Clinical and Functional Outcomes following Primary Repair versus Reconstruction of the Medial Patellofemoral Ligament for Recurrent Patellar Instability
Background. The purpose of this study was to compare outcomes of medial patellofemoral ligament (MPFL) repair or reconstruction. Methods. Fourteen knees that underwent MPFL repair and nine (F5, M4) knees that underwent reconstruction at our institution were evaluated for objective and subjective outcomes. The mean age at operation was 20.1 years for repair and 19.8 years for reconstruction. All patients had a minimum of 2 years of follow-up (range: 24–75 months). Patient subjective outcomes were obtained using the International Knee Documentation Committee (IKDC) and Kujala patellofemoral subjective evaluations, as well as Visual Analog (VAS) and Tegner Activity Scales. Bilateral isometric quadriceps strength and vastus medialis obliquus (VMO) and vastus lateralis (VL) surface EMG were measured during maximal isometric quadriceps contractions at 30° and 60° of flexion. Results. There were no redislocations in either group. There was no difference in IKDC ( ), Kujala ( ), Tegner ( ), or VAS ( ) scores at follow-up. There were no differences between repair and reconstruction in torque generation of the involved side at 30° ( ) and 60° ( ). In addition, there was no side to side difference in torque generation or surface EMG activation of VL or VMO. Conclusions. There were minimal differences found between patients undergoing MPFL repair and MPFL reconstruction for the objective and subjective evaluations in this study. 1. Introduction Patellar instability poses a difficult treatment problem in the setting of recurrent instability [1]. Many types of operative management to address injury to the medial patellofemoral ligament (MPFL) have been described [2]. These include repair of the MPFL, which has been described using arthroscopic, arthroscopically assisted, or open techniques [3–6]. When the pathology is within the midsubstance of the tendon such as chronic stretching of the MPFL, imbrication has been described where the fibers of the MPFL are tightened [7–12]. Finally, when repair and imbrication are not possible or not recommended, reconstruction of the MPFL using various techniques has been described [13–22]. Long term clinical studies evaluating management options for patellar instability have come in many forms. In recurrent patellar instability or chronic injury to the MPFL, repair of the MPFL has provided mixed clinical results [23–34]. Reconstruction of the MPFL in recurrent patellar instability has been evaluated in many long term studies with good results, in general [13, 18, 25–33]. All of the techniques for repair or reconstruction come with
References
[1]
E. A. Arendt, D. C. Fithian, and E. Cohen, “Current concepts of lateral patella dislocation,” Clinics in Sports Medicine, vol. 21, no. 3, pp. 499–519, 2002.
[2]
D. K. Davis and D. C. Fithian, “Techniques of medial retinacular repair and reconstruction,” Clinical Orthopaedics and Related Research, no. 402, pp. 38–52, 2002.
[3]
C. C. Dodson, M. K. Shindle, J. S. Dines, and D. W. Altchek, “Arthroscopic suture anchor repair for lateral patellar instability,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 18, no. 2, pp. 143–146, 2010.
[4]
K. Fukushima, T. Horaguchi, T. Okano, T. Yoshimatsu, A. Saito, and J. Ryu, “Patellar dislocation: arthroscopic patellar stabilization with anchor sutures,” Arthroscopy, vol. 20, no. 7, pp. 761–764, 2004.
[5]
J. L. Halbrecht, “Arthroscopic patella realignment: an all-inside technique,” Arthroscopy, vol. 17, no. 9, pp. 940–945, 2001.
[6]
M. Haspl, N. cicak, H. Klobucar, and M. Pecina, “Fully arthroscopic stabilization of the patella,” Arthroscopy, vol. 18, no. 1, p. E2, 2002.
[7]
R. N. Steensen, R. M. Dopirak, and P. B. Maurus, “Minimally invasive “crescentic” imbrication of the medial patellofemoral ligament for chronic patellar subluxation,” Arthroscopy, vol. 21, no. 3, pp. 371–375, 2005.
[8]
A. Tom and J. P. Fulkerson, “Restoration of native medial patellofemoral ligament support after patella dislocation,” Sports Medicine and Arthroscopy Review, vol. 15, no. 2, pp. 68–71, 2007.
[9]
S. Ali and A. Bhatti, “Arthroscopic proximal realignment of the patella for recurrent instability: report of a new surgical technique with 1 to 7 years of follow-up,” Arthroscopy, vol. 23, no. 3, pp. 305–311, 2007.
[10]
J. C. Hughston and W. M. Walsh, “Proximal and distal reconstruction of the extensor mechanism for patellar subluxation,” Clinical Orthopaedics and Related Research, no. 144, pp. 36–42, 1979.
[11]
J. N. Insall, P. Aglietti, and A. J. Tria Jr., “Patellar pain and incongruence. II: clinical application,” Clinical Orthopaedics and Related Research, vol. 176, pp. 225–232, 1983.
[12]
E. K. Nam and R. P. Karzel, “Mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation: a medium-term follow-up,” The American Journal of Sports Medicine, vol. 33, no. 2, pp. 220–230, 2005.
[13]
M. Deie, M. Ochi, Y. Sumen, N. Adachi, K. Kobayashi, and M. Yasumoto, “A long-term follow-up study after medial patellofemoral ligament reconstruction using the transferred semitendinosus tendon for patellar dislocation,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 13, no. 7, pp. 522–528, 2005.
[14]
D. Drez Jr., T. B. Edwards, and C. S. Williams, “Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation,” Arthroscopy, vol. 17, no. 3, pp. 298–306, 2001.
[15]
Y. Nietosvaara, R. Paukku, S. Palmu, and S. T. Donell, “Acute patellar dislocation in children and adolescents: surgical technique,” Journal of Bone and Joint Surgery A, vol. 91, no. 2, pp. 139–145, 2009.
[16]
P. J. Sillanp？？, H. M. M？enp？？, V. M. Mattila, T. Visuri, and H. Pihlajam？ki, “A mini-invasive adductor magnus tendon transfer technique for medial patellofemoral ligament reconstruction: a technical note,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 17, no. 5, pp. 508–512, 2009.
[17]
R. N. Steensen, R. M. Dopirak, and P. B. Maurus, “A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft,” Arthroscopy, vol. 21, no. 3, pp. 365–370, 2005.
[18]
S. E. Christiansen, B. W. Jacobsen, B. Lund, and M. Lind, “Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes,” Arthroscopy, vol. 24, no. 1, pp. 82–87, 2008.
[19]
J. Farr and A. A. Schepsis, “Reconstruction of the medial patellofemoral ligament for recurrent patellar instability,” The Journal of Knee Surgery, vol. 19, no. 4, pp. 307–316, 2006.
[20]
P. B. Sch？ttle, S. F. Fucentese, and J. Romero, “Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 13, no. 7, pp. 516–521, 2005.
[21]
M. Thaunat and P. J. Erasmus, “The favourable anisometry: an original concept for medial patellofemoral ligament reconstruction,” Knee, vol. 14, no. 6, pp. 424–428, 2007.
[22]
C. S. Ahmad, G. D. Brown, and B. S. Stein, “The docking technique for medial patellofemoral ligament reconstruction: surgical technique and clinical outcome,” The American Journal of Sports Medicine, vol. 37, no. 10, pp. 2021–2027, 2009.
[23]
E. A. Arendt, A. Moeller, and J. Agel, “Clinical outcomes of medial patellofemoral ligament repair in recurrent (chronic) lateral patella dislocations,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 19, no. 11, pp. 1909–1914, 2011.
[24]
C. L. Camp, A. J. Krych, D. L. Dahm, B. A. Levy, and M. J. Stuart, “Medial patellofemoral ligament repair for recurrent patellar dislocation,” The American Journal of Sports Medicine, vol. 38, no. 11, pp. 2248–2254, 2010.
[25]
J. L. E. Gomes, “Medial patellofemoral ligament reconstruction for recurrent dislocation of the patella: a preliminary report,” Arthroscopy, vol. 8, no. 3, pp. 335–340, 1992.
[26]
Y. Mikashima, M. Kimura, Y. Kobayashi, M. Miyawaki, and T. Tomatsu, “Clinical results of isolated reconstruction of the medial patellofemoral ligament for recurrent dislocation and subluxation of the patella,” Acta Orthopaedica Belgica, vol. 72, no. 1, pp. 65–71, 2006.
[27]
E. Nomura and M. Inoue, “Surgical technique and rationale for medial patellofemoral ligament reconstruction for recurrent patellar dislocation,” Arthroscopy, vol. 19, no. 5, pp. 1–9, 2003.
[28]
T. M. Steiner, R. Torga-Spak, and R. A. Teitge, “Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia,” The American Journal of Sports Medicine, vol. 34, no. 8, pp. 1254–1261, 2006.
[29]
T. Watanabe, T. Muneta, H. Ikeda, T. Tateishi, and I. Sekiya, “Visual analog scale assessment after medial patellofemoral ligament reconstruction: with or without tibial tubercle transfer,” Journal of Orthopaedic Science, vol. 13, no. 1, pp. 32–38, 2008.
[30]
M. Ronga, F. Oliva, U. G. Longo, V. Testa, G. Capasso, and N. Maffulli, “Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation,” The American Journal of Sports Medicine, vol. 37, no. 9, pp. 1735–1742, 2009.
[31]
B. Fisher, J. Nyland, E. Brand, and B. Curtin, “Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy,” Arthroscopy, vol. 26, no. 10, pp. 1384–1394, 2010.
[32]
J. L. Ellera Gomes, L. R. Stigler Marczyk, P. C. De César, and C. F. Jungblut, “Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study,” Arthroscopy, vol. 20, no. 2, pp. 147–151, 2004.
[33]
E. Nomura, Y. Horiuchi, and M. Kihara, “A mid-term follow-up of medial patellofemoral ligament reconstruction using an artificial ligament for recurrent patellar dislocation,” Knee, vol. 7, no. 4, pp. 211–215, 2000.
[34]
L. D. Higgins, M. K. Taylor, D. Park et al., “Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form,” Joint Bone Spine, vol. 74, no. 6, pp. 594–599, 2007.
[35]
U. M. Kujala, L. H. Jaakkola, S. K. Koskinen, S. Taimela, M. Hurme, and O. Nelimarkka, “Scoring of patellofemoral disorders,” Arthroscopy, vol. 9, no. 2, pp. 159–163, 1993.
[36]
Y. Tegner and J. Lysholm, “Rating systems in the evaluation of knee ligament injuries,” Clinical Orthopaedics and Related Research, vol. 198, pp. 43–49, 1985.
[37]
H. Dejour, G. Walch, L. Nove-Josserand, and C. Guier, “Factors of patellar instability: an anatomic radiographic study,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 2, no. 1, pp. 19–26, 1994.
[38]
S. Lippacher, D. Dejour, M. Elsharkawi et al., “Observer agreement on the dejour trochlear dysplasia classification: a Comparison of true lateral radiographs and axial magnetic resonance images,” The American Journal of Sports Medicine, vol. 40, no. 4, pp. 837–843, 2012.
[39]
P. B. Sch？ttle, A. Schmeling, N. Rosenstiel, and A. Weiler, “Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction,” The American Journal of Sports Medicine, vol. 35, no. 5, pp. 801–804, 2007.
[40]
R. Philippot, J. Chouteau, J. Wegrzyn, R. Testa, M. H. Fessy, and B. Moyen, “Medial patellofemoral ligament anatomy: implications for its surgical reconstruction,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 17, no. 5, pp. 475–479, 2009.
[41]
R. N. Steensen, R. M. Dopirak, and W. G. McDonald III, “The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction,” The American Journal of Sports Medicine, vol. 32, no. 6, pp. 1509–1513, 2004.
[42]
J. J. Elias and A. J. Cosgarea, “Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis,” The American Journal of Sports Medicine, vol. 34, no. 9, pp. 1478–1485, 2006.
[43]
M. J. Callaghan and J. A. Oldham, “Quadriceps atrophy: to what extent does it exist in patellofemoral pain syndrome?” British Journal of Sports Medicine, vol. 38, no. 3, pp. 295–299, 2004.
[44]
K. Cerny, “Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome,” Physical Therapy, vol. 75, no. 8, pp. 672–683, 1995.
[45]
D. Kaya, S. Citaker, U. Kerimoglu et al., “Women with patellofemoral pain syndrome have quadriceps femoris volume and strength deficiency,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 19, no. 2, pp. 242–247, 2011.
[46]
B. Ott, N. L. Cosby, T. L. Grindstaff, and J. M. Hart, “Hip and knee muscle function following aerobic exercise in individuals with patellofemoral pain syndrome,” Journal of Electromyography and Kinesiology, vol. 21, pp. 631–637, 2011.
[47]
A. C. S. Ribeiro, D. B. Grossi, B. Foerster, C. Candolo, and V. Monteiro-Pedro, “Electromyographic and magnetic resonance imaging evaluations of individuals with patellofemoral pain syndrome,” Revista Brasileira de Fisioterapia, vol. 14, no. 3, pp. 221–228, 2010.
[48]
D. Kohn, O. Steimer, and R. Seil, “Anteromedialization of the tibial tubercle,” Orthopade, vol. 33, no. 2, pp. 218–223, 2004.
[49]
W. J. Morshuis, P. W. Pavlov, and K. P. De Rooy, “Anteromedialization of the tibial tuberosity in the treatment of patellofemoral pain and malalignment,” Clinical Orthopaedics and Related Research, no. 255, pp. 242–250, 1990.
[50]
A. J. Pidoriano, R. N. Weinstein, D. A. Buuck, and J. P. Fulkerson, “Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer,” The American Journal of Sports Medicine, vol. 25, no. 4, pp. 533–537, 1997.
[51]
G. Diederichs, A. S. Issever, and S. Scheffler, “MR imaging of patellar instability: injury patterns and assessment of risk factors,” Radiographics, vol. 30, no. 4, pp. 961–981, 2010.
