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Double-Tunnel Technique Was Similar to Single-Tunnel Technique in Clinical, Imaging and Functional Outcomes for Medial Patellofemoral Ligament Reconstruction: A Randomized Clinical Trial

  • Author Footnotes
    ∗ Y.Q., J.X., and Z.Y. contributed equally to this article.
    Yi Qiao
    Footnotes
    ∗ Y.Q., J.X., and Z.Y. contributed equally to this article.
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Author Footnotes
    ∗ Y.Q., J.X., and Z.Y. contributed equally to this article.
    Junjie Xu
    Footnotes
    ∗ Y.Q., J.X., and Z.Y. contributed equally to this article.
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Author Footnotes
    ∗ Y.Q., J.X., and Z.Y. contributed equally to this article.
    Zipeng Ye
    Footnotes
    ∗ Y.Q., J.X., and Z.Y. contributed equally to this article.
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Jiebo Chen
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Xiuyuan Zhang
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Song Zhao
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Caiqi Xu
    Correspondence
    and Caiqi Xu, M.D., Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233, China.
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Jinzhong Zhao
    Correspondence
    Address correspondence to Jinzhong Zhao, M.D., Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233, China.
    Affiliations
    Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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  • Author Footnotes
    ∗ Y.Q., J.X., and Z.Y. contributed equally to this article.

      Purpose

      This study aimed to compare the clinical, functional, and imaging outcomes of single-tunnel (ST) and double-tunnel (DT) techniques for medial patellofemoral ligament (MPFL) reconstruction.

      Methods

      Ninety-four patients with recurrent patellar instability were randomly divided into 2 groups, receiving either ST or DT MPFL reconstruction. Lateral reticulum release (LRR) and tibial tuberosity (TT) transfer were performed as combined procedures when necessary. Preoperative and postoperative clinical characteristics (symptoms and episodes of redislocation), functional outcomes (Kujala, Lysholm, Tegner, IKDC, and KOOS score), and radiological measurements (congruence angle, patellar tilt angle, lateral patellar angle, and lateral patellar translation) were analyzed.

      Results

      The analysis included data from 90 patients with 48 patients in the ST group and 42 patients in the DT group. Patients were followed up for a mean period of 37.8 (range: 27-50) months in the ST group and 38.6 (range: 25-53) months in the DT group. Forty-three patients in the ST group and 40 patients in the DT group received combined TT transfer, and all patients underwent LRR. At the latest follow-up, 1 patient in ST group experienced redislocation, while no patient in the DT group sustained clinical failure (P = .347). Imaging measurements decreased significantly to the normal range postoperatively. No significant difference was noted between the postoperative radiological results of the 2 groups. All clinical scores significantly improved postoperatively, and no significant difference was observed between the 2 groups except for the higher Lysholm score (P = .031), KOOS symptoms score (P = .021) and KOOS knee-related quality of life score (P = .043) in the DT group.

      Conclusion

      Both techniques could equally mitigate the patellar lateral translation or redislocation. Our results demonstrate several significant differences in functional outcomes that favored DT MPFL reconstruction but no difference in clinical failure rates and radiological results between ST and DT MPFL reconstruction.

      Level of Evidence

      Level I, randomized clinical trial.
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      References

        • Frings J.
        • Balcarek P.
        • Tscholl P.
        • Liebensteiner M.
        • Dirisamer F.
        • Koenen P.
        Conservative versus surgical treatment for primary patellar dislocation.
        Dtsch Arztebl Int. 2020; 117: 279-286
        • Huntington L.S.
        • Webster K.E.
        • Devitt B.M.
        • Scanlon J.P.
        • Feller J.A.
        Factors associated with an increased risk of recurrence after a first-time patellar dislocation: A systematic review and meta-analysis.
        Am J Sports Med. 2020; 48: 2552-2562
        • Nha K.W.
        • Ha Y.
        • Oh S.
        • et al.
        Surgical treatment with closing wedge distal femoral osteotomy for recurrent patellar dislocation with genu valgum.
        Am J Sports Med. 2018; 46: 1632-1640
        • Purushothaman B.
        • Agarwal A.
        • Dawson M.
        Posttraumatic chronic patellar dislocation treated by distal femoral osteotomy and medial patellofemoral ligament reconstruction.
        Orthopedics. 2012; 35 (:e1668-1672.)
        • Lee J.I.
        • Jaffar M.S.A.
        • Choi H.G.
        • Kim T.W.
        • Lee Y.S.
        Effect of isolated medial patellofemoral ligament reconstruction in patellofemoral instability regardless of predisposing factors.
        J Knee Surg. 2022; 35: 299-307
        • 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
        • Placella G.
        • Tei M.M.
        • Sebastiani E.
        • et al.
        Shape and size of the medial patellofemoral ligament for the best surgical reconstruction: A human cadaveric study.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2327-2333
        • Wilkens O.E.
        • Hannink G.
        • van de Groes S.A.W.
        Recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 1919-1931
        • Panagopoulos A.
        • van Niekerk L.
        • Triantafillopoulos I.K.
        MPFL reconstruction for recurrent patella dislocation: A new surgical technique and review of the literature.
        Int J Sports Med. 2008; 29: 359-365
        • Ferrua P.
        • Kruckeberg B.M.
        • Pasqualotto S.
        • Berruto M.
        • Randelli P.
        • Arendt E.A.
        Proximal medial patellar restraints and their surgical reconstruction.
        J Orthop Traumatol. 2019; 20: 17
        • Desai V.S.
        • Tagliero A.J.
        • Parkes C.W.
        • et al.
        Systematic review of medial patellofemoral ligament reconstruction techniques: Comparison of patellar bone socket and cortical surface fixation techniques.
        Arthroscopy. 2019; 35: 1618-1628
        • Migliorini F.
        • Trivellas A.
        • Colarossi G.
        • Eschweiler J.
        • Tingart M.
        • Rath B.
        Single- versus double-bundle patellar graft insertion for isolated MPFL reconstruction in patients with patellofemoral instability: A systematic review of the literature.
        Arch Orthop Trauma Surg. 2020; 140: 769-776
        • Dejour D.H.
        • Deroche É.
        Trochleoplasty: Indications in patellar dislocation with high-grade dysplasia. Surgical technique.
        Orthop Traumatol Surg Res. 2022; 108103160
        • Tang J.
        • Zhao J.
        Wide patellar insertion medial patellofemoral ligament reconstruction with internal bracing.
        Arthrosc Tech. 2021; 10: e2487-e2493
        • Chen J.
        • Han K.
        • Jiang J.
        • et al.
        Radiographic reference points do not ensure anatomic femoral fixation sites in medial patellofemoral ligament reconstruction: A quantified anatomic localization method based on the saddle sulcus.
        Am J Sports Med. 2021; 49: 435-441
        • Zhang X.
        • Xie G.
        • Zhang C.
        • Fang Z.
        • Zhao J.
        • Huangfu X.
        Comparation and evaluation of the accuracy of the sulcus localization method to establish the medial patellofemoral ligament femoral tunnel: a cadaveric and clinical study.
        BMC Musculoskelet Disord. 2019; 20: 53
        • Xu C.
        • Zhao J.
        • Xie G.
        Medial patella-femoral ligament reconstruction using the anterior half of the peroneus longus tendon as a combined procedure for recurrent patellar instability.
        Asia-Pacific J Sports Med Arthrosc Rehabil Technol. 2016; 4: 21-26
        • 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
        • Kujala U.M.
        • Jaakkola L.H.
        • Koskinen S.K.
        • Taimela S.
        • Hurme M.
        • Nelimarkka O.
        Scoring of patellofemoral disorders.
        Arthroscopy. 1993; 9: 159-163
        • Roos E.M.
        • Roos H.P.
        • Lohmander L.S.
        • Ekdahl C.
        • Beynnon B.D.
        Knee Injury and Osteoarthritis Outcome Score (KOOS)—Development of a self-administered outcome measure.
        J Orthop Sports Phys Ther. 1998; 28: 88-96
        • Tegner Y.
        • Lysholm J.
        Rating systems in the evaluation of knee ligament injuries.
        Clin Orthop Relat Res. 1985; : 43-49
        • Irrgang J.J.
        • Anderson A.F.
        • Boland A.L.
        • et al.
        Development and validation of the international knee documentation committee subjective knee form.
        Am J Sports Med. 2001; 29: 600-613
        • Rossi M.J.
        • Lubowitz J.H.
        • Guttmann D.
        Development and validation of the International Knee Documentation Committee Subjective Knee Form.
        Am J Sports Med. 2002; 30: 152
        • Lysholm J.
        • Gillquist J.
        Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.
        Am J Sports Med. 1982; 10: 150-154
        • Harris J.D.
        • Brand J.C.
        • Cote M.P.
        • Faucett S.C.
        • Dhawan A.
        Research pearls: The significance of statistics and perils of pooling. Part 1: Clinical versus statistical significance.
        Arthroscopy. 2017; 33: 1102-1112
        • Agarwalla A.
        • Liu J.N.
        • Wu H.H.
        • Kalbian I.L.
        • Garcia G.H.
        • Shubin Stein B.E.
        Return to work following tibial tubercle osteotomy for patellofemoral osteoarthritis and pain.
        Cartilage. 2021; 13: 1066s-1073s
        • Roos E.M.
        • Lohmander L.S.
        The Knee injury and Osteoarthritis Outcome Score (KOOS): From joint injury to osteoarthritis.
        Health Qual Life Outcomes. 2003; 1: 64
        • Grevnerts H.T.
        • Terwee C.B.
        • Kvist J.
        The measurement properties of the IKDC-subjective knee form.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 3698-3706
        • Zhao J.
        • Huangfu X.
        • He Y.
        • Liu W.
        Recurrent patellar dislocation in adolescents: medial retinaculum plication versus vastus medialis plasty.
        Am J Sports Med. 2012; 40: 123-132
        • 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
        • Ji G.
        • Wang H.
        • Su X.
        • Wang J.
        • Wang F.
        The modified semi-tunnel bone bridge technique achieved statistically better knee function than the suture anchor technique.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 995-1001
        • 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
        • Russo F.
        • Doan J.
        • Chase D.C.
        • Farnsworth C.L.
        • Pennock A.T.
        Medial patellofemoral ligament reconstruction: Fixation technique biomechanics.
        J Knee Surg. 2016; 29: 303-309
        • Ercan N.
        • Akmese R.
        • Ulusoy B.
        Single-tunnel and double-tunnel medial patellofemoral ligament reconstructions have similar clinical, radiological and functional results.
        Knee Surg Sports Traumatol Arthrosc. 2021; 29: 1904-1912
        • Sarikaya B.
        • Bozkurt C.
        • Sipahioglu S.
        • Çetin B.V.
        • Altay M.A.
        Patellar fixation with suspensory fixation device in single-tunnel medial patellofemoral ligament reconstruction.
        Arthrosc Tech. 2021; 10: e1109-e1116
        • Lenschow S.
        • Schliemann B.
        • Gestring J.
        • Herbort M.
        • Schulze M.
        • Kösters C.
        Medial patellofemoral ligament reconstruction: Fixation strength of 5 different techniques for graft fixation at the patella.
        Arthroscopy. 2013; 29: 766-773
        • Ge Y.
        • Chen S.
        • Kato T.
        • Zdanowicz U.
        • Smigielski R.
        A polygon-shaped complex appearance of medial patellofemoral ligament with dynamic functional insertion based on an outside-in and inside-out dissection technique.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 3754-3761
        • Kang H.J.
        • Cao J.H.
        • Pan S.
        • Wang X.J.
        • Yu D.H.
        • Zheng Z.M.
        The horizontal Y-shaped graft with respective graft tension angles in anatomical two-bundle medial patellofemoral ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2445-2451
        • Kang H.
        • Cao J.
        • Yu D.
        • Zheng Z.
        • Wang F.
        Comparison of 2 different techniques for anatomic reconstruction of the medial patellofemoral ligament: A prospective randomized study.
        Am J Sports Med. 2013; 41: 1013-1021
        • 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
        • Elias J.J.
        • Cosgarea A.J.
        Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: A computational analysis.
        Am J Sports Med. 2006; 34: 1478-1485
        • Zhao J.
        • Huangfu X.
        The biomechanical and clinical application of using the anterior half of the peroneus longus tendon as an autograft source.
        Am J Sports Med. 2012; 40: 662-671
        • Parikh S.N.
        • Wall E.J.
        Patellar fracture after medial patellofemoral ligament surgery: A report of five cases.
        J Bone Joint Surg Am. 2011; 93 (:e97(91-98))
        • Schiphouwer L.
        • Rood A.
        • Tigchelaar S.
        • Koëter S.
        Complications of medial patellofemoral ligament reconstruction using two transverse patellar tunnels.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 245-250
        • Bonazza N.A.
        • Lewis G.S.
        • Lukosius E.Z.
        • Roush E.P.
        • Black K.P.
        • Dhawan A.
        Effect of transosseous tunnels on patella fracture risk after medial patellofemoral ligament reconstruction: A cadaveric study.
        Arthroscopy. 2018; 34: 513-518
        • Astur D.C.
        • Gouveia G.B.
        • Borges J.H.
        • et al.
        Medial patellofemoral ligament reconstruction: A longitudinal study comparison of 2 techniques with 2 and 5-years follow-up.
        Open Orthop J. 2015; 9: 198-203
        • Mohammed R.
        • Hunt N.
        • Gibbon A.J.
        Patellar complications in single versus double tunnel medial patellofemoral ligament reconstruction.
        J Orthop Surg (Hong Kong). 2017; 252309499017691007
        • Christiansen S.E.
        • Jacobsen B.W.
        • Lund B.
        • Lind M.
        Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes.
        Arthroscopy. 2008; 24: 82-87
        • Deasey M.J.
        • Moran T.E.
        • Lesevic M.
        • Burnett Z.R.
        • Diduch D.R.
        Small, short, oblique patellar tunnels for patellar fixation do not increase fracture risk or complications in MPFL reconstruction: A retrospective cohort study.
        Orthop J Sports Med. 2020; 82325967120954430
        • Niu J.
        • Qi Q.
        • Fu K.
        • Duan G.
        • Liu C.
        • Wang F.
        Medial patellofemoral ligament reconstruction with semi-patellar tunnel fixation: Surgical technique and mid-term follow-up.
        Med Sci Monit. 2017; 23: 5870-5875
        • Toritsuka Y.
        • Amano H.
        • Mae T.
        • et al.
        Dual tunnel medial patellofemoral ligament reconstruction for patients with patellar dislocation using a semitendinosus tendon autograft.
        Knee. 2011; 18: 214-219
        • Makovicka J.L.
        • Hartigan D.E.
        • Patel K.A.
        • Tummala S.V.
        • Chhabra A.
        Medial patellofemoral ligament reconstruction using all-soft suture anchors for patellar fixation.
        Arthrosc Tech. 2018; 7: e231-e237
        • Parikh S.N.
        • Nathan S.T.
        • Wall E.J.
        • Eismann E.A.
        Complications of medial patellofemoral ligament reconstruction in young patients.
        Am J Sports Med. 2013; 41: 1030-1038
        • Burnham J.M.
        • Howard J.S.
        • Hayes C.B.
        • Lattermann C.
        Medial patellofemoral ligament reconstruction with concomitant tibial tubercle transfer: A systematic review of outcomes and complications.
        Arthroscopy. 2016; 32: 1185-1195
        • Kang H.
        • Zheng R.
        • Dai Y.
        • Lu J.
        • Wang F.
        Single- and double-bundle medial patellofemoral ligament reconstruction procedures result in similar recurrent dislocation rates and improvements in knee function: a systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 827-836
        • Otsuki S.
        • Nakajima M.
        • Fujiwara K.
        • et al.
        Influence of age on clinical outcomes of three-dimensional transfer of the tibial tuberosity for patellar instability with patella alta.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2392-2396
        • Sappey-Marinier E.
        • Sonnery-Cottet B.
        • O'Loughlin P.
        • et al.
        Clinical outcomes and predictive factors for failure with isolated MPFL reconstruction for recurrent patellar instability: A series of 211 reconstructions with a minimum follow-up of 3 years.
        Am J Sports Med. 2019; 47: 1323-1330
        • Erickson B.J.
        • Nguyen J.
        • Gasik K.
        • Gruber S.
        • Brady J.
        • Shubin Stein B.E.
        Isolated medial patellofemoral ligament reconstruction for patellar instability regardless of tibial tubercle-trochlear groove distance and patellar height: Outcomes at 1 and 2 years.
        Am J Sports Med. 2019; 47: 1331-1337
        • Kim J.M.
        • Sim J.A.
        • Yang H.
        • Kim Y.M.
        • Wang J.H.
        • Seon J.K.
        Clinical comparison of medial patellofemoral ligament reconstruction with or without tibial tuberosity transfer for recurrent patellar instability.
        Am J Sports Med. 2021; 49: 3335-3343