Poster 228: Comparison of Isometric Properties Between the Medial Patellofemoral Complex Fibers

Abstract

Objectives: The medial patellofemoral complex (MPFC) has a broad attachment on the patella and quadriceps tendon. Recent anatomic studies have demonstrated a corresponding elongated footprint on the medial femur in which the proximal fibers constitute the MQTFL and the distal fibers form the MPFL. Reconstruction of the MPFL and MQTFL have traditionally been described using the midpoint of the femoral footprint (Schottle’s point) while varying the graft’s position on the patella or quadriceps tendon. The purpose of this study was to compare graft isometry of MPFL, MQTFL, and MPFC reconstruction when using a standard femoral tunnel versus the corresponding anatomic femoral tunnel, and to identify the morphologic risk factors that influence each reconstruction technique. Methods: 3D digital knee models were created from dynamic CT images of asymptomatic knees of patients with contralateral patellar instability. Knee models were grouped into 10° intervals and graft length, or distance between the defined points on the femur and extensor mechanism were measured in the following conditions: 1) standard MQTFL (sMQTFL), between the midpoint of the femoral footprint and the quadriceps tendon attachment, 2) anatomic MQTFL (aMQTFL), between the proximal femoral footprint and quadriceps tendon attachment, 3) standard MPFL (sMPFL), between the femoral footprint midpoint and the patellar attachment, 4) anatomic MPFL (aMPFL), between the distal femoral footprint and patellar attachment, and 5) MPFC, between the midpoints of the femoral and quadriceps tendon/patellar attachments. Changes in graft length between 0°and 40° flexion were compared for each reconstruction technique and assessed for their relationship to morphologic risk factors using stepwise multiple regression analyses. Results: 12 knees were included in this study (3M, 9F; mean age 23.1+/-8.0y). Mean graft length was significantly greater at 0° than 40° in all reconstructive techniques (p<0.001 to p=0.045). Graft length changes showed no significant differences between reconstructive techniques when using corresponding anatomic femoral tunnels (aMQTFL, aMPFL, aMPFC). When compared to aMPFC (8.8mm), graft length changes were greater in sMQTFL (11.3, p=0.005) and smaller in sMPFL (6.9, p=0.037); however 2/12 (16.7%) of the sMPFL had unfavorable length change patterns that were tighter in flexion than extension. Overall, proximal reconstructions (aMQTFL and sMQTFL) were the most sensitive to the presence of morphologic risk factors (R=.933, R2=0.87 and R=0.898,R2=0.81, respectively) with patella alta having the greatest effect. In contrast, the distal reconstructions (aMPFL and sMPFL) did not have a significant relationship with risk factors but trended toward a significant relationship with TTTG distance (p=0.072 and 0.064, respectively). Conclusions: For MQTFL and MPFL reconstructions, using the corresponding anatomic femoral attachment showed more favorable length change patterns over using the currently described standard femoral tunnel. Overall, graft length changes in proximal (quadriceps tendon) reconstructions were more sensitive to the presence of patella alta, while distal (patellar) reconstructions were influenced by TTTG distance. Further studies are needed to identify the optimal reconstructive technique based on each patient-specific morphologic patterns in the treatment of patellar instability.