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White AE, James EW, Jahandar A, Jones RH, Fabricant PD. Effect of Medial Patellofemoral Complex Reconstruction Technique on Patellofemoral Contact Pressure, Contact Area, and Kinematics. Am J Sports Med 2024:3635465241252818. [PMID: 38872411 DOI: 10.1177/03635465241252818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is considered by many to be the gold standard to treat lateral patellar instability; however, some investigators have reported good clinical results after isolated medial quadriceps tendon-femoral ligament (MQTFL) reconstruction or a combined MPFL/MQTFL reconstruction. A handful of studies have preliminarily investigated the biomechanical consequences of these various medial patellar stabilizing procedures. Despite this, no existing study has included multiple medial patellofemoral complex (MPFC) reconstructions and assessment of lateral patellar translation at distinct flexion angles. HYPOTHESIS Combined MPFL/MQTFL reconstruction would restore patellofemoral contact areas, forces, and kinematics closest to the native state compared with isolated reconstruction of the MPFL or MQTFL alone. STUDY DESIGN Controlled laboratory study. METHODS Ten adult cadaveric knee specimens were prepared and analyzed under 5 different conditions: (1) intact state, (2) transected MPFC, (3) isolated MPFL reconstruction, (4) isolated MQTFL reconstruction, and (5) combined MPFL/MQTFL reconstruction. Patellar tilt, lateral patellar translation, patellofemoral contact forces, and patellofemoral contact areas were measured in each condition from 0° to 80° through simulated knee flexion using a custom servohydraulic load frame with pressure sensor technology and a motion capture system for kinematic data acquisition. RESULTS The isolated MPFL, isolated MQTFL, and combined MPFL/MQTFL reconstruction conditions produced significantly less lateral patellar tilt compared with the transected MPFC state (P < .05). No statistically significant differences were found when each reconstruction technique was compared with the intact state in patellar tilt, lateral patellar translation, contact forces, and contact areas. CONCLUSION All 3 reconstruction techniques (isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction) restored native knee kinematics, contact forces, and contact areas without overconstraint. CLINICAL RELEVANCE Isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction all restore patellofemoral stability comparable with the intact MPFC state without the overconstraint that could be concerning for increasing risk of patellofemoral arthritis.
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Affiliation(s)
| | - Evan W James
- Raleigh Orthopaedic, Raleigh, North Carolina, USA
| | | | - Ruth H Jones
- Hospital for Special Surgery, New York, New York, USA
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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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Matzkin E. Editorial Commentary: When Managing Patellofemoral Instability, Mind Your P's and Q's: Medial Patellofemoral Ligament Versus Medial Quadriceps Tendon Femoral Ligament Versus Medial Patellofemoral Complex. Arthroscopy 2024; 40:1277-1278. [PMID: 38219108 DOI: 10.1016/j.arthro.2023.10.042] [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: 10/18/2023] [Accepted: 10/30/2023] [Indexed: 01/15/2024]
Abstract
Our understanding of patellar instability and the medial patellofemoral complex (MPFC) has evolved over the past 15 years. Despite advancements and appreciation of the anatomy and biomechanics of the MPFC, the best surgical treatment for recurrent patellar instability has yet to be determined. The goals of medial patellofemoral ligament (MPFL), medial quadriceps tendon femoral ligament (MQTFL), or MPFC reconstructions (with grafts from both the patella and quad to the femur) are to return patients back to activity and avoid complications such as recurrent instability, overconstraint, secondary arthrosis, and potential patellar fracture from surgical drill holes. Other considerations when managing recurrent instability include patella alta, hypermobility, and whether an osteotomy procedure is indicated. Although we always need to make good choices and mind our P's and Q's, the big question remains: Is MPFL, MQTFL, or MPFC the best choice for our patients?
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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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Shankar DS, DeClouette B, Avila A, Vasavada KD, Lan R, Strauss EJ, Jazrawi LM, Alaia MJ, Gonzalez-Lomas G, Campbell KA. Medial quadriceps tendon femoral ligament reconstruction and medial patellofemoral ligament reconstruction have no significant differences in clinical outcomes for treatment of lateral patellar instability: a matched-cohort study. J ISAKOS 2024:S2059-7754(24)00053-1. [PMID: 38490437 DOI: 10.1016/j.jisako.2024.03.008] [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: 07/03/2023] [Revised: 02/01/2024] [Accepted: 03/09/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. METHODS A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. RESULTS Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p = 0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p = 0.47), return to sport (MQTFLR 50%, MPFLR 75%, p = 0.61), return to work (MQTFLR 100%, MPFLR 88%, p = 1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p = 0.31). CONCLUSION There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dhruv S Shankar
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Brittany DeClouette
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Amanda Avila
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Kinjal D Vasavada
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Rae Lan
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Eric J Strauss
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Laith M Jazrawi
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Michael J Alaia
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Guillem Gonzalez-Lomas
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA
| | - Kirk A Campbell
- Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, 4th Floor, New York, NY, 10016, USA.
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Elias JJ, Cosgarea AJ, Tanaka MJ. Adding Tibial Tuberosity Medialization to Medial Patellofemoral Ligament Reconstruction Reduces Lateral Patellar Maltracking During Multidirectional Motion in a Computational Simulation Model. Arthrosc Sports Med Rehabil 2023; 5:100753. [PMID: 37645404 PMCID: PMC10461214 DOI: 10.1016/j.asmr.2023.100753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/29/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To determine whether adding tibial tuberosity medialization to medial patellofemoral ligament (MPFL) reconstruction reduces lateral patellar maltracking during a dynamic multidirectional activity and to investigate when medial patellofemoral contact pressures are elevated during daily activities, such as squatting. Methods Seven computational models representing knees with patellar instability, including lateral patellar maltracking, were evaluated following simulated MPFL reconstruction (bisect offset index > .75). Tibial tuberosity medialization was added to MPFL reconstruction for each model. Patellar tracking during multidirectional motion was evaluated by simulating pivot landing. Analysis of pivoting focused on early flexion (5° to 40°). Patellofemoral contact pressures during daily function were evaluated by simulating knee squatting. Data were analyzed with paired comparisons between MPFL reconstruction with and without tuberosity medialization. Results The patella dislocated during pivoting for 2 models with an isolated MPFL reconstruction and for 1 model including tibial tuberosity medialization. Adding tibial tuberosity medialization to MPFL reconstruction significantly decreased bisect offset index by ∼0.1 from 5° to 40° (P < .03). For knee squatting, medializing the tibial tuberosity significantly increased maximum medial contract pressure by ∼0.5 MPa from 30° to 85° (P < .05) but did not significantly influence maximum lateral pressure. Conclusions In this study of simulated multidirectional motion, MPFL reconstruction did not sufficiently constrain the patella for some knees. Adding tibial tuberosity medialization to MPFL reconstruction in these models reduced lateral patellar maltracking during multidirectional motion but increased pressure applied to medial cartilage during squatting. Clinical Relevance After establishing the influence of tibial tuberosity medialization on patellar maltracking for an idealized population, as was done in the current study, future simulation studies can be performed to better determine the anatomical characteristics of patients for whom tibial tuberosity medialization is needed to reduce the risk of postoperative patellar maltracking.
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Affiliation(s)
- John J. Elias
- Department of Health Sciences, Cleveland Clinic Akron General, Cleveland, Ohio, U.S.A
| | - Andrew J. Cosgarea
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Miho J. Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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Wu CH, Hsu KY, Cheng YH, Yang CP, Sheu H, Chang SS, Chen CY, Chiu CH. Reconstruction of High-Grade Trochlea Dysplasia in a Young Female with Recurrent Patella Dislocation: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050986. [PMID: 37241218 DOI: 10.3390/medicina59050986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
The patellofemoral joint involves a combination of bony structures and soft tissues to maintain stability. Patella instability is a disabling condition, and the cause is multifactorial. The main risk factors include patella alta, trochlea dysplasia, excessive tibial tuberosity to trochlea grove (TT-TG) distance, and excessive lateral patella tilt. In this case report, we highlight the thinking process of diagnosis and method for selecting the optimal treatment in accordance with the guidelines by Dejour et al. when we are presented with a patient with patella instability. A 20-year-old Asian woman without underlying medical conditions, presented with recurrent (>3 episodes) right patella dislocation for 7 years. Investigations revealed a type D trochlea dysplasia, increased TT-TG distance, and excessive lateral tilt angle. She underwent trochlea sulcus deepening, sulcus lateralization and lateral facet elevation, lateral retinacular release, and medial quadriceps tendon-femoral ligament (MQTFL) reconstruction. Due to the complexity behind the anatomy and biomechanics of patella instability, an easy-to-follow treatment algorithm is essential for the treating surgeon to provide effective and efficient treatment. MQTFL reconstruction is recommended for recurrent patella dislocation due to satisfactory clinical and patient reported outcomes and a reduced risk of iatrogenic patella fracture. Controversies for surgical indication in lateral retinacular release, and whether the sulcus angle is an accurate parameter for diagnosis of trochlea dysplasia, remain, and further research is required.
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Affiliation(s)
- Chih-Hsuan Wu
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Kuo-Yao Hsu
- Department of Orthopedic Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan
| | - You-Hung Cheng
- Department of Orthopedic Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan
| | - Cheng-Pang Yang
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Huan Sheu
- Department of Orthopedic Surgery, Taoyuan Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Shih-Sheng Chang
- Department of Orthopedic Surgery, Taoyuan Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chao-Yu Chen
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chih-Hao Chiu
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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Jabbouri SS, McLaughlin W, Joo P, Cooperman D, Fulkerson JP, Frumberg DB. Localization of the Adductor Tubercle in the Skeletally Immature: A Computed Tomography Study With Patellofemoral Surgical Implications. Am J Sports Med 2023:3635465231166027. [PMID: 37093662 DOI: 10.1177/03635465231166027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND The adductor tubercle of the distal femur is utilized by surgeons as an anatomic landmark to identify graft anchor placement during medial patellofemoral ligament (MPFL) and medial quadriceps tendon femoral ligament (MQTFL) reconstruction for patellofemoral instability. In the skeletally immature population, its location relative to the physis has not been well defined. PURPOSE To identify the location of the adductor tubercle relative to the distal femoral physis in skeletally immature individuals and gain insight regarding optimal graft anchor placement for pediatric patients undergoing MPFL and MQTFL reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS Thin-cut computed tomography scans of 37 male cadaveric specimens (age, 4-16 years) were obtained from the New Mexico Decedent Image Database. A measurement protocol to identify the adductor tubercle was created with guidance from a fellowship-trained musculoskeletal radiologist. By utilizing axial, coronal, and sagittal views of knee computed tomography scans, the adductor magnus tendon was identified and followed distally to its insertion (adductor tubercle) on the distal femur. Distance from the midpoint of the adductor magnus tendon insertion relative to the physis in the proximal-distal orientation was measured. The anterior-posterior distance of the midpoint tendon insertion relative to the posterior femoral cortex line was also evaluated. RESULTS The midpoint of the adductor magnus tendon was at the physis in 30 specimens. One 8-year-old cadaveric specimen had an insertion 1.1 mm distal to the physis. In all specimens ≥15 years old (n = 6), the adductor magnus tendon insertion was distal to the physis with a mean distance of 2.73 mm. The location of the adductor tubercle was always posterior (mean, 5.1 mm) with respect to the posterior femoral cortex line. CONCLUSION The location of the adductor tubercle in male pediatric patients is likely at or distal to the physis. Thus, the findings of this study directly conflict with previous studies that suggested a more proximal location. CLINICAL RELEVANCE Optimal graft anchor placement during MPFL and MQTFL reconstruction in the skeletally immature patient can be challenging because of the variability reported in previous studies of the medial patellofemoral complex origin relative to the physis. This study suggests that distal-rather than proximal-graft anchor placement might better help restore patellofemoral isometry.
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Affiliation(s)
- Sahir S Jabbouri
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - William McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Peter Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Cooperman
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - John P Fulkerson
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - David B Frumberg
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
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Hohmann E. Editorial Commentary: From Lateral Release and Medial Plication to Complex Medial Patellofemoral Ligament Reconstruction Techniques: Medial Quadriceps Tendon Femoral Ligament Reconstruction Is the Most Anatomic Repair. Arthroscopy 2023; 39:670-672. [PMID: 36740289 DOI: 10.1016/j.arthro.2022.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 02/07/2023]
Abstract
Patella instability and dislocation are common in younger patients, and 1 in 5 patients are at risk of recurrent dislocations. Conservative treatment should be considered for first dislocations unless other concomitant injuries are present. Historically, lateral patella release and medial plication techniques were used for repair but have been superseded by medial patellofemoral ligament reconstruction. Overconstraint is a potential problem and often related to nonanatomic femoral tunnel position and graft tension, which could result in increased patellar contact pressures and graft failure. The medial quadriceps tendon-femoral ligament reconstruction technique (MQTFL) avoids patellar tunnels without the risk of patella fracture. When comparing medial patellofemoral ligament, MQTFL, and the combination of both techniques in a cadaver model, MQTFL resulted in less constraint with no differences for patellar contact pressures. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair.
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Dahm F, Syed H, Tomescu S, Lin HA, Haimovich Y, Chandrashekar N, Whyne C, Wasserstein D. Biomechanical Comparison of 3 Medial Patellofemoral Complex Reconstruction Techniques Shows Medial Overconstraint but No Significant Difference in Patella Lateralization and Contact Pressure. Arthroscopy 2023; 39:662-669. [PMID: 36328339 DOI: 10.1016/j.arthro.2022.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The purpose of this study was to investigate biomechanical differences of medial patellofemoral ligament (MPFL) reconstruction, medial quadriceps tendon femoral ligament (MQTFL) reconstruction, and a combination of these techniques to restore lateral patellar constraint and contact pressures. METHODS Eight fresh frozen cadaver knees were mounted to a custom jig with physiological quadriceps tendon loading. Flexion angles and contact pressure (CP) were dynamically measured using Tekscan® pressure sensors and Polhemus® Liberty 6 degree of freedom (6DOF) positioning sensors in the following conditions: 1) intact 2) MPFL and MQTFL deficient, 3) MPFL reconstructed, 4) Combined MPFL + MQTFL reconstructed, and 5) MQTFL reconstructed. Lateral patellar translation was tested using horizontally directed 30 N force applied at 30° of knee flexion. The knees were flexed in dynamic fashion, and CP values were recorded for 10°, 20°, 30°, 50°, 70°, and 90° degrees of flexion. Group differences were assessed with ANOVA's followed by pairwise comparisons with Bonferroni correction. RESULTS MPFL (P = .002) and combined MPFL/MQTFL (P = .034) reconstruction significantly reduced patellar lateralization from +19.28% (9.78%, 28.78%) in the deficient condition to -17.57% (-27.84%, -7.29%) and -15.56% (-33.61%, 2.30%), respectively. MPFL reconstruction was most restrictive and MQTFL reconstruction the least -7.29% (-22.01%, 7.45%). No significant differences were found between the three reconstruction techniques. Differences in CP between the three reconstruction techniques were not significant (<.02 MPa) at all flexion angles. CONCLUSION The present study found no significant difference for patellar lateralization and patellofemoral CP between MPFL, combined MPFL/MQTFL, and MQTFL reconstruction. All 3 techniques resulted in stronger lateral patellar constraint compared to the native state, while the MQTFL reconstruction emulated the intact state the closest. CLINICAL RELEVANCE Various surgical techniques for medial patellofemoral complex reconstruction can restore patellar stability with similar patellofemoral articular pressures.
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Affiliation(s)
- Falko Dahm
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.
| | - Hassan Syed
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto Orthopedic Sports Medicine, Women's College Hospital Toronto, Toronto, Ontario, Canada; Institute for Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sebastian Tomescu
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto Orthopedic Sports Medicine, Women's College Hospital Toronto, Toronto, Ontario, Canada
| | - Heng An Lin
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto Orthopedic Sports Medicine, Women's College Hospital Toronto, Toronto, Ontario, Canada; Department of Orthopedic Surgery, Sengkang General Hospital, Singapore
| | - Yaron Haimovich
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Naveen Chandrashekar
- Department of Orthopedic Surgery, Wolfson Medical Center, Holon, Israel; and Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Cari Whyne
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute for Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - David Wasserstein
- Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto Orthopedic Sports Medicine, Women's College Hospital Toronto, Toronto, Ontario, Canada; Institute for Medical Science, University of Toronto, Toronto, Ontario, Canada
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Arthroscopic Anatomical Double-Bundle Medial Patellofemoral Complex Reconstruction Improves Clinical Outcomes in Treating Recurrent Patellar Dislocation Despite Trochlear Dysplasia, Elevated Tibial Tubercle-Trochlear Groove Distance, and Patellar Alta. Arthroscopy 2023; 39:102-111. [PMID: 35840069 DOI: 10.1016/j.arthro.2022.06.038] [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] [Received: 01/11/2022] [Revised: 06/25/2022] [Accepted: 06/26/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical outcomes of arthroscopically assisted double-bundle medial patellofemoral complex reconstruction (MPFC-R). METHODS A retrospective review was carried out among adult patients who experienced at least 2 patellar dislocations and underwent primary arthroscopically assisted MPFC-R between January 2014 and November 2019. Dejour classification, tibial tubercle-trochlear groove (TT-TG) distance, and patellar height (with Insall-Salvati index) were measured. Pre- and postoperative patellar tilt were compared. Information on outcome scores, ability to return to sports, postoperative recurrent dislocations, and complications was recorded. RESULTS A total of 42 MPFC-Rs in 39 patients were included. Mean age at surgery was 22.2 ± 7.6 years; 69.2% of patients were female. Mean follow-up was 47.3 ± 20.2 months. Seventy-four percent of cases had Dejour B (19.0%), C (33.3%), and D (21.4%) trochlear dysplasia; mean TT-TG distance was 19.6 ± 3.5 mm, and mean Insall-Salvati index was 1.21 ± 0.17. Mean patellar tilt decreased from 27.6 ± 11.6° to 9.4 ± 6.5° (P < .001). All patients had statistically significant (P < .001) improvement in mean International Knee Documentation Committee (IKDC) (44.9 ± 18.2 to 87.5 ± 6.9), Lysholm (61.4 ± 16.6 to 94.1 ± 6.4), Kujala (56.0 ± 16.8 to 92.9 ± 5.3), and Tegner score (2.7 ± 1.3 to 4.6 ± 1.4). The majority of patients (96.9%) returned to sports, with 90.3% returning to the same or greater level of activity. No postoperative dislocations or subluxations were reported. CONCLUSIONS Arthroscopically assisted double-bundle MPFC-R is a promising procedure to treat recurrent patellar instability at 2- to 7-year mid-term follow-up, despite the presence of trochlear dysplasia, elevated TT-TG distance and patellar alta. The improvement of IKDC score exceeded the minimal clinically important difference in 95.2% patients, and 66.7% surpassed the patient acceptable symptomatic state based on postoperative IKDC score with no redislocations being reported at latest follow-up. LEVEL OF EVIDENCE Level IV, case series, retrospective.
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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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Bhimani R, Ashkani-Esfahani S, Mirochnik K, Lubberts B, DiGiovanni CW, Tanaka MJ. Radiographic Landmarks for the Femoral Attachment of the Medial Patellofemoral Complex: A Cadaveric Study. Arthroscopy 2022; 38:2504-2510. [PMID: 35157967 DOI: 10.1016/j.arthro.2022.01.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/27/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the radiographic landmarks for the medial patellofemoral complex (MPFC) footprint on the medial femur and describe the difference between the radiographic positions corresponding to the medial quadriceps tendon femoral ligament (MQTFL) and medial patellofemoral ligament (MPFL) fibers. METHODS In 8 unpaired cadaveric knees, the MPFC footprint was exposed on the medial femur, and the proximal and distal boundaries of the footprint were marked. Lateral fluoroscopic images of the knee were obtained and analyzed using Image J. The proximal boundary corresponding to the MQTFL, the MPFC midpoint, and distal boundary corresponding to the MPFL were described radiographically and compared for differences in position. RESULTS The proximal MQTFL footprint was 0.8 ± 0.6 mm anterior (P = .013) and 5.2 ± 1.8 mm proximal to the MPFC midpoint (P <.001), whereas the distal MPFL footprint was 0.8 ± 0.7 mm posterior (P = .012) and 5.9 ± 1.1 mm distal to the radiographic MPFC midpoint (P <.001). The radiographic point corresponding to the distal MPFL footprint was 0.8 ± 0.9 mm posterior (P = .011) and 11.1 ± 2.3 mm distal to the radiographic point of the proximal MQTFL footprint (P <.001). When using the point of intersection of the posterior cortical line and the proximal posterior condyle as a reference, 91.6% of all points correlating to the MQTFL, MPFC midpoint and MPFL, were within 10 mm in any direction from this radiographic landmark. CONCLUSIONS On fluoroscopic imaging, the proximal MQTFL and distal MPFL fibers had significantly different radiographic positions from the MPFC midpoint on the femur. These findings should be considered when reconstructing specific components of the MPFC. CLINICAL RELEVANCE As fluoroscopy is often used intraoperatively to guide graft placement, our findings may serve as a reference when differentiating the locations of the MPFL vs MQTFL on the femur for anatomic reconstruction.
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Affiliation(s)
- Rohan Bhimani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Soheil Ashkani-Esfahani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Karina Mirochnik
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Bart Lubberts
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
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15
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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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16
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Shimodaira H, Tensho K, Koyama S, Iwaasa T, Kumaki D, Horiuchi H, Takahashi J. Simultaneous Medial Patellofemoral Ligament and Medial Quadriceps Tendon-Femoral Ligament Reconstructions Using an Artificial Ligament for Lateral Patella Instability. Arthrosc Tech 2022; 11:e1021-e1026. [PMID: 35782857 PMCID: PMC9244637 DOI: 10.1016/j.eats.2022.02.007] [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: 12/03/2021] [Accepted: 02/05/2022] [Indexed: 02/03/2023] Open
Abstract
Recent studies on the detailed anatomy of the medial patellar stabilizer have revealed that the medial patellofemoral ligament (MPFL) not only attaches to the patella but also has fibers that attach to the quadriceps muscle, known as the medial quadriceps tendon femoral ligament (MQTFL). Reconstruction of the medial stabilizer for patellar dislocation that includes both the MPFL and MQTFL may achieve better anatomical and physiological correction. In this Technical Note, we will describe a simultaneous reconstruction technique of the MPFL and MQTFL for patellar dislocation using an artificial ligament.
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Affiliation(s)
| | - Keiji Tensho
- Address correspondence to Keiji Tensho, M.D., Ph.D., Department of Orthopedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan.
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17
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Yu KE, Barden B, Molho DA, Reed DN, Schneble C, McLaughlin W, Fulkerson JP. Quadriceps Tendon Attachment Technique for Medial Quadriceps Tendon-Femoral Ligament (MQTFL) Reconstruction in the Surgical Treatment of Recurrent Patella Dislocation. Arthrosc Tech 2021; 11:e95-e98. [PMID: 35127434 PMCID: PMC8807880 DOI: 10.1016/j.eats.2021.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/15/2021] [Indexed: 02/03/2023] Open
Abstract
Medial quadriceps tendon-femoral ligament (MQTFL) reconstruction for prevention of recurrent patella dislocation is an alternative to medial patellofemoral ligament (MPFL) reconstruction. Because the reconstruction graft attaches to the quadriceps tendon, no patella drill hole is required, thereby eliminating iatrogenic fracture risk. The procedure remains anatomically accurate and early results are comparable to MPFL reconstruction for preventing patella dislocation. The MQTFL reconstruction graft is brought up under the vastus medialis obliquus distal to the patella apex, such that its orientation is directed toward the medial patellofemoral complex (MPFC) midpoint, also known as Tanaka's point. The graft is then secured by looping it around the vastus medialis and rectus femoris tendons, after which optimal graft length is easily established by cycling the knee, after which it is sutured securely into the deep quadriceps tendon precisely at the anatomic midpoint of the MPFC. Anatomic reconstruction of the MQTFL-in which graft orientation is crucial-confers reliable patellofemoral joint stability in the surgical treatment of patients with recurrent patella dislocations.
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Affiliation(s)
- Kristin E. Yu
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A,Address correspondence to Kristin E. Yu, B.A., Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, U.S.A.
| | - Benjamin Barden
- Northside Hospital, Orthopaedic Sports Surgery, Marietta, Georgia, U.S.A
| | - David A. Molho
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A
| | - Dale N. Reed
- Associates In Orthopedics And Sports Medicine, Dalton, Georgia, U.S.A
| | - Christopher Schneble
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A
| | - William McLaughlin
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A
| | - John P. Fulkerson
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A
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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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Abstract
Through this article, the authors aim to summarize the techniques performed on both first time and recurrent skeletally immature patients experiencing patellar dislocation. This article focuses on several key points, such as the importance of medial patellofemoral ligament femoral insertions being distal to the growth plate and performing extensive lateral release and quadricep tendon lengthening in cases of obligatory dislocation. Although acknowledging the procedures discussed cannot be considered for all patients, as individuals with open growth plates may require additional operative time, in many cases these techniques yield high rates of success.
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20
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Sherman SL, Curtis DM. Editorial Commentary: Is the Pendulum "Swinging" Away From Patellar Fixation in Medial Patellofemoral Ligament Reconstruction? Arthroscopy 2021; 37:3198-3199. [PMID: 34602157 DOI: 10.1016/j.arthro.2021.06.001] [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: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 02/02/2023]
Abstract
Medial patellofemoral ligament (MPFL) reconstruction is the "workhorse" for surgical stabilization of recurrent patella instability. Complications of patella fixation (i.e., patella fracture) are rare but potentially catastrophic. Modifications to traditional MPFL reconstruction that avoid patella fixation are promising. These alternatives may be favored in high-risk scenarios such as revision, smaller pediatric cases, and patellofemoral arthroplasty with concomitant instability. Large-scale prospective and/or randomized studies are needed to differentiate between MPFL reconstruction techniques.
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21
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Temponi EF, Saithna A, Gonçalves MBJ, Soares LFM, Carvalho RB, de Carvalho Júnior LH. Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon-Femoral Ligament. Arthrosc Tech 2021; 10:e193-e198. [PMID: 33532228 PMCID: PMC7823114 DOI: 10.1016/j.eats.2020.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/23/2020] [Indexed: 02/03/2023] Open
Abstract
Most patellar dislocations are associated with disruption of the proximal medial patellar restraints (PMPRs). The PMPRs comprise the medial patellofemoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL). Although isolated MPFL reconstruction is the most frequently performed procedure for the surgical management of recurrent dislocation, recent studies have shown that the MQTFL has a synergistic role with the MPFL in resisting lateral patellar displacement close to full extension. It has therefore been suggested that surgical techniques that gain the benefits of both proximal and distal PMPR biomechanical behavior may be best. This article describes an established technique for combined MPFL and MQTFL reconstruction using semitendinosus autograft.
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Affiliation(s)
- Eduardo Frois Temponi
- Hospital Madre Teresa, Belo Horizonte, Brazil,School of Science and Technology, Nottingham Trent University, Clifton Campus, East Midlands, England,Departamento do Aparelho Locomotor, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil,Departamento de Medicina, Pontifícia Universidade Católica, Belo Horizonte, Brazil,Address correspondence to Eduardo Frois Temponi, M.D., M.Sc., Avenida Raja Gabáglia 1002, Gutierrez, Belo Horizonte, Brazil.
| | - Adnan Saithna
- Kansas City University of Medicine, Kansas City, Missouri, U.S.A.,School of Science and Technology, Nottingham Trent University, Clifton Campus, East Midlands, England
| | | | | | | | - Lúcio Honório de Carvalho Júnior
- Hospital Madre Teresa, Belo Horizonte, Brazil,Kansas City University of Medicine, Kansas City, Missouri, U.S.A.,Departamento do Aparelho Locomotor, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil,Departamento de Medicina, Pontifícia Universidade Católica, Belo Horizonte, Brazil
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