Clinical outcomes after revision surgery for medial patellofemoral ligament reconstruction

  • Andreas Chatterton
  • Torsten Grønbech Nielsen
  • Ole Gade Sørensen
  • Martin Lind
Knee

Abstract

Purpose

Medial patellofemoral ligament reconstruction (MPFL-R) is the standard surgical intervention for patella instability. However, limited knowledge exists concerning the causes for failure, and outcome after revision MPFL-R. The purpose of this study is to evaluate the causes of primary MPFL-R failure and clinical outcomes after revision MPFL-R.

Methods

Twenty-three patients (6 males and 17 females) with failed primary MPFL-R underwent isolated revision MPFL-R or combined revision MPFL-R with tibial tuberosity osteotomy (TTO). The mean age was 23 (SD 8.6). Prior to surgery, dysplasia of the patellofemoral joint, sulcus angle, Insall-Salvati index, cartilage lesions, tibial tuberosity trochlear groove (TTTG) distance, and tunnel placement were evaluated by magnetic resonance imaging (MRI). Their scores on the Kujala Anterior Knee Pain Scale and pain scores were assessed prior to surgery, 1 year post-operatively and at final follow-up. The mean follow-up time was 44 months (median range 39). The radiographic characteristics and clinical outcomes were compared with a 224 primary MPFL-R patient cohort (240 knees).

Results

Non-anatomical fixation of the graft at the medial femoral condyle after primary MPFL-R was seen in 67% of revision patients with anterior/proximal misplacement in most cases. Severe trochlear dysplasia Dejour types C and D were seen in 36% of the patients compared to 30% of primary MPFL-R patients (NS). The mean Kujala Anterior Knee Pain Scale score at final follow-up was 61.7 (SD 18.8) compared to 80.3 (SD 18) in primary MPFL-R patients (P < 0.01). The mean pain score at rest was 2.3 (SD 2.5) for revision MPFL-R patients compared to 1.7 (SD 2.5) in primary MPFL-R patients (NS) and their mean pain score during activity was 5.0 (SD 3.2) compared to 1.3 (SD 2.2) in primary MPFL patients (P < 0.001).

Conclusion

Although revision MPFL-R establishes acceptable patellar stability, the subjective outcomes after revision MPFL-R do not improve significantly, and are poorer than after primary MPFL-R. Non-anatomical graft position can be an important cause of MPFL-R failure. The clinical relevance of this study is that it shows that it may be difficult to improve self-reported outcomes in revision MPFL-R patients.

Level of evidence

III.

Keywords

Medial patellofemoral ligament MPFL Patella instability Ligament reconstruction Revision surgery Dislocation 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare to have no conflicts of interets.

Funding

No funding was accepted for the study

Ethical approval

The institutional review board (IRB) approval (number 261/2016) was authorized by the The National Committee on Health Research Ethics of Denmark.

Informed consent

Informed consent from each participant was obtained before investigation.

References

  1. 1.
    Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220CrossRefPubMedGoogle Scholar
  2. 2.
    Arendt EA, Fithian DC, Cohen E (2002) Current concepts of lateral patella dislocation. Clin Sports Med 21:499–519CrossRefPubMedGoogle Scholar
  3. 3.
    Beck P, Brown NA, Greis PE, Burks RT (2007) Patellofemoral contact pressures and lateral patellar translation after medial patellofemoral ligament reconstruction. Am J Sports Med 35:1557–1563CrossRefPubMedGoogle Scholar
  4. 4.
    Bicos J, Fulkerson JP, Amis A (2007) Current concepts review: the medial patellofemoral ligament. Am J Sports Med 35:484–492CrossRefPubMedGoogle Scholar
  5. 5.
    Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. The Lancet 1:307–310CrossRefGoogle Scholar
  6. 6.
    Bollier M, Fulkerson J, Cosgarea A, Tanaka M (2011) Technical failure of medial patellofemoral ligament reconstruction. Arthroscopy 27:1153–1159CrossRefPubMedGoogle Scholar
  7. 7.
    Brittberg M, Winalski CS (2003) Evaluation of cartilage injuries and repair. J Bone Joint Surg Am 85-A(Suppl 2):58–69CrossRefGoogle Scholar
  8. 8.
    Buckens CF, Saris DB (2010) Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. Am J Sports Med 38:181–188CrossRefPubMedGoogle Scholar
  9. 9.
    Burrus MT, Werner BC, Cancienne JM, Gwathmey FW, Diduch DR (2016) MPFL graft fixation in low degrees of knee flexion minimizes errors made in the femoral location. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-016-4111-4 PubMedGoogle Scholar
  10. 10.
    Caton JH, Dejour D (2010) Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop 34:305–309CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Christiansen SE, Jacobsen BW, Lund B, Lind M (2008) Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes. Arthroscopy 24:82–87CrossRefPubMedGoogle Scholar
  12. 12.
    Dejour D, Le Coultre B (2007) Osteotomies in patello-femoral instabilities. Sports Med Arthrosc 15:39–46CrossRefPubMedGoogle Scholar
  13. 13.
    Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26CrossRefPubMedGoogle Scholar
  14. 14.
    Donell ST, Joseph G, Hing CB, Marshall TJ (2006) Modified Dejour trochleoplasty for severe dysplasia: operative technique and early clinical results. Knee 13:266–273CrossRefPubMedGoogle Scholar
  15. 15.
    Elias JJ, Cosgarea AJ (2006) Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. Am J Sports Med 34:1478–1485CrossRefPubMedGoogle Scholar
  16. 16.
    Enderlein D, Nielsen T, Christiansen SE, Fauno P, Lind M (2014) Clinical outcome after reconstruction of the medial patellofemoral ligament in patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 22:2458–2464CrossRefPubMedGoogle Scholar
  17. 17.
    Feller JA, Richmond AK, Wasiak J (2014) Medial patellofemoral ligament reconstruction as an isolated or combined procedure for recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc 22:2470–2476CrossRefPubMedGoogle Scholar
  18. 18.
    Fisher B, Nyland J, Brand E, Curtin B (2010) Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy. Arthroscopy 26:1384–1394CrossRefPubMedGoogle Scholar
  19. 19.
    Goutallier D, Bernageau J, Lecudonnec B (1978) The measurement of the tibial tuberosity. Patella groove distanced technique and results (author’s transl). Rev Chir Orthop Reparatrice Appar Mot 64:423–428PubMedGoogle Scholar
  20. 20.
    Herschel R, Hasler A, Tscholl PM, Fucentese SF (2016) Visual-palpatory versus fluoroscopic intraoperative determination of the femoral entry point in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-016-4057-6 PubMedGoogle Scholar
  21. 21.
    Howells NR, Barnett AJ, Ahearn N, Ansari A, Eldridge JD (2012) Medial patellofemoral ligament reconstruction: a prospective outcome assessment of a large single centre series. J Bone Joint Surg Br 94:1202–1208CrossRefPubMedGoogle Scholar
  22. 22.
    Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101:101–104CrossRefPubMedGoogle Scholar
  23. 23.
    Jaecker V, Brozat B, Banerjee M, Otchwemah R, Bouillon B, Shafizadeh S (2015) Fluoroscopic control allows for precise tunnel positioning in MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3613-9 PubMedGoogle Scholar
  24. 24.
    Kohn LM, Meidinger G, Beitzel K, Banke IJ, Hensler D, Imhoff AB, Schöttle PB (2013) Isolated and combined medial patellofemoral ligament reconstruction in revision surgery for patellofemoral instability: a prospective study. Am J Sports Med 41:2128–2135CrossRefPubMedGoogle Scholar
  25. 25.
    Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9:159–163CrossRefPubMedGoogle Scholar
  26. 26.
    Lind M, Enderlein D, Nielsen T, Christiansen SE, Fauno P (2016) Clinical outcome after reconstruction of the medial patellofemoral ligament in paediatric patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 24:666–671CrossRefPubMedGoogle Scholar
  27. 27.
    Lind M, Jakobsen BW, Lund B, Christiansen SE (2008) Reconstruction of the medial patellofemoral ligament for treatment of patellar instability. Acta Orthop 79:354–360CrossRefPubMedGoogle Scholar
  28. 28.
    Malghem J, Maldague B (1989) Depth insufficiency of the proximal trochlear groove on lateral radiographs of the knee: relation to patellar dislocation. Radiology 170:507–510CrossRefPubMedGoogle Scholar
  29. 29.
    McCarthy M, Ridley TJ, Bollier M, Wolf B, Albright J, Amendola A (2013) Femoral tunnel placement in medial patellofemoral ligament reconstruction. Iowa Orthop J 33:58–63PubMedPubMedCentralGoogle Scholar
  30. 30.
    Mulford JS, Wakeley CJ, Eldridge JD (2007) Assessment and management of chronic patellofemoral instability. J Bone Joint Surg Br 89:709–716CrossRefPubMedGoogle Scholar
  31. 31.
    Mulliez A, Lambrecht D, Verbruggen D, Van Der Straeten C, Verdonk P, Victor J (2015) Clinical outcome in MPFL reconstruction with and without tuberositas transposition. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3654-0 PubMedGoogle Scholar
  32. 32.
    Nelitz M, Williams RS, Lippacher S, Reichel H, Dornacher D (2014) Analysis of failure and clinical outcome after unsuccessful medial patellofemoral ligament reconstruction in young patients. Int Orthop 38:2265–2272CrossRefPubMedGoogle Scholar
  33. 33.
    Parikh SN, Nathan ST, Wall EJ, Eismann EA (2013) Complications of medial patellofemoral ligament reconstruction in young patients. Am J Sports Med 41:1030–1038CrossRefPubMedGoogle Scholar
  34. 34.
    Redziniak DE, Diduch DR, Mihalko WM, Fulkerson JP, Novicoff WM, Sheibani-Rad S, Saleh KJ (2009) Patellar instability. J Bone Joint Surg Am 91:2264–2275PubMedGoogle Scholar
  35. 35.
    Schepsis AA, Rogers AJ (2012) Medial patellofemoral ligament reconstruction: indications and technique. Sports Med Arthrosc 20:162–170CrossRefPubMedGoogle Scholar
  36. 36.
    Schottle PB, Fucentese SF, Pfirrmann C, Bereiter H, Romero J (2005) Trochleaplasty for patellar instability due to trochlear dysplasia: a minimum 2-year clinical and radiological follow-up of 19 knees. Acta Orthop 76:693–698CrossRefPubMedGoogle Scholar
  37. 37.
    Schottle PB, Schmeling A, Rosenstiel N, Weiler A (2007) Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 35:801–804CrossRefPubMedGoogle Scholar
  38. 38.
    Servien E, Fritsch B, Lustig S, Demey G, Debarge R, Lapra C, Neyret P (2011) In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med 39:134–139CrossRefPubMedGoogle Scholar
  39. 39.
    Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C (2012) A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 40:1916–1923CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Stephen JM, Kaider D, Lumpaopong P, Deehan DJ, Amis AA (2014) The effect of femoral tunnel position and graft tension on patellar contact mechanics and kinematics after medial patellofemoral ligament reconstruction. Am J Sports Med 42:364–372CrossRefPubMedGoogle Scholar
  41. 41.
    Stephen JM, Lumpaopong P, Dodds AL, Williams A, Amis AA (2015) The effect of tibial tuberosity medialization and lateralization on patellofemoral joint kinematics, contact mechanics, and stability. Am J Sports Med 43:186–194CrossRefPubMedGoogle Scholar
  42. 42.
    Tanaka MJ, Bollier MJ, Andrish JT, Fulkerson JP, Cosgarea AJ (2012) Complications of medial patellofemoral ligament reconstruction: common technical errors and factors for success: AAOS exhibit selection. J Bone Joint Surg Am 94:e87CrossRefPubMedGoogle Scholar
  43. 43.
    Testa EA, Camathias C, Amsler F, Henle P, Friederich NF, Hirschmann MT (2015) Surgical treatment of patellofemoral instability using trochleoplasty or MPFL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3698-1 PubMedGoogle Scholar
  44. 44.
    Thaunat M, Erasmus PJ (2009) Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 17:480–483CrossRefPubMedGoogle Scholar
  45. 45.
    Tischer T, Geier A, Lenz R, Woernle C, Bader R (2016) Impact of the patella height on the strain pattern of the medial patellofemoral ligament after reconstruction: a computer model-based study. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-016-4190-2 Google Scholar
  46. 46.
    Utting MR, Mulford JS, Eldridge JD (2008) A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability. J Bone Joint Surg Br 90:180–185CrossRefPubMedGoogle Scholar
  47. 47.
    Verdonk R, Jansegers E, Stuyts B (2005) Trochleoplasty in dysplastic knee trochlea. Knee Surg Sports Traumatol Arthrosc 13:529–533CrossRefPubMedGoogle Scholar
  48. 48.
    Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, Engebretsen L (2009) Radiographic identification of the primary medial knee structures. J Bone Joint Surg Am 91:521–529CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  1. 1.Department of Sports TraumatologyAarhus University HospitalAarhus CDenmark

Personalised recommendations