Original article| Volume 22, ISSUE 3, P308-319, March 2006

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In Vitro Investigation of the Effect of Medial Patellofemoral Ligament Reconstruction and Medial Tibial Tuberosity Transfer on Lateral Patellar Stability

      Purpose: Two different operative techniques for stabilizing the patella against lateral displacement movement were investigated. Type of Study: In vitro experimental study. Methods: Five human cadaver knee specimens with a normal Q-angle were mounted in a kinematic knee simulator and investigated under simulated isokinetic extension motions. Patellar movement was measured while a 100-N laterally directed subluxation load was applied to the patella. Ligament loading of the medial patellofemoral ligament was measured using a strain gage based buckle transducer inserted in the fibers of the ligament. The knee was evaluated in an intact physiologic state, as well as after medial transfer of the tibial tuberosity, and after the medial patellofemoral ligament was transected and reconstructed using a hamstring autograft. Results: A significant reduction in lateral displacement and ligament load was observed with the use of the hamstring autograft reconstruction compared with the medial transfer of the tibial tuberosity. Conclusions: Medial transfer of the tibial tuberosity showed no significant relief of ligament loading and stabilizing effect on patellar movement, whereas reconstruction of the medial patellofemoral ligament showed a significant stabilizing effect on patellar movement. Clinical Relevance: In cadaver specimens, we evaluated the effect of tibial tubercle transfer and the patellofemoral ligament and found that reconstruction of the patellofemoral ligament alone was sufficient to restore stability in a cadaveric model. Additionally, we found that the flexion angle had little effect on the loading of the medial patellofemoral ligament autograft, which would support early mobilization of patients after surgery. We found that the graft was not unduly loaded.

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        • Ahmad C.S.
        • Stein B.E.
        • Matuz D.
        • Henry J.H.
        Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation. A review of eight cases.
        Am J Sports Med. 2000; 28: 804-810
        • Anderson D.D.
        • Guanche C.A.
        The effect of reconstruction of the medial patellofemoral ligament on patellar tracking.
        Am J Sports Med. 2000; 28: 920-921
        • Arendt E.A.
        • Fithian D.C.
        • Cohen E.
        Current concepts of lateral patella dislocation.
        Clin Sports Med. 2002; 21: 499-519
        • Avikainen V.J.
        • Nikku R.K.
        • Seppanen-Lehmonen T.K.
        Adductor magnus tenodesis for patellar dislocation. Technique and preliminary results.
        Clin Orthop. 1993; 297: 12-16
        • Beasley L.S.
        • Vidal A.F.
        Traumatic patellar dislocation in children and adolescents.
        Curr Opin Pediatr. 2004; 16: 29-36
        • Davis D.K.
        • Fithian D.C.
        Techniques of medial retinacular repair and reconstruction.
        Clin Orthop. 2002; 402: 38-52
        • Deie M.
        • Ochi M.
        • Sumen Y.
        • Yasumoto M.
        • Kobayashi K.
        • Kimura H.
        Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children.
        J Bone Joint Surg Br. 2003; 85: 887-890
        • Drez Jr, D.
        • Edwards T.B.
        • Williams C.S.
        Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation.
        Arthroscopy. 2001; 17: 298-306
        • Fithian D.C.
        • Paxton E.W.
        • Cohen A.B.
        Indications in the treatment of patellar instability.
        J Knee Surg. 2004; 17: 47-56
        • Gomes J.L.
        Medial patellofemoral ligament reconstruction for recurrent dislocation of the patella.
        Arthroscopy. 1992; 8: 335-340
        • Hautamaa P.V.
        • Fithian D.C.
        • Kaufman K.R.
        • Daniel D.M.
        • Pohlmeyer A.M.
        Medial soft tissue restraints in lateral patellar instability and repair.
        Clin Orthop. 1998; 349: 174-182
        • Muneta T.
        • Sekiya I.
        • Tsuchiya M.
        • Shinomiya K.
        A technique for reconstruction of the medial patellofemoral ligament.
        Clin Orthop. 1999; 359: 151-155
        • Garth Jr, W.P.
        • DiChristina D.G.
        • Holt G.
        Delayed proximal repair and distal realignment after patellar dislocation.
        Clin Orthop. 2000; : 132-144
        • Wirth C.J.
        • Kohn D.
        Patellare Instabilität.
        in: Wirth C.J. Kohn D. Gelenkchirurgie offene und arthroskopische Verfahren; Tabellen. Thieme, Stuttgart1999: 229-233
        • Benvenuti J.F.
        • Rakotomanana L.
        • Leyvraz P.F.
        • Pioletti D.P.
        • Heegaard J.H.
        • Genton M.G.
        Displacements of the tibial tuberosity. Effects of the surgical parameters.
        Clin Orthop. 1997; 343: 224-234
        • Fulkerson J.P.
        • Shea K.P.
        Disorders of patellofemoral alignment.
        J Bone Joint Surg Am. 1990; 72: 1424-1429
        • Fulkerson J.P.
        Operative management of patellofemoral pain.
        Ann Chir Gynaecol. 1991; 80: 224-229
        • Kohn D.
        • Steimer O.
        • Seil R.
        Anterior medial correction the tibial tuberosity.
        Orthopade. 2004; 33: 218-223
        • Fulkerson J.P.
        Anteromedialization of the tibial tuberosity for patellofemoral malalignment.
        Clin Orthop. 1983; 177: 176-181
        • Shelbourne K.D.
        • Porter D.A.
        • Rozzi W.
        Use of a modified Elmslie-Trillat procedure to improve abnormal patellar congruence angle.
        Am J Sports Med. 1994; 22: 318-323
        • Post W.R.
        Proximales Realignment bei patellofemoralen Erkrankungen.
        in: Wirth C.J. Rudert M. Das patellofemorale Schmerzsyndrom. Steinkopff Verlag, Darmstadt2000: 147-155
        • Fulkerson J.P.
        Patellar subluxation.
        in: Fulkerson J.P. Disorders of the patellofemoral joint. Lippincott Williams & Wilkins, Philadelphia2004: 185
        • Conlan T.
        • Garth Jr, W.P.
        • Lemons J.E.
        Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee.
        J Bone Joint Surg Am. 1993; 75: 682-693
        • Farahmand F.
        • Naghi T.M.
        • Amis A.
        The contribution of the medial retinaculum and quadriceps muscles to patellar lateral stability—An in-vitro study.
        Knee. 2004; 11: 89-94
        • Steensen R.N.
        • Dopirak R.M.
        • McDonald III, W.G.
        The anatomy and isometry of the medial patellofemoral ligament.
        Am J Sports Med. 2004; 32: 1509-1513
        • Smirk C.
        • Morris H.
        The anatomy and reconstruction of the medial patellofemoral ligament.
        Knee. 2003; 10: 221-227
        • Amis A.A.
        • Firer P.
        • Mountney J.
        • Senavongse W.
        • Thomas N.P.
        Anatomy and biomechanics of the medial patellofemoral ligament.
        Knee. 2003; 10: 215-220
        • Desio S.M.
        • Burks R.T.
        • Bachus K.N.
        Soft tissue restraints to lateral patellar translation in the human knee.
        Am J Sports Med. 1998; 26: 59-65
        • Sandmeier R.H.
        • Burks R.T.
        • Bachus K.N.
        • Billings A.
        The effect of reconstruction of the medial patellofemoral ligament on patellar tracking.
        Am J Sports Med. 2000; 28: 345-349
        • Stukenborg-Colsman C.
        • Ostermeier S.
        • Hurschler C.
        • Wirth C.J.
        Tibiofemoral contact stress after total knee arthroplasty.
        Acta Orthop Scand. 2002; 73: 638-646
        • Ostermeier S.
        • Hurschler C.
        • Stukenborg-Colsman C.
        Quadriceps function after TKA—An in vitro study in a knee kinematic simulator.
        Clin Biomech (Bristol Avon). 2004; 19: 270-276
        • Knoll Z.
        • Kiss R.M.
        • Kocsis L.
        Gait adaptation in ACL deficient patients before and after anterior cruciate ligament reconstruction surgery.
        J Electromyogr Kinesiol. 2004; 14: 287-294
        • Malmstrom E.M.
        • Karlberg M.
        • Melander A.
        • Magnusson M.
        Zebris versus Myrin: A comparative study between a three-dimensional ultrasound movement analysis and an inclinometer/compass method: Intradevice reliability, concurrent validity, intertester comparison, intratester reliability, and intraindividual variability.
        Spine. 2003; 28 (available online at E433-E440
        • Fleming B.C.
        • Peura G.D.
        • Beynnon B.D.
        Factors influencing the output of an implantable force transducer.
        J Biomech. 2000; 33: 889-893
        • Blauth W.
        • Mann M.
        Medial-and simultaneous anterior-transfer of the tibial tuberosity.
        Z Orthop Ihre Grenzgeb. 1977; 115 (author’s translation): 252-255
        • Reilly D.T.
        • Martens M.
        Experimental analysis of the quadriceps muscle force and patello-femoral joint reaction force for various activities.
        Acta Orthop Scand. 1972; 43: 126-137
        • Heegaard J.
        • Leyvraz P.F.
        • Van Kampen A.
        • Rakotomanana L.
        • Rubin P.J.
        • Blankevoort L.
        Influence of soft structures on patellar three-dimensional tracking.
        Clin Orthop. 1994; 299: 235-243
        • Cosgarea A.J.
        • Schatzke M.D.
        • Seth A.K.
        • Litsky A.S.
        Biomechanical analysis of flat and oblique tibial tubercle osteotomy for recurrent patellar instability.
        Am J Sports Med. 1999; 27: 507-512
        • Kuroda R.
        • Kambic H.
        • Valdevit A.
        • Andrish J.T.
        Articular cartilage contact pressure after tibial tuberosity transfer. A cadaveric study.
        Am J Sports Med. 2001; 29: 403-409
        • Muneta T.
        • Yamamoto H.
        • Ishibashi T.
        • Asahina S.
        • Furuya K.
        Computerized tomographic analysis of tibial tubercle position in the painful female patellofemoral joint.
        Am J Sports Med. 1994; 22: 67-71
        • Van Kampen A.
        • Huiskes R.
        The three-dimensional tracking pattern of the human patella.
        J Orthop Res. 1990; 8: 372-382
        • Reider B.
        • Marshall J.L.
        • Ring B.
        Patellar tracking.
        Clin Orthop. 1981; 157: 143-148
        • Reider B.
        • Marshall J.L.
        Patella tracking.
        Surg Forum. 1977; 28: 502-504
        • Nagamine R.
        • Whiteside L.A.
        • Otani T.
        • White S.E.
        • McCarthy D.S.
        Effect of medial displacement of the tibial tubercle on patellar position after rotational malposition of the femoral component in total knee arthroplasty.
        J Arthroplasty. 1996; 11: 104-110
        • Cossey A.J.
        • Paterson R.
        A new technique for reconstructing the medial patellofemoral ligament.
        Knee. 2005; 12: 93-98
        • Ishibashi Y.
        • Okamura Y.
        • Otsuka H.
        • Tsuda E.
        • Toh S.
        Lateral patellar retinaculum tension in patellar instability.
        Clin Orthop. 2002; 397: 362-369
        • Luo Z.P.
        • Sakai N.
        • Rand J.A.
        • An K.N.
        Tensile stress of the lateral patellofemoral ligament during knee motion.
        Am J Knee Surg. 1997; 10: 139-144
        • Nomura E.
        • Inoue M.
        Surgical technique and rationale for medial patellofemoral ligament reconstruction for recurrent patellar dislocation.
        Arthroscopy. 2003; 19 ((available online at E47