Advertisement

Biomechanical comparison of 3 medial patellofemoral complex reconstruction techniques shows medial over- constraint but no significant difference in lateralization and contact pressure

  • Author Footnotes
    ∗ These authors contributed equally to this work.
    Falko Dahm
    Correspondence
    Corresponding author: Dr. Falko Dahm, MD, Institutional address: 2075 Bayview Ave, Toronto, ON, M4N 3M5, Phone: +1 416-480-5798
    Footnotes
    ∗ These authors contributed equally to this work.
    Affiliations
    Holland Bone and Joint Program, Sunnybrook Research Institute

    University of Toronto Orthopedic Sports Medicine, Women’s College Hospital Toronto
    Search for articles by this author
  • Author Footnotes
    ∗ These authors contributed equally to this work.
    Hassan Syed
    Footnotes
    ∗ These authors contributed equally to this work.
    Affiliations
    Holland Bone and Joint Program, Sunnybrook Research Institute

    Institute for Medical Science, University of Toronto
    Search for articles by this author
  • Sebastian Tomescu
    Affiliations
    Holland Bone and Joint Program, Sunnybrook Research Institute

    University of Toronto Orthopedic Sports Medicine, Women’s College Hospital Toronto
    Search for articles by this author
  • Heng An Lin
    Affiliations
    Holland Bone and Joint Program, Sunnybrook Research Institute

    University of Toronto Orthopedic Sports Medicine, Women’s College Hospital Toronto

    Department of Orthopedic Surgery, Sengkang General Hospital
    Search for articles by this author
  • Yaron Haimovich
    Affiliations
    Holland Bone and Joint Program, Sunnybrook Research Institute

    Department of Orthopedic Surgery, Wolfson Medical Center, Holon, Israel
    Search for articles by this author
  • Naveen Chandrashekar
    Affiliations
    Mechanical and Mechatronics Engineering, University of Waterloo
    Search for articles by this author
  • Cari Whyne
    Affiliations
    Holland Bone and Joint Program, Sunnybrook Research Institute

    Institute for Medical Science, University of Toronto
    Search for articles by this author
  • David Wasserstein
    Affiliations
    Holland Bone and Joint Program, Sunnybrook Research Institute

    University of Toronto Orthopedic Sports Medicine, Women’s College Hospital Toronto

    Institute for Medical Science, University of Toronto
    Search for articles by this author
  • Author Footnotes
    ∗ These authors contributed equally to this work.
Published:October 31, 2022DOI:https://doi.org/10.1016/j.arthro.2022.10.027

      Abstract

      Purpose

      The purpose of this study was to investigate biomechanical differences of medial patellofemoral ligament (MPFL) reconstruction, medial quadriceps tendon femoral ligament (MQTFL) reconstruction and a combination of these techniques to restore lateral patellar constraint and contact pressures.

      Methods

      Eight fresh frozen cadaver knees were mounted to a custom jig with physiologic quadriceps tendon loading. Flexion angles and contact pressure (CP) were dynamically measured using Tekscan® pressure sensors and Polhemus® Liberty 6 degree of freedom (6DOF) positioning sensors in the following conditions: 1. Intact 2. MPFL and MQTFL deficient 3. MPFL reconstructed 4. Combined MPFL + MQTFL reconstructed 5. MQTFL reconstructed
      Lateral patellar translation was tested using horizontally directed 30N force applied at 30° of knee flexion. The knees were flexed in dynamic fashion and CP values were recorded for 10°, 20°, 30°, 50°, 70°, and 90° degrees of flexion. Group differences were assessed with ANOVA’s followed by pairwise comparisons with Bonferroni correction.

      Results

      MPFL (p=0.002) and combined MPFL/MQTFL (p=0.034) reconstruction significantly reduced patellar lateralization from +19.28% (9.78%, 28.78%) in the deficient condition to -17.57% (-27.84%, -7.29%) and -15.56% (-33.61%, 2.30%) respectively. MPFL reconstruction was most restrictive and MQTFL reconstruction the least -7.29% (-22.01%, 7.45%). No significant differences were found between the three reconstruction techniques. Differences in CP between the three reconstruction techniques were not significant (<0.02 MPa) at all flexion angles.

      Conclusion

      The present study found no significant difference for patellar lateralization and patellofemoral CP between MPFL, combined MPFL/MQTFL and MQTFL reconstruction. All 3 techniques resulted in stronger lateral patellar constraint compared to the native state while the MQTFL reconstruction emulated the intact state the closest.

      Clinical relevance

      Various surgical techniques for medial patellofemoral complex reconstruction can restore patellar stability with similar patellofemoral articular pressures.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Majewski M.
        • Susanne H.
        • Klaus S.
        Epidemiology of athletic knee injuries: A 10-year study.
        Knee. 2006; 13: 184-188https://doi.org/10.1016/j.knee.2006.01.005
        • Gravesen K.S.
        • Kallemose T.
        • Blønd L.
        • Troelsen A.
        • Barfod K.W.
        High incidence of acute and recurrent patellar dislocations: a retrospective nationwide epidemiological study involving 24.154 primary dislocations.
        Knee Surgery, Sport Traumatol Arthrosc. 2018; 26: 1204-1209https://doi.org/10.1007/s00167-017-4594-7
        • Askenberger M.
        • Bengtsson Moström E.
        • Ekström W.
        • et al.
        Operative Repair of Medial Patellofemoral Ligament Injury Versus Knee Brace in Children With an Acute First-Time Traumatic Patellar Dislocation: A Randomized Controlled Trial.
        Am J Sports Med. 2018; 46: 2328-2340https://doi.org/10.1177/0363546518770616
        • Bitar A.C.
        • Demange M.K.
        • D’Elia C.O.
        • Camanho G.L.
        Traumatic patellar dislocation: Nonoperative treatment compared with MPFL reconstruction using patellar tendon.
        Am J Sports Med. 2012; 40: 114-122https://doi.org/10.1177/0363546511423742
        • Yang F.
        • Guo W.
        • Wang Q.
        • et al.
        Surgical versus nonsurgical treatment of primary acute patellar dislocation A systematic review and meta-analysis.
        Med (United States). 2019; 98https://doi.org/10.1097/MD.0000000000016338
        • 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: 2552-2562https://doi.org/10.1177/0363546519888467
        • 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: 1030-1038https://doi.org/10.1177/0363546513482085
        • 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: 1916-1923https://doi.org/10.1177/0363546512442330
        • Uimonen M.M.
        • Repo J.P.
        • Huttunen T.T.
        • Nurmi H.
        • Mattila V.M.
        • Paloneva J.
        Surgery for patellar dislocation has evolved towards anatomical reconstructions with assessment and treatment of anatomical risk factors.
        Knee Surgery, Sport Traumatol Arthrosc. 2021; 29: 1944-1951https://doi.org/10.1007/s00167-020-06277-x
        • Frosch K.H.
        • Schmeling A.
        A new classification system of patellar instability and patellar maltracking.
        Arch Orthop Trauma Surg. 2016; 136: 485-497https://doi.org/10.1007/s00402-015-2381-9
        • Mochizuki T.
        • Nimura A.
        • Tateishi T.
        • Yamaguchi K.
        • Muneta T.
        • Akita K.
        Anatomic study of the attachment of the medial patellofemoral ligament and its characteristic relationships to the vastus intermedius.
        Knee Surgery, Sport Traumatol Arthrosc. 2013; 21: 305-310https://doi.org/10.1007/s00167-012-1993-7
        • Fulkerson J.P.
        • Edgar C.
        Medial quadriceps tendon-femoral ligament: Surgical anatomy and reconstruction technique to prevent patella instability.
        Arthrosc Tech. 2013; 2: e125-e128https://doi.org/10.1016/j.eats.2013.01.002
        • Kang H.J.
        • Wang F.
        • Chen B.C.
        • Su Y.L.
        • Zhang Z.C.
        • Yan C.B.
        Functional bundles of the medial patellofemoral ligament.
        Knee Surgery, Sport Traumatol Arthrosc. 2010; 18: 1511-1516https://doi.org/10.1007/s00167-010-1090-8
        • Chahla J.
        • Smigielski R.
        • Laprade R.F.
        • Fulkerson J.P.
        An Updated Overview of the Anatomy and Function of the Proximal Medial Patellar Restraints (Medial Patellofemoral Ligament and the Medial Quadriceps Tendon Femoral Ligament).
        Sports Med Arthrosc. 2019; 27: 136-142https://doi.org/10.1097/JSA.0000000000000252
        • Tanaka M.J.
        Femoral Origin Anatomy of the Medial Patellofemoral Complex: Implications for Reconstruction.
        Arthroscopy - J Arthroscopy Relat Surg. 2020; 36: 3010-3015https://doi.org/10.1016/j.arthro.2020.06.015
        • Spang R.C.
        • Tepolt F.A.
        • Paschos N.K.
        • Redler L.H.
        • Davis E.A.
        • Kocher M.S.
        Combined reconstruction of the medial patellofemoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL) for patellar instability in children and adolescents: Surgical technique and outcomes.
        J Pediatr Orthop. 2019; 39: e54-e61https://doi.org/10.1097/BPO.0000000000001259
        • Joseph S.M.
        • Fulkerson J.P.
        Medial Quadriceps Tendon Femoral Ligament Reconstruction Technique and Surgical Anatomy.
        Arthrosc Tech. 2019; 8: e57-e64https://doi.org/10.1016/j.eats.2018.09.002
        • Temponi E.F.
        • Saithna A.
        • Gonçalves M.B.J.
        • Soares L.F.M.
        • Carvalho R.B.
        • de Carvalho Júnior L.H.
        Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon–Femoral Ligament.
        Arthrosc Tech. 2021; 10: e193-e198https://doi.org/10.1016/j.eats.2020.09.026
        • Parikh S.N.
        • Wall E.J.
        Patellar fracture after medial patellofemoral ligament surgery: A report of five cases.
        J Bone Jt Surg - Ser A. 2011; 93: 1-8https://doi.org/10.2106/JBJS.J.01558
        • Tanaka M.J.
        • Bollier M.J.
        • Andrish J.T.
        • Fulkerson J.P.
        • Cosgarea A.J.
        Complications of medial patellofemoral ligament reconstruction: Common technical errors and factors for success AAOS exhibit selection.
        J Bone Jt Surg - Ser A. 2012; 94: 1-8https://doi.org/10.2106/JBJS.K.01449
        • Spang R.
        • Egan J.
        • Hanna P.
        • et al.
        Comparison of Patellofemoral Kinematics and Stability After Medial Patellofemoral Ligament and Medial Quadriceps Tendon–Femoral Ligament Reconstruction.
        Am J Sports Med. 2020; 48: 2252-2259https://doi.org/10.1177/0363546520930703
        • Stephen J.M.
        • Kaider D.
        • Lumpaopong P.
        • Deehan D.J.
        • Amis A.A.
        The effect of femoral tunnel position and graft tension on patellar contact mechanics and kinematics after medial patellofemoral ligament reconstruction.
        Am J Sports Med. 2014; 42: 364-372https://doi.org/10.1177/0363546513509230
        • Garretson R.B.
        • Katolik L.I.
        • Verma N.
        • Beck P.R.
        • Bach B.R.
        • Cole B.J.
        Contact pressure at osteochondral donor sites in the patellofemoral joint.
        Am J Sports Med. 2004; 32: 967-974https://doi.org/10.1177/0363546503261706
        • Stephen J.
        • Alva A.
        • Lumpaopong P.
        • Williams A.
        • Amis A.A.
        A cadaveric model to evaluate the effect of unloading the medial quadriceps on patellar tracking and patellofemoral joint pressure and stability.
        J Exp Orthop. 2018; 5https://doi.org/10.1186/s40634-018-0150-8
        • Quirbach S.
        • Smekal V.
        • Rosenberger R.E.
        • Attal R El
        • Schöttle P.B.
        Anatomische rekonstruktion des medialen patellofemoralen bands mit gedoppelter gracilissehne.
        Oper Orthop Traumatol. 2012; 24: 131-139https://doi.org/10.1007/s00064-011-0123-x
        • Aframian A.
        • Smith T.O.
        • Tennent T.D.
        • Cobb J.P.
        • Hing C.B.
        Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy.
        Knee Surgery, Sport Traumatol Arthrosc. 2017; 25: 3755-3772https://doi.org/10.1007/s00167-016-4272-1
        • Schöttle P.B.
        • Schmeling A.
        • Rosenstiel N.
        • Weiler A.
        Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction.
        Am J Sports Med. 2007; 35: 801-804https://doi.org/10.1177/0363546506296415
        • 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: 153-162https://doi.org/10.1177/0363546517729818
        • Tanaka M.J.
        • Voss A.
        • Fulkerson J.P.
        The anatomic midpoint of the attachment of the medial patellofemoral complex.
        J Bone Jt Surg - Am. 2016; 98: 1199-1205https://doi.org/10.2106/JBJS.15.01182
        • Tanaka M.J.
        Variability in the Patellar Attachment of the Medial Patellofemoral Ligament.
        Arthroscopy - J Arthroscopy Relat Surg. 2016; 32: 1667-1670https://doi.org/10.1016/j.arthro.2016.01.046
        • Christian D.R.
        • Redondo M.L.
        • Cancienne J.M.
        • et al.
        Differential Contributions of the Quadriceps and Patellar Attachments of the Proximal Medial Patellar Restraints to Resisting Lateral Patellar Translation.
        Arthroscopy - J Arthroscopy Relat Surg. 2020; 36: 1670-1676https://doi.org/10.1016/j.arthro.2020.01.058
        • Schlichte L.M.
        • Sidharthan S.
        • Green D.W.
        • Parikh S.N.
        Pediatric Management of Recurrent Patellar Instability.
        Sports Med Arthrosc. 2019; 27: 171-180https://doi.org/10.1097/JSA.0000000000000256
        • Zanon G.
        • Marullo M.
        • Benazzo F.
        Double-Bundle Medial Patellofemoral Ligament Reconstruction With a Single Patellar Tunnel.
        Arthrosc Tech. 2013; 2: 401-404https://doi.org/10.1016/j.eats.2013.06.008
        • Lind M.
        • Enderlein D.
        • Nielsen T.
        • Christiansen S.E.
        • Faunø P.
        Clinical outcome after reconstruction of the medial patellofemoral ligament in paediatric patients with recurrent patella instability.
        Knee Surgery, Sport Traumatol Arthrosc. 2016; 24: 666-671https://doi.org/10.1007/s00167-014-3439-x