Anisometry of Medial Patellofemoral Ligament Reconstruction in the Setting of Increased Tibial Tubercle–Trochlear Groove Distance and Patella Alta

Redler, Lauren H.; Meyers, Kathleen N.; Brady, Jacqueline M.; Dennis, Elizabeth R.; Nguyen, Joseph; Stein, Beth E. Shubin

doi:10.1016/j.arthro.2017.08.256

Cited by 55 publications

(50 citation statements)

References 35 publications

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“…Deficient medial soft tissue restraints are the "essential" lesion of patella instability, and MPFL reconstruction has emerged as the gold standard for surgical stabilization. 1 Overall, MPFL reconstruction has excellent subjective outcomes and high patient satisfaction in short-and medium-term follow-up. 2 The learning curve for MPFL reconstruction is steep.…”

Section: See Related Article On Page 2410mentioning

confidence: 87%

Editorial Commentary: When It Comes to Patient Outcome, Femoral Tunnel Vision May Miss the ‘Point’ in Knee Medial Patellofemoral Ligament Reconstruction

Sherman¹

2018

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Surgeons care deeply about optimizing femoral tunnel position in medial patellofemoral ligament reconstruction. We use a combination of anatomy, isometry, and fluoroscopy to determine the appropriate position of our graft. Although malposition does increase the risk of surgical complication, it is unclear whether femoral tunnel position actually matters for clinical outcome. Surgeons should avoid "tunnel vision" in medial patellofemoral ligament reconstruction by recognizing the combination of anatomic, biomechanical, patient-specific, and technique-dependent variables that may drive patient satisfaction and subjective outcome.

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Section: See Related Article On Page 2410mentioning

confidence: 87%

Editorial Commentary: When It Comes to Patient Outcome, Femoral Tunnel Vision May Miss the ‘Point’ in Knee Medial Patellofemoral Ligament Reconstruction

Sherman¹

2018

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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“…A previous simulation study similarly showed that graft tension peaks at 10 degrees of flexion and begins to decrease as the patella enters the trochlear groove, with minimal tension by 30 degrees of knee flexion. 17 The in vitro studies that measured the path length between femoral and patellar attachment points for a graft showed a wide variety of results, including a decrease in graft length with flexion, 27 isometric function over the flexion range, [23][24][25][26] and an increase in graft length with flexion. 28 Previous studies that measured the path length with computational models reconstructed from imaging data of subjects indicated that graft length decreases with flexion, 29 decreases in early flexion followed by an increase, 30 and increases in early flexion followed by a decrease 31 Differences with respect to the previously published data are likely related to the experimental approach.…”

Section: Discussionmentioning

confidence: 99%

Factors Influencing Graft Function following MPFL Reconstruction: A Dynamic Simulation Study

et al. 2020

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Medial patellofemoral ligament (MPFL) reconstruction is currently the primary surgical procedure for treating recurrent lateral patellar instability. The understanding of graft function has largely been based on studies performed with normal knees. The current study was performed to characterize graft function following MPFL reconstruction, focusing on the influence of pathologic anatomy on graft tension, variations with knee flexion, and the influence on patellar tracking. Knee squatting was simulated with 15 multibody dynamic simulation models representing knees being treated for recurrent lateral patellar instability. Squatting was simulated in a preoperative condition and following MPFL reconstruction with a hamstrings tendon graft set to allow 0.5 quadrants of lateral patellar translation with the knee at 30 degrees of flexion. Linear regressions were performed to relate maximum tension in the graft to parameters of knee anatomy. Repeated measures comparisons evaluated variations in patellar tracking at 5-degree increments of knee flexion. Maximum graft tension was significantly correlated with a parameter characterizing lateral position of the tibial tuberosity (maximum lateral tibial tuberosity to posterior cruciate ligament attachment distance, r 2 = 0.73, p < 0.001). No significant correlations were identified for parameters related to trochlear dysplasia (lateral trochlear inclination) or patella alta (Caton–Deschamps index and patellotrochlear index). Graft tension peaked at low flexion angles and was minimal by 30 degrees of flexion. MPFL reconstruction decreased lateral patellar shift (bisect offset index) compared with preoperative tracking at all flexion angles from 0 to 50 degrees of flexion, except 45 degrees. At 0 degrees, the average bisect offset index decreased from 0.81 for the preoperative condition to 0.71. The results indicate that tension within an MPFL graft increases with the lateral position of the tibial tuberosity. The graft tension peaks at low flexion angles and decreases lateral patellar maltracking. The factors that influence graft function following MPFL reconstruction need to be understood to limit patellar maltracking without overloading the graft or over constraining the patella.

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“…21,22 Some authors have suggested normalizing measures of patellar height alongside MPFL reconstruction to decrease graft anisometry and secondary failure. 12 Lind et al 16 did not account for the role of patella alta or hypermobility in their study, and they elected not to perform corrective distalization to correct alta, even with medializing tibial tubercle osteotomy. As a result, they are unable to comment on the comparative results of soft-tissue sling fixation in the presence of combined alta and axial malalignment.…”

Section: See Related Article On Page 1130mentioning

confidence: 99%

“…10 Despite these approaches, many have expressed concerns about femoral socket morbidity and finding isometry with a single point of fixation on the femoral side, 11 particularly with patella alta. 12 Furthermore, with even subtle malposition of the attachment point or suboptimal lateral radiographic views, 13 rigid femoral tunnel fixation can result in overconstraint of the MPFL, limitations in knee flexion, or worse yet, advanced patellofemoral arthrosis or iatrogenic medial instability. 14,15 In An interesting finding was that no postoperative dislocations occurred in either group, and only 1 patient in the soft-tissue group experienced subluxation.…”

Section: See Related Article On Page 1130mentioning

confidence: 99%

Editorial Commentary: The “F” in MPFL (Medial Patellofemoral Ligament) Reconstruction—How Should We Fix It and Does It Matter?

Waterman¹

2019

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Our understanding of the medial patellofemoral complex anatomy has evolved significantly over the past several decades, and this has informed our current surgical approach to management of lateral patellar instability. Medial patellofemoral ligament reconstruction remains the gold standard for decreasing the risk of secondary patellar dislocation and returning patients to active physical function. However, concerns about isometry, overconstraint, secondary arthrosis, and surgical-site morbidity remain with femoral socket fixation, particularly when patella alta, rotational malalignment, or hypermobility is present. Medial patellofemoral ligament reconstruction with soft-tissue fixation, on either the patellar or femoral side, may mitigate some of these risks by offering a more dynamic checkrein to lateral translation. However, longer-term studies are required to determine comparative efficacy with varying surgical techniques, and the ideal graft tension and degree of knee flexion during fixation have not yet been determined.

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Anisometry of Medial Patellofemoral Ligament Reconstruction in the Setting of Increased Tibial Tubercle–Trochlear Groove Distance and Patella Alta

Cited by 55 publications

References 35 publications

Editorial Commentary: When It Comes to Patient Outcome, Femoral Tunnel Vision May Miss the ‘Point’ in Knee Medial Patellofemoral Ligament Reconstruction

Editorial Commentary: When It Comes to Patient Outcome, Femoral Tunnel Vision May Miss the ‘Point’ in Knee Medial Patellofemoral Ligament Reconstruction

Factors Influencing Graft Function following MPFL Reconstruction: A Dynamic Simulation Study

Editorial Commentary: The “F” in MPFL (Medial Patellofemoral Ligament) Reconstruction—How Should We Fix It and Does It Matter?

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