Safe Drilling Paths in the Distal Femoral Epiphysis for Pediatric Medial Patellofemoral Ligament Reconstruction

Nguyen, Cynthia; Farrow, Lutul D.; Liu, Raymond W.; Gilmore, Allison

doi:10.1177/0363546516677795

Cited by 39 publications

(35 citation statements)

References 26 publications

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“…The safest trajectory is approximately 15°-20°both anterior and distal as this angle minimizes the risk of iatrogenic damage to the physis, intercondylar notch, and the distal femoral cartilage. There is an increased emphasis on the intraoperative anteroposterior view to facilitate obtaining the appropriate angles [70].…”

Section: Mpfl Reconstructionmentioning

confidence: 99%

Avoiding Complications with MPFL Reconstruction

Smith

Werner

Diduch

2018

Curr Rev Musculoskelet Med

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Multiple cadaveric studies have characterized the anatomy of the MPFL and the related morphologic abnormalities that contribute to recurrent lateral patellar instability. Such abnormalities include patella alta, excessive tibial tubercle to trochlear grove (TT-TG) distance, trochlear dysplasia, and malalignment. Recent studies have evaluated the clinical outcomes associated with the treatment of concomitant pathology in combination with MPFL reconstruction, which is critical in avoiding recurrent instability and complications. Although there remains a lack of consensus regarding various critical aspects of MPFL reconstruction, certain concepts remain imperative. Our preferred methods and rationales for surgical techniques are described. These include appropriate work up, a combination of procedures to address abnormal morphology, anatomical femoral insertion, safe and secure patellar fixation, appropriate graft length fixation, and thoughtful knee flexion during fixation.

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Section: Mpfl Reconstructionmentioning

confidence: 99%

Avoiding Complications with MPFL Reconstruction

Smith

Werner

Diduch

2018

Curr Rev Musculoskelet Med

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“…However, anatomic reconstruction of the MPFL can be difficult in the pediatric population, as the MPFL femoral attachment lies in close proximity to the distal femoral physis. 9 , 19 – 22 Nonanatomic reconstruction of the MPFL can result in altered patellofemoral contact pressures and recurrent patellofemoral instability. Specifically, malpositioning of the MPFL femoral attachment has been implicated as a major cause of graft failure and poor patient outcomes.…”

mentioning

confidence: 99%

Evaluation of the Schöttle Technique in the Pediatric Knee

Huston

Okoroafor

Kaar

et al. 2017

Orthopaedic Journal of Sports Medicine

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Background:The Schöttle point is commonly used for anatomic femoral tunnel placement during medial patellofemoral ligament (MPFL) reconstruction. This technique has not been previously validated in the skeletally immature patient, in whom femoral tunnel placement may put the distal femoral physis at risk of iatrogenic injury.Hypothesis:Interobserver reliability for femoral tunnel placement will be higher in adult knees compared with pediatric knees.Study Design:Cross-sectional study (diagnosis); Level of evidence, 3.Methods:We selected 30 perfect lateral radiographs for this study: 20 from pediatric knees (mean patient age, 10 years; range, 8-11 years) and 10 from adult knees (mean patient age, 18.5 years; range, 18-23 years). Six observers with varying levels of clinical experience evaluated each radiograph and approximated the site of the MPFL femoral tunnel using the Schöttle technique. Intra- and interobserver reliabilities for femoral tunnel placement were evaluated. Statistical analysis was used to compare measurements.Results:During initial interobserver measurements, the diameter of the composite perfect circles averaged 9.0 and 6.8 mm in adult and pediatric knees, respectively (P = .004). At repeat measurement, circles averaged 9.8 and 7.3 mm in adult and pediatric knees, respectively (P = .0001). Femoral tunnel placement intraobserver variance averaged 2.9 mm in adult knees (range, 1.9-4.0 mm) and 2.3 mm in pediatric knees (range, 1.9-2.9 mm). This difference was not significant (P = .14).Conclusion:This study demonstrated that interobserver variance is actually greater in adult knees compared with pediatric knees, although interobserver variance was significantly different for both populations. Additionally, intraobserver variance is small on repeat measures, demonstrating that the Schöttle technique is reproducible for individual observers. Sources of this increased variance between observers are differences in agreement on the bony landmarks required for the Schöttle technique. Due to this variability in tunnel placement, we recommend caution when the Schöttle technique is used in pediatric knees to avoid iatrogenic injury to the distal femoral physis during femoral tunnel placement.

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“…They suggested angling the tunnel distal and anterior to decrease the risk of distal growth plate damage. 12 A recent study by Nguyen et al 13 analyzed the safe angle for drilling the distal femoral epiphysis in MPFL reconstruction. The authors studied 23 three-dimensional images of cadaveric specimens simulating drill paths for the placement of a 6-mm interference screw.…”

Section: Anatomymentioning

confidence: 99%

“…Changes of angulation in sagittal and coronal plane of 5 degrees in each direction decreased the percentage of safe tunnels. 13 Therefore, as the femoral origin of MPFL seems to be located distally to distal femoral physis, a safe drill path for reconstruction has to be angulated at 15 to 20 degrees distally and anteriorly. Determining the insertion point only using lateral radiographs is not safe and also an AP view is recommended.…”

Section: Anatomymentioning

confidence: 99%

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

Pilone

Bonasia

Rosso

et al. 2019

Joints

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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).

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Safe Drilling Paths in the Distal Femoral Epiphysis for Pediatric Medial Patellofemoral Ligament Reconstruction

Abstract: During drilling into the distal femoral epiphysis at the MPFL origin in skeletally immature patients, angling the drill appropriately 15° to 20° both distally and anteriorly minimizes damage to the physis, notch, and distal femoral cartilage.

Cited by 39 publications

References 26 publications

Avoiding Complications with MPFL Reconstruction

Avoiding Complications with MPFL Reconstruction

Evaluation of the Schöttle Technique in the Pediatric Knee

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

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