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Walsh JM, Credille K, Allahabadi S, Kaplan DJ, Darbandi AD, Huddleston HP, Hevesi M, Wang Z, Dandu N, Yanke AB. Biomechanical Properties and Kinematics of Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Orthop J Sports Med 2024; 12:23259671241241537. [PMID: 38855071 PMCID: PMC11159569 DOI: 10.1177/23259671241241537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/01/2023] [Indexed: 06/11/2024] Open
Abstract
Background While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of MPFL reconstruction (MPFLR). An accurate understanding of the kinematic properties and functional behavior of current techniques used in MPFLR is imperative to restoring native biomechanics and improving outcomes. Purpose To provide a comprehensive review of the biomechanical effects of variations in MPFLR, specifically to determine the effect of graft choice and reconstruction technique. Study Design Systematic review. Methods A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 32 studies met inclusion criteria: (1) using ≥8 human cadaveric specimens, (2) reporting on a component of MPFLR, and (3) having multiple comparison groups. Results Gracilis, semitendinosus, and quadriceps grafts demonstrated an ultimate load to failure (N) of 206.2, 102.8, and 190.0 to 205.0 and stiffness (N/mm) of 20.4, 8.5, and 21.4 to 33.6, respectively. Single-bundle and double-bundle techniques produced an ultimate load to failure (N) of 171 and 213 and stiffness (N/mm) of 13.9 and 17.1, respectively. Anchors placed centrally and superomedially in the patella produced the smallest degree of length changes throughout range of motion in contrast to anchors placed more proximally. Sutures, suture anchors, and transosseous tunnels all produced similar ultimate load to failure, stiffness, and elongation data. Femoral tunnel malpositioning resulted in significant increases in contact pressures, patellar translation, tilt, and graft tightening or loosening. Low tension grafts (2 N) most closely restored the patellofemoral contact pressures, translation, and tilt. Graft fixation angles variably and inconsistently altered contact pressures, and patellar translation and tilt. Conclusion Data demonstrated that placement of the MPFLR femoral tunnel at the Schöttle point is critical to success. Femoral tunnel diameter should be ≥2 mm greater than graft diameter to limit graft advancement and overtensioning. Graft fixation, regardless of graft choice or fixation angle, is optimally performed under minimal tension with patellar fixation at the medial and superomedial patella. However, lower fixation angles may reduce graft strain, and higher fixation angles may exacerbate anisometry and length changes if femoral tunnel placement is nonanatomic.
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Affiliation(s)
| | | | - Sachin Allahabadi
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Daniel J. Kaplan
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Azad D. Darbandi
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Zachary Wang
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Navya Dandu
- University of Illinois Chicago, Chicago, Illinois, USA
| | - Adam B. Yanke
- Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, USA
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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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Hu F, Wang C, Du Y, Guo Z, Zhang K, Ma Y, Yang Y, Gong X, Wang H, Liu P, Shi W. Medial Patellofemoral Complex Reconstruction (Combined Reconstruction of Medial Patellofemoral Ligament and Medial Quadriceps Tendon-Femoral Ligament) With Semitendinosus Autograft Resulted in Similar Clinical and Radiographic Outcomes to Medial Patellofemoral Ligament Reconstruction in Treating Recurrent Patellar Dislocation. Arthroscopy 2024; 40:1264-1276.e1. [PMID: 37716628 DOI: 10.1016/j.arthro.2023.08.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE To compare clinical and radiographic outcomes of medial patellofemoral ligament reconstruction (MPFL-R) and medial patellofemoral complex reconstruction (MPFC-R) for recurrent patellar dislocation. Outcome measures were compared based on the Insall-Salvati index. METHODS Patients who were diagnosed with recurrent patellar dislocation and underwent either MPFL-R or MPFC-R (combined reconstruction of MPFL and medial quadriceps tendon-femoral ligament) were retrospectively analyzed. Group allocation was based on surgical procedure and patient characteristics were collected. Clinical assessments included patient-reported outcome measures (PROMs) and return-to-sports rates. Minimal clinically important difference analysis was performed. A subgroup analysis of PROMs was carried out between patients with an Insall-Salvati index ≤1.2 versus >1.2. The patellar tilt angle, lateral patellar displacement, and bisect offset ratio were measured pre- and postsurgery. Functional failures and complications were assessed. RESULTS Overall, 70 patients (72 knees) in the MPFL-R group and 58 patients (61 knees) in the MPFC-R group were included. Patient characteristics were comparable between the groups. At a minimum follow-up of 24 (mean, 50.6 ± 22.1) months, all PROMs were substantially improved (P < .001), without significant intergroup differences. The percentages of patients reaching the minimal clinically important difference were similar after MPFL-R and MPFC-R: 98.6% versus 93.4% (International Knee Documentation Committee), 97.2% versus 98.4% (Lysholm), 98.6% versus 100% (Kujala), and 77.8% versus 72.1% (Tegner). The subgroup analysis based on patellar height and the return-to-sport rates also suggested comparable results. Radiographic evaluation demonstrated significantly smaller lateral patellar displacements (P = .004) and bisect offset ratios (P < .001) but similar patellar tilt angles after MPFC-R. Four (5.6%) patients receiving MPFL-R and 2 (3.3%) patients receiving MPFC-R reported recurrence of functional instability, without statistically significant difference. CONCLUSIONS MPFC-R resulted in similar overall clinical and radiographic outcomes to MPFL-R in treating recurrent patellar dislocation. MPFC-R might not provide additional benefits for patients with an Insall-Salvati index >1.2. LEVEL OF EVIDENCE Level IV, therapeutic, retrospective cohort study.
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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
| | - 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
| | - Yingying Du
- Peking University Health Science Center, Beijing, China
| | - Zejing Guo
- Peking University Health Science Center, Beijing, China
| | - Keying Zhang
- Peking University Health Science Center, 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
| | - 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
| | - 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
| | - 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
| | - 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
| | - 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.
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Mostowy M, Puzio T, Matera K, Kozieł M, Stanek J, Bawor M, Grzelak P, Domżalski ME. Quadriceps muscle contraction causes medial patellofemoral ligament elongation by intermeshed fibers of vastus medialis oblique muscle. J Anat 2024; 244:325-332. [PMID: 37737508 PMCID: PMC10780142 DOI: 10.1111/joa.13954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023] Open
Abstract
The first aim of this study was to compare the medial patellofemoral length between contracted and relaxed quadriceps muscle and second to assess the importance of the intermeshed vastus medialis oblique fibers. After a priori power analysis (α = 0.05, power [1-β] = 0.95), 35 healthy males aged 18-30 were prospectively examined with a 3.0-T magnetic resonance imaging (MRI) scanner in 10-15° of knee flexion. Two axial MRI sequences (25 s each) were made with relaxed and contracted quadriceps. Two blinded, independent raters measured twice medial patellofemoral ligament length (curved line) and attachment-to-attachment length (straight line). Mean medial patellofemoral ligament length and attachment-to-attachment length with relaxed quadriceps was: 65.5 mm (SD = 3.7), 59.7 mm (SD = 3.6), and after contraction, it increased to 68.7 mm (SD = 5.3), 61.2 mm (SD = 4.7); p < 0.01 and <0.001, respectively. Intraclass correlation coefficients for intra- and inter-rater reliabilities ranged from 0.55 (moderate) to 0.97 (excellent). Mean medial patellofemoral ligament length elongation after quadriceps contraction was significantly greater (3.2 mm, SD = 3.9) than mean attachment-to-attachment length elongation (1.6 mm, SD = 2.8); p < 0.001. Contraction of quadriceps muscle causes elongation of the medial patellofemoral ligament to the extent greater than the elongation of distance between its attachments. This confirms that medial patellofemoral ligament elongation after quadriceps contraction results not only from movement of its patellar attachment but also directly from intermeshed vastus medialis oblique fibers pulling medial patellofemoral ligament in a different direction creating a bow-like construct in agreement with the "pull-and-guide mechanism" proposed in the literature.
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Affiliation(s)
- Marcin Mostowy
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Tomasz Puzio
- Department of Diagnostic Imaging, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Katarzyna Matera
- Department of Diagnostic Imaging, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Michał Kozieł
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Jakub Stanek
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Michalina Bawor
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | - Piotr Grzelak
- Department of Diagnostic Imaging, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Marcin E Domżalski
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
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Boot MR, van de Groes SA, Dunning H, Tanck E, Janssen D. Length Changes of the Medial Patellofemoral Ligament During In Vivo Knee Motion: An Evaluation Using Dynamic Computed Tomography. Am J Sports Med 2023; 51:3724-3731. [PMID: 37960850 PMCID: PMC10691293 DOI: 10.1177/03635465231205597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/23/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is associated with high complication rates because of graft overloading from incorrect graft positioning. To improve clinical outcomes, it is crucial to gain a better understanding of MPFL elongation patterns. PURPOSE To assess MPFL length changes in healthy knees from 0° to 90° of dynamic flexion and their relationship with anatomic parameters of the patellofemoral joint. STUDY DESIGN Descriptive laboratory study. METHODS Dynamic computed tomography scans of an active flexion-extension-flexion movement in 115 knees from 63 healthy participants were evaluated to construct knee joint models. Using these models, the MPFL length was measured as the shortest wrapping path from the Schöttle point on the femur to 3 insertion points on the superomedial border of the patella (proximal, central, and distal). MPFL length changes (%) relative to the length in full extension were calculated, and their correlations with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination were analyzed. RESULTS The proximal fiber was the longest in full extension and progressively decreased to a median length of -6.0% at 90° of flexion. The central fiber exhibited the most isometric pattern during knee flexion, showing a median maximal decrease of 2.8% relative to the full extension length and no evident elongation. The distal fiber first slightly decreased in length but increased at deeper flexion angles. The median overall length changes were 4.6, 4.7, and 5.7 mm for the proximal, central, and distal patellar insertion, respectively. These values were either not or very weakly correlated with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination when the anatomic parameters were within the healthy range. CONCLUSION The median MPFL length changed by approximately 5 mm between 0° and 90° of flexion. Proximally, the length continuously decreased, indicating slackening behavior. Distally, the length increased at deeper flexion angles, indicating tightening behavior. CLINICAL RELEVANCE In MPFL reconstruction techniques utilizing the Schöttle point to establish the femoral insertion, one should avoid distal patellar insertion, as it causes elongation of the ligament, which may increase the risk for complications due to overloading.
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Affiliation(s)
- Miriam R. Boot
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Hans Dunning
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dennis Janssen
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
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Johnson EE, Campbell MP, Reddy M, Paul RW, Erickson BJ, Tjoumakaris FP, Freedman KB, Bishop ME. Differences in the Severity and Location of Patellofemoral Cartilage Damage Between Instability Patients With and Without Patella Alta. Orthop J Sports Med 2023; 11:23259671231186823. [PMID: 37533500 PMCID: PMC10392508 DOI: 10.1177/23259671231186823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/11/2023] [Indexed: 08/04/2023] Open
Abstract
Background Patella alta is a risk factor for recurrent patellar instability. Differences in chondral injury in patients with patellar instability between patella alta and patella norma have not been evaluated. Purpose To analyze whether preoperative cartilage damage differs in severity and location between patellar instability patients with and without patella alta. Study Design Cohort study; Level of evidence, 3. Methods Patients with patellar instability who underwent patellar realignment surgery at a single institution with preoperative magnetic resonance imaging (MRI) scans were included. After measurement of Caton-Deschamps index (CDI) on MRI, patients were divided into patella alta (CDI ≥1.3) and patella norma groups. The area measurement and depth and underlying structures (AMADEUS) score was used to quantify cartilage defect severity on MRI. Results A total of 121 patients were divided into patella alta (n = 50) and patella norma (n = 71) groups. The groups did not differ significantly in sex ratio, age at MRI, body mass index, mean reported number of previous dislocations, or mean interval between first reported dislocation and date of MRI. A total of 34 (68%) of the patella alta group and 44 (62%) of the patella norma group had chondral defects (P = .625) with no significant between-group differences in defect size (P = .419). In both groups, chondral injuries most affected the medial patellar facet (55% in patella alta vs 52% in patella norma), followed by the lateral facet (25% vs 18%), and lateral femoral condyle (10% vs 14%). A smaller proportion of patients had full-thickness defects in the patella alta compared with the patella norma group (60% vs 82%; P = .030). The overall AMADEUS score was higher for the patella alta versus the patella norma group (68.9 vs 62.1; P = .023), indicating superior articular cartilage status. Conclusion Patients with patella alta had less severe cartilage injury after patellar instability, including a lower proportion with full-thickness defects and better overall cartilage grade. The location of injury when present was similar between alta and norma, with most defects affecting the medial facet, lateral facet, and lateral femoral condyle in descending frequency.
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Affiliation(s)
- Emma E. Johnson
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | | | - Manoj Reddy
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
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Brutico J, Paul RW, Wright M, Destine H, Johnson EE, Bishop ME, Erickson BJ, Freedman KB, Tjoumakaris FP. Preoperative Patella Alta on Caton-Deschamps Index Is a Predictor of Outcome Following Isolated Medial Patellofemoral Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:e523-e528. [PMID: 37101886 PMCID: PMC10123505 DOI: 10.1016/j.asmr.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 02/14/2023] [Indexed: 03/13/2023] Open
Abstract
Purpose The purpose of this study was to determine whether a preoperative Caton-Deschamps index (CDI) ≥ 1.30, as measured by magnetic resonance imaging, is associated with rates of postoperative instability, revision knee surgery, and patient-reported outcomes in patients undergoing isolated medial patellofemoral ligament (MPFL) reconstruction. Methods Patients who underwent primary medial patellofemoral ligament reconstruction (MPFLR) between 2015 and 2019 at a single institution were assessed. Only those with at least 2 year follow up were included. Patients who had undergone a previous ipsilateral knee surgery, concomitant tibial tubercle osteotomy and/or ligamentous repair/reconstruction at the time of MPFL reconstruction were excluded from the study. CDIs were evaluated by three investigators based on magnetic resonance imaging measurement. Patients with a CDI ≥ 1.30 were included in the patella alta group, while those with a CDI between 0.70 and 1.29 served as controls. A retrospective review of clinical notes was used to evaluate the number of postoperative instability episodes and revisions. Functional outcomes were measured by the International Knee Documentation Committee (IKDC) and 12-Item Short Form Health Survey (SF-12) physical and mental scores. Results Overall, 49 patients (50 knees, 29 males, 59.2%) underwent isolated MPFLR. Nineteen (38.8%) patients had a CDI ≥ 1.30 (mean: 1.41, range: 1.30-1.66). The patella alta group was significantly more likely to experience a postoperative instability episode (36.8% vs 10.0%; P = .023) and was more likely to return to the operating room for any reason (26.3% vs 3.0%; P = .022) compared to those with normal patellar height. Despite this, the patella alta group had significantly greater postoperative IKDC (86.5 vs 72.4; P = .035) and SF-12 physical (54.2 vs 46.5; P = .006) scores. Pearson's correlation showed a significant association between CDI and postoperative IKDC (R 2 = 0.157; P = .022) and SF-12P (R 2 = .246; P = .002) scores. There was no difference in postoperative Lysholm (87.9 vs 85.1; P = .531). and SF-12M (48.9 vs 52.5; P = .425) scores between the groups. Conclusion Patients with preoperative patella alta, as measured by CDI had higher rates of postoperative instability and return to the OR with isolated MPFL reconstruction for patellar instability. Despite this, higher preoperative CDI was associated with greater postoperative IKDC scores and SF-12 physical scores in these patients. Level of Evidence Retrospective cohort study, Level IV.
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Affiliation(s)
- Joseph Brutico
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Maggie Wright
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Henson Destine
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Emma E. Johnson
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | | | | | - Fotios P. Tjoumakaris
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
- Address correspondence to Fotios Tjoumakaris, M.D., Rothman Orthopaedics at Thomas Jefferson University, 125 South 9th St., Philadelphia, PA, 19130, U.S.A.
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Landmarks Used in Medial Patellofemoral Ligament Reconstruction Have Variable Topography. Arthrosc Sports Med Rehabil 2022; 4:e2043-e2050. [PMID: 36579037 PMCID: PMC9791883 DOI: 10.1016/j.asmr.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 09/15/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose To describe the morphology of the adductor tubercle (AT), medial epicondyle (ME), and gastrocnemius tubercle (GT); to quantify their relationships to the medial patellofemoral ligament (MPFL) footprint location; and to classify the reliability of each landmark based on measurement variability. Methods Eight cadaveric specimens were dissected to expose the following landmarks on the femur: MPFL footprint, AT, ME, and GT. Using the MicroScribe 3D digitizer, each landmark was projected into a 3-dimensional coordinate system and reconstructed into a complex, closed polygon. For each specimen tubercle, the base surface area, volume, height, base:height ratio, sulcus point, and distance from the MPFL footprint center were calculated. Levene's test was performed to evaluate differences in variance of the morphologic parameters between the three osseous structures. Results The ME had significantly greater variance in volume than the GT (P = .032), and the AT (17.5 ± 3.9) and GT (19.5 ± 3.6) were significantly less variable in base:height ratio than the ME (95.3 ± 19.2; P < .001). The GT was the closest to the MPFL footprint center (7.1 ± 3.1 mm) compared with the AT (13.4 ± 3.6 mm, P = .002) and ME (13.2 ± 2.7 mm, P = .003). However, the tubercles were equally variable in terms of distance to the MPFL footprint center (P = .86). Lastly, the sulcus point was estimated to be on average 1.9 ± 2.9 mm distal and 2.0 ± 2.0 mm posterior to the MPFL center point. Conclusions The 3 major osseous landmarks of the medial femur have significantly different variances in volume and base:height ratio. Specifically, the variability and elongated morphology of the ME differentiated this landmark from the AT and GT, which demonstrated the most consistent morphology. Clinical Relevance The results of this study may be useful to accurately locate landmarks for femoral tunnel placement and determine the isometric MPFL point during reconstruction.
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Hinkley P, Fletcher C, Strickland S. Patellar Tendon Imbrication for the Treatment of Patella Alta in Skeletally Immature Patients. Arthrosc Tech 2022; 11:e1577-e1582. [PMID: 36185114 PMCID: PMC9519932 DOI: 10.1016/j.eats.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/01/2022] [Indexed: 02/03/2023] Open
Abstract
Patella alta is a major contributor to recurrent patellar instability, which is commonly seen in young athletes. Distalizing tibial tubercle osteotomy has been used for the correction of patella alta and patellar instability, but this procedure is contraindicated in the skeletally immature patient population, as it could lead to growth arrest of the proximal tibial physes. We propose a patellar tendon imbrication technique as a soft-tissue alternative to tibial tubercle osteotomy. When used with concomitant medial patellofemoral ligament reconstruction, we suggest this procedure may prove beneficial for the treatment of patellar instability in skeletally immature patients.
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Affiliation(s)
- Paige Hinkley
- Address correspondence to Paige Hinkley, B.A., Hospital for Special Surgery, Sports Medicine and Shoulder Service, 535 East 70th St., New York, NY 10021, U.S.A.
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Dandu N, Trasolini NA, Shewman EF, Kim HD, Zavras AG, Huddleston HP, Browning RB, Yanke AB. Medial Patellofemoral Complex Reconstruction Techniques Are Not Equivalent at Lower Flexion in the Setting of Patella Alta: A Biomechanical Comparison. Arthroscopy 2022; 38:2493-2503. [PMID: 35157963 DOI: 10.1016/j.arthro.2022.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To (1) determine the effect of severe patella alta on lateral patellar displacement after medial patellofemoral ligament (MPFL) reconstruction and medial quadriceps tendon-femoral ligament (MQTFL) reconstruction and (2) determine whether lateral displacement significantly differs between MPFL and MQTFL reconstructions in the setting of severe patella alta (Caton-Deschamps Index [CDI] of 1.6). METHODS Eight cadaveric specimens were included. High-tensile strength suture was used to create a model of adjustable patellar height. Patellar height was set using fluoroscopy to CDI ratios of 1.0 (normal) and 1.6 (alta). Specimens underwent testing (1) with MPFL reconstruction, (2) with MQTFL reconstruction, and (3) in a medial patellofemoral complex (MPFC)-deficient control state, in randomized order, at both CDI settings: 1.0 and 1.6. Lateral patellar translation was measured at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of knee flexion with 10 N of laterally directed load. RESULTS At a CDI of 1.6, MPFL reconstruction showed significantly lower lateral displacement than MQTFL reconstruction at 0° and 20°. When compared with MPFC-deficient controls at a CDI of 1.6, MPFL reconstruction showed significantly lower displacement at 0° and 20° whereas MQTFL reconstruction was not significantly different at any degree of flexion. CONCLUSIONS In the setting of severe patella alta (CDI of 1.6), MPFL reconstruction results in less lateral patellar displacement than MQTFL reconstruction at 0° and 20° of knee flexion. At higher flexion angles (≥30°), there is no difference between the 2 reconstruction techniques and the CDI no longer has an effect. At a CDI of 1.0, MPFL reconstruction shows lower displacement than MQTFL reconstruction in full extension only. Surgeons performing MPFC reconstruction should evaluate patients for patella alta and consider patellar height when deciding on the reconstruction technique. CLINICAL RELEVANCE This study suggests that MQTFL reconstruction may be less stable than MPFL reconstruction in the setting of patella alta, without other known pathoanatomic factors, at early knee flexion angles. Patellar height should be considered when choosing the appropriate reconstruction technique in the absence of a distalization procedure.
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Affiliation(s)
- Navya Dandu
- Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | | | - Han D Kim
- Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Athan G Zavras
- Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | | | - Adam B Yanke
- Rush University Medical Center, Chicago, Illinois, U.S.A..
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Duchman KR. Editorial Commentary: The Medial Patellofemoral Ligament Is Not Isometric and Anatomic Reconstruction Is Important, But Just a Small Piece of the Patellar Instability Puzzle. Arthroscopy 2022; 38:1568-1570. [PMID: 35501021 DOI: 10.1016/j.arthro.2021.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 11/16/2021] [Indexed: 02/02/2023]
Abstract
Medial patellofemoral ligament (MPFL) reconstruction has proven to be a reliable procedure to reduce patellar instability events in patients with recurrent patellar instability. As our reconstruction techniques have evolved to address pathology in a diverse patient population, there continues to be an obsessive focus on the precise anatomy of the MPFL origin on the medial knee, due in large part to concerns that improper femoral tunnel position may result in excessive graft anisometry and failure. However, recurrent patellar instability involves many complexities and should not be simply reduced to a single point on the medial knee.
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Dandu N, Trasolini NA, DeFroda SF, Darwish RY, Yanke AB. The Lateral Side: When and How to Release, Lengthen, and Reconstruct. Clin Sports Med 2021; 41:171-183. [PMID: 34782073 DOI: 10.1016/j.csm.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The lateral patellofemoral complex is an important stabilizer to medial and lateral displacement of the patella. Soft tissue abnormalities can range from pathologic tightness to laxity, presenting with symptoms related to patellar instability, anterior knee pain, or arthritis. Clinical evaluation should be performed to confirm patellar dislocation, assess the integrity of the lateral and medial soft tissues, and explore other pathoanatomic factors that may need to be addressed. Lateral retinacular lengthening is recommended over lateral release owing to the potential of iatrogenic medial instability with release, and a lateral patellofemoral ligament reconstruction can be performed to effectively treat medial instability.
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Affiliation(s)
- Navya Dandu
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Nicholas A Trasolini
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Steven F DeFroda
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Reem Y Darwish
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Adam B Yanke
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA.
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Patellar Tendon Shortening for Treatment of Patella Alta in Skeletally Immature Patients With Patellar Instability. Arthrosc Tech 2021; 10:e1979-e1984. [PMID: 34401243 PMCID: PMC8355506 DOI: 10.1016/j.eats.2021.04.025] [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: 01/03/2021] [Accepted: 04/22/2021] [Indexed: 02/03/2023] Open
Abstract
Aberrant anatomy, such as patella alta, can be a risk factor for recurrent patellar instability or inferior clinical outcomes after medial patellofemoral ligament reconstruction. In patients with significant patella alta (Caton Deschamps Index >1.2), tibial tubercle distalization may be considered to improve outcomes. However, despite patellar instability commonly affecting pediatric patients, a distalization osteotomy is not feasible in this patient population due to the presence of open physes. Our article presents a technique describing an alternative soft-tissue distalization approach whereby patellar height is decreased by shortening the patellar tendon.
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