Functional outcomes of MPFL reconstruction vs. graft tissue placement (original) (raw)
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A review of functional anatomy and surgical reconstruction of medial patellofemoral ligament
Journal of Arthroscopy and Joint Surgery, 2014
Background: Recurrent patella dislocation is a very disabling condition. The stability of patellofemoral joint depends on many general and local factors. It is believed that the Medial Patellofemoral Ligament (MPFL) is one of the major stabilisers of the patellofemoral joint in early knee flexion. Injury to the MPFL occurs in almost every patellar dislocation. This result in a significant increase in lateral patellofemoral joint tracking and contact pressures, which may affect long-term articular cartilage health. Therefore, in recent years MPFL reconstruction has become a popular surgical option in the treatment of patella instability. However there is still a growing debate regarding the correct surgical technique and post-operative rehabilitation. In addition, the long-term effect of MPFL reconstruction procedure on the patellofemoral joint is unknown. Recent research has emphasised the importance of anatomic femoral tunnel placement with the help of intraoperative radiograph. Mal-positioned femoral tunnels and over tensioned grafts during MPFL reconstruction have been reported to result in adverse outcomes such as joint stiffness, pain, recurrent instability and possibly early degenerative joint changes. Aim: To review of our current knowledge of the anatomy, function and the surgical reconstruction of MPFL Methods: We conducted cadaveric dissection to understand the anatomy of MPFL, its femoral and patellar attachments and its role in the functional stability of the patellofemoral joint. We also describe the surgical reconstruction of the MPFL using hamstring tendons, technique and accurate placements of femoral tunnel. Results: Our findings showed that the MPFL insert in an area midway between the adductor tubercle and medial epicondyle of the femur, dorsal to an extended line from the posterior cortex of the femur and attaches to the superomedial portion of the patella, and under the surface of the Vastus Medialis Obliquus tendon (VMO). The ideal graft for reconstruction is the gracilis tendon. The femoral tunnel entry point is behind the posterior cortex of the femur and above the Blumensaat's line. Conclusion: We conclude that anatomic femoral attachment and minimal tension during reconstruction of MPFL is essential for a successful outcome.
Revista Brasileira de Ortopedia (English Edition), 2015
Objective: To analyze the radiographic positioning of the femoral tunnel and correlate this with the postoperative clinical results among patients undergoing reconstruction of the medial patellofemoral ligament (MPFL) alone. Method: This was a retrospective study in which 30 knees of 26 patients with recurrent dislocation of the patella that underwent MPFL reconstruction were evaluated. The femoral insertion point of the graft and the postoperative clinical condition were analyzed and correlated using the Kujala and Lysholm scales. Results: 22 knees presented a femoral tunnel in the anatomical area (group A) and 8 outside of this location (group B). In group A, the mean score on the Kujala scale was 89.68 points and on the Lysholm scale was 92.45 points. In group B, the mean score on the Kujala scale was 84.75 points and on the Lysholm scale was 92 points. The difference between the means was not significant on either of the two scales. Conclusion: Correlation with the clinical results did not show any difference in relation to the positioning of the femoral insertion of the graft.
Reconstruction of the medial patellofemoral ligament for treatment of patellar instability
Acta Orthopaedica, 2008
Purpose: To compare the results of reconstruction of the medial patellofemoral ligament (MPFL) using a synthetic graft (Poly-Tape) between knee joints in which the patella was reduced to the strict center and those in which it was slightly lateral to the center of the trochlea to determine whether patellar position within this range affects the results. Methods: Forty-six knee joints in 46 patients were examined retrospectively with a minimum follow-up of 2 years. The position of the patellar central ridge in the trochlea on arthroscopy immediately after reconstruction of the MPFL was measured. The joints were classified into group 1 (6 male and 12 female patients), in which the patella was reduced to the strict center of the trochlea, and group 2 (10 male and 18 female patients), in which the patella was reduced slightly lateral to the center. The mean age was 20.7 years in group 1 and 20.3 years in group 2. Knee joints were assessed using the Kujala score and the International Knee Documentation Committee (IKDC) subjective evaluation score. Results: The mean Kujala and IKDC scores improved significantly in both groups after surgery (both P < .001). There was no significant difference between the groups for any assessment before surgery or in the Kujala score after surgery (P ¼ .075). However, the IKDC score after surgery was significantly better in group 2 (91.3 AE 9.1) than in group 1 (82.8 AE 13.1) (P ¼ .012). Conclusions: When recurrent dislocation of the patella was treated with MPFL reconstruction using a synthetic graft, subjective evaluations were better in knee joints in which the patella was repositioned slightly lateral to the center of the trochlea than in those in which the patella was reduced to the strict center, although there was no significant difference in knee function between them. Level of Evidence: Level III, retrospective comparative study. M any studies have reported that reconstruction of the medial patellofemoral ligament (MPFL) for recurrent patellar dislocation provides significant improvements in knee function 1-3 ; however, a variety of postsurgical complications have also been reported. 4-7 Most complications have been attributed to incorrect positioning of anchoring sites of the reconstructed MPFL, potentially resulting in patellar maltracking during knee motion, restricted range of motion (ROM), and graft failure. Therefore, many researchers have shed light on determining the anatomic insertion 8-10 and isometric point 11,12 of the MPFL on the medial femoral condyle and the patella. Graft tensioning is reported to be another important factor in keeping the patella centered in the trochlear groove without overloading the patellofemoral joint. 6 A clinical report showed that anterior knee pain and decreased ROM occurred when the graft was over-tightened. 13 A computational analysis showed that the compressive force applied to the medial cartilage increased significantly at 30 to 40 of flexion of the knee joint when a graft was 3 mm shorter than the intact MPFL. 14 Cadaveric studies showed that 2 N of tension applied to an MPFL reconstruction stabilized the patella without increasing medial patellofemoral contact pressure 15 whereas 10 N of graft tension restored normal patellar tilt, lateral shift, and rotation. 16 However, these studies were conducted for knees without apparent patellofemoral malalignment, and thus the study results may not be applied to knees with patellar instability. When a malpositioned femoral attachment site and over-tightened graft were combined, the compressive force applied to the medial cartilage increased
Medial Patellofemoral Ligament Reconstruction-State of the Art
The management of recurrent patellar instability has undergone progressive changes over the past few decades with improved optimal and predictable outcomes for the patients. Open surgical realignment procedures with bony osteotomies either proximal or distal to the Patella, designed to correct the imbalance of the extensor mechanism such that the patella tracks smoothly over the trochlea were commonly advocated. These procedures aimed to restore normal chondral loading of the patellofemoral joint and modify or delay progression of arthritic changes at an early age. With enhanced knowledge on the biomechanics of the anatomical structures providing medial and lateral restraints around the knee, the role of the Medial Patello-Femoral Ligament has been shown to be a vital one. This has refined the surgical options available to minimally invasive arthroscopic approaches with satisfying calculable results. This review article outlines the evolution of the surgical management of patellar instability and the prominent role of the MPFL reconstruction in achieving it. The biomechanics, surgical principles, anatomic landmarks, types of grafts and fixation methods, along with the senior surgeon's preferred surgical technique are described in detail.
Medial Patellofemoral Ligament Reconstruction
Video Journal of Sports Medicine, 2021
Background: Patellar instability is a relatively common condition in the young, active population and causes disruption of the medial patellofemoral ligament (MPFL). MPFL reconstruction is often performed to restore this medial stabilizer and reduce the risk of recurrent instability. Indications: Isolated MPFL reconstruction has been shown to reduce the risk of recurrent patellar dislocation. It is indicated in our patients who have had more than 1 dislocation in the absence of other significant bony malalignment or cartilage defects that require concurrent surgery. Technique Description: Diagnostic arthroscopy is first performed to evaluate the patellar and trochlear cartilage surfaces. A medial approach to the patella is then performed and the 2 free limbs of the allograft are secured to the patella at the 9 to 11 (or 1 to 3) o’clock position. A small approach to the femoral insertion site of the MPFL is performed and confirmed with fluoroscopy, and the graft is secured to the fem...
International Journal of Research in Orthopaedics, 2021
The purpose of this study was to present new surgical technique for MPFL reconstruction. We also describe its functional outcome, complications, and the advantages of the procedure. This study is a prospective analysis of collected data during the period of august 2018 to January 2020. Ten cases of patients with recurrent symptomatic patellar instability and who underwent isolated MPFL reconstruction were included in the study. Kujala scoring and lysholm scoring was done to assess the functional outcome at follow-up. Post-operative dislocation and apprehension were recorded in each case along with any complication. Pre-operative Kujala score was 36.80 which improved to 89.80 postoperatively at the time follow-up. Pre-operative lysholm score was 36.80 which improved to 92.70 postoperatively at the time follow-up. The improvement in Kujala score and Lysholm score was found to be highly significant (p<0.01). We have done a simple technique where MPFL is reconstructed anatomically to...
MPFL Reconstruction and Patellofemoral Chondral Status
Advances in Knee Ligament and Knee Preservation Surgery, 2021
The MPFL was first described by Kaplan in 1957 as the transverse reinforcement extending from the base of the patella to the tendon of the medial head of the gastrocnemius [1]. In 1979, Warren and Marshall named it as the patellofemoral ligament [2]. In the 1990s, several authors revealed the importance of the MPFL as a primary restraint for the lateral deviation of the patella, which provides 50-60% of resistance to lateral displacement [3-5]. Nomura reported that MPFL injury was observed in 96% of the patients with acute patellar dislocation [6]. Thereafter, numerous surgical techniques to restore the function of the MPFL have been reported with excellent outcomes in terms of the prevention of re-dislocation. 22.1.2 Anatomy Warren and Marshall [2] described the MPFL as a collection of transverse fibers running across the plane of Layer II from the region of attachment of the medial collateral ligament to the patella. In 2002, Tuxøe [7] reported the MPFL as being 1.9 cm (1.0-3.0) in width and 5.3 cm (4.5-6.4) in length. Nomura [8] investigated the anatomy of the MPFL in detail and described that the total length of the MPFL was 58.8 ± 4.7 mm, the width and thickness being 12.0 ± 3.1 mm and 0.44 ± 0.19 mm in the middle. The center of the patellar attachment was located at 27 ± 10% from the upper end of the patella in the longitudinal patellar height, and the femoral attachment was superoposterior to the medial femoral epicondyle and just distal to the adductor tubercle. Thereafter, several researchers reported similar results [9-12]. Recently, Mochizuki [13] reported that the proximal fibers of the MPFL were mainly attached to the vastus
Indications for Medial Patellofemoral Ligament Reconstruction: A Systematic Review
Journal of Knee Surgery, 2015
Patellofemoral instability is reported as the second most common cause of traumatic knee hemarthrosis 1 and is commonly seen in young, active patients. 2,3 Complications following a primary patellofemoral dislocation include redislocation (15-49% 1,3-9 ), patellofemoral pain, 3,10 and patellofemoral osteoarthritis. 3,10 Subjective complaints of giving way, instability, decreased physical activity, diminished function, and reduced quality of life have also been described. Furthermore, studies have shown that up to 55% of patients are unable to return to their previous level of physical activity. 7,8 A long-term study by Cofield and Bryan reported on 48 acute primary dislocations treated conservatively and followed for an average of 11 years. 12 Only 25% of patients reported being asymptomatic, with the remaining patients having complaints ranging from a conscious limitation of their activities to avoiding all vigorous sports. In 1997, Mäenpää et al reported results of a longterm study (13-year mean follow-up) on conservative treatment of acute patellar dislocation. 9 In 25% of cases, retropatellar crepitation was observed during physical examination, which was interpreted as a sign of cartilaginous degeneration.
Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy
Purpose: The medial patellofemoral ligament (MPFL) is the major medial soft-tissue stabiliser of the patella, originating from the medial femoral condyle and inserting onto the medial patella. The exact position reported in the literature varies. Understanding the true anatomical origin and insertion of the MPFL is critical to successful reconstruction. The purpose of this systematic review was to determine these locations. Methods: A systematic search of published (AMED, CINAHL, MEDLINE, EMBASE, PubMed and Cochrane Library) and unpublished literature databases was conducted from their inception to the 3 February 2016. All papers investigating the anatomy of the MPFL were eligible. Methodological quality was assessed using a modified CASP tool. A narrative analysis approach was adopted to synthesise the findings. Results: After screening and review of 2045 papers, a total of 67 studies investigating the relevant anatomy were included. From this, the origin appears to be from an area rather than (as previously reported) a single point on the medial femoral condyle. The weighted average length was 56 mm with an 'hourglass' shape, fanning out at both ligament ends. Conclusion: The MPFL is an hourglass-shaped structure running from a triangular space between the adductor tubercle, medial femoral epicondyle and gastrocnemius tubercle and inserts onto the superomedial aspect of the patella. Awareness of anatomy is critical for assessment , anatomical repair and successful surgical patellar stabilisation. Level of evidence Systematic review of anatomical dissections and imaging studies, Level IV.