The Efficacy of Medial Patellofemoral Ligament Reconstruction Combined with Tibial Tuberosity Transfer in the Treatment of Patellofemoral Instability

Boutefnouchet, Tarek; Downham, Christopher; Bassett, James; Thompson, P.; Sprowson, Andrew P.

doi:10.5792/ksrr.2016.28.2.99

Cited by 15 publications

(13 citation statements)

References 41 publications

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“…[1][2][3][4]14,17,22,75 Whereas some authors have found good clinical outcomes and low redislocation rates after isolated MPFL reconstruction even in the presence of ARFs, 24,49,51,60,76 other authors have found a correlation between ARFs and unsatisfactory outcomes and failure after MPFL reconstruction. k Therefore, additional stabilization procedures are increasingly performed in combination with MPFL reconstruction, such as trochleoplasty, 5,6,10,34,54 medialization or distalization of the tibial tuberosity, 12,26,44,50 and osteotomies to correct torsion and/or valgus malalignment. [19][20][21][22][23]27,28,55 The results of the current study suggest that the presence of ARFs is related to failure after MPFL reconstruction, as only 15% of patients had no ARFs, whereas 2 or more ARFs were observed in 65% of patients.…”

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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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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“…A tibial tubercle osteotomy (TTO) may also be performed, often in combination with MPFL reconstruction, especially in those with patella alta [17]. Case series have suggested good outcomes for MPFL reconstruction, alone or combined with tubercle osteotomy approaches [14][15][16][17][18][19][20].…”

Section: Introductionmentioning

confidence: 99%

The feasibility of a randomised control trial to assess physiotherapy against surgery for recurrent patellar instability

Rahman

Mannion

Qureshi

et al. 2020

Pilot Feasibility Stud

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Background: Patellar instability is a relatively common condition that leads to disability and restriction of activities. People with recurrent instability may be given the option of physiotherapy or surgery though this is largely driven by clinician preference rather than by a strong evidence base. We sought to determine the feasibility of conducting a definitive trial comparing physiotherapy with surgical treatment for people with recurrent patellar instability. Methods: This was a pragmatic, open-label, two-arm feasibility randomised control trial (RCT) with an embedded interview component recruiting across three NHS sites comparing surgical treatment to a package of best conservative care; 'Personalised Knee Therapy' (PKT). The primary feasibility outcome was the recruitment rate per centre (expected rate 1 to 1.5 participants recruited each month). Secondary outcomes included the rate of followup (over 80% expected at 12 months) and a series of participant-reported outcomes taken at 3, 6 and 12 months following randomisation, including the Norwich Patellar Instability Score (NPIS), the Kujala Patellofemoral Disorder Score (KPDS), EuroQol-5D-5L, self-reported global assessment of change, satisfaction at each time point and resources use. Results: We recruited 19 participants. Of these, 18 participants (95%) were followed-up at 12 months and 1 (5%) withdrew. One centre recruited at just over one case per month, one centre was unable to recruit, and one centre recruited at over one case per month after a change in participant screening approach. Ten participants were allocated into the PKT arm, with nine to the surgical arm. Mean Norwich Patellar Instability Score improved from 40.6 (standard deviation 22.1) to 28.2 (SD 25.4) from baseline to 12 months. Conclusion: This feasibility trial identified a number of challenges and required a series of changes to ensure adequate recruitment and follow-up. These changes helped achieve a sufficient recruitment and follow-up rate. The revised trial design is feasible to be conducted as a definitive trial to answer this important clinical question for people with chronic patellar instability.

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“…45 Current guidelines on the treatment of patellar instability associated with patella alta recommend MPFL reconstruction (MPFLr) and tibial tuberosity distalization to better stabilize the patella. 6,9,21 The overall reported complication rate of tibial tubercle transfer is 7.4% (eg, proximal tibial fractures, tibial tuberosity nonunion, skin necrosis), and about 50% of these patients require hardware removal. 18,34,41 On the other hand, some preliminary studies reported a slight decrease in patellar height in the postoperative…”

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confidence: 99%

How Does Isolated Medial Patellofemoral Ligament Reconstruction Influence Patellar Height?

et al. 2020

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Background: Reconstruction of the medial patellofemoral ligament (MPFL) is the gold standard treatment for recurrent patellar dislocation. Patella alta has been reported in about half of patients with recurrent patellofemoral instability. Hypothesis: MPFL reconstruction (MPFLr) has a beneficial role in the correction of patellar height in patients with mild patella alta (Caton-Deschamps index [CDI] between 1.20 and 1.40). Study Design: Case series; Level of evidence, 4. Methods: Skeletally mature patients, with no history of previous or concomitant knee surgical procedures, who underwent isolated MPFLr using hamstring autograft for recurrent patellar instability between 2005 and 2018, were included in this study. The authors calculated CDI, modified Insall-Salvati index (MISI), and Blackburne-Peel index (BPI) ratios. Measurements done by 2 independent observers were calculated and used to compare pre- and postoperative patellar height (patella alta: CDI >1.20). Results: A total of 89 patients (95 knees) were included in the study, with a mean age of 25.0 years (range, 15.0-45.0 years). There were 70% women and 30% men. We found patella alta in 35.8% of cases preoperatively. Among them, 79.4% had reduced patellar height indices, within normal limits, postoperatively (mean follow-up, 18.4 ± 12.0 months). All the ratios showed a significant reduction in patellar height after surgery (CDI: 0.19 [range, –0.05, 0.60]; MISI: 0.22 [–0.14, 0.76]; BPI: 0.18 [–0.08, 0.59]; P < .00001). The CDI of 79.4% of the study knees was reduced to within normal limits postoperatively. The CDI was maintained within normal limits postoperatively in 93.4% of the knees with normal patellar height and reduced to normal in 50% of the knees with severe patella alta before surgery . No patient reported patella infera before surgery, whereas this condition was found in 8.2% of study patients postoperatively. A moderate correlation was reported between preoperative radiographic indices and their reduction after surgery (CDI: P < .001, ρ = 0.39; MISI: P < .001, ρ = 0.39; BPI: P < .001, ρ = 0.48). Conclusion: The higher the preoperative patellar height, the more important is the lowering effect of MPFLr using the hamstring for patellar instability. Bony procedures should not be indicated in patients with patellar instability and a CDI between 1.20 and 1.40.

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The Efficacy of Medial Patellofemoral Ligament Reconstruction Combined with Tibial Tuberosity Transfer in the Treatment of Patellofemoral Instability

Cited by 15 publications

References 41 publications

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

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

The feasibility of a randomised control trial to assess physiotherapy against surgery for recurrent patellar instability

How Does Isolated Medial Patellofemoral Ligament Reconstruction Influence Patellar Height?

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