Lateral to medial fluoroscopic view improves the accuracy of identifying the MPFL femoral footprint using Schottle's technique.

PURPOSE: This study investigated the effect of different fluoroscopy settings on the accuracy of locating Schottle's point during medial patellofemoral ligament (MPFL) reconstruction. METHODS: The centre of the MPFL femoral footprint was identified and marked on 44 dry femurs. Two standard true lateral knee fluoroscopic images were obtained: (1) medial to lateral (ML) and (2) lateral to medial (LM). The deviation between the anatomically determined MPFL femoral footprint and the fluoroscopically identified point was measured on both fluoroscopic images. An 'acceptable tunnel location' was defined as within a 5- or 7-mm margin of error from the anatomic MPFL footprint. Distal femoral morphometric dimensions were also measured using digital calipers. Statistical analysis determined discrepancies between techniques and their relation to femoral morphometry. RESULTS: The LM view yielded a significantly smaller distance between the anatomical MPFL footprint and Schottle's point compared to the ML view (3.2 ± 1.5 vs. 4.5 ± 2.1 mm, p < 0.001). The LM view achieved acceptable tunnel locations, meeting the 5-mm error criterion in 90.9% of cases, while the ML view achieved 65.9% (p < 0.001). Both views yielded acceptable tunnel locations at similar rates using the 7-mm error criterion (n.s.). The anatomic MPFL footprint was displaced towards the anterior and proximal location in the ML view in reference to the Schottle point. No correlation was observed between any of the morphometric measurements and the deviations. CONCLUSIONS: This study demonstrated that using the LM fluoroscopic view improves the accuracy of femoral tunnel placement when identifying the MPFL footprint via the Schottle technique. Adopting the LM view in surgical practice will help surgeons locate the anatomical femoral footprint accurately, replicating the native MPFL and enhancing clinical outcomes. LEVEL OF EVIDENCE: Level 4, cadaveric study.

Anatomical Characteristics Contributing to Patellar Dislocations Following MPFL Reconstruction: A Dynamic Simulation Study.

Pathologic anatomy is a primary factor contributing to redislocation of the patella following reconstruction of the medial patellofemoral ligament (MPFL). A pivot landing was simulated following MPFL reconstruction, with the hypothesis that position of the tibial tuberosity, depth of the trochlear groove, and height of the patella are correlated with lateral patellar maltracking. Thirteen dynamic simulation models represented subjects being treated for recurrent patellar instability. Simplified Hertzian contact governed patellofemoral and tibiofemoral joint reaction forces. Pivot landing was represented with and without an MPFL graft in place. Measurements related to patellar height (Caton-Deschamps index), trochlear groove depth (lateral trochlear inclination), and position of the tibial tuberosity (lateral tibial tuberosity to posterior cruciate attachment distance, or lateral TT-PCL distance) were measured from the models and correlated with patellar lateral shift with the knee extended (5 deg of flexion) and flexed (40 deg). The patella dislocated for all models without an MPFL graft and for two models with a graft represented. With an MPFL graft represented, patellar lateral shift was correlated with Caton-Deschamps index (r2 > 0.35, p < 0.03) and lateral trochlear inclination (r2 ≥ 0.45, p < 0.02) at both 5 deg and 40 deg of flexion. For a simulated pivot landing with an MPFL graft in place, lateral patellar tracking was associated with a high patella (alta) and shallow trochlear groove. The study emphasizes the importance of simulating activities that place the patella at risk of dislocation when evaluating patellar stability.

Reconstruction of the medial patellofemoral ligament with nonresorbable suture tape normalizes patellar maltracking independent of patella-side fixation technique.

PURPOSE: Patellar maltracking caused by a rupture of the medial patellofemoral ligament (MPFL) can be improved by MPFL reconstruction (MPFL-R) with a tendon graft. Nonresorbable suture tape (FiberTape®, FT) is possibly becoming an option to tendon grafts for MPFL-R. Patella-side fixation of FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate patellar tracking considering soft-tissue-based and anchor-based patella-side fixation techniques. METHODS: In eight fresh-frozen human knee joint specimens (m/f 4/4; age 75 ± 10 years), the MPFL was identified, and a rupture was placed near the femoral insertion site. In the study group (SG; 4 knees), soft-tissue fixation of the FT was performed at the medial patellar retinaculum; in the control group (CG; 4 knees), FT was fixed at the patella via suture anchors. For native MPFL (nMPFL), ruptured ("injured") MPFL (iMPFL) and reconstructed MPFL (FT-MPFL-SG, respectively, FT-MPFL-CG) cone beam CT scans were performed in 15°, 30°, and 45° of knee joint flexion. Patellar tracking was assessed using the radiological parameters patellar tilt (PT), congruence angle (CA) and posterior patellar edge-trochlear groove ratio (PTR). RESULTS: All recorded radiological parameters increased, respectively, decreased in the CG and SG from the nMPFL to the iMPFL state. After MPFL-R, all parameters normalized when compared to the intact state (nMPFL), regardless of patella-side fixation technique. All investigated parameters of patellotrochlear alignment were positively, respectively, negatively significantly (p < 0.05) correlated throughout all evaluated conditions (nMPFL, iMPFL, FT-MPFL-SG, FT-MPFL-CG). CONCLUSION: MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique. The investigated parameters of patellotrochlear alignment correlate with each other.

Soft-tissue fixation is not inferior to suture-anchor fixation in reconstruction of the medial patellofemoral ligament using a nonresorbable suture tape.

PURPOSE: Reconstruction of the medial patellofemoral ligament (MPFL-R) with nonresorbable suture tape (FiberTape®, FT) is becoming popular. Patella-side fixation of the FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate whether patella-side soft-tissue fixation can achieve equivalent primary stability compared to suture-anchor fixation. METHODS: In ten human, fresh-frozen knee joint specimens (m/f 6/4; age 74 ± 9 a), the MPFL was identified and dissected near the femoral insertion site. In five knee joints, the MPFL-R using FT was performed with soft-tissue fixation at the patella (study group; SG), and in five knee joints, the FT was fixed via suture anchors (control group, CG). All reconstructions were evaluated until load to failure of the patella-side fixation with a displacement rate of 200 mm/min. RESULTS: The mean maximum load to failure in the SG was 395.3 ± 57.9 N. All reconstructions failed by complete tearing off the medial patellar retinaculum from its medial patellar margin, but fixation of the FT remained stable. In the CG, the mean maximum load to failure was 239.4 ± 54.5 N and was significantly different compared to the SG (p = 0.04). All reconstructions failed via pullout of the suture anchors. Stiffness and elongation did not differ between the groups, and no failure of the FT was observed in any of the specimens. CONCLUSION: Primary stability of soft-tissue MPFL-R using FT was superior to suture-anchor fixation. Both fixation techniques provided sufficient primary stability, superior to previously reported native MPFL tensile strengths. MPFL-R with FT could be a possible alternative procedure for MPFL-R, eliminating potential complications due to autologous tendon graft harvesting.

Patients who undergo bilateral medial patellofemoral ligament reconstruction return to sport at a similar rate as those that undergo unilateral reconstruction.

PURPOSE: Lateral patellar instability is a debilitating condition not only to athletes, but also to a wide range of highly active individuals. Many of these patients experience symptoms bilaterally, though it is unknown how these patients fair with return to sports following a second medial patellofemoral ligament reconstruction (MPFLR). The purpose of this study is to evaluate the rate of return to sport following bilateral MPFLR compared to a unilateral comparison group. METHODS: Patients who underwent primary MPFLR with minimum 2-year follow-up were identified from 2014 to 2020 at an academic center. Those who underwent primary MPFLR of bilateral knees were identified. Pre-injury sport participation and Tegner score, Kujala score, Visual Analog Score (VAS) for pain, satisfaction, and MPFL-Return to Sport after Injury (MPFL-RSI) scale were collected. Bilateral and unilateral MPFLRs were matched in a 1:2 ratio based on age, sex, body mass index, and concomitant tibial tubercle osteotomy (TTO). A sub-analysis was performed regarding concomitant TTO. RESULTS: The final cohort consisted of 63 patients, including 21 patients who underwent bilateral MPFLR, matched to 42 unilateral patients at mean follow-up of 47 ± 27 months. Patients who underwent bilateral MPFLR returned to sport at a rate of 62% at a mean of 6.0 ± 2.3 months, compared to a unilateral rate of 72% at 8.1 ± 4.2 months (n.s.). The rate of return to pre-injury level was 43% among bilateral patients and 38% in the unilateral cohort. There were no significant differences in VAS pain, Kujala, current Tegner, satisfaction, and MPFL-RSI scores between cohorts. Approximately half of those (47%) who failed to return to sport cited psychological factors and had significantly lower MPFL-RSI scores (36.6 vs 74.2, p = 0.001). CONCLUSION: Patients who underwent bilateral MPFLR returned to sports at a similar rate and level compared to a unilateral comparison group. MPFL-RSI was found to be significantly associated with return to sport. LEVEL OF EVIDENCE: III.

Medial patellofemoral ligament reconstruction using nonresorbable sutures yields comparable outcomes to reconstruction with a pedicled quadriceps tendon autograft when performed in addition to bony risk factor correction.

PURPOSE: To evaluate the results for reconstruction of the medial patellofemoral ligament using synthetic nonresorbable sutures (S-MPFL-R) in comparison to MPFL-R using quadriceps tendon autograft (QT-MPFL-R) in patients undergoing simultaneous correction of anatomic risk factors for lateral patellar instability (LPI) at a minimum of 2 years of follow-up. METHODS: Between November 2018 and June 2019, 19 patients (male/female 8/11; mean age 26 ± 7 years) underwent S-MPFL-R (FiberTape®) in combination with the correction of predisposing risk factors for LPI. The control group of 38 patients (male/female 16/22, mean age 26 ± 6 years) who underwent QT-MPFL-R was matched 1:2 by sex, age, anatomic risk factors, and concomitant surgical correction of bony risk factors. The Banff Patella Instability Instrument 2.0 (BPII 2.0) and a numerical analog scale (NAS 0-10) for patellofemoral pain and subjective knee joint function were used to assess patients' reported quality of life before and after surgery. RESULTS: The BPII 2.0 score increased from 35.0 ± 21.7 points to 79.7 ± 13.3 points (p < 0.0001) in the S-MPRL-R group and from 44.3 ± 19.6 points to 80.9 ± 15 points (p < 0.0001) in the QT-MPFL-R group from preoperatively to postoperatively, respectively, without any significant difference between the groups. In the S-MPFL-R group and QT-MPFL-R group, 95% (18/19) and 92% (35/38) of patients, respectively, crossed the minimally clinically important difference reported for the BPII 2.0. NAS values for pain and subjective knee joint function improved significantly in both groups (p < 0.0001, p < 0.0001) without any significant difference between the groups at the final follow-up. CONCLUSIONS: This study demonstrates that nonresorbable sutures can serve as a viable option for MPFL-R, yielding comparable outcomes compared to quadriceps tendon autograft reconstruction when performed concomitantly with the correction of anatomic risk factors for LPI. This option reduces the need for autologous tendon harvesting or the use of allografts for MPFL-R. LEVEL OF EVIDENCE: Level III.

Low re-dislocation rate following Bereiter trochleoplasty for recurrent patellar instability with severe trochlear dysplasia.

PURPOSE: Trochlear dysplasia is an independent risk factor for recurrent patellar instability with evidence demonstrating its presence in up to 85% of patients with patellar instability. Severe trochlear dysplasia can be treated with trochleoplasty to improve engagement of the patella in the trochlear groove and prevent future dislocations. The aim of this study was to determine the clinical outcome of Bereiter trochleoplasty in patients with recurrent patellar instability and severe trochlear dysplasia. METHODS: This was a retrospective case series of all trochleoplasties performed in our institution from 2008-2019. All clinical records and pre-operative MRI scans were reviewed to assess for trochlear dysplasia, tibial tuberosity to trochlear groove distance (TTTG) and patella height using patella trochlear index (PTI). Trochlear dysplasia was classified using Dejour classification. Incidence of re-dislocation, infection, arthrofibrosis, chondral necrosis and re-operation were recorded. All patients were invited to complete a post-operative visual analog score for pain (VAS-P) and Banff Patella Instability Instrument (BPII). RESULTS: Fifty-eight trochleoplasties were performed in fifty patients during this period. All trochleoplasties were combined with additional procedures. 93% had concomitant medial patellofemoral ligament (MPFL) reconstructions and 47% had tibial tuberosity transfer. The mean follow-up period was 36.8 months. The rate of dislocation and arthrofibrosis were 5% each. There were no chondral necrosis or nonunion. The mean post-operative BPII was 58.4 and VAS-P was 30.4. CONCLUSIONS: Bereiter trochleoplasty, often combined with MPFL reconstruction and/or tibial tuberosity transfer results in low re-dislocation and complication rate. LEVEL OF EVIDENCE: IV.

Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: systematic review and meta-analysis.

PURPOSE: This study updates the current evidence on the role of allografts versus autografts for medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral instability. METHODS: The study was performed according to the PRISMA guidelines. In March 2021, a literature search in the main online databases was performed. Studies reporting quantitative data concerning primary MPFL reconstruction using an allograft were considered for inclusion. The Coleman Methodology Score was used to assess the methodological quality of the selected articles. RESULTS: Data from 12 studies (474 procedures) were retrieved. The mean follow-up was 42.2 (15-78.5) months. The mean age was 21.1 ± 6.2 years. 64.9% (285 of 439) of patients were female. At the last follow-up, the Tegner (p < 0.0001), Kujala (p = 0.002) and the Lysholm (p < 0.0001) scores were minimally greater in the autografts. The similarity was found in the rate of persistent instability sensation and revision. The allograft group evidenced a lower rate of re-dislocations (p = 0.003). CONCLUSION: Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability. Allograft tendons yielded similar PROMs, rates of persistent instability, and revision. Allograft reconstructions tended to have modestly lower re-dislocation rates. LEVEL OF EVIDENCE: IV.

Femoral tunnel malposition is the most common indication for revision medial patellofemoral ligament reconstruction with promising early outcomes following revision reconstruction: a systematic review.

PURPOSE: The purpose of this study was to identify the causes of failure of previous medial patellofemoral ligament reconstruction (MPFL-R), and to furthermore report the surgical techniques available for MPFL revision surgery. METHODS: Four databases [PubMed, Ovid (MEDLINE), Cochrane Database, and EMBASE] were searched until September 29, 2020 for human studies pertaining to revision MPFL. Two reviewers screened the literature independently and in duplicate. Methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria, or the CAse REport guidelines (CARE), where appropriate. RESULTS: Fourteen studies (one level II, one level III, two level IV, ten level V) were identified. This search resulted in a total of 76 patients with a mean age (range) of 22 (14-39) years. The patients were 75% female with a mean (range) time to revision of 24.1 (1-60) months and mean (range) follow-up of 36.2 (2-48) months. The most common indication for revision surgery was malpositioning of the femoral tunnel (38.1%), unaddressed trochlear dysplasia (18.4%), patellar fracture (11.8%). Femoral tunnel malposition was typically treated via revision MPFL-R with quadriceps tendon or semitendinosus autograft and may retain the primary graft if fixation points were altered. Unaddressed trochlear dysplasia was treated with deepening trochleoplasty with or without revision MPFL-R, and patella fracture according to the nature of the fracture pattern and bone quality. Though generally, outcomes in the revision scenario across all indications were inferior to those post-primary procedure, overall, revision patients demonstrated positive improvements in pain and instability symptoms. Transverse patella fractures treated with debridement and filling with demineralized bone matrix if required with further fixation according to the fracture pattern. CONCLUSION: The most common causes of MPFL failure in literature published to date, in order of decreasing frequency, are: malposition of the femoral tunnel, unaddressed trochlear dysplasia, and patellar fracture. Although surgical techniques of revision MPFL-R to manage these failures were varied, promising outcomes have been reported to date. Larger prospective comparative studies would be useful to clarify optimal surgical management of MPFL-R failure at long-term follow-up. LEVEL OF EVIDENCE: IV.

Medial patellofemoral ligament reconstruction is superior to active rehabilitation in protecting against further patella dislocations.

PURPOSE: Isolated reconstruction of the medial patellofemoral ligament (MPFL-R) has become the predominant stabilizing procedure in the treatment of recurrent lateral patellar dislocation (LPD). To minimize the risk of re-dislocations, isolated MPFL-R is recommended in patients with no significant trochlea dysplasia and tibial tuberosity trochlear groove distance < 20 mm on computed tomography (CT). Incidentally, these criteria are the same that are used to identify first time LPD patients where conservative treatment is recommended. The purpose of this study was therefore to compare MPFL-R with active rehabilitation for patients with recurrent LPD (RLPD) in absence of the above mentioned underlying anatomical high-risk factors for further patellar dislocations. METHODS: RLPD-patients aged 12-30 without underlying anatomical high-risk factors for further LPD were randomized into treatment either with isolated MPFL-R or active rehabilitation provided and instructed by a physiotherapist. All patients underwent diagnostic arthroscopy for concomitant problems. The main outcome measure was persistent patellar instability at 12 months. Knee function at baseline and 12 months was asses using the following patient reported outcomes measures (PROMS); KOOS, Kujala, Cincinnati knee rating, Lysholm score and Noyes sports activity rating scale. RESULTS: Between 2010 and 2019, 61 patients were included in the study (MPFL-R, N = 30, Controls, N = 31). Persistent patellar instability at 12 months was reported by 13 (41.9%) controls, versus 2 (6.7%) in the MPFL-group (RR 6.3 (95% CI 1.5-25.5). No statistically significant differences in activity level were found between the MPFL-group and the Controls at neither baseline nor follow up. The patients with persistent instability at 12 months did not score significantly lower on any of the PROMs compared to their stable peers, regardless of study group. CONCLUSION: Patients with recurrent patellar dislocations have a six-fold increased risk of persistent patellar instability if treated with active rehabilitation alone, compared to MPFL-R in combination with active rehabilitation, even in the absence of significant anatomical risk factors. Active rehabilitation of the knee without MPFL-R improves patient reported knee function after one year, but does not protect against persistent patellar instability.

Prognostic factors for isolated medial patellofemoral ligament reconstruction: A systematic review.

BACKGROUND: Evidence concerning the influence gender, age, and the time elapsed from the first dislocation to surgery in the outcomes of Medial Patella Femoral Ligament (MPFL) reconstruction are lacking. This systematic review was conducted to investigate whether patient characteristics have an influence in the clinical outcomes of MPFL reconstruction for patients with patellofemoral instability. MATERIAL AND METHODS: This study followed the PRISMA guidelines. The main databases were accessed in February 2021. All the studies reporting outcomes of primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. A multivariate analysis diagnostic tool was used to analyse the association between age, gender and time from injury to surgery and the surgical outcomes at last follow-up. RESULTS: A total of 50 articles (2037 procedures) were included. The mean follow-up was 40.90 ± 24.8 months. The mean age was 23.6 ± 3.9 years. 64.3% (1309 of 2037 patients) were female. The mean time from injury to surgery was 64.5 ± 48.9 months. Women showed no statistically significant association with the Kujala score or complications. Older patients had a reduced risk to incur re-dislocations (P = 0.01) and revisions (P = 0.01). Longer time from injury to surgery was associated with greater risk to incur re-dislocations (P = 0.01), and with lower Kujala score (P < 0.0001). No other statistically significant association was evidenced. CONCLUSION: The time span from the first patellar dislocation to the surgical reconstruction was a negative prognostic factor, while sex had no influence on surgical outcomes. The role of patients age on surgical outcomes remains unclear.

The novel dynamic MPFL-reconstruction technique: cheaper and better?

PURPOSE: Reconstruction of the medial patellofemoral ligament (MPFL) is an established procedure to restore patellar stability. Aim of this study is to evaluate the results of a dynamic MPFL reconstruction technique in a large university hospital setting. METHODS: Two hundred and thirteen consecutive patients with 221 knees were surgically treated for recurrent lateral patellar dislocation. All patients obtained dynamic reconstruction of the MPFL with detachment of the gracilis tendon at the pes anserinus while maintaining the proximal origin at the gracilis muscle. Patellar fixation was performed by oblique transpatellar tunnel transfer. Follow-up data including Kujala and BANFF score, pain level as well as recurrent patella instability were collected at a minimum follow-up of 2 years. RESULTS: Follow-up could be obtained from 158 patients (71%). The mean follow-up time was 5.4 years. Mean pain level was 1.9 ± 2.0 on the VAS. Mean Kujala score was 78.4 ± 15.5. Mean BANFF score was 62.4 ± 22.3. MPFL-reconstructions that were performed by surgeons with a routine of more than ten procedures had a significantly shorter surgical time 52.3 ± 17.6 min. Male patients yielded higher satisfaction rates and better clinical scores compared to females. Complications occurred in 27.2% of procedures, 20.9% requiring revision surgery of which were 9.5% related to recurrent patellar instability. 78% of all patients indicated they would undergo the procedure again. CONCLUSION: Dynamic MPFL reconstruction presents a reproducible procedure with increased complication rates, inferior to the results of static reconstruction described in the literature. Despite, it appears to be an efficient procedure to restore patellar stability in a large university hospital setting, without the necessity for intraoperative fluoroscopy. TRIAL REGISTRATION: The study was registered in ClinicalTrials.gov with the registration number NCT04438109 on June 18th 2020.

MPFL reconstruction corrects patella alta: a cohort study.

PURPOSE: Patella alta is an established risk factor for recurrent lateral patella dislocations. Medial patellofemoral ligament (MPFL) reconstruction has been shown to reduce patella height. Our hypothesis is that isolated MPFL reconstruction corrects patella alta, thereby reducing the risk of recurrent patella dislocation. METHODS: A prospective cohort study of 33 knees which underwent MPFL reconstruction for recurrent patella dislocation. The pre-operative and post-operative patella height and Kujala knee outcome scores, as well as tibial tuberosity-trochlear groove (TT-TG) distance, and the grade of trochlear dysplasia were recorded. RESULTS: The mean age was 21.5 years (16-34 years). There was significant reduction in patella height in all patients (p < 0.001), a 67% normalisation of patella alta (CD ≥ 1.2) (p < 0.004), and improvement in the Kujala scores 57.1 (pre-operatively) to 94.8 (post-operatively, p < 0.0001). The recurrent dislocation rate was 3%. CONCLUSION: MPFL reconstruction alone results in correction in patella alta and improvement in clinical outcomes.

MRI following medial patellofemoral ligament reconstruction: assessment of imaging features found with post-operative pain, arthritis, and graft failure.

OBJECTIVE: To assess MR features following MPFL reconstruction and determine their influence on post-operative pain, progressive arthritis, or graft failure. MATERIALS AND METHODS: Retrospective study on 38 patients with MPFL reconstruction and a post-operative MRI between January 2010 and June 2019. Two radiologists assessed MPFL graft signal, graft thickness, femoral screw, femoral tunnel widening, and patellofemoral cartilage damage. The third performed patellofemoral instability measurements. All three assessed femoral tunnel position with final result determined by majority consensus. Imaging findings were evaluated in the setting of post-operative pain, patellofemoral arthritis, and MPFL graft failure including need for MPFL revision. Statistics included chi-square, Fisher's exact test, t test, and kappa. RESULTS: Mean graft thickness was 6.0 ± 1.8 mm; 24% of the grafts were diffusely hypointense. Mean femoral tunnel widening was 2.5 ± 1.8 mm; 34% of the femoral screws were broken or extruded. Fifty-two percent of the patients had no interval cartilage change. Non-anatomic femoral tunnels were found in 66% of patients, including in all 9 patients requiring revision MPFL reconstruction (p = 0.013). Revised MPFL grafts had more abnormal femoral screws compared to those that did not (67% vs. 24%) (p = 0.019). Other MR features did not significantly influence the evaluated outcomes. CONCLUSION: The need for revision MPFL reconstruction occurs more frequently when there is a non-anatomic femoral tunnel and broken or extruded femoral screws. The appearance of the MPFL graft itself is not an influencing factor for post-operative pain, progression of patellofemoral arthritis, or graft failure.

Anterior and distal tunnel orientation for anatomic reconstruction of the medial patellofemoral ligament is safer in patients with open growth plates.

PURPOSE: In patients with open growth plates, the direction of tunneling that avoids distal femoral physis (DFP) damage in anatomic reconstructions of the medial patellofemoral ligament (MPFL) has been a topic of discussion. The objective of this study was to determine the ideal orientation for anatomic reconstructions of MPFL tunneling that minimized DFP damage while avoiding breaching the intercondylar notch. METHODS: Eighty magnetic resonance images of patients aged 10 through 17 were obtained, randomly sampled from the institutional database. A de novo software was developed to obtain 3D models of the distal femur and DFP. In each model, the anatomical insertion point of the MPFL was determined as defined by Stephen. A 20-mm-depth drilling was simulated, starting from the insertion point at every possible angle within a 90° cone using 5-, 6- and 7-mm drills. Physeal damage for each pair of angles and each drill size was determined. Damage was expressed as a percentage of total physis volume. Statistical analysis was conducted using Student's t test and one-way ANOVA. RESULTS: Maximum physeal damage (5.35% [4.47-6.24]) was obtained with the 7-mm drill when drilling 3° cephalic and 15° posterior from insertion without differences between sexes (n.s.). Minimal physeal damage (0.22% [0.07-0.37]) was obtained using the 5-mm drill aimed 45° distal and 0° anteroposterior, not affected by sex (n.s.). Considering intra-articular drilling avoidance, the safest zone was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. CONCLUSION: Ideal femoral tunnel orientation, avoiding physeal damage and breaching of the intercondylar notch, was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. This area is a safe zone that allows anatomic MPFL reconstruction of patients with an open physis.

Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability.

PURPOSE: The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors. METHODS: Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores. RESULTS: Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p < 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p < 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship. CONCLUSION: This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research. Level of evidence IV.

Lateral retinacular release combined with MPFL reconstruction for patellofemoral instability: a systematic review.

INTRODUCTION: The role of the lateral retinaculum in patellofemoral instability is still debated. Lateral retinacular release (LRR), has been extensively performed in combination with different surgical procedures, including reconstruction of medio-patellofemoral ligament (MPFL). Despite controversial indications, the results from these studies seem promising. The present study conducts a systematic review about current biomechanical and clinical evidence concerning the role of LRR in combination with MPFL reconstruction. We performed a comprehensive literature research, comparing the outcomes of MPFL reconstruction with and without LRR. MATERIALS AND METHODS: This systematic review was conducted according to the PRISMA guidelines. The literature search was performed in August 2020. All articles describing the outcome of isolated MPFL reconstruction alone or in combination with a LRR in patients with recurrent patellofemoral instability were considered for inclusion. Only articles reporting data on patients with a minimum of 12-month follow-up were included. Only articles reporting quantitative data under the outcomes of interest were included. RESULTS: A total of 63 articles were eligible for this systematic review, including 2131 knees. The mean follow-up was 40.87 ± 24.1 months. All scores of interests improved in favour of the combined group: Kujala + 3.8% (P = 0.01), Lysholm + 4.2% (P = 0.004), Tegner + 0.8 points (P = 0.04), IKDC + 9.8% (P = 0.02). The ROM was comparable between the two groups (P = 0.4). Similarity was found in terms of positivity to the apprehension test (P = 0.05), rate of complications (P = 0.1), re-dislocations (P = 0.8), and revision surgeries (P = 0.1). CONCLUSION: There is no evidence that adding a lateral release impacts positively on the outcome of MPFL reconstruction. LEVEL OF EVIDENCE: IV, Systematic review.

Arthroscopic assessment of patella tracking correlates with recurrent patellar instability.

PURPOSE: For recurrent lateral patellar instability surgical algorithm, an arthroscopic assessment of patellar tracking can aid with the decision of adding a tibial tubercle transfer procedure based on knee flexion angle at which patella centrally engages in its groove. Tibial tubercle-trochlear groove distance is variable in normal values and has discrepancies between imaging modalities. The aims of our study were to assess correlation of arthroscopic patellar tracking technique with recurrent patellar instability, and to assess the accuracy and reproducibility of this technique. METHODS: 157 patients were evaluated, 64 control patients with no patellar instability, and 93 patients with recurrent patellar instability. This included 57 consecutive knee arthroscopy procedures evaluated for accuracy and reproducibility of our technique. The technique involved low flow arthroscopy and anterolateral viewing portal. Patients' knees were extended from a flexed position of 120°, and paused when the patella disengaged from its groove. The KFA was then estimated by the primary surgeon, and compared with a goniometer measurement. The assisting surgeon, blinded to the primary surgeon measurements, repeated this process. For the primary outcome, goniometer readings for KFA from the primary surgeon were used to correlate with patellar instability diagnosis. RESULTS: Patients with patellar instability had a mean KFA of 118° compared to 44°for patients without patellar instability (p < 0.001). The mean difference between goniometer reading and estimation of KFA by each surgeon was 5° (p < 0.001) with intra-class correlation of 0.99. The mean difference between the two surgeons' goniometer readings was 8° (p < 0.001) with intra-class correlation of 0.99. CONCLUSION: This study confirms arthroscopic assessment of patella tracking is accurate, reproducible, and a knee flexion angle of greater than 44° correlates with patellar instability diagnosis. Patella tracking can be used as an adjunct or an alternative assessment method to tibial tubercle-trochlear groove distance to determine the need for tibial tubercle transfer in patellar stabilisation surgery. LEVEL OF EVIDENCE: Prospective Cohort Study, Level III.

Clinical outcomes of medial retinaculum plasty versus MPFL reconstruction with concomitant tibial tubercle transfer: a retrospective study.

PURPOSE: To elucidate the clinical outcomes of medial retinaculum plasty versus MPFL reconstruction with concomitant tibial tubercle transfer. METHODS: From January 2014 to July 2018, 57 patients who underwent tibial tubercle transfer combined with medial retinaculum plasty or MPFL reconstruction were enrolled in the present study. The 57 patients were divided into two comparison groups according to the therapeutic protocol. The 25 patients in group I underwent the medial retinaculum plasty and tibial tubercle transfer. The 32 patients in group II underwent the MPFL reconstruction and tibial tubercle transfer. Clinical outcomes were assessed using the knee injury and osteoarthritis outcome score, Kujala score, congruence angle, patellar tilt angle, patellar lateral shift, tibial tuberosity-trochlear groove distance and Caton-Deschamps Index. The clinical outcomes were compared between the two groups preoperatively and at the time of the last follow-up. RESULTS: Significant improvement was seen in both groups postoperatively (P < 0.05). There were no significant differences in the knee injury and osteoarthritis outcome score, Kujala score, congruence angle, patellar tilt angle, patellar lateral shift, tibial tuberosity-trochlear groove distance and Caton-Deschamps Index between the two groups (P > 0.05). CONCLUSION: The combined medial retinaculum plasty and tibial tubercle transfer achieved similar clinical outcomes versus the MPFL reconstruction with concomitant TTT. This therapeutic protocol was a good option in treatment of patellar dislocation with increased TT-TG distance or patella alta.

Patellar fixation graft via suture anchors versus tunnel techniques during isolated MPFL reconstruction for recurrent patellofemoral instability: a systematic review of the literature.

INTRODUCTION: There is still a lack of evidence concerning the patellar fixation of the medial patellofemoral ligament (MPFL) graft in selected patient with recurrent instability. The purpose of the present study was to investigate and compare clinical outcomes and further complications of isolated MPFL reconstruction via suture anchors versus tunnel techniques for recurrent patellofemoral instability. MATERIALS AND METHODS: This systematic review of the literature was conducted according to the PRISMA guidelines. In September 2019, the main databases were accessed. All the clinical trials performing isolated MPFL reconstruction in patients with recurrent patellofemoral instability were included in the present study. Only articles fixing the MPFL graft through suture anchors and/ or patellar tunnel techniques were included in the analysis. RESULTS: Data from 46 papers (1712 patients) were recorded. The mean follow-up was 40 ± 18 months. No differences were found in Kujala, Lysholm and Tegner score, International Knee Documentation Committee, visual analogic scale, range of motion and re-dislocation rate. The suture anchors fixation group detected reduced rate of apprehension test (OR: 0.6; p = 0.03), revision surgeries (OR: 0.4; p = 0.02) and anterior knee pain (OR: 0.05; p < 0.0001) and reduced not-classified complications (OR: 0.18; p < 0.0001). CONCLUSION: Both the suture anchors and the bone-tunnels are a feasible option for isolated MPFL reconstruction in patients with recurrent patellofemoral instability. Patellar fixation via suture anchors evidenced a reduced rate of anterior knee pain, revision surgeries, apprehension test and an overall reduced complication compared to the bone-tunnel technique.