Femoral tunnel widening is associated with tunnel malposition but not with clinical failure after medial patellofemoral ligament reconstruction with a free gracilis tendon graft

Schüttler, Karl F.; Hoeger, A.; Heyse, Thomas J.; Figiel, Jens; Timmesfeld, Nina; Stein, Thomas; Ziring, Ewgeni; Efe, Turgay

doi:10.1007/s00402-018-2923-z

Cited by 20 publications

(30 citation statements)

References 23 publications

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“…These findings indicate that it is not a single but rather a combination of conditions that underly the indication for a two-staged procedure in the majority of patients. The association of ligament malposition and tunnel widening is a phenomenon also observed in other studies [16,18,22,33]. Concerning the extend of tunnel malpositioning and the distribution of tunnel widenings, no differences were noted between the two groups (Figs.…”

Section: Discussionsupporting

confidence: 83%

Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery

Prall

Kusmenkov

Schmidt

et al. 2020

Arch Orthop Trauma Surg

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Objectives Patients with recurrent instability after anterior cruciate ligament (ACL) reconstruction often present with enlarged or misplaced tunnels and bone grafting is required prior to the actual revision reconstruction. Autologous bone grafting features limited quantity and donor site morbidity. These problems may be eliminated utilizing cancellous bone allografts, but their efficiency and reliability have not been investigated systematically. The aim of the present study was to compare tunnel filling rates attained by utilizing either allogenic or autologous cancellous bone grafts. Materials and methods A total of 103 consecutive patients were enrolled retrospectively. All patients suffered from recurrent instability and underwent either allogenic or autologous cancellous bone grafting. Computed tomography (CT) was carried out before and after the bone grafting procedure. Based on preoperative CT scans, positioning and maximum diameter of the femoral and tibial tunnels were determined. Tunnel filling rates were calculated as a ratio of pre-and postoperative tunnel volumes. Primary outcome was the tibial tunnel filling rate. Femoral filling rates and density of the grafted bone were assessed secondarily. Results Preoperative CT scans revealed no significant differences between the two groups regarding distribution of misplacement and widening of the femoral or tibial tunnel. Postoperative CT scans were conducted after an interval of 5.2 months. Tunnel filling rates of 74.5% (± 14.3) femoral and 85.3% (± 10.3) tibial were achieved in the allogenic compared to 74.3% (± 15.9) femoral and 84.9% (± 9.4) tibial in the autologous group. With p values of 0.85 at the femur and 0.83 at the tibia, there were no significant differences between the groups. The density of the grafted bone revealed significantly higher values in the allogenic group. Conclusions Utilizing cancellous bone allografts in two-staged revision ACL surgery provides for sufficient and reproducible filling of enlarged or misplaced tunnels. The filling rates are comparable to those achieved with autologous bone grafting. Advantages of allografts are the unrestricted quantity and the absence of any harvesting procedure.

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Section: Discussionsupporting

confidence: 83%

Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery

Prall

Kusmenkov

Schmidt

et al. 2020

Arch Orthop Trauma Surg

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“…43,58 However, only few reports have described the potential causes of postoperative complications in the eye of femoral tunnel placement. 10,13,52,56,57 In the case series by Camp et al, 13 nonanatomic femoral positioning of the MPFL was found to be the only significant risk factor for failure. Sanchis-Alfonso et al 52 found that failed MPFL reconstruction was significantly anteriorly when compared with clinically successful reconstruction.…”

Section: Discussionmentioning

confidence: 92%

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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“…11 In other clinical studies, malpositioned femoral tunnels have been associated with postoperative complications, 81 recurrent patellar instability or patellofemoral pain, 37,59 and tunnel widening. 69 Despite knowledge about the importance of anatomic tunnel placement, the rate of nonanatomic placement is reported to be as high as 60%. 52,72 The femoral MPFL insertion site can be identified fluoroscopically through use of radiographic landmarks on a true lateral knee radiograph or by palpation of anatomic landmarks.…”

Section: Discussionmentioning

confidence: 99%

Failure Analysis in Patients With Patellar Redislocation After Primary Isolated Medial Patellofemoral Ligament Reconstruction

Feucht

Mehl²,

Forkel³

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: Reconstruction of the medial patellofemoral ligament (MPFL) has become a popular surgical procedure to address patellofemoral instability. As a consequence of the growing number of MPFL reconstructions performed, a higher rate of failures and revision procedures has been seen. Purpose: To perform a failure analysis in patients with patellar redislocation after primary isolated MPFL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing revision surgery for reinstability after primary isolated MPFL reconstruction were included. Clinical notes were reviewed to collect demographic data, information on the primary surgery, and the mechanism of patellar redislocation (traumatic vs nontraumatic). Preoperative imaging was analyzed regarding femoral tunnel position and the prevalence of anatomic risk factors (ARFs) associated with patellofemoral instability: trochlear dysplasia (types B through D), patella alta (Caton-Deschamps index >1.2, patellotrochlear index <0.28), lateralization of the tibial tuberosity (tibial tuberosity–trochlear groove distance >20 mm, tibial tuberosity–posterior cruciate ligament [TT-PCL] distance >24 mm), valgus malalignment (mechanical valgus axis >5°), and torsional deformity (internal femoral torsion >25°, external tibial torsion >35°). The prevalence of ARF was compared between patients with traumatic and nontraumatic redislocations and between patients with anatomic and nonanatomic femoral tunnel position. Results: A total of 26 patients (69% female) with a mean age of 25 ± 7 years were included. The cause of redislocation was traumatic in 31% and nontraumatic in 69%. Position of the femoral tunnel was considered nonanatomic in 50% of patients. Trochlear dysplasia was the most common ARF with a prevalence of 50%, followed by elevated TT-PCL distance (36%) and valgus malalignment (35%). The median number of ARFs per patient was 3 (range, 0-6), and 65% of patients had 2 or more ARFs. Patients with nontraumatic redislocations showed significantly more ARFs per patient, and the presence of 2 or more ARFs was significantly more common in this group. No significant difference was observed between patients with anatomic versus nonanatomic femoral tunnel position. Conclusion: Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction. Before revision surgery, a focused clinical examination and adequate imaging including radiographs, magnetic resonance imaging (MRI), standing full-leg radiographs, and torsional measurement with computed tomography or MRI are recommended to assess all relevant anatomic parameters to understand an individual patient’s risk profile. During revision surgery, care must be taken to ensure anatomic placement of the femoral tunnel through use of anatomic and/or radiographic landmarks.

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Femoral tunnel widening is associated with tunnel malposition but not with clinical failure after medial patellofemoral ligament reconstruction with a free gracilis tendon graft

Cited by 20 publications

References 23 publications

Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery

Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery

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

Failure Analysis in Patients With Patellar Redislocation After Primary Isolated Medial Patellofemoral Ligament Reconstruction

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