Isolated reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon
Isolated reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon
Giovanni Vavalle 0 1 2
Michele Capozzi 0 1 2
0 Via Martiri della Giustizia , 9, 70016 Noicattaro , Italy
1 Department of Orthopaedics, Saint Mary Hospital , De Ferrariis 18/D, 70124 Bari , Italy
2 & Giovanni Vavalle
Background Since the role of the medial patellofemoral ligament (MPFL) as the primary soft-tissue restraint against lateral patellar translation has been recognized, several different reconstruction procedures for the treatment of patellar instability have been proposed over recent years. Many of these techniques require bony procedures and hardware fixation at the patellar and femoral side, leading to complications as described previously in the literature. The purpose of the present study is to describe the technique of isolated MPFL reconstruction using the quadriceps tendon and report the results at a mean followup of 38 months. The hypothesis is that this technique, not requiring drilling of bone tunnels on the patellar and femoral side, may be a ''simple and safe'' mean to manage patellar instability, giving good clinical results with low complication rate in selected patients with normal osseous anatomy. Materials and methods Sixteen consecutive patients (9 male, 7 female; mean age 22 years) with chronic patellar instability underwent medial patellofemoral reconstruction with the superficial layer of the quadriceps tendon. All the patients were evaluated preoperatively and postoperatively by physical examination and subjectively with Kujala and Lysholm scores. Results The average follow-up was 38 months (range 28-48 months). No recurrent episodes of dislocation or subluxation and no complications occurred. The mean Kujala score increased from 35.8 preoperatively to 88.8 postoperatively and the Lysholm score improved from 43.3 preoperatively to 89.3 postoperatively. Conclusions Isolated MPFL reconstruction using an autologous quadriceps tendon and not requiring bone tunnels, may be a safe, simple and effective procedure for the treatment of patellar instability without complications such as patellar fracture as reported by clinical studies using hamstring grafts. For the same reason it may also be indicated in skeletally immature patients. Level of evidence Level IV.
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Acute patellar dislocation is a common disorder among
young active patients with a 50 % recurrence rate [1].
Several bony and soft-tissue etiologic factors can
predispose patients to recurrent dislocation or subluxation of
the patella. Over the past decade, attention has been
directed to the medial patellofemoral ligament (MPFL) as a
primary passive soft-tissue restraint to lateral patellar
translation at 0–30 of knee flexion, providing
approximately 53–67 % of the total medial restraining force [2, 3].
When patellar dislocation occurs, the MPFL is involved in
[90 % of cases [4, 5].
When conservative treatment fails, different surgical
techniques can be used, including proximal and distal
realignment or a combination of both.
Among the proximal procedures, there has been growing
interest in the MPFL over recent years.
Many different techniques have been advocated for the
reconstruction of the MPFL, but there is no agreement
regarding the choice of graft, the type of fixation, the graft
positioning, the correct tension and the clinical outcomes.
Furthermore, most of the techniques are associated with
several complications, such as patellar fracture [6],
stiffness [7], hemarthrosis [8], and implant [9] and wound
complications [10].
In 2005, Steensen et al. [9] described their original
technique using the central one-third of the most superficial
layer of the quadriceps tendon, and leaving it attached to
the superior pole of the patella. Once the graft is harvested,
it is turned 90 medially and fixed to the femoral side with
transosseous sutures. Their clinical experience which
involved 14 knees in 13 patients showed early promising
results, no episodes of recurrent dislocations and no
complications.
After 1 year, Noyes et al. [10] presented their surgical
technique using the same graft fixed to the medial
intermuscular septum with no need for bone tunnels or suture
anchors.
Overall, the technique of Steensen et al. seemed simple
and less invasive than other procedures previously
described in the literature, by not involving bone tunnels and
hardware implants.
Therefore, in 2009 we started our clinical experience
using a quadriceps graft, focusing on anatomic femoral
attachment, which is known to have an important effect on
length change pattern of ligaments [11, 12]. Anchor
sutures, which are normally used in arthroscopic shoulder
rotator cuff tendon surgery, were implanted.
Here, we describe the mid- and long-term results of
isolated MPFL reconstruction with an autologous
quadriceps graft, in 16 patients affected by recurrent patellar
dislocation. The hypothesis was that this technique is a
simple and safe way to ma (...truncated)