Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies

Sanchis-Alfonso, Vicente; Montesinos-Berry, Erik; Ramírez-Fuentes, Cristina; Leal-Blanquet, Joan; Gelber, Pablo Eduardo; Monllau, Joan Carles

doi:10.5312/wjo.v8.i2.115

Cited by 33 publications

(37 citation statements)

References 48 publications

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“… 11 Mistakes in the femoral attachment point have resulted in increased patellofemoral contact pressure, increased rates of MPFL reconstruction failure, and loss of graft isometry. 3 , 9 In the present study, it was observed that certain patients may have had more errors with the 2D method (female patients with trochlear dysplasia), but this was not a significant finding. The clinical relevance of this finding lies in the fact that lateral patellar instability is more frequent in female patients with severe trochlear dysplasia.…”

Section: Discussioncontrasting

confidence: 62%

Radiographic Location Does Not Ensure a Precise Anatomic Location of the Femoral Fixation Site in Medial Patellofemoral Ligament Reconstruction

Sanchis-Alfonso

Ramírez-Fuentes

Montesinos-Berry

et al. 2017

Orthopaedic Journal of Sports Medicine

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Background:A frequently used method to determine the anatomic femoral fixation point in the operating room during medial patellofemoral ligament (MPFL) reconstruction is the radiographic method. However, the ability of this radiological method to establish an anatomic femoral attachment point might not be as accurate as expected.Purpose:(1) To evaluate the accuracy of the radiological method to locate the anatomic femoral fixation point in MPFL reconstruction surgery and (2) to determine the factors influencing the predictability of this method to obtain this objective.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 100 consecutive 3-dimensional computed tomography (3D CT) knee examinations were performed at 0° of extension in 87 patients treated for chronic lateral patellar instability. For each knee, 2 virtual 7 mm–diameter femoral tunnels were created: 1 using the adductor tubercle as a landmark (anatomic tunnel) and the other according to the radiological method described by Schöttle et al (radiographic tunnel). We measured the percentage of overlap between both tunnels. Moreover, of the 100 included knees, 10 were randomly selected for a variability study.Results:Considering an overlap area greater than 50% as reasonable, the radiographic method achieved this in only 38 of the 100 knees. Intrarater and interrater reliability were excellent. There was a trend for female patients with severe trochlear dysplasia to have less overlap. This model accounted for 64.2% of the initial variability in the data.Conclusion:An exact anatomic femoral tunnel placement could not be achieved with the radiographic method. Radiography provided only an approximation and should not be the sole basis for the femoral attachment location. Moreover, in female patients with severe trochlear dysplasia, the radiographic method was less accurate in determining the anatomic femoral fixation point, although differences were not statistically significant.

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Section: Discussioncontrasting

confidence: 62%

Radiographic Location Does Not Ensure a Precise Anatomic Location of the Femoral Fixation Site in Medial Patellofemoral Ligament Reconstruction

Sanchis-Alfonso

Ramírez-Fuentes

Montesinos-Berry

et al. 2017

Orthopaedic Journal of Sports Medicine

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“…[3][4][5]13,37,43,58,68 One of the primary causes of these complications is technical surgical errors, of which femoral tunnel malpositioning has been found to be one of the most common. 10,43,51,52,68 Knowledge about the native anatomy and understanding its function are paramount in ligament reconstruction. The anatomy of the MPFL has been heavily debated, and recent publications have shown variability of its femoral attachment.…”

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confidence: 99%

The Medial Patellofemoral Ligament Is a Dynamic and Anisometric Structure: An In Vivo Study on Length Changes and Isometry

Kernkamp

Wang

et al. 2019

Am J Sports Med

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Background: Medial patellofemoral ligament (MPFL) reconstruction is associated with a high rate of complications, including recurrent instability and persistent knee pain. Technical errors are among the primary causes of these complications. Understanding the effect of adjusting patellofemoral attachments on length change patterns may help surgeons to optimize graft placement during MPFL reconstruction and to reduce graft failure rates. Purpose: To determine the in vivo length changes of the MPFL during dynamic, weightbearing motion and to map the isometry of the 3-dimensional wrapping paths from various attachments on the medial femoral epicondyle to the patella. Study Design: Descriptive laboratory study. Methods: Fifteen healthy participants were studied with a combined computed tomography and biplane fluoroscopic imaging technique during a lunge motion (full extension to ~110° of flexion). On the medial femoral epicondyle, 185 attachments were projected, including the anatomic MPFL footprint, which was divided into 5 attachments (central, proximal, distal, posterior, and anterior). The patellar MPFL area was divided into 3 possible attachments (proximal, central, and distal). The length changes of the shortest 3-dimensional wrapping paths of the various patellofemoral combinations were subsequently measured and mapped. Results: For the 3 patellar attachments, the most isometric attachment, with an approximate 4% length change, was located posterior and proximal to the anatomic femoral MPFL attachment, close to the adductor tubercle. Attachments proximal and anterior to the isometric area resulted in increasing lengths with increasing knee flexion, whereas distal and posterior attachments caused decreasing lengths with increasing knee flexion. The anatomic MPFL was tightest in extension, decreased in length until approximately 30° of flexion, and then stayed near isometric for the remainder of the motion. Changing both the femoral and patellar attachments significantly affected the length changes of the anatomic MPFL ( P < .001 for both). Conclusion: The most isometric location for MPFL reconstruction was posterior and proximal to the anatomic femoral MPFL attachment. The anatomic MPFL is a dynamic, anisometric structure that was tight in extension and early flexion and near isometric beyond 30° of flexion. Clinical Relevance: Proximal and anterior MPFL tunnel positioning should be avoided, and the importance of anatomic MPFL reconstruction is underscored with the results found in this study.

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“…Feller et al[ 36 ] tension the graft with one quadrant of lateral translation in knee extension, then the knee is flexed to 20° for permanent fixation. Other authors prefer techniques with the use of 30° of knee flexion for graft fixation[ 8 , 26 , 28 ] and some prefer a position between 60° and 90° of flexion because this might allow a more precise settling of the patella within the deeper, more inferior parts of the trochlear groove[ 37 ]. Therefore, finding the most appropriate technique for graft fixation seems quite confusing.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, our technique to simply test and balance the tension during knee motion before permanent fixation might be a feasible and satisfying solution. Considering that 30° of knee flexion seems to be recommended most frequently in the literature[ 8 , 26 , 28 ], we begin with a temporary graft fixation at 30° of flexion. Only after testing and balancing the tension is the graft permanently fastened[ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Deepening trochleoplasty combined with balanced medial patellofemoral ligament reconstruction for an adequate graft tensioning

Engelhardt

Weskamp

Lahner

et al. 2017

WJO

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AIMTo evaluate our modified deepening trochleoplasty combined with a balanced medial patellofemoral ligament (MPFL) reconstruction for soft tissue alignement.METHODSThirty-three knees with with recurrent patellar dislocations and a trochlear dysplasia in 30 patients (m/f = 12/21, mean age 24 ± 9 years) underwent a combination of a modified deepening trochleoplasty and a balanced MPFL reconstruction for a medial soft tissue alignement. After a mean follow-up period of 29 ± 23 mo, patients’ return to sports, possible complications as well as the clinical outcomes using the Kujala, International Knee Documentation Committee (IKDC) and Lysholm scoring were evaluated. Moreover, patients’ satisfaction with the general outcome, the cosmetic outcome, the pre- and postoperative pain and a potential avoidance behaviour were assessed with additional standardized questionnaires which also included different visual analog scales.RESULTSThere were no signs of a persistent instability. The Kujala score improved from a mean of 64 ± 16 points to 94 ± 9 points, the Lysholm score improved from a mean of 63 ± 17 to 95 ± 6 points and the IKDC score from 58 ± 11 to 85 ± 12 points, P < 0.0001, respectively. The assessment of pain using a visual analog scale showed a significant pain reduction from a mean of 4.8 ± 2.0 to 1.3 ± 3.4 points (P < 0.0001). Two of 26 cases (92%) who were engaged in regular physical activity before surgery did not return to full sporting activities. One patient felt that his sport was too risky for his knee and reported an ongoing avoidance behaviour. The other patient preferred to wait for surgery of her contralateral knee. Of the eight patients who were not engaged in sporting activities before surgery, three started regular sporting activities after surgery. In 31 of the 33 cases (94%), the patients were very satisfied with the clinical outcome of the surgery. Regarding the cosmetic results, no patients felt impaired in their self-confidence and in their clothing decisions.CONCLUSIONOur technique shows a good clinical outcome in terms of the common scorings as well as in terms of pain, return to sports and patient satisfaction.

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Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies

Cited by 33 publications

References 48 publications

Radiographic Location Does Not Ensure a Precise Anatomic Location of the Femoral Fixation Site in Medial Patellofemoral Ligament Reconstruction

Radiographic Location Does Not Ensure a Precise Anatomic Location of the Femoral Fixation Site in Medial Patellofemoral Ligament Reconstruction

The Medial Patellofemoral Ligament Is a Dynamic and Anisometric Structure: An In Vivo Study on Length Changes and Isometry

Deepening trochleoplasty combined with balanced medial patellofemoral ligament reconstruction for an adequate graft tensioning

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