"Basket weave technique" for medial patellofemoral ligament reconstruction: Clinical outcome of a prospective study.

BACKGROUND: Bone tunneling and implants with rigid fixations for medial patellofemoral ligament (MPFL) reconstruction are known to compromise results and are avoidable, especially in skeletally immature subjects. This study was to assess if these deficiencies were overcome with the technique devised by the author which avoids implants and bone tunnels. Results were assessed for complication rate and outcome. MATERIALS AND METHODS: Fifty six knees of recurrent lateral patellar dislocation were treated in the past 49 months by MPFL reconstruction. Thirty nine were female and 17 male knees. The mean age was 20.6 years (range 9-48 years). Mean followup was 26 months. Five knees had previously failed stabilization procedures. Thirty one cases had Dejours Type A or B and 12 had Type C trochlear dysplasia. Arthroscopy was performed for associated injuries and loose bodies. Seven knees required loose body removal. Five knees underwent lateral retinacular release. Four knees had tibial tuberosity transfer. One knee had an associated anterior cruciate ligament reconstruction. An anatomical MPFL reconstruction was performed using hamstring autograft without the need for intraoperative fluoroscopy. Only soft tissue fixation was necessary with this newly devised technique and suturing. A rapid rehabilitation protocol was implemented with monthly followup until normalcy and 6 monthly thereafter. RESULTS: All achieved full range of motion and normal mediolateral stability. There was no recurrence of dislocation. No major surgery related complications. One patella fracture at 8 months was due to a fall developed terminal restriction of flexion. Those in sports could return to their sporting activities (Tegner 1-9). Cases with osteochondral fractures had occasional pain that subsided in 1 year. Mean Kujala score improved from 64.3 to 99.69 with KOOS score near normal in all. CONCLUSION: This new method of MPFL reconstruction gives excellent results. It avoids complications related to bone tunneling and implants. It is a safe, effective, reliable and reproducible technique.

Basket-Weave Technique for Medial Patellofemoral Ligament Reconstruction.

The anatomy of the medial patellofemoral ligament (MPFL) has been well defined, with parts of its uppermost fibers having a soft-tissue insertion onto the vastus intermedius. Bone tunnels and implants on the patellar side therefore cannot replicate this anatomic construct precisely. Because of implants and tunnels, complications have been reported with bone tunnel fracture. Similarly, on the femoral side, rigid fixation with implants can result in over-constraint with compromised results. Moreover, bone tunnels cannot be used in skeletally immature cases. To overcome issues related to bone tunneling and implants, as well as to reconstruct the MPFL in a precise anatomic manner, an all-soft-tissue fixation technique was devised. Bony landmarks were used as reference points instead of radiologic markers to achieve a more precise construct and to eliminate intraoperative radiography. Hamstring graft was used to reconstruct the MPFL. Special suturing techniques were used to achieve optimal graft fixation with minimal suture knots. A special tissue elevator-suture passer device was designed to facilitate graft passage and ease in performing the procedure. This technique permits differential tensioning, and therefore one achieves stability throughout the range of motion.

Dome osteotomy of the proximal tibia for genu varum treated with a new fixation device.

An innovative uniplanar-bilateral external fixator was designed, developed, and implemented for barrel-vault osteotomy of the proximal tibia. Eighteen cases of medial compartmental osteoarthritis of the knee with genu varum and one case of tibia vara were treated with dome osteotomy fixed with this new fixator to meet patient expectations regarding pain relief, early recovery with ability to squat, dependency periods, avoiding serious complications, convenience, and economic conditions. All cases achieved the desired degree of bony correction except for one case with 5 degrees undercorrection due to preoperative posterolateral corner laxity. Plaster immobilization was not required during the treatment period, and all osteotomies united within 6-10 weeks with no major complications. Superficial pin tract infection occurred in three cases. All patients returned to their activities of daily living by postoperative week 2. The Knee Society Score was 75-100 with average function/knee scores of 88.89/96.32 by the end of 2 months. Patients maintained these scores up to 2-year follow-up. This new fixator is compact and economical, with excellent patient compliance. It provides a stable fixation for the osteotomy and permits early joint mobilization, full weight bearing, and early return to activities of daily living. The fixator has the ability to alter correction in the early postoperative period to achieve a precise correction of the deformity. It qualifies as a safe device for this procedure, produces reliable and reproducible results, as well as satisfies patient expectations.

A new technique of graft harvest for anterior cruciate ligament reconstruction with quadruple semitendinosus tendon autograft.

A new technique of graft harvesting was used in 8 cases for arthroscopic anterior cruciate ligament reconstruction with quadruple semitendinosus tendon autograft. The graft is acquired through a small incision on the posteromedial aspect of the knee at the flexor crease instead of the standard anteromedial approach through a paramedian incision. Compared with the standard technique of graft harvesting, this new method of graft harvest facilitates easier identification of the semitendinosus and avoids inadvertent amputation of the semitendinosus tendon during graft harvest, disinsertion of the pes anserinus, or injury to the infrapatellar branch of saphenous nerve. The surgical scars, in addition to the standard portal scars, include a small scar on the posteromedial aspect, which merges into the flexor crease and a 1-cm anteromedial scar. This provides improved cosmesis and better patient compliance for early rehabilitation with less pain in the immediate postoperative period. There is no compromise on the intraoperative ligament reconstruction with good postoperative results. No intraoperative or postoperative complications were encountered. It would be advisable to follow this technique of graft harvesting for all individuals undergoing arthroscopic anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon to avoid the problems encountered with the standard technique, and also to achieve an excellent cosmetic and functional outcome.