the medial border of the patella. The reported data indicated ultimate failure loads from 72 N to 208 N, ultimate failure elongation from 8.4 mm to 26 mm, and stiffness values from 8.0 N/mm to 42.5 N/mm. In both cadaveric and in vivo studies, the average elongation pattern demonstrated close to isometric behavior of the ligament in the first 50° to 60° of knee flexion, followed by progressive shortening into deep flexion. Kinematic data suggested clear lateralization of the patella in the MPFL-deficient knee during early knee flexion under simulated muscle forces. CONCLUSION A lack of knowledge regarding the morphology and attachment sites of the MPFL remains. The reported mechanical properties also lack consistency, thus requiring further investigations. However, the results regarding patellar tracking confirm that the lack of an MPFL leads to lateralization of the patella, followed by delayed engagement of the trochlear groove, plausibly leading to an increased risk of patellar dislocations. The observed isometric behavior up to 60° of knee flexion plausibly suggests that reconstruction of the ligament can occur at flexion angles below 60°, including the 30° and 60° range as recommended in previous studies.
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Affiliation(s)
| | - Qiang Zhang
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | | | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - Colin Smith
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
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A new device for patellofemoral instrumented stress-testing provides good reliability and validity. Knee Surg Sports Traumatol Arthrosc 2020; 28:389-397. [PMID: 31250058 DOI: 10.1007/s00167-019-05601-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/24/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the reliability of an instrumented patellofemoral (PF) stress-testing-the Porto Patellofemoral Testing Device (PPTD)-and validate the instrumented assessment method comparing to manual physical examination. METHODS Eight asymptomatic volunteers underwent bilateral PF-instrumented examination with the PPTD and magnetic resonance imaging (MRI) to assess intra-rater reliability of the instrumented assessment methodology. Six patients with unilateral PF instability underwent physical examination and PPTD concomitantly with MRI. Manual examination was performed by two blinded surgeons and compared with PPTD test. Ligament stiffness was calculated and compared between injured and non-injured lower limbs. RESULTS PPTD showed a pre-determined and reproducible stress-force application with excellent intra-rater agreement (intra-class correlation coefficient 0.83-0.98). The manual exam was imprecise with variable examiner-dependent stress-force application. The PPTD resulted in greater lateral patellar translation (converted in quadrants) than manual exam for patients that have reached maximum translation force. Measurement of patellar position and displacement using PPTD was more accurate and precise than the visual estimation of translated quadrants by manual exam. Ligament stiffness curves showed no relevant changes in patellar displacement after 62 N. CONCLUSION The PPTD instrumented stress-testing is a valid device to quantify PF position and displacement with high intra-rater reliability, showing more accuracy, more precision and less variability than physical examination. This device provides an accurate and objective measure to quantify the patellar movement which can augment the physical examination procedures and assist clinicians in the management of decision-making and in the assessment of post-treatment outcomes of PF pathological conditions.
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Chahla J, Smigielski R, LaPrade RF, Fulkerson JP. An Updated Overview of the Anatomy and Function of the Proximal Medial Patellar Restraints (Medial Patellofemoral Ligament and the Medial Quadriceps Tendon Femoral Ligament). Sports Med Arthrosc Rev 2019; 27:136-142. [PMID: 31688531 DOI: 10.1097/jsa.0000000000000252] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The medial patellofemoral ligament (MPFL) has been widely accepted to function as "the primary static restraint to lateral patellar displacement." However, current growing evidence suggests that there is a complex of medial patellofemoral/tibial ligaments, both proximal [MPFL, and medial quadriceps tendon femoral ligament (MQTFL)], and distal (medial patellotibial ligament and the medial patellomeniscal ligament) which restrain lateral patellar translation at different degrees of knee flexion. Specifically, the MQTFL has gained popularity over the last decade because of pure soft tissue attachments into the extensor mechanism that allow for avoidance of drilling tunnels into the patella during reconstruction. The purpose of this article was to report on the current knowledge (anatomy, biomechanics, diagnosis, indications for surgery, and techniques) on the proximal medial patellar restraints, namely the MPFL and the MQTFL, collectively referred to as the proximal medial patellar restraints.
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Affiliation(s)
| | - Robert Smigielski
- "Mirai" Institute: Trauma, Orthopaedics and Physical Therapy.,"ARS Medicinalis" Foundation, Warsaw, Poland
| | | | - John P Fulkerson
- Orthopedic Associates of Hartford, University of Connecticut School of Medicine, Farmington, CT
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Concepts of the Distal Medial Patellar Restraints: Medial Patellotibial Ligament and Medial Patellomeniscal Ligament. Sports Med Arthrosc Rev 2019; 27:143-149. [PMID: 31688532 DOI: 10.1097/jsa.0000000000000269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The important medial patellar ligamentous restraints to lateral dislocation are the proximal group (the medial quadriceps tendon femoral ligament and the medial patellofemoral ligament) and the distal group [medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML)]. The MPTL patellar insertion is at inferomedial border of patella and tibial insertion is in the anteromedial tibia. The MPML originates in the inferomedial patella, right proximal to the MPTL, inserting in the medial meniscus. On the basis of anatomy and biomechanical studies, the MPTL and MPML are more important in 2 moments during knee range of motion: terminal extension, when it directly counteracts quadriceps contraction. In a systematic review on MPTL reconstructions 19 articles were included detailing the clinical outcomes of 403 knees. All were case series. Overall, good and excellent outcomes were achieved in >75% of cohorts in most studies and redislocations were <10%, with or without the association of the medial patellofemoral ligament. The MPTL is a relevant additional tool to proximal restraint reconstruction in select patient profiles; however, more definitive clinical studies are necessary to better define surgical indications.
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Isolated medial patellofemoral ligament reconstruction significantly improved quality of life in patients with recurrent patella dislocation. Knee Surg Sports Traumatol Arthrosc 2019; 27:3513-3517. [PMID: 30820603 DOI: 10.1007/s00167-019-05447-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/25/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to measure the improvement in quality of life (QoL) following isolated anatomical double-bundle medial patellofemoral ligament reconstruction. METHODS This is a single-centre, prospective study of 56 consecutive patients (57 knees) who underwent isolated MPFL reconstruction between 2014 and 2017. Functional outcome and QoL were assessed with the Kujala score and the EQ-5D-3L questionnaire, respectively. Objective outcomes were obtained through clinical examination at the latest follow-up assessing redislocation rate, patella apprehension test, patellar tilt, pain and range of motion. RESULTS The median Kujala score increased from 60 (range 31-96) to 92 (range 34-100) at latest follow-up (p < 0.001). The median EQ-5D index also increased, from 0.69 (range 0.10-1) at baseline to 1 (range 0.16-1) at latest follow-up (p < 0.001), as well as the median EQ-5D VAS from 75 (range 20-95) to 92 (range 40-100) (p < 0.001). Four dimensions of the EQ-5D were significantly improved except for the anxiety/depression scores. Female patients reported lower scores at baseline and at latest follow-up, for all three outcomes (Kujala, EQ-5D index, EQ-5D VAS), however there was no evidence that gender negatively impacted on the benefit of surgery. The re-dislocation rate was 0%. Apprehension and patellar tilt test were negative in all patients and no flexion deficit was identified at latest follow-up. Two patients had tenderness along the reconstruction requiring femoral screw removal in one of them. CONCLUSIONS Isolated anatomical double-bundle aperture MPFL reconstruction, offered significantly improved short-term QoL along with excellent functional outcome. Female patients scored lower, but this did not affect the overall outcome. Including QoL tools in the assessment of ligament reconstruction operations, such as the MPFL, can provide more accurate understanding of the overall patient benefit. LEVEL OF EVIDENCE II.
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Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:2537-2550. [PMID: 30370440 DOI: 10.1007/s00167-018-5266-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/23/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE The scientific literature concerning the anatomy of medial soft-tissue stabilizers of the patella is growing exponentially. Much of the surgical literature has focused on the role of the medial patellofemoral ligament (MPFL) and techniques to reconstruct it, yet our understanding of its anatomy has evolved during the past several years. Given this, we report on the current understanding of medial patellofemoral anatomy and implications for reconstruction. METHODS Current and historical studies of medial patellar anatomy were reviewed, which include the MPFL and medial quadriceps tendon femoral ligament (MQTFL), as well as that of the distal medial patellar restraints, the medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML). In addition to the reported findings, the authors' anatomic descriptions of each ligament during their dissections were identified and recorded. RESULTS Despite the name of the MPFL, which implies that the ligament courses between the femur and patella, recent studies have highlighted the proximal MPFL fibers that attach to the quadriceps tendon, known as the MQTFL. The MPFL and MQTFL have also been referred to as the medial patellofemoral complex, reflecting the variability in anatomical attachment sites. The MPFL accounts for only half of the total restraint to lateral patellar displacement, and the remaining contributions to patellar stability are derived from the combination of the MPTL and MPML, which function primarily in greater degrees of knee flexion. CONCLUSION The understanding of the complexity of the medial patellar stabilizers continues to evolve. Although MPFL reconstruction is gaining wide acceptance as a procedure to treat patellar instability, it is important to recognize the complex and changing understanding of the anatomy of the medial soft-tissue stabilizers and the implications for reconstruction. LEVEL OF EVIDENCE V.
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LaPrade RF, Chahla J, Moatshe G. Biomechanical Evaluation of the Medial Stabilizers of the Patella: Response. Am J Sports Med 2019; 47:NP41-NP42. [PMID: 31251663 DOI: 10.1177/0363546519851101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Vlaic J, Josipovic M, Bohacek I, Jelic M. Biomechanical Evaluation of the Medial Stabilizers of the Patella: Letter to the Editor. Am J Sports Med 2019; 47:NP41. [PMID: 31251666 DOI: 10.1177/0363546519851099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Agarwalla A, Gowd AK, Liu JN, Puzzitiello RN, Yanke AB, Verma NN, Forsythe B. Concomitant Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Osteotomy Do Not Increase the Incidence of 30-Day Complications: An Analysis of the NSQIP Database. Orthop J Sports Med 2019; 7:2325967119837639. [PMID: 31019984 PMCID: PMC6463332 DOI: 10.1177/2325967119837639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Lateral patellar dislocations account for 2% to 3% of total knee injuries, especially in adolescents. Depending on the anatomic abnormality contributing to lateral patellar instability, medial patellofemoral ligament reconstruction (MPFLR) and/or tibial tubercle osteotomy (TTO) may be indicated. Purpose: To assess the risk of adverse events (AEs) after TTO, MPFLR, and concomitant MPFLR and TTO. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent MPFLR, TTO, and concomitant MPFLR and TTO between 2005 and 2016 were identified through the American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database. Medical complications (eg, surgical site infection and deep vein thrombosis), readmission rates, and extended hospital stay within 30 days of the procedure were recorded. Outcomes were compared with bivariate and multivariate Poisson regression. Results: Out of 882 patients, 617 (70.0%) underwent isolated MPFLR, 170 (19.3%) underwent TTO, and 95 (10.8%) underwent concomitant MPFLR and TTO. The operative time for concomitant MPFLR and TTO was significantly longer (122 ± 45 minutes) compared with isolated MPFLR (97 ± 55 minutes; P < .001) and isolated TTO (89 ± 51 minutes; P < .001). There were 32 AEs (3.6%), with 10 AEs in the isolated TTO group (5.9%), 18 AEs in the isolated MPFLR group (2.9%), and 4 AEs in the MPFLR + TTO group (4.2%). There was no significant difference in the rate of AEs between the isolated MPFLR and isolated TTO groups (P = .1), isolated MPFLR and MPFLR + TTO groups (P = .5), and isolated TTO and MPFLR + TTO groups (P = .8). Diabetes mellitus was associated with an increased risk of developing an AE (odds ratio, 4.0; P = .003), and hypertension resulted in an increased risk of an extended hospital stay (odds ratio, 4.0; P = .010). Conclusion: While concomitant MPFLR and TTO significantly increased operative time, there was no difference in the rate of AEs, extended hospital stay, and readmissions within 30 days after isolated MPFLR, isolated TTO, and concomitant MPFLR and TTO.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Joseph N Liu
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Richard N Puzzitiello
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Adam B Yanke
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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Espregueira-Mendes J, Andrade R, Bastos R, Joseph S, Fulkerson JP, Silva LD. Combined Soft Tissue Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon-Femoral Ligament. Arthrosc Tech 2019; 8:e481-e488. [PMID: 31194085 PMCID: PMC6551554 DOI: 10.1016/j.eats.2019.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/10/2019] [Indexed: 02/03/2023] Open
Abstract
Patellar dislocation is a major orthopaedic concern in pediatric and adult populations, with both conservative and surgical options available. Several surgical techniques of the combined or isolated reconstruction of the medial patellofemoral ligament are described in the literature using different grafts, locations, and types of fixations, providing different advantages and disadvantages. New recent developments in cadaveric dissection studies have unveiled the importance of structures that were neglected until recently, such as the medial quadriceps tendon-femoral ligament, which provides a connection between the medial femur and the quadriceps tendon component of the knee extensor mechanism. Hence, we present a surgical technique with combined reconstruction of the medial patellofemoral ligament and medial quadriceps tendon-femoral ligament without the use of hardware and with no need for patellar or femoral drilling (no physis compromise or risk of patellar fracture), which can be used concomitantly with other bony procedures.
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Affiliation(s)
- João Espregueira-Mendes
- School of Medicine, Minho University, Braga, Portugal,Clínica do Dragão, Espregueira-Mendes Sports Centre, FIFA Medical Centre of Excellence, Porto, Portugal,Dom Henrique Research Centre, Porto, Portugal,ICVS/3Bs, PT Government Associate Laboratory, Braga/Guimarães, Portugal,Address correspondence to João Espregueira-Mendes, M.D., Ph.D., Via Futebol Clube do Porto, F. C. Porto Stadium, Porto, Portugal.
| | - Renato Andrade
- Clínica do Dragão, Espregueira-Mendes Sports Centre, FIFA Medical Centre of Excellence, Porto, Portugal,Dom Henrique Research Centre, Porto, Portugal,Faculty of Sports, University of Porto, Porto, Portugal
| | - Ricardo Bastos
- Clínica do Dragão, Espregueira-Mendes Sports Centre, FIFA Medical Centre of Excellence, Porto, Portugal,Dom Henrique Research Centre, Porto, Portugal,ICVS/3Bs, PT Government Associate Laboratory, Braga/Guimarães, Portugal,3Bs Research Group, I3Bs, Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Guimarães, Portugal,Fluminense Federal University, Niteroi, Rio de Janeiro, Brazil
| | - Sheeba Joseph
- Michigan State University, East Lansing, Michigan, U.S.A
| | - John P. Fulkerson
- Orthopedic Associates of Hartford, Hartford, Connecticut, U.S.A.,University of Connecticut School of Medicine, Farmington, Connecticut, U.S.A.,The Patellofemoral Foundation, Farmington, Connecticut, U.S.A
| | - Luís Duarte Silva
- Clínica do Dragão, Espregueira-Mendes Sports Centre, FIFA Medical Centre of Excellence, Porto, Portugal,Dom Henrique Research Centre, Porto, Portugal
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Editorial Commentary: Medial Patellofemoral Complex: Driving a Better Understanding of Medial Knee Anatomy. Arthroscopy 2019; 35:1147-1151. [PMID: 30954108 DOI: 10.1016/j.arthro.2019.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 02/02/2023]
Abstract
Although its importance as the prime restraint to lateral patellar instability is undoubted, the anatomy of the medial patellofemoral ligament has never been agreed on. Since it was first described by Warren and Marshall in 1979, most of the anatomic studies confirmed its presence in 90% of the cases, but they usually provide inconsistent descriptions of its femoral and patellar attachments. It is proven that length changes in the reconstructed medial patellofemoral ligament depend principally on the femoral attachment site. Moreover, the femoral attachment site affects the patellar tilt, translation, and joint reaction force. Because of the early inconsistent descriptions of the medial patellofemoral ligament attachment sites, some authors have suggested that its anatomy is not fixed or may be patient specific.
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Ferrua P, Kruckeberg BM, Pasqualotto S, Berruto M, Randelli P, Arendt EA. Proximal medial patellar restraints and their surgical reconstruction. J Orthop Traumatol 2019; 20:17. [PMID: 30915690 PMCID: PMC6435766 DOI: 10.1186/s10195-019-0525-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/08/2019] [Indexed: 01/27/2023] Open
Abstract
Reconstruction of the medial patellofemoral ligament (MPFL) has been increasing as a surgical solution for treatment of recurrent lateral patellofemoral dislocation. Recent attention has been given to fibers extending from the femur to the quadriceps tendon, proximal to the MPFL, termed the medial quadriceps tendon-femoral ligament. This article briefly reviews the proximal medial patellar restraints and surgical procedures for their reconstruction.
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Affiliation(s)
- Paolo Ferrua
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Bradley M Kruckeberg
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Stefano Pasqualotto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Massimo Berruto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Pietro Randelli
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
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