Evaluation of Patellar Contact Pressure Changes after Static versus Dynamic Medial Patellofemoral Ligament Reconstructions Using a Finite Element Model

Vicente Sanchis-Alfonso,Diego Alastruey-López,María Angeles Pérez,Erik Montesinos-Berry,Joan Carles Monllau,Gerard Ginovart,Angel Alberich-Bayarri

doi:10.3390/jcm8122093

Abstract

Objectives: To evaluate the effect of various medial patellofemoral ligament (MPFL) fixation techniques on patellar pressure compared with the native knee. Methods: A finite element model of the patellofemoral joint consisting of approximately 30,700 nodes and 22,200 elements was created from computed tomography scans of 24 knees with chronic lateral patellar instability. Patellar contact pressures and maximum MPFL graft stress at five positions of flexion (0°, 30°, 60°, 90°, and 120°) were analyzed in three types of MPFL reconstruction (MPFLr): (1) static/anatomic, (2) dynamic, using the adductor magnus tendon (AMT) as the femoral fixation, and (3) dynamic, using the quadriceps tendon as the attachment (medial quadriceps tendon-femoral ligament (MQTFL) reconstruction). Results: In the static/anatomic technique, the patellar contact pressures at 0° and 30° were greater than in the native knee. As in a native knee, the contact pressures at 60°, 90°, and 120° were very low. The maximum MPFL graft stress at 0° and 30° was greater than in a native knee. However, the MPFL graft was loose at 60°, 90°, and 120°, meaning it had no tension. In the dynamic MPFLr using the AMT as a pulley, the patellar contact pressures were like those of a native knee throughout the entire range of motion. However, the maximum stress of the MPFL graft at 0° was less than that of a native ligament. Yet, the maximum MPFL graft stress was greater at 30° than in a native ligament. After 30° of flexion, the MPFL graft loosened, similarly to a native knee. In the dynamic MQTFL reconstruction, the maximum patellar contact pressure was slightly greater than in a normal knee. The maximum stress of the MPFL graft was much greater at 0° and 30° than that of a native MPFL. After 30° of flexion, the MQPFL graft loosened just as in the native knee. Conclusions: The patellar contact pressures after the dynamic MPFLr were like those of the native knee, whereas a static reconstruction resulted in greater pressures, potentially increasing the risk of patellofemoral osteoarthritis in the long term. Therefore, the dynamic MPFLr might be a safer option than a static reconstruction from a biomechanical perspective.

Highlights

Chronic lateral patellar instability (CLPI) is a common finding of knee surgeons in their daily clinical practice
The static MPFL reconstruction (MPFLr) resulted in greater peak and mean pressures from 60◦ to 110◦ of flexion when compared to dynamic reconstructions
We have shown that the dynamic technique using the adductor magnus tendon (AMT) as a pulley with a gracilis tendon autograft [8] does not increase the patellar contact pressure compared to an intact knee, and shows a slightly lower resistance to rupture of the graft compared to a native ligament at 0◦ (Figure 2D–E, Table 3)

Summary

Introduction

Chronic lateral patellar instability (CLPI) is a common finding of knee surgeons in their daily clinical practice. In the less used dynamic reconstruction, only one of the graft’s extremities is fixed to bone, while the other one is fixed to soft tissues. This type of reconstruction is a less rigid reconstruction [7,8,9,10,11,12]. Static and dynamic reconstructions show MPFL isometry between 0◦ and 90◦ [9,13]. In a static/anatomic MPFLr, the graft is isometric in all the cases between 0◦ and 30◦ of knee flexion [13]. A ligament is considered isometric when there is less than 5 mm of length change throughout the entire range of motion [14]

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