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Runer A, Klotz S, Schneider F, Egelseer T, Csapo R, Hoser C, Abermann E, Mayr R, Raas C, Attal R, Arora R, Fink C, Liebensteiner M. Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient-Reported Outcomes but Less Donor-Site Morbidity Compared With Gracilis Tendon Autograft. Arthroscopy 2024; 40:438-445. [PMID: 37479150 DOI: 10.1016/j.arthro.2023.07.006] [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: 01/22/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To compare clinical and patient-reported outcome measures (PROMs) in patients with recurrent patellar dislocation after medial patellofemoral ligament (MPFL) reconstruction using either a gracilis tendon (GT) or quadriceps tendon autograft (QT). METHODS All MPFL reconstruction performed between 2017 and 2019 were reviewed retrospectively. Only patients with isolated MPFL reconstruction, without any major patellofemoral risk factors and a minimum follow-up of 24 months, were included in the study. Patients were matched with respect to sex, age, and body mass index. All patients were evaluated clinically and using PROMs. RESULTS A total of 64 patients with an average follow up of 28.7 ± 7.5 months were included in this study. The mean Kujala score (GT: 84.8 ± 12.9, QT: 88.9 ± 10.1), Lysholm score (GT: 89.4 ± 10.2, QT: 88.4 ± 5.0), and visual analog scale score for pain (GT: 1.9 ± 1.8, QT: 1.1 ± 1.3) did not significantly differ between both groups. Tegner activity level was significantly greater (P = .027) in the QT group (5.5 ± 1.9) compared with the GT group (4.6 ± 1.8), but within the minimal clinically important differences. Occasional patellar instability events, but no recurrent dislocation, were reported in 12.5% in the GT group and 6.3% in the QT group (P = .39). Of all patients, 90.6% in the QT and 68.8% in the HT group exceeded the PASS for the Kujala score (P = .06). Significantly more patients (59.4%) treated with GT reported donor-site morbidity in the form of sensitivity deficit at the lower leg compared with those treated with QT (3.1%, P = .001). CONCLUSIONS GT and QT MPFL reconstruction have comparable PROMs and patellar redislocation rates 2 years' postoperatively. Significantly more patients treated with GT reported lower-leg sensitivity deficit compared with those treated with QT. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Stefan Klotz
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Friedemann Schneider
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tim Egelseer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Csapo
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Centre for Sport Science and University Sports, University of Vienna, Vienna, Austria
| | - Christin Hoser
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Hall in Tirol, Austria
| | | | - Raul Mayr
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Raas
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rene Attal
- Department of Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, LKH Feldkirch, Austria
| | - Rohit Arora
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Hall in Tirol, Austria
| | - Michael Liebensteiner
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Orthopädie Knie & Fuß im Zentrum, Innsbruck, Austria
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Bartsch A, Nüesch C, Rieger B, Mündermann A, Egloff C. Dynamic versus static medial patellofemoral ligament reconstruction technique in the treatment of recurrent patellar dislocation: a randomized clinical trial protocol. J Orthop Surg Res 2022; 17:345. [PMID: 35818060 PMCID: PMC9275045 DOI: 10.1186/s13018-022-03158-6] [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: 12/08/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The redislocation rate of conservatively treated patella instability is high. One of the leading surgical strategies is medial patellofemoral ligament reconstruction. Over-tensioning is one of the most challenging complications in static medial patellofemoral ligament reconstruction as the graft used for reconstruction is isometric and the anatomical MPFL is a mostly dynamic structure. As an alternative to established static reconstruction techniques, dynamic graft techniques have been introduced for stabilizing the patella with the aim of providing a more physiological reconstruction of the medial patellofemoral ligament. To date, data on clinical outcomes are scarce and on biomechanical outcomes of the dynamic MPFL reconstruction are lacking. Here, we present the protocol of a randomized clinical trial for comparing clinical and biomechanical outcomes of dynamic versus static medial patellofemoral ligament reconstruction. METHODS This study is a prospective, single blinded, randomized, multicenter, multimodal (clinical and biomechanical) clinical trial. Patients with recurrent patella dislocation requiring isolated MPFL reconstruction will be recruited and randomized to the dynamic or static reconstruction technique. Participants will be followed up for 2 years with a total of five follow-ups. Preoperative magnetic resonance imaging, upright radiographs, surgical reports and patient records will be evaluated, and clinical and functional outcomes will be measured. Patient-reported knee function and anterior knee pain as assessed with the Kujala score will serve as primary outcome. For biomechanical outcome, pre- and postoperative evaluations will be performed to assess isokinetic muscle strength, gait asymmetry, joint kinematics and kinetics, and timing of muscle activity. DISCUSSION The results of the study will clarify whether the reported surgery success for patella stabilization via dynamic MPFL reconstruction is due to muscle contraction or to the passive tenodesis effect combined with clinical outcome measures. With this study, we will provide much needed information on knee biomechanics after dynamic versus static MPFL reconstruction to provide evidence to support orthopedic surgeons in evidence-based decision-making in their quest for surgical techniques most favorable for their patients. Trial registration The study protocol was registered at clinicaltrials.gov (NCT04849130). Registered 19 April 2021, https://clinicaltrials.gov/ct2/show/NCT04849130 .
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Affiliation(s)
- Anna Bartsch
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Corina Nüesch
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Department of Biomedical Engineering, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland.,Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
| | - Bertram Rieger
- Orthopedic Surgery and Sportsmedicine, ALTIUS Swiss Sportmed Center, Rheinfelden, Switzerland
| | - Annegret Mündermann
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Department of Biomedical Engineering, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland.,Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
| | - Christian Egloff
- Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland. .,Department of Clinical Research, University of Basel, Basel, Switzerland.
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Burger D, Feucht M, Muench LN, Forkel P, Imhoff AB, Mehl J. Good clinical outcomes after patellar cartilage repair with no evidence for inferior results in complex cases with the need for additional patellofemoral realignment procedures: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:1752-1768. [PMID: 34510221 PMCID: PMC9033684 DOI: 10.1007/s00167-021-06728-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Focal, patellar cartilage defects are a challenging problem as most cases have an underlying multifactorial pathogenesis. This systematic review of current literature analysed clinical results after regenerative cartilage repair of the patella with a special focus on the assessment and treatment of existing patellofemoral malalignment. METHODS A systematic review was conducted to identify articles reporting clinical results after cartilage regenerative surgeries of the patella using the PubMed and Scopus database. The extracted data included patient-reported outcome measures (PROMS) and whether cartilage repair was performed alone or in combination with concomitant surgeries of underlying patellofemoral co-pathologies. In cases of isolated cartilage repair, specific exclusion criteria regarding underlying co-pathologies were screened. In cases of concomitant surgeries, the type of surgeries and their specific indications were extracted. RESULTS A total of 35 original articles were included out of which 27 (77%) were cohort studies with level IV evidence. The most frequently used technique for cartilage restoration of the patella was autologous chondrocyte implantation (ACI). Results after isolated cartilage repair alone were reported by 15 (43%) studies. Of those studies, 9 (60%) excluded patients with underlying patellofemoral malalignment a priori and 6 (40%) did not analyse underlying co-pathologies at all. Among the studies including combined surgeries, the most frequently reported concomitant procedures were release of the lateral retinaculum, reconstruction of the medial patellofemoral ligament (MPFL), and osteotomy of the tibial tubercle. In summary, these studies showed lower preoperative PROMS but similar final PROMS in comparison with the studies reporting on isolated cartilage repair. The most frequently used PROMS were the IKDC-, Lysholm- and the Modified Cincinnati Score. CONCLUSION This comprehensive literature review demonstrated good clinical outcomes after patellar cartilage repair with no evidence of minor results even in complex cases with the need for additional patellofemoral realignment procedures. However, a meaningful statistical comparison between isolated patellar cartilage repair and combined co-procedures is not possible due to very heterogeneous patient cohorts and a lack of analysis of specific subgroups in recent literature. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Daniel Burger
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Matthias Feucht
- Department of Orthopaedic Surgery, Paulinenhilfe, Diakonieklinikum, Stuttgart, Germany
| | - Lukas N. Muench
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Philipp Forkel
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Andreas B. Imhoff
- grid.6936.a0000000123222966Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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Olotu O, Siddiqui A, Peterson D, de Sa D. The Superficial "Swing-Down" Quadriceps Tendon Autograft Is a Viable Option for Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Arthroscopy 2021; 37:3187-3197. [PMID: 33961979 DOI: 10.1016/j.arthro.2021.04.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review is to ascertain the reported clinical outcomes and complication profiles of medial patellofemoral ligament (MPFL) reconstruction performed using a superficial "swing-down" quadriceps tendon autograft. METHODS Three databases (PubMed, EMBASE, and MEDLINE) were searched from January 1, 2000, to April 06, 2020. Keywords used in the search included: "medial patellofemoral ligament" and "reconstruction". After screening based on inclusion and exclusion criteria, patient demographics, graft type, outcomes, and complications were extracted. Methodological Index for Non-Randomized Studies criteria were used to assess the quality of each included study. RESULTS Eleven studies were included, comprising data from 226 patients with mean follow up ranging from 12 to 38 months. All reconstructions used a superficial "swing-down" quadriceps tendon autograft fixed at 20-30 degrees of knee flexion where reported. Eight of eleven studies reported significant improvement in patient reported outcomes such as Kujala score, Lysholm score, and Tegner score. The mean preoperative Kujala score ranged from 35.8 to 82.1 (167 patients), while the mean postoperative Kujala score ranged from 88.4 to 94.8 (197 patients). The mean of the preoperative Lysholm score ranged from 43.3 to 79.3 (77 patients), while the mean of the postoperative Lysholm score ranged from 81.9 to 90.9 (99 patients). The I2 statistic for Lysholm and Kujala scores was 94% and 97%, respectively. Across data reported on 194 patients, there was no incidence of patellar redislocation, patellar fracture, or graft site morbidity. CONCLUSION The quadriceps tendon produced improved clinical outcomes with low rates of recurrent postoperative patellar dislocation. These data suggest that the quadriceps tendon remains a suitable alternative for MPFL reconstruction and should remain part of the arsenal of knee ligament surgeons. LEVEL OF EVIDENCE Systematic review of Level III and IV studies.
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Affiliation(s)
- Olumide Olotu
- MACSports Research Program, McMaster University, Hamilton, Ontario, Canada; School of Medicine, St. George's University, True Blue, Grenada, West Indies
| | - Ali Siddiqui
- MACSports Research Program, McMaster University, Hamilton, Ontario, Canada
| | - Devin Peterson
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
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Moreland CM, Shaw KA, Burks R, Baird M, Hattaway J, Parada SA, Waterman BR. Primary Medial Patellofemoral Ligament Reconstruction in Military Servicemembers: Can We Reliably Restore Preinjury Function and Stability? Orthop J Sports Med 2021; 9:23259671211013334. [PMID: 34179209 PMCID: PMC8202279 DOI: 10.1177/23259671211013334] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/12/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Medial patellofemoral ligament (MPFL) reconstruction for patellar instability is a commonly performed procedure with a reported high rate of return to preinjury activity. However, no previous study has assessed the functional outcomes of military servicemembers undergoing MPFL reconstruction. Hypothesis: Primary MPFL reconstruction confers patellar stability, but with limited return to preinjury function and ability to maintain unrestricted military active duty status. Study Design: Case series; Level of evidence, 4. Methods: Using the Management Analysis and Reporting Tool database, we conducted a retrospective review of active duty servicemembers throughout the US Department of Defense Health System who underwent primary MPFL reconstruction between 2012 and 2015. Demographic variables were recorded as well as ability to return to impact activities—defined as running, jumping, rucking with a load >40 pounds (18 kg), and returning to airborne operations—and to remain on active duty status. The rates of recurrent instability and the need for subsequent surgeries were identified and assessed for statistical significance using uni- and multivariate analyses. Patients were evaluated for a minimum of 2 years postoperatively. Results: Of the 213 patients who underwent primary MPFL reconstruction, including 34 with concomitant tibial tubercle osteotomy, 19 (8.9%) patients developed recurrent instability. The presence of bilateral patellar instability was associated with higher recurrence rate. Patients with bilateral instability comprised 47.3% of those with recurrence but only 24.9% of patients without recurrence (P = .019). Impact activity restrictions were present in 57.6% of patients (n = 121), with 86 patients (52.1%) undergoing medical separation from the military. Patients who were prescribed activity restriction before surgery were significantly more likely to have postoperative activity restrictions (64.5%; P = .019), and junior enlisted servicemembers were more likely to be medically separated from service postoperatively than higher ranking senior enlisted members or officers. Conclusion: Only 42.4% of US military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity after surgery. Bilateral instability negatively affected return to impact activities. Military servicemembers, particularly junior enlisted members, should be counseled on this poor prognosis for a full return to unrestricted activity postoperatively.
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Affiliation(s)
- Colleen M Moreland
- Department of Orthopaedic Surgery, Dwight David Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - K Aaron Shaw
- Department of Orthopaedic Surgery, Dwight David Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Robert Burks
- Department of Defense Analysis, Naval Postgraduate School, Monterrey, California, USA
| | - Michael Baird
- Department of Orthopaedic Surgery, Walter Reed Army Medical Center, Washington, District of Colombia, USA
| | - Joshua Hattaway
- Department of Orthopaedic Surgery, Dwight David Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Stephen A Parada
- Department of Orthopaedic Surgery, Augusta University, Augusta, Georgia, USA
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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Selective bundle tensioning in double-bundle MPFL reconstruction to improve restoration of dynamic patellofemoral contact pressure. Knee Surg Sports Traumatol Arthrosc 2020; 28:1144-1153. [PMID: 31740983 DOI: 10.1007/s00167-019-05789-5] [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] [Received: 03/02/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the optimal graft tension angles in a medial patellofemoral ligament (MPFL) reconstruction with selective bundle tensioning in order to restore patellofemoral contact pressure distributions closest to the native state. METHODS Twelve human cadaveric knee specimens were mounted with the femur on a custom-made fixation device allowing free range of motion in the knee joint for testing. Using a sensitive pressure film (Tekscan) patellofemoral contact pressure was measured in 15° intervals during a dynamic flexion movement from 0°-90° in the native state, in cut MPFL and after MPFL-reconstruction with a gracilis tendon. The graft was separated in two bundles and was fixed independently on the patella using two knotless anchors. Two groups were made with either the proximal or distal bundle fixed at the femur at a knee flexion angle of 30° and the corresponding other bundle subsequently fixed at the femur at 15°, 45°, 60°, 75° and 90° of knee flexion using extra-cortical fixation and controlled tension of 2N in both groups. The sequence of the flexion angles at the graft fixation was alternated. Pressure measurements were repeated after every fixation of the graft. RESULTS Cutting the MPFL resulted in significantly reduced patellofemoral contact pressure at all flexion angles. After MPFL reconstruction the patellofemoral contact pressure remained significantly reduced during dynamic knee flexion in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°. Selective evaluation of lateral patellofemoral contact pressure, however, showed significant reduction in all tested double-bundle combinations (p < 0.05) from 15° to 90°. Evaluation of isolated medial patellofemoral pressure changes showed no significant difference in all tested combinations compared to the intact knee. Furthermore, evaluation of the isolated proximal and distal patellofemoral contact pressure also revealed a significantly reduced contact pressure in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°. CONCLUSION According to this study, selective bundle tensioning in anatomic MPFL-reconstruction should be considered as an easy and more anatomic alternative to current popular techniques to restore patella kinematics and give clear recommendation about knee flexion angle and tension during fixation. Although tensioning two bundles separately may further improve clinical results. If performed, fixation of the graft is recommended under low tension (2N) with the proximal bundle at 30° and the distal bundle at 75° of knee flexion.
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Uppstrom TJ, Price M, Black S, Gausden E, Haskel J, Green DW. Medial patellofemoral ligament (MPFL) reconstruction technique using an epiphyseal femoral socket with fluoroscopic guidance helps avoid physeal injury in skeletally immature patients. Knee Surg Sports Traumatol Arthrosc 2019; 27:3536-3542. [PMID: 30852626 DOI: 10.1007/s00167-019-05412-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to assess the physeal safety associated with the use of an epiphyseal femoral socket for paediatric medial patellofemoral ligament (MPFL) reconstruction. METHODS Fifty-four knees in 49 skeletally immature patients underwent physeal-sparing MPFL reconstruction performed by 1 surgeon at a tertiary care academic medical centre from 2007 to 2016. A femoral socket distal to the femoral physis was used for graft fixation in all the patients. To assess physeal safety, all included patients either had post-operative MRIs of the operative knee or standing hip-to-ankle radiographs. Physeal safety was assessed on MRI, and the distance between the femoral socket relative to the physis was measured at both the aperture and the end of the socket. Development of lower limb angular deformities and/or limb length discrepancy (LLD) was evaluated using post-operative standing hip-to-ankle radiographs, patient records, and clinical assessments. RESULTS The mean age at time of surgery was 13.3 ± 1.6 years. The median length of radiographic follow-up was 2.2 years (range 1.0-5.7 years). At most recent clinical follow-up, five patients (9.3%) had recurrent patellar instability, with three patients (5.6%) undergoing subsequent tibial tubercle osteotomy or revision MPFL reconstruction. There was no statistically significant difference in leg length between operated and non-operated extremities (n.s.). There was no statistically significant difference between non-operated and operated mMPTA (n.s.) and mLDFA (n.s.) measurements. On post-operative MRI, there was no evidence of physeal arrest. The median distance from the physis to the socket at the aperture and distal end of the femoral socket were 5.9 mm (range 1.9-12) and 7.1 mm (1.3-12.4), respectively. CONCLUSION These results demonstrate that with fluoroscopic guidance, placing the femoral socket distal to the distal femoral physis is an effective method for avoiding physeal injury and subsequent growth disturbances in children with patellar instability. Clinically, this information is essential in optimal surgical management of these patients, as this technique allows for femoral fixation of the MPFL reconstruction graft within the epiphysis while also preserving normal growth. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Tyler J Uppstrom
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA.,Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Meghan Price
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Sheena Black
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Elizabeth Gausden
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA
| | - Jonathan Haskel
- Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Daniel W Green
- Hospital for Special Surgery, 525 E 70th Street, New York, NY, 10021, USA.
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Lei M, Hua Q. [Ressarch of prior-localization femoral tunnel in medial patellofemoral ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:546-550. [PMID: 31090346 PMCID: PMC8337200 DOI: 10.7507/1002-1892.201811098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/07/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To introduce the method of prior-localization femoral tunnel by using a special positioning tool under the C-arm radiographic machine before surgery, and to study the effect on the knee function recovery after medial patellofemoral ligament (MPFL) reconstruction. METHODS Between January 2014 and January 2016, 32 patients with recurrent unilateral knee patellar dislocation were treated by arthroscopic patellofemoral lateral retinaculum release and MPFL reconstruction. The femoral tunnel position during MPFL reconstruction was prior-localizated under C-arm radiographic machine before operation. There were 8 males and 24 females, aged from 15 to 37 years, with an average of 23.8 years. The time from injury to admission ranged from 1 to 24 months, with an average of 9.7 months. Isometric point distance was measured on CT three-dimensional reconstruction image after operation to evaluate whether the position of femoral tunnel was isometric, and knee joint function was evaluated by Lysholm score. Spearman correlation analysis was performed between isometric point distance and Lysholm score. RESULTS All the 32 patients were followed up 12-18 months (mean, 14.2 months). No symptoms of patellar subluxation or dislocation was found during follow-up. Patellar extrapolation test and patellar extrapolation fear test were negative. The isometric point distance was 1.5-5.9 mm (mean, 3.44 mm) at 3 days after operation. All femoral tunnels were located in equidistant tunnels. At last follow-up, the Lysholm score of the patients was 92.8±2.1, which was significantly improved when compared with preoperative score (54.4±2.8) ( t=61.911, P=0.000). Isometric point distance was negatively correlated with Lysholm score ( r=-0.454, P=0.009). CONCLUSION C-arm radiographic machine can locate the femoral tunnel position of MPFL easily and accurately before operation. The short-term and medium-term effectiveness are satisfactory, and the ionizing radiation injury caused by multiple fluoroscopy during operation is avoided.
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Affiliation(s)
- Mingming Lei
- Department of Orthopaedic Sports Medicine and Arthroscope, the Sports Hospital Affiliated to Chengdu Sport University, Chengdu Sichuan, 610041, P.R.China
| | - Qiang Hua
- Department of Orthopaedic Sports Medicine and Arthroscope, the Sports Hospital Affiliated to Chengdu Sport University, Chengdu Sichuan, 610041,
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Ferrua P, Kruckeberg BM, Pasqualotto S, Berruto M, Randelli P, Arendt EA. Proximal medial patellar restraints and their surgical reconstruction. J Orthop Traumatol 2019; 20:17. [PMID: 30915690 PMCID: PMC6435766 DOI: 10.1186/s10195-019-0525-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/08/2019] [Indexed: 01/27/2023] Open
Abstract
Reconstruction of the medial patellofemoral ligament (MPFL) has been increasing as a surgical solution for treatment of recurrent lateral patellofemoral dislocation. Recent attention has been given to fibers extending from the femur to the quadriceps tendon, proximal to the MPFL, termed the medial quadriceps tendon-femoral ligament. This article briefly reviews the proximal medial patellar restraints and surgical procedures for their reconstruction.
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Affiliation(s)
- Paolo Ferrua
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Bradley M Kruckeberg
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Stefano Pasqualotto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Massimo Berruto
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Pietro Randelli
- I clinica ortopedica ASST Gaetano Pini-CTO Gaetano Pini, Via Quadronno, 25, 20122, Milan, Italy
| | - Elizabeth A Arendt
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
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Kang H, Zheng R, Dai Y, Lu J, Wang F. Single- and double-bundle medial patellofemoral ligament reconstruction procedures result in similar recurrent dislocation rates and improvements in knee function: a systematic review. Knee Surg Sports Traumatol Arthrosc 2019; 27:827-836. [PMID: 30136103 DOI: 10.1007/s00167-018-5112-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 08/10/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate medial patellofemoral ligament (MPFL) reconstruction using hamstring tendon autografts using single-bundle (SB) and double-bundle (DB) techniques, and compare the clinical outcomes including the Kujala score, postoperative apprehension, recurrent subluxation or dislocation, and complications. METHODS The PubMed, Embase, and Cochrane Library databases were searched for relevant literature using the terms ''medial patellofemoral ligament'' and ''MPFL''. The pooled mean values of improvement in the Kujala score were calculated by random effects meta-analysis. Unweighted estimates for the rates of postoperative apprehension, recurrent subluxation or dislocation, and complications were determined by dividing the total number of occurrences by the total number of knees. RESULTS Thirty-one articles were included, involving 1063 patients (1116 knees). Two hundred and forty-four patients (254 knees) underwent SB reconstruction, while 819 patients (862 knees) underwent DB reconstruction. The pooled mean values of Kujala score improvement were similar in the SB group (30.1; 95% CI 26.6-33.6) and DB group (30.7; 95% CI 27.7-33.7). The SB group had a significantly greater rate of postoperative apprehension (7.9%) than the DB group (4.1%; P = 0.014). There were no significant differences between the two groups in the rates of recurrent subluxation or dislocation (1.2 and 1.6%) and complications (10.6 and 7.7%). CONCLUSION With variability in patient populations and surgical techniques, the DB procedure for isolated MPFL reconstruction demonstrates similar outcomes to the SB technique regarding improvement of knee function, recurrent subluxation or dislocation, and complications. The SB technique may have a greater risk of postoperative apprehension, whereas the DB technique may cause more stiffness. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Huijun Kang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China
| | - Rui Zheng
- Department of Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yike Dai
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China
| | - Jiangfeng Lu
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China
| | - Fei Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China.
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No influence of patellar fixation technique on clinical outcomes of double-bundle medial patellofemoral ligament reconstruction: a systematic review. Arch Orthop Trauma Surg 2019; 139:79-90. [PMID: 30046892 DOI: 10.1007/s00402-018-3008-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 02/09/2023]
Abstract
PURPOSE To compare clinical outcomes of double-bundle medial patellofemoral ligament (MPFL) reconstruction with different patellar fixation techniques including Kujala score, functional failure and complications. METHODS Pubmed, Embase, and Cochrane Library databases were searched for studies with clinical results of double-bundle MPFL reconstruction. The hamstring tendon autografts were used, and femoral fixation was performed with bone tunnel and an interference screw, and knee fixation angle was less than or equal to 45°. Patellar fixation methods were broadly categorized into 3 treatment groups: suture anchor (SA), bone tunnel (BT) and suture techniques (SU). Pooled means for Kujala score and pooled estimates for functional failure rate and complication rate were compared. RESULTS 21 studies (23 groups) consisting of 691 knees met the inclusion criteria. 12 groups with 344 knees were in SA group, 5 groups of 161 knees were in BT group and 6 groups with 186 knees were in SU group. Statistically significant differences in Kujala score were found among three groups, 90.2 (95% CI 88.7-91.7) in SA group, 88.7 (95% CI 85.3-92.2) in BT group and 89.4 (95% CI 84.2-94.6) in SU group (all P < 0.001), but these differences were not clinically significant. No statistically significant differences were found in the positive apprehension sign rate, recurrent subluxation or dislocation rate, and major or minor complication rate among three groups. CONCLUSION Patellar fixation with bone tunnel, suture anchor or suture techniques were all effective in the double-bundle MPFL reconstruction. The present systematic review failed to show that one technique was better than the others. More high-quality trials and randomized controlled trials are needed.
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Validation of the German version of the Kujala score in patients with patellofemoral instability: a prospective multi-centre study. Arch Orthop Trauma Surg 2018; 138:527-535. [PMID: 29372384 PMCID: PMC5854722 DOI: 10.1007/s00402-018-2881-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The Kujala score is the most frequently used questionnaire for patellofemoral disorders like pain, instability or osteoarthritis. Unfortunately, we are not aware of a validated German version of the Kujala score. The aim of our study was the translation and linguistic validation of the Kujala score in German-speaking patients with patella instability and the assessment of its measurement characteristics. MATERIALS AND METHODS The German Kujala score was developed in several steps of translation. In addition to healthy controls, the Kujala German was assessed in consecutive patients undergoing reconstruction of the medial patellofemoral ligament for recurrent patellar dislocations. Pre-op, 6 and 12 months postop the patients completed the Kujala German score, the KOOS, the Lysholm score, a VAS Pain, and the SF-12v2 scores. In addition, there was a Kujala German Score retest preop after a 1-week interval. RESULTS We found high reliability in terms of internal consistency for the Kujala score (Cronbach's alpha = 0.87). Convergent validity with the KOOS (symptom r = 0.65, pain r = 0.78, ADL r = 0.74, sports/recreation r = 0.84, quality of life r = 0.70), the Lysholm score (r = 0.88) and the SF-12 physical component summary score (r = 0.79) and VAS pain (r = - 0.71) was also very high. Discriminant validity in terms of correlation with the SF-12 mental component summary Score was satisfactory (r = 0.14). CONCLUSIONS In conclusion, the German version of the Kujala score proved to be a reliable and valid instrument in the setting of a typical patellofemoral disease treated with a standard patellofemoral procedure.
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Joyner PW, Bruce J, Roth TS, Mills FB, Winnier S, Hess R, Wilcox L, Mates A, Frerichs T, Andrews JR, Roth CA. Biomechanical tensile strength analysis for medial patellofemoral ligament reconstruction. Knee 2017; 24:965-976. [PMID: 28684171 DOI: 10.1016/j.knee.2017.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 03/16/2017] [Accepted: 04/25/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is a surgery for acute and chronic dislocating patella. Several surgical techniques have been described. No biomechanical study has compared suture anchors, interference screws, and suspensory cortical fixation for MPFL reconstruction using human gracilis allograft. METHODS Twelve human cadaver knees were used for the analysis of five MPFL reconstruction techniques on the femur (F) and patella (P): suspensory cortical (SC), interference screw (IS) and suture anchor (SA) fixation (SC-F/SC-P, SC-F/IS-P, SC-F/SA-P, IS-F/SC-P, IS-F/IS-P). Each method was examined six times, each using a new human gracilis allograft. The force necessary for 50% patellar displacement and 100% patellar displacement were recorded for each method. Additionally, we examined the peak force to fixation failure for all methods. Patella dislocation or loss of fixation was considered failure. RESULTS SC-F/SC-P, IS-F/SC-P, and SC-F/IS-P required force to failure greater than that of the native MPFL. The SC-F/IS-P required the largest force to failure. The SC-F/SA-P fixation technique required significantly less force to failure (P<0.05) than the native MPFL and significantly less force to failure (P<0.05) than all four other fixation techniques. All methods of fixation employing an interference screw failed secondary to graft pullout at the interference screw-bone interface. Methods employing suture anchors and two suspensory cortical fixations failed at the graft-suture anastomosis. CONCLUSION SC-F/SC-P, IS-F/SC-P, and SC-F/IS-P fixations were found to be stronger than the native MPFL, with the strongest being SC-F/IS-P.
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Affiliation(s)
- Patrick W Joyner
- Bone & Joint/Sports Medicine Institute, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708, United States
| | - Jeremy Bruce
- University of Tennessee - Chattanooga, 1806 Gunbarrel Rd., Chattanooga, TN 37421, United States
| | - Travis S Roth
- 1222 S. Orange Ave., 5th Floor Orthopaedic Institute, Orlando, FL 32806, United States
| | - Frederic Baker Mills
- University of South Carolina School of Medicine, 6311 Garners Ferry Road, Columbia, SC 29209, United States.
| | - Scott Winnier
- The Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Parkway, Gulf Breeze, FL 32561, United States
| | - Ryan Hess
- Twin Cities Orthopedics, 9630 Grove Circle N, #200 Maple Grove, MN 55369, United States
| | - Luke Wilcox
- Michigan State University, 4660 S. Hagadorn Rd., Suite 420, East Lansing, MI 48823, United States
| | - Aaron Mates
- Florida Joint Care Institute, 2165 Little Road, Trinity, FL 34655, United States
| | - Tim Frerichs
- The Orthopedic Group, 1711 North McKenzie Street, Foley, AL 36535, United States
| | - James R Andrews
- The Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Parkway, Gulf Breeze, FL 32561, United States
| | - Charles A Roth
- The Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Parkway, Gulf Breeze, FL 32561, United States
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Mulliez A, Lambrecht D, Verbruggen D, Van Der Straeten C, Verdonk P, Victor J. Clinical outcome in MPFL reconstruction with and without tuberositas transposition. Knee Surg Sports Traumatol Arthrosc 2017; 25:2708-2714. [PMID: 26032604 DOI: 10.1007/s00167-015-3654-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/18/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE There are several surgical options for recurrent patella dislocations. As the reconstruction of the medial patellofemoral ligament (MPFL) has been proven to restore stability, it has become more accepted. Aim of this study was to investigate the clinical outcome after MPFL reconstruction as an isolated procedure or in association with a transposition of the tibial tubercle (in case of patella alta or an excessive TT-TG) in a large prospective cohort study. Additionally, the effect on patellar height was analysed radiographically using the Caton-Deschamps index. METHODS In a large prospective cohort study of 129 knees in 124 patients (81 females, 48 males, mean age 22.8 ± 7.7 years), 91 knees received primary MPFL reconstruction (group 1) and 38 were a combination with a transposition of the tibial tubercle (group 2). The clinical follow-up was evaluated using KOOS and Kujala scores preoperatively and 1 year postoperatively. Patient satisfaction, complications and revision surgery were recorded. RESULTS Overall, Kujala improved significantly from 53.5 (SD 22.7) preoperatively to 74.7 (SD 20.5) postoperatively (p < 0.01). All KOOS subdomains improved significantly (p < 0.01). No significant difference for Kujala score between groups was noticed. Revision rate was (5/129) 3.9 %. Reconstruction was supplemented with a transfer of the tibial tuberosity in (38/129) 29.4 % of the cases and shows a comparable outcome. CONCLUSION MPFL reconstruction is a viable treatment option for episodic patellar dislocation. A concomitant tuberositas transposition is useful in selected patients. LEVEL OF EVIDENCE I.
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Affiliation(s)
- A Mulliez
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - D Lambrecht
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - D Verbruggen
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - C Van Der Straeten
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - P Verdonk
- Department of Physiotherapy and Orthopaedic Surgery, Faculty of Medicine, Ghent University, Ghent, Belgium.,Department of Orthopaedic Surgery, Monica Hospitals, Antwerp, Belgium
| | - J Victor
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
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Lorbach O, Haupert A, Efe T, Pizanis A, Weyers I, Kohn D, Kieb M. Biomechanical evaluation of MPFL reconstructions: differences in dynamic contact pressure between gracilis and fascia lata graft. Knee Surg Sports Traumatol Arthrosc 2017; 25:2502-2510. [PMID: 26820966 DOI: 10.1007/s00167-016-4005-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 01/18/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the knee kinematics of the intact, MPFL-ruptured and MPFL-reconstructed knee and, moreover, to compare dynamic patellofemoral contact pressure of the gracilis tendon and the fascia lata as an alternative graft option for reconstruction of the MPFL. METHODS Eight paired human cadaveric knees were fixed in a custom-made fixation device. Patellofemoral contact pressure was assessed during a dynamic flexion movement at 15°-30°-45°-60°-75° and 90° using a pressure-sensitive film (Tekscan). The medial patellofemoral ligament was cut, and measurements were repeated. Finally, reconstruction of the MPFL was performed using the gracilis tendon (group I) or a fascia lata graft (group II). Tunnel localization was performed under fluoroscopic control. Grafts were fixed at 30° of flexion, and pressure measurements were repeated. RESULTS Incision of the medial patellofemoral ligament significantly reduced patellofemoral contact pressure at 15°, 30° and 45° of knee flexion compared to the intact knee (p < 0.05), whereas reconstruction of the MPFL using either gracilis tendon of the fascia lata was able to restore pressure distributions at 15° and 30° of knee flexion. However, in the hamstring group, reconstruction of the MPFL revealed a significantly reduced contact pressure at 45° of flexion (p = 0.038) compared to the intact knee. In the fascia lata group, a significant reduction in patellofemoral contact pressure was observed after MPFL reconstruction at 45°, 60°, 75° and 90° of knee flexion (p < 0.05). CONCLUSIONS Anatomic reconstruction of the MPFL with either a gracilis or a fascia lata graft showed comparable patellofemoral pressure distributions which were closely restored compared to the native knee. Therefore, the fascia lata has shown to be a viable alternative to the gracilis tendon for reconstruction of the MPFL. However, anatomic reconstruction of the MPFL may lead to persistently altered patellofemoral contact pressure during knee flexion compared to the native knee independent of the tested graft.
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Affiliation(s)
- Olaf Lorbach
- Department of Orthopaedic Surgery, Saarland University, Kirrberger Str, Geb. 37, 66421, Homburg (Saar), Germany.
| | - Alexander Haupert
- Department of Orthopaedic Surgery, Saarland University, Kirrberger Str, Geb. 37, 66421, Homburg (Saar), Germany
| | - Turgay Efe
- Department of Orthopaedic Surgery, Marburg University, Marburg, Germany
| | - Antonius Pizanis
- Department of Trauma-Hand and Reconstructive Surgery, Saarland University, Homburg (Saar), Germany
| | - Imke Weyers
- Institute of Anatomy, Lübeck University, Lübeck, Germany
| | - Dieter Kohn
- Department of Orthopaedic Surgery, Saarland University, Kirrberger Str, Geb. 37, 66421, Homburg (Saar), Germany
| | - Matthias Kieb
- Department of Orthopaedic and Trauma Surgery, Klinikum Ernst von Bergmann, Potsdam/Bad Belzig, Germany
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Hohn E, Pandya NK. Does the Utilization of Allograft Tissue in Medial Patellofemoral Ligament Reconstruction in Pediatric and Adolescent Patients Restore Patellar Stability? Clin Orthop Relat Res 2017; 475:1563-1569. [PMID: 27590642 PMCID: PMC5406326 DOI: 10.1007/s11999-016-5060-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is one of several surgical procedures used to treat patellofemoral instability. Use of allograft tissue can preserve autogenous tissue and may be preferable in patients with connective tissue disorders or ligamentous laxity. Although there are successful reports in adults, it is unclear if the use of allograft tissue in MPFL reconstruction can restore patellofemoral stability in children and adolescents. QUESTIONS/PURPOSES (1) Does allograft tissue in MPFL reconstruction in pediatric and adolescent patients restore patellar stability? (2) What complications were associated with allograft MPFL reconstructions in children and adolescents? METHODS Between June 2012 and August 2015, one surgeon (NKP) performed 26 MPFL reconstructions in 23 patients with gracilis allograft for traumatic patellar instability. Of those, 25 (96%) were available for followup more than 1 year later (mean, 24 months; range, 12-44 months). During this time, the surgeon suggested reconstruction to patients who had recurrent dislocation or subluxation after 6 weeks of bracing, physical therapy, and activity modification if they were noted to have a torn or attenuated MPFL on MRI. During that period, this was the only surgical technique the surgeon used to treat traumatic patellar instability. Patients undergoing concurrent bony procedures were ineligible for inclusion. The mean age of the patients in the series was 16.0 (± 2) years. Age, sex, skeletal maturity, presence of trochlear dysplasia, and additional arthroscopic procedures at the time of reconstruction were collected. Postoperative notes and imaging were reviewed for presence of complications defined as recurrent dislocation, recurrent subluxations, fractures, infection, or arthrofibrosis. These complications were identified by chart review by the senior surgeon (NKP) and study personnel (EH) not involved in clinical care of the patients or by patient-reported complications. Recurrent subluxation or dislocation was patient-reported at the time of the clinic visit or followup phone/email contact. Fractures were defined as any cortical disruption in the femur or patella that required treatment (change in postoperative protocol), infection requiring treatment (antibiotics and/or return to the operating room), or arthrofibrosis (stiffness that necessitated a change in the postoperative protocol or manipulation under anesthesia). RESULTS Ninety-two percent (23 of 25) of patients reported no further instability episodes after MPFL reconstruction. Sixteen percent (four of 25) of patients had complications: two repeat episodes of patellar instability, one patella fracture, and one symptomatic hardware requiring interference screw removal. No patients developed arthrofibrosis or infection. CONCLUSIONS In this small case series, we found that MPFL reconstruction using allograft tissue in children and adolescents resulted in a low risk of recurrent instability, perhaps comparable to what has been published by others who have used autograft tissue. Longer followup is needed, because in some orthopaedic applications, allograft ligaments have been observed to attenuate over time. Future studies might compare these techniques using patient-reported outcomes scores as well as use a control group of patients with autograft tissue. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Eric Hohn
- San Francisco Orthopaedic Residency Program, San Francisco, CA USA
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California San Francisco, UCSF Benioff Children’s Hospital Oakland, 747 52nd Street, Oakland, CA 94605 USA
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Schiphouwer L, Rood A, Tigchelaar S, Koëter S. Complications of medial patellofemoral ligament reconstruction using two transverse patellar tunnels. Knee Surg Sports Traumatol Arthrosc 2017; 25:245-250. [PMID: 27405577 DOI: 10.1007/s00167-016-4245-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/06/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to report the complication rate after a medial patellofemoral ligament (MPFL) reconstruction using transverse patellar tunnels in a retrospective case series performed in a single institution. METHODS Case series of 179 patients (192 knees) that had an MPFL reconstruction, with or without additional bony realignment procedures, between January 2009 and March 2015. Data were obtained from available patient charts. RESULTS Thirty-nine complications (20.3 %) were registered. Twenty-seven of these (14.7 %) were minor. Seven patients (3.6 %) sustained a patellar fracture without adequate trauma. Male gender was a risk factor for patellar fracture (p < 0.001). Sixteen (8.1 %) reported recurrence of instability, of whom 10 (5.1 %) were defined as objective instability (reported dislocation and positive apprehension test). CONCLUSION This is largest patient series to date in which the complications after a two tunnel MPFL reconstruction are described. The use of transverse patellar tunnels increases the risk of sustaining a patellar fracture. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Loes Schiphouwer
- Department of Orthopedic Surgery, Canisius-Wilhelmina Ziekenhuis, PO Box 9015, 6500 GS, Nijmegen, The Netherlands.
| | - Akkie Rood
- Department of Orthopedic Surgery, Canisius-Wilhelmina Ziekenhuis, PO Box 9015, 6500 GS, Nijmegen, The Netherlands
| | - Siebren Tigchelaar
- Department of Orthopedic Surgery, Canisius-Wilhelmina Ziekenhuis, PO Box 9015, 6500 GS, Nijmegen, The Netherlands
| | - Sander Koëter
- Department of Orthopedic Surgery, Canisius-Wilhelmina Ziekenhuis, PO Box 9015, 6500 GS, Nijmegen, The Netherlands
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Sadigursky D, de Melo Laranjeira MS, Nunes M, Caneiro RJF, Colavolpe PO. Reconstrução do ligamento patelofemoral medial pela técnica anatômica do duplo‐feixe com âncoras metálicas. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Sadigursky D, de Melo Laranjeira MS, Nunes M, Caneiro RJF, Colavolpe PO. Reconstruction of the medial patellofemoral ligament by means of the anatomical double-bundle technique using metal anchors. Rev Bras Ortop 2016; 51:290-7. [PMID: 27274482 PMCID: PMC4887436 DOI: 10.1016/j.rboe.2015.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/30/2015] [Indexed: 01/16/2023] Open
Abstract
Objective To evaluate double-bundle reconstruction of the medial patellofemoral ligament (MPFL) using a graft from the semitendinosus tendon and fixation with metal anchors over the medium term. Methods This was a prospective cross-sectional study. After approval from the research ethics committee, 31 patients with patellofemoral instability who underwent MPFL reconstruction by means of the anatomical double-bundle technique, with fixation using metal anchors, were analyzed between May 2010 and January 2015. To evaluate the effectiveness of the MPFL reconstruction surgery, the Kujala scale and the Tegner–Lysholm score were assessed before the procedure and one year afterwards, along with clinical data such as pain levels, range of motion and J sign. The data were tabulated in the Excel® software and were analyzed using the SPSS Statistics® software, version 21. The statistical analysis was performed using the Wilcoxon T test and the McNemar test. Results The mean preoperative score from the Kujala test was 45.64 ± 1.24 and the postoperative score was 94.03 ± 0.79 (p < 0.001). The preoperative Tegner–Lysholm score was 40.51 ± 1.61 and the postoperative score was 91.64 ± 0.79 (p < 0.001). The preoperative range of motion was 125.96 ± 2.11 and the postoperative range was 138.38 ± 1.49 (p < 0.05). Conclusion MPFL reconstruction by means of the anatomical double-bundle technique is easily reproducible, without episodes of recurrence, with satisfactory results regarding restoration of stability and function of the patellofemoral joint.
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Affiliation(s)
- David Sadigursky
- Clínica Ortopédica Traumatológica, Salvador, BA, Brazil; Faculdade de Tecnologia e Ciências, Salvador, BA, Brazil
| | | | - Marzo Nunes
- Clínica Ortopédica Traumatológica, Salvador, BA, Brazil
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Khemka A, Lord SJ, Doyle Z, Bosley B, Al Muderis M. Minimally invasive medial patellofemoral ligament reconstruction for patellar instability using an artificial ligament: A two year follow-up. Knee 2016; 23:261-6. [PMID: 26275579 DOI: 10.1016/j.knee.2015.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 06/18/2015] [Accepted: 07/01/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recurrence of acute patellar dislocation affects approximately 30% of individuals, and up to 75% of those with grade IV instability. The medial patellofemoral ligament (MPFL) is considered to be critical for patellar stabilization. MPFL reconstruction with allografts has been proposed to reduce risk of recurrence, but there is limited evidence about the safety and effectiveness of techniques using synthetic allografts. METHODS We present a retrospective case series of 29 individuals who underwent a MPFL reconstruction between 2009 and 2012, using an artificial ligament for patellar instability by a single surgeon. Clinical, radiological and functional outcomes were measured at a minimum of 24 months. RESULTS 31 knees (29 individuals) were followed up for a median of 43 (range: 24-68) months. Using the Crosby and Insall grading system, 21 (68%) were graded as excellent, nine (29%) were good, one (3%) as fair and none as worse at 24 months. The mean improvement in Lysholm knee score for knee instability was 68 points (standard deviation 10). Ligamentous laxity was seen in 17 (55%) of individuals. In this subset, 12 were graded as excellent, four as good and one as fair. The mean improvement in patellar height was 11% at three months follow-up. All knees had a stable graft fixation with one re-dislocation following trauma. CONCLUSIONS We propose a minimally invasive technique to reconstruct the MPFL using an artificial ligament allowing early mobilization without bracing. This study indicates the procedure is safe, with a low risk of re-dislocation in all grades of instability. LEVEL OF EVIDENCE Level IV Case Series.
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Affiliation(s)
- Aditya Khemka
- School of Medicine, University of Notre Dame Australia; Norwest Private Hospital, Australia.
| | - Sarah J Lord
- School of Medicine, University of Notre Dame Australia; National Health and Medical Research Council (NHMRC) Clinical Trials Centre, The University of Sydney, Australia.
| | - Zelda Doyle
- Rural Clinical School, University of Notre Dame Australia, Australia.
| | - Belinda Bosley
- Rural Clinical School, University of Notre Dame Australia, Australia.
| | - Munjed Al Muderis
- School of Medicine, University of Notre Dame Australia; Norwest Private Hospital, Australia; The Australian School of Advanced Medicine, Macquarie University, Australia.
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Zhang N, Jiang Z, Wen X, Sugamoto K, Yang C. The triangle zone as a femoral attachment location in medial patellofemoral ligament reconstruction: An in vivo three-dimensional analysis using an open MRI scanner. Knee 2015; 22:585-90. [PMID: 26277882 DOI: 10.1016/j.knee.2015.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/02/2015] [Accepted: 04/15/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The exact isometric points for medial patellofemoral ligament (MPFL) fixation during MPFL reconstruction remain a matter of debate. PURPOSE The aim of this study was to characterize the functional length changes of various patellar and femoral fixation sites using in vivo three-dimensional (3D) movement patterns and to determine the ideal fixation sites at which the graft remains largely isometric. METHODS Twelve right knees of healthy volunteers were examined at early flexion angles (0°, 10°, 20°, 30°, 40°, 50°, and 60°) with a horizontal-type open magnetic resonance scanner, and 3D models were reconstructed using the marching cubes algorithm. Six points on the femoral condyle and three points on the medial aspect of the patella were simulated. The matching points represented the MPFL, which crossed the bony obstacle. The MPFL length changes were analyzed at various flexion degrees. RESULTS The lengths from the dome of Blumensaat's line (G), the point 10mm inferior to the adductor tubercle (H), to the midpoint between the adductor tubercle and the medial epicondyle (I) were more isometric than other points. The lengths between the dome of Blumensaat's line and the superior pole of the patella changes significantly between 20° and 60° of flexion (p=0.040). CONCLUSIONS The femoral fixation site may be more accurately located during MPFL reconstruction at the G, H, and I points to restore the native biomechanical function of the MPFL. The dome of Blumensaat's line should be avoided during MPFL reconstruction with the superficial quad technique. CLINICAL RELEVANCE A triangular region composed of the dome of Blumensaat's line, 10mm inferior to the adductor tubercle, and the midpoint between the adductor tubercle and medial epicondyle is recommended as the femoral fixation site.
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Affiliation(s)
- Ning Zhang
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Xinmin Street No.71, Changchun, China.
| | - Zhengang Jiang
- School of Computer Science and Technology, Changchun University of Science and Technology, Weixing Street No.7089, Changchun, China.
| | - Xiaoyu Wen
- Department of Hepatology, The First Hospital of Jilin University, Xinmin Street No.71, Changchun, China.
| | - Kazuomi Sugamoto
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka 565-0871, Japan.
| | - Chen Yang
- Department of Orthopaedic Surgery, The First Hospital of Jilin University, Xinmin Street No.71, Changchun, China.
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Medial Patellofemoral Ligament Reconstruction in a Below-Knee Amputee. Case Rep Orthop 2015; 2015:429463. [PMID: 26579321 PMCID: PMC4633562 DOI: 10.1155/2015/429463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/30/2015] [Accepted: 10/08/2015] [Indexed: 01/16/2023] Open
Abstract
Patellar instability is a common finding in patients with below-knee amputation and yet management options are not commonly described in the literature. We describe the first reported case of a medial patellofemoral ligament reconstruction using allograft in a patient with a below-knee amputation. Clinical outcome at two-year follow-up remains very good.
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Gausden EB, Fabricant PD, Taylor SA, McCarthy MM, Weeks KD, Potter H, Shubin Stein B, Green DW. Medial Patellofemoral Reconstruction in Children and Adolescents. JBJS Rev 2015; 3:01874474-201510000-00002. [DOI: 10.2106/jbjs.rvw.n.00091] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Rood A, Hannink G, Lenting A, Groenen K, Koëter S, Verdonschot N, van Kampen A. Patellofemoral Pressure Changes After Static and Dynamic Medial Patellofemoral Ligament Reconstructions. Am J Sports Med 2015; 43:2538-44. [PMID: 26283233 DOI: 10.1177/0363546515594447] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reconstructing the medial patellofemoral ligament (MPFL) has become a key procedure for stabilizing the patella. Different techniques to reconstruct the MPFL have been described: static techniques in which the graft is fixed rigidly to the bone or dynamic techniques with soft tissue fixation. Static MPFL reconstruction is most commonly used. However, dynamic reconstruction deforms more easily and presumably functions more like the native MPFL. PURPOSE/HYPOTHESIS The aim of the study was to evaluate the effect of the different MPFL fixation techniques on patellofemoral pressures compared with the native situation. The hypothesis was that dynamic reconstruction would result in patellofemoral pressures closer to those generated in an intact knee. STUDY DESIGN Controlled laboratory study. METHODS Seven fresh-frozen knee specimens were tested in an in vitro knee joint loading apparatus. Tekscan pressure-sensitive films fixed to the retropatellar cartilage measured mean patellofemoral and peak pressures, contact area, and location of the center of force (COF) at fixed flexion angles from 0° to 110°. Four different conditions were tested: intact, dynamic, partial dynamic, and static MPFL reconstruction. Data were analyzed using linear mixed models. RESULTS Static MPFL reconstruction resulted in higher peak and mean pressures from 60° to 110° of flexion (P < .001). There were no differences in pressure between the 2 different dynamic reconstructions and the intact situation (P > .05). The COF in the static reconstruction group moved more medially on the patella from 50° to 110° of flexion compared with the other conditions. The contact area showed no significant differences between the test conditions. CONCLUSION After static MPFL reconstruction, the patellofemoral pressures in flexion angles from 60° to 110° were 3 to 5 times higher than those in the intact situation. The pressures after dynamic MPFL reconstruction were similar as compared with those in the intact situation, and therefore, dynamic MPFL reconstruction could be a safer option than static reconstruction for stabilizing the patella. CLINICAL RELEVANCE This study showed that static MPFL reconstruction results in higher patellofemoral pressures and thus enhances the chance of osteoarthritis in the long term, while dynamic reconstruction results in more normal pressures.
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Affiliation(s)
- Akkie Rood
- Department of Orthopaedics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerjon Hannink
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anke Lenting
- Department of Orthopaedics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karlijn Groenen
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sander Koëter
- Department of Orthopedic Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Nico Verdonschot
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands Laboratory of Biomechanical Engineering, University of Twente, Enschede, the Netherlands
| | - Albert van Kampen
- Department of Orthopaedics, Radboud University Medical Center, Nijmegen, the Netherlands
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Astur DC, Gouveia GB, Borges JHDS, Astur N, Arliani GG, Kaleka CC, Cohen M. Medial Patellofemoral Ligament Reconstruction: A Longitudinal Study Comparison of 2 Techniques with 2 and 5-Years Follow-Up. Open Orthop J 2015; 9:198-203. [PMID: 26161157 PMCID: PMC4493629 DOI: 10.2174/1874325001509010198] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/07/2015] [Accepted: 04/19/2015] [Indexed: 11/28/2022] Open
Abstract
Background : The purpose of this study was to compare the results of two popular surgical techniques for medial patellofemoral ligament MPFL reconstruction with a minimum of two-year follow-up. Methods : Fifty-eight patients with traumatic tear of the medial patellofemoral ligament were included in one of the two surgical groups. Group 1 MPFLs were reconstructed through graft endobutton fixation and Group 2 through graft anchor fixation into the patella. After two to five-year follow-up, patients were asked to answer knee function questionnaires (Fulkerson and Kujala) as well as the SF-36 life quality score. Results : There were no statistical difference among postoperative Kujala, Fulkerson, and SF-36 questionnaires scores between Groups 1 and 2. There were statistical significant differences favorable to patients in Group 1 with a shorter follow-up length (2-5 years) compared to those with a longer period of 5-10 years for both Kujala and Fulkerson scores and no difference for group 2. Conclusion : Both medial patellofemoral ligament reconstruction techniques had similar results in a two to ten-year follow-up according to functions and life quality questionnaires. Furthermore, endobutton fixation for the patellar edge of the graft had better results in patients with 2 years of follow-up than those with 5 years. Gender was not significant for surgical results. Moreover, group 1 patients had higher number of complications.
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Affiliation(s)
- Diego C Astur
- Centro de Traumatologia do Esporte do Departamento de Ortopedia e Traumatologia da Escola Paulista de Medicina/ Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Nelson Astur
- Faculdade de Ciencias Médicas da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Gustavo G Arliani
- Centro de Traumatologia do Esporte do Departamento de Ortopedia e Traumatologia da Escola Paulista de Medicina/ Universidade Federal de São Paulo, São Paulo, Brazil
| | - Camila C Kaleka
- Faculdade de Ciencias Médicas da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Moises Cohen
- Departamento de Ortopedia e Traumatologia da Escola Paulista de Medicina/ Universidade Federal de São Paulo, São Paulo, Brazil
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Becher C, Kley K, Lobenhoffer P, Ezechieli M, Smith T, Ostermeier S. Dynamic versus static reconstruction of the medial patellofemoral ligament for recurrent lateral patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2014; 22:2452-7. [PMID: 24781275 DOI: 10.1007/s00167-014-3020-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 04/13/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare clinical and radiological outcomes of static and dynamic medial patellofemoral ligament (MPFL) reconstruction techniques. METHODS In a retrospective, matched-paired, cohort analysis, 30 patients surgically treated for recurrent lateral patellar dislocation were divided into two groups of 15 patients matched for inclusion and exclusion criteria. The static technique group underwent rigid fixation of the gracilis tendon at the anatomic femoral MPFL insertion and the superomedial border of the patella; the dynamic technique group underwent detachment of the gracilis tendon at the pes anserinus with fixation to the proximal medial patellar margin via tunnel transfer obliquely through the patella. Kujala, Lysholm, and Tegner scores; pain level; and pre- and postoperative radiographic changes of patellar height, patellar tilt, and bisect offset were compared. RESULTS No significant between-group differences were found in mean Kujala, Tegner, Lysholm, or visual analogue scale scores or radiographic parameters. One case of resubluxation was observed in the dynamic group. All but one patient in each group would have been willing to undergo the procedure again. CONCLUSIONS Both techniques provided satisfactory short-term outcomes. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Christoph Becher
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany,
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