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Medial Patellotibial Ligament Reconstruction Improves Patella Tracking When Combined With Medial Patellofemoral Reconstruction: An In Vitro Kinematic Study

      Purpose

      To investigate the isolated and combined effects of medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) deficiency and reconstruction on patellofemoral kinematics.

      Methods

      Sixteen matched-paired female cadaveric knee specimens with a mean age of 53.5 years (range, 26-65) were tested in 5 conditions: (1) intact, (2) MPFL or MPTL cut, (3) MPFL and MPTL combined cut, (4) MPFL or MPTL reconstruction, and (5) MPFL and MPTL combined reconstruction. Dynamic testing allowed continuous analysis of kinematics from 0° to 90° of knee flexion. Knees were also tested statically using a lateral load of 45 N at 0°, 30°, 60°, and 90° of flexion. In both dynamic and static loading tests, a motion capture system detected patellar position for each testing state to distinguish changes in patellar kinematics. Random-intercepts linear mixed-effects models were used to compare patellar kinematics.

      Results

      The MPFL is the primary restraint to lateral translation of the patella at all knee flexion angles. MPTL deficiency alone did not create significant patella instability, but further increased instability when the MPFL was deficient. Isolated MPFL and combined reconstruction provided improved stability. Through full range of motion native patella tracking was best recreated with combined ligament reconstruction.

      Conclusions

      The MPFL plays the greatest role in medial patellar stability, but the MPTL appears to have an influence on patella tracking. This study provides further understanding to the impact of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking.

      Clinical Relevance

      This study provides further understanding of the role of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking.
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      References

        • Arendt E.A.
        • Fithian D.C.
        • Cohen E.
        Current concepts of lateral patella dislocation.
        Clin Sports Med. 2002; 21: 499-519
        • Askenberger M.
        • Ekström W.
        • Finnbogason T.
        • Janarv P.-M.
        Occult Intra-articular knee injuries in children with hemarthrosis.
        Am J Sports Med. 2014; 42: 1600-1606
        • Dejour H.
        • Walch G.
        • Nove-Josserand L.
        • Guier C.
        Factors of patellar instability: An anatomic radiographic study.
        Knee Surg Sports Traumatol Arthrosc. 1994; 2: 19-26
        • 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
        • Hinckel B.B.
        • Gobbi R.G.
        • Kaleka C.C.
        • Camanho G.L.
        • Arendt E.A.
        Medial patellotibial ligament and medial patellomeniscal ligament: Anatomy, imaging, biomechanics, and clinical review.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 685-696
        • Kruckeberg B.M.
        • Chahla J.
        • Moatshe G.
        • et al.
        Quantitative and qualitative analysis of the medial patellar ligaments: An anatomic and radiographic study.
        Am J Sports Med. 2018; 46: 153-162
        • LaPrade M.D.
        • Kallenbach S.L.
        • Aman Z.S.
        • et al.
        Biomechanical evaluation of the medial stabilizers of the patella.
        Am J Sports Med. 2018; 46: 1575-1582
        • Conlan T.
        • Garth 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
        • 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 Relat Res. 1998; : 174-182
        • Panagiotopoulos E.
        • Strzelczyk P.
        • Herrmann M.
        • Scuderi G.
        Cadaveric study on static medial patellar stabilizers: The dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 7-12
        • 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
        • Ebied A.M.
        • El-Kholy W.
        Reconstruction of the medial patello-femoral and patello-tibial ligaments for treatment of patellar instability.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 926-932
        • Hinckel B.B.
        • Gobbi R.G.
        • Demange M.K.
        • et al.
        Medial patellofemoral ligament, medial patellotibial ligament, and medial patellomeniscal ligament: Anatomic, histologic, radiographic, and biomechanical study.
        Arthroscopy. 2017; 33: 1862-1873
        • Philippot R.
        • Boyer B.
        • Testa R.
        • Farizon F.
        • Moyen B.
        The role of the medial ligamentous structures on patellar tracking during knee flexion.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 331-336
        • 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
        • 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
        • Dean C.S.
        • Chahla J.
        • Serra Cruz R.
        • Cram T.R.
        • LaPrade R.F.
        Patellofemoral joint reconstruction for patellar instability: Medial patellofemoral ligament reconstruction, trochleoplasty, and tibial tubercle osteotomy.
        Arthrosc Tech. 2016; 5: e169-e175
        • Lenth R.
        Emmeans: Estimated Marginal Means, Aka Least-Squares Means. R Package Version 1.3.3.; 2019.
        (Accessed June 17, 2019)
        • Pinheiro J.
        • Bates D.
        • DebRoy S.
        • Sarkar D.
        _nlme: Linear and Nonlinear Mixed Effects Models_. R Package Version 3.1-137; 2018.
        (Accessed June 17, 2019)
        • R Core Team (2018)
        R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing.
        (Accessed June 17, 2019)
        • 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
        • Aulisa A.G.
        • Falciglia F.
        • Giordano M.
        • Savignoni P.
        • Guzzanti V.
        Galeazzi’s modified technique for recurrent patella dislocation in skeletally immature patients.
        J Orthop Sci. 2012; 17: 148-155
        • Baker R.H.
        • Carroll N.
        • Dewar F.P.
        • Hall J.E.
        The semitendinosus tenodesis for recurrent dislocation of the patella.
        J Bone Joint Surg Br. 1972; 54: 103-109
        • Grannatt K.
        • Heyworth B.E.
        • Ogunwole O.
        • Micheli L.J.
        • Kocher M.S.
        Galeazzi semitendinosus tenodesis for patellofemoral instability in skeletally immature patients.
        J Pediatr Orthop. 2012; 32: 621-625
        • Hall J.E.
        • Micheli L.J.
        • McManama G.B.
        Semitendinosus tenodesis for recurrent subluxation or dislocation of the patella.
        Clin Orthop Relat Res. 1979; 144: 31-35
        • Joo S.Y.
        • Park K.B.
        • Kim B.R.
        • Park H.W.
        • Kim H.W.
        The “four-in-one” procedure for habitual dislocation of the patella in children: Early results in patients with severe generalised ligamentous laxity and aplasis of the trochlear groove.
        J Bone Joint Surg Br. 2007; 89: 1645-1649
        • Kocon H.
        • Kabacyj M.
        • Zgoda M.
        The results of the operative treatment of patellar instability in children with Down’s syndrome.
        J Pediatr Orthop B. 2012; 21: 407-410
        • Letts R.M.
        • Davidson D.
        • Beaule P.
        Semitendinosus tenodesis for repair of recurrent dislocation of the patella in children.
        J Pediatr Orthop. 1999; 19: 742-747
        • Marcacci M.
        • Zaffagnini S.
        • Lo Presti M.
        • Vascellari A.
        • Iacono F.
        • Russo A.
        Treatment of chronic patellar dislocation with a modified Elmslie-Trillat procedure.
        Arch Orthop Trauma Surg. 2004; 124: 250-257
        • Moyad T.F.
        • Blakemore L.
        Modified Galeazzi technique for recurrent patellar dislocation in children.
        Orthopedics. 2006; 29: 302-304
        • Myers P.
        • Williams A.
        • Dodds R.
        • Bülow J.
        The three-in-one proximal and distal soft tissue patellar realignment procedure. Results, and its place in the management of patellofemoral instability.
        Am J Sports Med. 1999; 27: 575-579
        • Niedzielski K.R.
        • Malecki K.
        • Flont P.
        • Fabis J.
        The results of an extensive soft-tissue procedure in the treatment of obligatory patellar dislocation in children with ligamentous laxity: a post-operative isokinetic study.
        Bone Joint J. 2015; 97-B: 129-133
        • Oliva F.
        • Ronga M.
        • Longo U.G.
        • Testa V.
        • Capasso G.
        • Maffulli N.
        The 3-in-1 procedure for recurrent dislocation of the patella in skeletally immature children and adolescents.
        Am J Sports Med. 2009; 37: 1814-1820
        • Rillmann P.
        • Dutly A.
        • Kieser C.
        • Berbig R.
        Modified Elmslie-Trillat procedure for instability of the patella.
        Knee Surg Sports Traumatol Arthrosc. 1998; 6: 31-35
        • Hetsroni I.
        • Mann G.
        • Dolev E.
        • Nyska M.
        Combined reconstruction of the medial patellofemoral and medial patellotibial ligaments: Outcomes and prognostic factors.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 507-515
        • Baumann C.A.
        • Pratte E.L.
        • Sherman S.L.
        • Arendt E.A.
        • Hinckel B.B.
        Reconstruction of the medial patellotibial ligament results in favorable clinical outcomes: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2920-2933
        • Brown G.D.
        • Ahmad C.S.
        Combined medial patellofemoral ligament and medial patellotibial ligament reconstruction in skeletally immature patients.
        J Knee Surg. 2008; 21: 328-332
        • Drez D.
        • Edwards T.B.
        • Williams C.S.
        Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation.
        Arthroscopy. 2001; 17: 298-306
        • Hinckel B.B.
        • Gobbi R.G.
        • Bonadio M.B.
        • Demange M.K.
        • Pécora J.R.
        • Camanho G.L.
        Reconstruction of medial patellofemoral ligament using quadriceps tendon combined with reconstruction of medial patellotibial ligament using patellar tendon: Initial experience.
        Rev Bras Ortop. 2016; 51: 75-82
        • Sobhy M.H.
        • Mahran M.A.
        • Kamel E.M.
        Midterm results of combined patellofemoral and patellotibial ligaments reconstruction in recurrent patellar dislocation.
        Eur J Orthop Surg Traumatol. 2013; 23: 465-470