Medial Patellofemoral Ligament Reconstruction and Nonanatomic Stabilization Techniques in Skeletally Immature Patients

Abstract

Patellar instability is a common cause of knee disability in children and adolescent, with a high recurrence rate. When conservative treatment fails, surgical options should be considered. The femoral insertion of the medial patellofemoral ligament (MPFL) is in close proximity to the distal femoral growth plate and precautions should be taken to avoid injuries to the physis. Anatomical features of the MPFL complex, with focus on the relationship between femoral MPFL attachment and femoral physis, are discussed together with surgical tips to avoid injuries to the growth plates. The aim of this article is to review the recent literature regarding MPFL reconstruction and other stabilization techniques for patellofemoral instability in skeletally immature patients, focusing on the different surgical options available. These can be classified as anatomical versus nonanatomical, proximal versus distal realignments, or based on the graft used: free graft and pedicled graft (quadriceps, patellar tendon, hamstring, and adductor magnus).

Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon Femoral Ligament in Skeletally Immature Patients

“…Several techniques were proposed, using adductor magnus tendon, MCL, or an anatomic epiphyseal tunnel. 12 Deie et al. 1 were the first to use the MCL for femoral attachment in their reconstructions: the harvested proximal end of semitendinosus is looped around the posterior third of the MCL and fixed on the periosteum of the patella, while its distal tibial end remains anatomically attached.…”

“…Many techniques for MPFL reconstruction in children, adolescents, and adults have been described over time. 12 , 19 , 20 An advantage of our technique is that it is implant-free, so the cost of the procedure is lower. The likelihood of residual pain 11 is reduced due to the “manual” tensioning at the quadriceps level, which is not a stiff point.…”

“… 3 , 4 Following a patellar dislocation, the chances are almost 100% that the medial patellofemoral ligament (MPFL) was injured. 4 , 5 , 6 , 7 Many procedures for MPFL restoration are now available, 2 , 8 , 9 , 10 , 11 , 12 , 13 especially developed to restore this main contributor in preventing lateral patellar dislocation. 1 Recently, several studies have revealed the importance of the medial quadriceps tendon femoral ligament (MQTFL) in restoring patellar stability.…”

Hardware-free MPFL reconstruction in patients with recurrent patellofemoral instability is safe and effective

“…Hardware-free MPFL reconstruction was initially developed for skeletally immature patients to avoid growth damage to the distal femur physis [17,51,61,63]. However, this technique has also been extended to the adult population [18,33,35,36].…”

The adductor magnus tendon is a viable option for medial patellofemoral ligament reconstruction, but with a busy surrounding neurovascular topography

“…The medial patellofemoral ligament (MPFL) is the primary medial stabilizer of the patella and its injury is more common during the pediatric age [15, 17]. The most common cause is traumatic patellar dislocation, which also sets the stage for subsequent recurrent instability [9]. After the initial dislocation, patients tend to re‐dislocate in up to 90% of cases [5].…”