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Recurrent Patellar Dislocations Without Untreated Predisposing Factors: Medial Patellofemoral Ligament Reconstruction Versus Other Medial Soft-Tissue Surgical Techniques—A Meta-analysis

Published:January 27, 2020DOI:https://doi.org/10.1016/j.arthro.2019.12.029

      Purpose

      To provide a direct comparison between medial patellofemoral ligament (MPFL) reconstruction and the other medial patellofemoral soft-tissue surgeries in the restoration of the medial patellar restraint after lateral patellar dislocations in the absence of untreated predisposing factors such as high grade trochlear dysplasia, knee malalignment, patella alta or high tibial tubercle-trochlear groove distance.

      Methods

      PubMed, Cochrane-library, Web of Science, and gray literature databases were searched to find all the relevant records. Study selection, data extraction, and risk of bias assessment were performed following the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Different techniques to treat lateral patellar dislocation in the absence of untreated predisposing factors were compared in terms of redislocation and complication rates, Kujala, Lysholm, International Knee Documentation Committee, and Tegner scores at the short-term (3 years) and long-term (>3 years) follow-up through meta-analyses.

      Results

      Six studies involving 319 knees were included in the meta-analysis. The analyses of redislocation (0.7% vs 2.9%) and minor complication rates (12% vs 9%) showed no significant differences between MPFL reconstruction and other medial soft-tissue surgeries. Significant differences favoring MPFL reconstruction were documented in Kujala and Lysholm scores at short-term (8.6, P< .001; 10.9, P < .001) and long-term follow-ups (6.3, P = .02; 13.5, P < .001). No significant differences were found in the analyses of International Knee Documentation Committee (P = .10) and Tegner scores (P = .19). Level of evidence was low or very low.

      Conclusions

      MPFL reconstruction and medial patellofemoral soft-tissue surgery procedures were both effective in restoring the medial restraining forces preventing redislocation, but MPFL reconstruction provided better functional outcomes both at short-term and long-term follow-up. Thus, besides the treatment of predisposing factors, MPFL reconstruction seems to be, based on the results of this meta-analysis, a suitable strategy to restore the medial restraining function in the treatment of recurrent LPD.

      Level of Evidence

      Level III (meta-analysis of randomized and nonrandomized comparative trials)
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      References

        • Zaffagnini S.
        • Colle F.
        • Lopomo N.
        • et al.
        The influence of medial patellofemoral ligament on patellofemoral joint kinematics and patellar stability.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 2164-2171
        • Balcarek P.
        • Ammon J.
        • Frosch S.
        • et al.
        Magnetic resonance imaging characteristics of the medial patellofemoral ligament lesion in acute lateral patellar dislocations considering trochlear dysplasia, patella alta, and tibial tuberosity–trochlear groove distance.
        Arthroscopy. 2010; 26: 926-935
        • Hsiao M.
        • Owens B.D.
        • Burks R.
        • Sturdivant R.X.
        • Cameron K.L.
        Incidence of acute traumatic patellar dislocation among active-duty United States military service members.
        Am J Sports Med. 2010; 38: 1997-2004
        • Fithian D.C.
        • Paxton E.W.
        • Stone M.L.
        • et al.
        Epidemiology and natural history of acute patellar dislocation.
        Am J Sports Med. 2004; 32: 1114-1121
        • Liu J.N.
        • Steinhaus M.E.
        • Kalbian I.L.
        • et al.
        Patellar instability management: A survey of the International Patellofemoral Study Group.
        Am J Sports Med. 2018; 46: 3299-3306
        • Pagliazzi G.
        • Napoli F.
        • Previtali D.
        • Filardo G.
        • Zaffagnini S.
        • Candrian C.
        A meta-analysis of surgical versus nonsurgical treatment of primary patella dislocation.
        Arthroscopy. 2019; 35: 2469-2481
        • Weber A.E.
        • Nathani A.
        • Dines J.S.
        • et al.
        An algorithmic approach to the management of recurrent lateral patellar dislocation.
        J Bone Joint Surg Am. 2016; 98: 417-427
        • Zaffagnini S.
        • Previtali D.
        • Tamborini S.
        • Pagliazzi G.
        • Filardo G.
        • Candrian C.
        Recurrent patellar dislocations: Trochleoplasty improves the results of medial patellofemoral ligament surgery only in severe trochlear dysplasia.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 3599-3613
        • Franciozi C.E.
        • Ambra L.F.
        • Albertoni L.J.B.
        • et al.
        Anteromedial tibial tubercle osteotomy improves results of medial patellofemoral ligament reconstruction for recurrent patellar instability in patients with tibial tuberosity–trochlear groove distance of 17 to 20 mm.
        Arthroscopy. 2019; 35: 566-574
        • Longo U.G.
        • Berton A.
        • Salvatore G.
        • et al.
        Medial patellofemoral ligament reconstruction combined with bony procedures for patellar instability: Current indications, outcomes, and complications.
        Arthroscopy. 2016; 32: 1421-1427
        • Cerciello S.
        • Lustig S.
        • Costanzo G.
        • Neyret P.
        Medial retinaculum reefing for the treatment for patellar instability.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2505-2512
        • Ji G.
        • Wang F.
        • Zhang Y.
        • Chen B.
        • Ma L.
        • Dong J.
        Medial patella retinaculum plasty for treatment of habitual patellar dislocation in adolescents.
        Int Orthop. 2012; 36: 1819-1825
        • Camp C.L.
        • Krych A.J.
        • Dahm D.L.
        • Levy B.A.
        • Stuart M.J.
        Medial patellofemoral ligament repair for recurrent patellar dislocation.
        Am J Sports Med. 2010; 38: 2248-2254
        • Song J.-G.
        • Kang S.-B.
        • Oh S.-H.
        • et al.
        Medial soft-tissue realignment versus medial patellofemoral ligament reconstruction for recurrent patellar dislocation: Systematic review.
        Arthroscopy. 2016; 32: 507-516
        • Matic G.T.
        • Magnussen R.A.
        • Kolovich G.P.
        • Flanigan D.C.
        Return to activity after medial patellofemoral ligament repair or reconstruction.
        Arthroscopy. 2014; 30: 1018-1025
        • Schneider D.K.
        • Grawe B.
        • Magnussen R.A.
        • et al.
        Outcomes after isolated medial patellofemoral ligament reconstruction for the treatment of recurrent lateral patellar dislocations: A systematic review and meta-analysis.
        Am J Sports Med. 2016; 44: 2993-3005
        • Weinberger J.M.
        • Fabricant P.D.
        • Taylor S.A.
        • Mei J.Y.
        • Jones K.J.
        Influence of graft source and configuration on revision rate and patient-reported outcomes after MPFL reconstruction: A systematic review and meta-analysis.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2511-2519
        • Stephen J.M.
        • Kittl C.
        • Williams A.
        • et al.
        Effect of medial patellofemoral ligament reconstruction method on patellofemoral contact pressures and kinematics.
        Am J Sports Med. 2016; 44: 1186-1194
        • Enderlein D.
        • Nielsen T.
        • Christiansen S.E.
        • Faunø P.
        • Lind M.
        Clinical outcome after reconstruction of the medial patellofemoral ligament in patients with recurrent patella instability.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2458-2464
        • Shah J.N.
        • Howard J.S.
        • Flanigan D.C.
        • Brophy R.H.
        • Carey J.L.
        • Lattermann C.
        A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation.
        Am J Sports Med. 2012; 40: 1916-1923
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        Ann Intern Med. 2009; 151: 264-269
        • Higgins J.
        • Sterne J.
        • Savović J.
        • Page M.
        • Hróbjartsson A.
        A revised tool for assessing risk of bias in randomized trials.
        in: Chandler J. McKenzie J. Boutron I. Welch V. Cochrane Methods. 10. Cochrane Database Syst Rev, 2016
        • Sterne J.A.
        • Hernán M.A.
        • Reeves B.C.
        • et al.
        ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions.
        Br Med J. 2016; 355: i4919
        • Higgins J.P.
        • Altman D.G.
        • Gøtzsche P.C.
        • et al.
        The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
        Br Med J. 2011; 343: d5928
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557
        • Hozo S.P.
        • Djulbegovic B.
        • Hozo I.
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Res Methodol. 2005; 5 (13-13)
      1. Review Manager (RevMan). 5.3 ed. The Nordic Cochrane Centre: The Cochrane Collaboration, Copenhagen2014
        • Du H.
        • Tian X-x
        • Guo F-q
        • et al.
        Evaluation of different surgical methods in treating recurrent patella dislocation after three-dimensional reconstruction.
        Int Orthop. 2017; 41: 2517-2524
        • Harle D.
        • Smith T.
        • Loveday D.
        • Donell S.
        Medial reefing versus medial patellofemoral ligament reconstruction for patellar instability.
        Eur J Orthop Surg Traumatol. 2010; 20: 547-551
        • Ma L.-F.
        • Wang F.
        • Chen B.-C.
        • Wang C.-H.
        • Zhou J.-W.
        • Wang H.-Y.
        Medial retinaculum plasty versus medial patellofemoral ligament reconstruction for recurrent patellar instability in adults: a randomized controlled trial.
        Arthroscopy. 2013; 29: 891-897
        • Niu C.
        • Fu K.
        • Lu J.
        • et al.
        A medium-term follow-up outcome of medial retinaculum plasty versus double-bundle anatomical medial patellofemoral ligament reconstruction for recurrent patellar dislocation in adults.
        Int J Clin Exp Med. 2016; 9: 9064-9072
        • Tompkins M.
        • Kuenze C.M.
        • Diduch D.R.
        • Miller M.D.
        • Milewski M.D.
        • Hart J.P.
        Clinical and functional outcomes following primary repair versus reconstruction of the medial patellofemoral ligament for recurrent patellar instability.
        J Sports Med (Hindawi Publ Corp). 2014; 2014: 702358
        • Zhao J.
        • Huangfu X.
        • He Y.
        The role of medial retinaculum plication versus medial patellofemoral ligament reconstruction in combined procedures for recurrent patellar instability in adults.
        Am J Sports Med. 2012; 40: 1355-1364
        • Lee D.-Y.
        • Park Y.-J.
        • Song S.-Y.
        • Hwang S.-C.
        • Park J.-S.
        • Kang D.-G.
        Which technique is better for treating patellar dislocation? A systematic review and meta-analysis.
        Arthroscopy. 2018; : 3082-3093
        • Magnussen R.A.
        • De Simone V.
        • Lustig S.
        • Neyret P.
        • Flanigan D.C.
        Treatment of patella alta in patients with episodic patellar dislocation: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2545-2550
        • Mountney J.
        • Senavongse W.
        • Amis A.A.
        • Thomas N.P.
        Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction.
        J Bone Joint Surg Br. 2005; 87: 36-40
        • Caton J.H.
        • Dejour D.
        Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality.
        Int Orthop. 2010; 34: 305-309
        • Wang C.H.
        • Ma L.F.
        • Zhou J.W.
        • et al.
        Double-bundle anatomical versus single-bundle isometric medial patellofemoral ligament reconstruction for patellar dislocation.
        Int Orthop. 2013; 37: 617-624
        • Wang Q.
        • Huang W.
        • Cai D.
        • Huang H.
        Biomechanical comparison of single- and double-bundle medial patellofemoral ligament reconstruction.
        J Orthop Surg Res. 2017; 12: 29
        • Li J.
        • Li Z.
        • Wang K.
        • Liu C.
        • Wang Y.
        • Wang H.
        Medial patellofemoral ligament reconstruction: A comparison of single-bundle transpatellar tunnel and double-anchor anatomic techniques for the treatment of recurrent lateral patellar dislocation in adults.
        Arthroscopy. 2019; 35: 845-854. e841
        • Placella G.
        • Speziali A.
        • Sebastiani E.
        • Morello S.
        • Tei M.M.
        • Cerulli G.
        Biomechanical evaluation of medial patello-femoral ligament reconstruction: Comparison between a double-bundle converging tunnels technique versus a single-bundle technique.
        Musculoskelet Surg. 2016; 100: 103-107
        • Mohammed R.
        • Hunt N.
        • Gibbon A.
        Patellar complications in single versus double tunnel medial patellofemoral ligament reconstruction.
        J Orthop Surg. 2017; 25 (2309499017691007)
        • Krych A.J.
        • O’Malley M.P.
        • Johnson N.R.
        • et al.
        Functional testing and return to sport following stabilization surgery for recurrent lateral patellar instability in competitive athletes.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 711-718

      Linked Article

      • Editorial Commentary: Repair or Reconstruct? Addressing Medial Patellofemoral Ligament Insufficiency in the Absence of Morphologic Abnormalities
        ArthroscopyVol. 36Issue 6
        • Preview
          The role of medial patellofemoral ligament (MPFL) repair versus reconstruction in the treatment of patellar instability continues to undergo debate. Repair of the ligament can be technically less demanding with fewer risks of morbidity, whereas reconstruction carries concerns of graft malpositioning or over-tensioning as well as the risk of patellar fracture. Studies directly comparing the 2 procedures in the setting of recurrent patellar instability have consisted of small series or low levels of evidence that inevitably include patients with concurrent morphologic risk factors such as tuberosity malalignment or patella alta, which are known factors that can influence the biomechanical behavior of the MPFL.
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