Arthroscopically Assisted Double-Bundle Reconstruction Technique for Medial Patellofemoral Ligament

Isolated Medial Patellar Femoral Ligament Reconstruction for Recurrent Patella Dislocation: A Prospective Cohort Study

What's New in Sports Medicine.

Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction (SS-76)

Background: Many factors are involved in causing patellar instability or recurrent patellar dislocations. However, factors affecting the outcomes of anatomic medial patellofemoral ligament (MPFL) reconstruction have not been fully documented. Purpose: To evaluate the rate of recurrent patellar instability after isolated MPFL reconstruction and to elucidate factors affecting the outcomes of isolated MPFL reconstruction using multivariable statistics. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 42 patients (44 knees) who underwent isolated, anatomic MPFL reconstruction using a semitendinosus autograft without any additional patellar stabilization procedures for treating recurrent patellar dislocations were included in this study. All patients were followed for more than 2 years; the mean follow-up period was 3.2 years (range, 2-9 years). Postoperative patellofemoral instability was diagnosed when the patient complained of recurrent patellar subluxations or dislocations or had a positive apprehension sign during follow-up. Preoperative radiographic findings were obtained using plain radiography and computed tomography. Femoral tunnel positions were assessed on postoperative radiographs. The strength of the relationship between postoperative patellofemoral instability and potential risk factors such as preoperative age, sex, body mass index, patellar type, sulcus angle, congruence angle, lateral tilt angle, patellar height, tibial tubercle–trochlear groove (TT-TG) distance, degree of trochlear dysplasia, and femoral bone tunnel position were evaluated by univariate and multivariate logistic regression analyses. Results: At follow-up, 2 knees had experienced a redislocation (4.5%). A positive apprehension sign was still evident in 8 knees (18.2%). Three factors, including the sulcus angle, the congruence angle, and trochlear dysplasia, were extracted by single linear regression analysis. Univariate logistic regression analysis showed that the sulcus angle (odds ratio [OR], 1.11; 95% CI, 1.01-1.22; P = .04) and trochlear dysplasia (OR, 3.04; 95% CI, 1.39-6.63; P = .01) were associated with postoperative patellofemoral instability. Trochlear dysplasia was independently associated with postoperative patellofemoral instability by multivariable logistic regression analysis (P < .05). An increased TT-TG distance exerted a significant effect on the outcomes of MPFL reconstruction, particularly in patients with type D trochlea. Conclusion: Severe trochlear dysplasia is the most important predictor of residual patellofemoral instability after isolated MPFL reconstruction. In addition, an increased TT-TG distance affected the outcomes in patients with type D trochlea. Additional patellar stabilization procedures should be considered for patients with severe trochlear dysplasia and an increased TT-TG distance.

Objective To explore the technique and efficacy of the arthroscopic reconstruction of medial patellofemoral ligament (MPFL) combined with adductor magnus tendon autograft in treatment of recurrent dislocation of patella(RDP) in children.Methods Six cases of RDP were treated using arthroscopic reconstruction of MPFL combined with adductor magnus tendon autogmft beween Jan 2007to Jul 2010.The condition of patellofemoral joint and MPFL were detected with X-ray,CT and MRI preoperatively.The arthroscopic exanination was conducted before reconstruction to observe pateltofemoral congruence and patellar track,as well as articular cartilage.The MPFL was reconstructed followed by adductor magnus tendon autograft.Then arthroscopic examination was taken again for measurement of patellofemoral congruence and patellar track after surgery.Function training of knee joint was applied and subjective symptoms were further scored postoperatively.Results No infection,graft rejection and rupture were seen in all cases.Patients were followed up for 12-36 months (Average 18 months).Lysholm scores showed an improvement from 76.7 ± 8.7 in pre-surgery to 95.6 ± 5.7 ( P =0.000) in post-surgery.X-ray detection indicated excellent patella reduction without recurrence of dislocation or subluxaion.Conclusions The reconstruction of medial patellofemoral ligament (MPFL) combined with adductor magnus tendon autograft,is effective approach to treat RDP. Key words: Patellar dislocation; Patellar ligament; Arthroscopy

Reconstruction of the Medial Patellofemoral Ligament Using the Adductor Magnus Tendon

Patellar instability is a common clinical problem encountered in orthopaedics. Double-bundle medial patellofemoral ligament (MPFL) reconstruction has become the most popular technique in MPFL reconstructions. However, the optimal method for graft fixation onto the patella remains controversial. In this article, we propose a new technique for double-bundle MPFL reconstruction using a custom-designed instrument. By using a Swan sagittal aimer to drill sagittal tunnels, two L-shaped tunnels are created. Double-bundle reconstruction is then performed. This technique makes the procedure more controllable, while retaining characteristics of an anatomic double-bundle MPFL reconstruction. We believe the technique of MPFL double-bundle reconstruction using a double L-shaped medial patellar tunnel is a new approach that is able to achieve stable and satisfactory results.

Background:Several fixation methods have been introduced in medial patellofemoral ligament (MPFL) reconstruction. However, the optimal management of patients with recurrent patellar dislocation remains controversial.Purpose:To present a case series with a minimum 2-year follow-up of 29 patients with recurrent patellar dislocation who underwent a new transosseous suture fixation technique for MPFL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:From January 2014 through February 2016, a total of 29 patients with recurrent patellar dislocation for which the MPFL was reconstructed with transosseous suture patellar fixation were studied. All patients were available for follow-up (mean, 37.52 months; range, 26-48 months). The patellar attachment was fixed by transosseous patellar sutures. The International Knee Documentation Committee (IKDC) subjective knee score, Kujala score, Tegner score, range of motion, congruence angle, patellar tilt angle, and complications were assessed both pre- and postoperatively.Results:No recurrent dislocation was observed in any of the 29 patients for a minimum of 2 years. All outcome scores improved significantly from preoperatively to postoperatively: the average IKDC subjective knee evaluation score from 53 to 87, Kujala from 54 to 90, Lysholm from 50 to 89, and Tegner from 3 to 5 (P < .001 for all). The congruence angle significantly decreased from 22° preoperatively to –3° postoperatively, and the patellar tilt angle (Merchant) decreased from 23° preoperatively to 5° postoperatively (P < .001 for both). In total, 25 patients (25/29; 86.21%) were completely pain-free when performing activities of daily living at the last follow-up, and 27 patients (93.1%) rated themselves as very satisfied or satisfied with the results.Conclusion:In patients with chronic recurrent patellar dislocation, transosseous patellar suture fixation for MPFL reconstruction can significantly improve patellar stability and achieve good results at short-term follow-up.

To evaluate the effect of medial patellofemoral ligament (MPFL) reconstruction with or without lateral retinacular release (LRR) on patellar height in patients with recurrent patellar dislocation (RPD). It was hypothesised that the addition of LRR would not significantly modify patellar height compared with isolated MPFL reconstruction. This prospective, single-blinded randomised controlled trial was conducted between 2011 and 2022. Patients aged 18-45 years with RPD were randomised into two groups: isolated MPFL reconstruction and MPFL reconstruction with associated LRR. Exclusion criteria included previous surgery on the same knee, concomitant bony procedures, or prior contralateral MPFL reconstruction. All patients were evaluated by blinded investigators. The primary outcome was patellar height measured by the Caton-Deschamps Index (CDI) on standardised lateral radiographs obtained at a minimum of 1 year after surgery. Out of 140 enrolled patients, 107 completed the study, with 59 in the LRR group and 48 in the isolated MPFL group. The preoperative CDI was similar in both groups (1.32 [±0.168] in the LRR group and 1.29 [±0.163] in the isolated MPFL group), and postoperative CDI showed a significant decrease in patellar height in both groups (1.1 [±0.133] in the LRR group and 1.1 [±0.166] in the isolated MPFL group), with a mean follow-up of 12.5 ± 0.3 months, with no significant difference between them. A statistically significant reduction in CDI of 0.2 was observed in both groups. Adding LRR to MPFL reconstruction has no effect on patellar height. Caton Deschamps Index demonstrated a mean decrease of 0.2 after MPFL reconstruction, with or without LRR. Level II, low-powered randomised clinical trial.

Allograft Versus Autograft for Medial Patellofemoral Ligament Reconstruction

The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted by lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring the MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair; however, long-term comparative studies are limited. To compare long-term clinical outcomes, complications, and recurrence rates of isolated MPFL reconstruction and MPFL repair for recurrent lateral patellar instability. Cohort study; Level of evidence, 3. A total of 55 patients (n = 58 knees) with recurrent lateral patellar instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. The exclusion criteria were previous or concomitant tibial tubercle osteotomy or trochleoplasty and follow-up of <8 years. Pre- and postoperative descriptive, surgical, imaging, and clinical data were recorded for each patient. MPFL repair was performed on 26 patients (n = 29 knees; 14 women, 15 men), with a mean age of 18.4 years. MPFL reconstruction was performed on 29 patients (n = 29 knees; 18 women, 11 men), with a mean age of 18.2 years. At a mean follow-up of 12 years (range, 8.3-18.9 years), the reconstruction group had a significantly lower rate of recurrent dislocation compared with the repair group (14% vs 41%; P = .019). There were no differences in the number of preoperative dislocations or tibial tubercle-trochlear groove distance. The reconstruction group had significantly more time from initial injury to surgery compared with the repair group (median, 1460 days vs 627 days; P = .007). There were no differences in postoperative Tegner, Lysholm, or Kujala scores at the final follow-up. In addition, no statistically significant differences were detected in return to sport (RTS) rates (repair [81%] vs reconstruction [75%]; P = .610) or reoperation rates for recurrent instability (repair [21%] vs reconstruction [7%]; P = .13). MPFL repair resulted in a nearly 3-fold higher rate of recurrent patellar dislocation (41% vs 14%) at the long-term follow-up compared with MPFL reconstruction. Given this disparate rate, the authors recommend MPFL reconstruction over repair because of the lower failure rate and similar, if not superior, clinical outcomes and RTS.

Background Patellar instability is a complex pathoanatomical phenomenon that requires an intricate understanding in order to properly treat patients. Often, the etiology of this entity is multifactorial, and can be the result of a combination of coronal limb malalignment, patella alta, malrotation secondary to internal femoral or external tibial torsion, a dysplastic trochlea, or disrupted and weakened medial soft tissue, including the medial patellofemoral ligament (MPFL) and the vastus medialis obliquus. Objective To review the currently available different modalities for management of recurrent patellar dislocation. This Review will analyze results concerned with Patellar instability to reach the most efficient modality that gives the best results. Material and Methods This systematic review study based on inclusion and exclusion criteria conducted to evaluate the outcome of different techniques of medial patellofemoral ligament reconstruction analyzing their efficacy and possible complications. This systematic review demonstrates that MPFL surgery for recurrent patellar dislocation isolated or in combination with other procedures results in a significant improvement in Kujala scores, a low redislocation rate, and an acceptable complication rate. Despite this, there is no consensus on indications for MPFL reconstruction, graft type, surgical technique, and rehabilitation program. The inclusion criteria for future studies were highly important, and consensus agreement within an expert panel should be sought prior to undertaking such a study. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2021. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Results Several fixation methods have been introduced in medial patellofemoral ligament (MPFL) reconstruction. However, the optimal management of patients with recurrent patellar dislocation remains controversial. This short-term study showed that after MPFL reconstruction (suture anchors or transosseous sutures), patellar stability could be restored. And no significant differences in outcome scores were observed between patients in the transosseous suture and suture anchor groups. Conclusion Evaluate the outcome of different techniques of medial patellofemoral ligament reconstruction analyzing their efficacy and possible complications.

Objectives:Medial patellofemoral ligament (MPFL) reconstruction is commonly performed in patients with recurrent patellar dislocations and associated instability. However, though general outcomes and when to perform concomitant surgical procedures such as a tibial tubercle osteotomy (TTO) have been studied, there remains limited information on the effects of underlying mental health conditions on baseline and post-operative outcome measures. Given the rising prevalence and number of undiagnosed number of patients with mental health conditions such as major depressive disorder (MDD), recognition that patients with chronic, recurrent patellar dislocations who require MPFL reconstruction may be at risk for inferior post-operative outcomes if they also have a mental health disorder. The purpose of this study is to assess how mental health disorders such as MDD or unrecognized depression can affect pre- and post-operative outcomes in patients undergoing MPFL.Methods:A retrospective, IRB approved review of patients undergoing MPFL reconstruction from 2015 to 2023 was performed. Demographic data, presence of diagnosed mental health disorders, complications, and Patient Reported Outcomes Measurement Information Systems (PROMIS) scores related to their procedure were collected. Exclusion criteria included patients aged <10 or >75 years, or those with incomplete PROMIS data. Patients without a formal diagnosis of MDD, but with a pre-op PROMIS-Dep score greater than or equal to 52.5 were considered PROMIS-Depressed. Kruskal-Wallis and chi-squared tests were used to compare continuous and categorical cohort descriptive statistics respectively. Logistic and mixed-effects regression were used to investigate the association between PROMIS T-scores and mental health disorders while adjusting for confounding patient and surgical variables.Results:187 patients met inclusion criteria. Descriptives of cohort variables tabulated by formal mental health disorder assessment are shown in Table 1. Patients with a mental health disorder were more likely to have an underlying connective tissue disease and require longer follow-up (512 vs 713 days, p <0.05). The presence of a mental health disorder led to significantly worse pre-and post-operative PROMIS scores, however there were no differences in the change in PROMIS scores after surgery nor was there a difference in ability to achieve MCID. Relative to patients without any mental health disorder, MDD patients and those PROMIS-depressed reported significantly worse pre- and post-operative PROMIS scores, with those who were PROMIS- depressed particularly doing worse (Figure 1). However, there were no differences in the change in PROMIS scores after surgery (despite depressed and PROMIS-depressed patients having more room for improvement), nor was there a difference in odds of achieving MCID (Figure 2). Regression analysis showed an association between underlying mental health disorders or need for additional procedures and worse average PROMIS scores in all domains. This was also seen with PROMIS-depressed patients, however presence of connective tissue disorders led to worse PROMIS-PI scores in this patient population. In addition, the odds of a reported complication or need to have a contralateral MPFL procedure were higher in patients requiring TTO. Increased age was associated with worse PROMIS-PI and PF scores. Partial correlation of the odds of needing MPFL on the contralateral extremity weakly correlated with lower odds of PROMIS-PI MCID achievement.Conclusions:The most important finding in our study is that underlying mental health disorders do not affect odds of achieving MCID after undergoing MPFL, however they do lead to worse pre- and post-operative PROMIS scores and prevented patients from deriving more improvement from their surgery. This finding was exacerbated in patients who were PROMIS-depressed. Overall, our cohort improved with surgery, but both diagnosed and undiagnosed MDD adversely affects patients who undergo MPFL reconstruction. Requiring a TTO or having an underlying connective tissue disorders may present as additional risk factors. These findings highlight the importance of identifying and addressing mental health in this patient population, especially given the number of patients who did require contralateral MPFL (with subsequently longer recovery times) and therefore may be susceptible to inferior long-term physical function.

CORR Synthesis: Can Guided Growth for Angular Deformity Correction Be Applied to Management of Pediatric Patellofemoral Instability?

We report on three cases of recurrent lateral patellar dislocation following a medial patellofemoral ligament (MPFL) reconstruction for patellar instability. In all three cases, an isolated MPFL reconstruction was performed with a double autogenous gracilis graft. The patellar fixation was done through bone tunnels. All three patients presented with a definite moderate to severe traumatic episode resulting in a recurrent patella dislocation and a transverse avulsion fracture at the medial rim of the patella. All three were treated by an open reduction and internal fixation with good results. No complication or recurrent dislocations occurred. We suggest that this complication is caused by the original underlying pathology such as dysplastic trochlea, abnormal TT-TG, patella alta and hyperlaxity, resulting a greater reliance upon the reconstructed MPFL for patellar stability. When subjected to a severe stress, the graft, which is stronger and stiffer than the original MPFL, will cause a fracture through the medial edge of the patella. This weak area results from the previous drill holes, which act as stress risers.