Reconstruction of medial patellofemoral ligament for chronic patellar instability

Background:

Disruption of the capsule, medial patellar retinaculum, and/or vastus medialis obliqus has been associated with recurrent patellar instability. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the main restraint against lateral patella displacement and reconstruction of the MPFL has become an accepted surgical technique to restore patellofemoral stability in patients having recurrent patellar dislocation. We report a prospective series of patients of chronic patellar instability treated by reconstruction of medial patellofemoral ligament.

Materials and Methods:

Twelve patients (15 knees) with recurrent dislocation of patella, were operated between January 2006 and December 2008. All patients had generalised ligament laxity with none had severe grade of patella alta or trochlear dysplasia. The MPFL was reconstructed with doubled semitendinosus tendon. Patients were followed up with subjective criteria, patellar inclination angle, and Kujala score.

Results:

The mean duration of followup after the operative procedures was an average of 42 months (range 24–60 months) 10 knees showed excellent results, 3 knees gave good results, and 2 knees had a fair result. The average patellar inclination angle decreased from 34.3° to 18.6°. The average preoperative Kujala functional score was 44.8 and the average postoperative score was 91.9.

Conclusion:

MPFL reconstruction using the semitendinosus tendon gives good results in patients with chronic patellar instability without predisposing factors like severe patella alta and high-grade trochlear dysplasia, and for revision cases.     

Isolated reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon

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 follow-up 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.

     

Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Using a Gracilis Autograft without Bone Tunnel

Background

Several tendon graft and fixation methods have been introduced in medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation. The purpose of this study was to evaluate the results of MPFL reconstruction using a gracilis autograft fixation without bone tunnel in patients with recurrent patellar instability.

Methods

Nine patients (four males and five females) diagnosed with recurrent patellar instability from July 2009 to January 2013 and had MPFL reconstruction using a gracilis autograft were included. The average age of the patients was 24.6 years (range, 13 to 48 years), and the average follow-up period was 19.3 months (range, 12 to 30 months). For every patient, femoral attachment was fixed using suture anchors securing the patella by suturing the periosteum and surrounding soft tissue. Clinical evaluation included the Kujala, Lysholm, and Tegner scores; in addition, patients were examined for any complication including recurrent dislocation. The congruence angle and patella alta were assessed radiologically before and after surgery.

Results

The Kujala score improved from an average of 42.7 ± 8.4 before surgery to 79.6 ± 13.6 (p = 0.008) at final follow-up; the Lysholm score improved from 45.8 ± 5.7 to 82.0 ± 10.5 (p = 0.008); and the Tegner score improved from 2.8 ± 0.8 to 5.6 ± 1.5 (p = 0.007). The Insall-Salvati ratio changed from 1.16 ± 0.1 (range, 0.94 to 1.35) before surgery to 1.14 ± 0.1 (range, 0.96 to 1.29; p = 0.233) at the final follow-up without significance. The congruence angle significantly improved from 26.5° ± 10.6° (range, 12° to 43°) before surgery to -4.0° ± 4.3° (range, -12° to 5°; p = 0.008) at final follow-up. Subluxation was observed in one patient and hemarthrosis occurred in another patient 2 years after surgery, but these patients were asymptomatic.

Conclusions

We achieved good results with a patellar fixation technique in MPFL reconstruction using a gracilis autograft employing soft tissue suturing in patients with recurrent patellar dislocation.     

A “sandwich” method of reconstruction of the medial patellofemoral ligament using a titanium interference screw for patellar instability in skeletally immature patients

Background

No standard surgical procedure for medial patellofemoral ligament (MPFL) reconstruction exists in skeletally immature patients with patellar instability. This study aimed to evaluate the clinical effectiveness of a novel reconstruction technique for the MPFL in patients with patellar instability because of non-closure of the epiphyseal line.

Methods

The “sandwich” method was fixation of the patella between a double-stranded semitendinosus tendon through the posterior third of the femoral insertion of the medial collateral ligament (MCL) as a pulley with a titanium interference screw in a single patellar tunnel. Five knees in five patients were studied: four with recurrent and one with habitual patellar dislocations. Subjects underwent MPFL reconstruction with or without lateral release. Patients were evaluated using pre-operative and post-operative physical and radiographic examinations, including apprehension testing, assessment of tilting and congruence angles, medial and lateral shift ratios under stress measured using X-ray imaging, and Kujala and Lysholm scores.

Results

No patient experienced recurrent post-operative episodes of dislocation or subluxation. By the final follow-up, patellar apprehension had disappeared in all patients. In addition, all patients showed significant improvement in the following: tilting angle, congruence angle, lateral shift ratio, Kujala score, and Lysholm score.

Conclusions

The MPFL reconstruction methods, using a double-stranded semitendinosus autograft and sparing the femoral physeal line in non-closure of the epiphyseal line, provide acceptable short-term results for the treatment of patellar instability.     

Double-bundle anatomical versus single-bundle isometric medial patellofemoral ligament reconstruction for patellar dislocation

Purpose

The purpose of this study was to evaluate reconstruction of the medial patellofemoral ligament (MPFL) using the double-bundle anatomical or single-bundle isometric procedure with respect to the patients’ clinical outcomes.

Methods

In this retrospective study, we evaluated the clinical outcome of double-bundle anatomical versus single-bundle isometric reconstruction of the MPFL for patellar dislocation patients. Sixty-three patients were included in this study from August 2004 to January 2008. From August 2004 to September 2006, MPFL reconstruction using a single-bundle isometric technique was performed in 21 patients (26 knees). Since October 2006, the double-bundle anatomical reconstruction of the MPFL has been used as the routine surgical procedure. It was performed in 37 patients (44 knees). Fifty-eight patients (70 knees) could be followed up. According to the different techniques, we divided the patients into two groups: group D with double-bundle anatomical reconstruction (37 patients) and group S with single-bundle isometric reconstruction (21 patients). Clinical evaluation consisted of the number with a patellar re-dislocation, patellar apprehension sign, Kujala score, subjective questionnaire score, the patella lateral shift rate and patellar tilt angle measured by cross-sectional CT scan.

Results

According to the Kujala score and the subjective questionnaire score, the outcome of the double-bundle group was better than the outcome of the single-bundle group especially in the long-term. Patellar re-dislocation occurred in three patients in the group S, while no re-dislocation occurred in the group D. In total, 26.9 % of group S was considered to have patellar instability, compared to 4.54 % of the group D. After operation, the patellar tilt angle (PTA) and the patella lateral shift rate (PLSR) were restored to the normal range, with statistical significance (P < 0.05) compared to the preoperative state.

Conclusion

Single- and double-bundle reconstruction of the MPFL can both effectively restore patella stability and improve knee function. However, outcomes in the follow-up period showed that the double-bundle surgery procedure was much better than in single-bundle surgery.     

单隧道异体肌腱重建内侧髌股韧带治疗髌骨不稳——12例临床报告

目的探讨单隧道同种异体肌腱移植重建内侧髌股韧带（MPFL）治疗髌骨不稳的手术技巧及临床疗效。方法回顾性分析2010年6月至2012年1月广州军区广州总医院采用膝关节镜监视下单隧道异体肌腱移植重建MPFL的12例（15膝）髌骨不稳患者的临床资料,评估患者术前和末次随访时Kujala评分、Lysholm评分等指标。结果术后随访时间3～21个月（平均12.3个月）。患者术前和末次随访时Kujala评分为（71.5±5.1）分和（93.2±2.4）分,两者比较,差异有统计学意义（t=-12.659,P=0.004）;Lysholm评分为（70.2±6.0）分和（94.4±1.8）分,两者比较,差异有统计学意义（t=-12.286,P=0.013）。结论膝关节镜监视下单隧道同种异体肌腱移植重建MPFL是一种治疗髌骨不稳的有效方法,对维持髌骨稳定有重要作用,但远期效果需进一步观察。     

Patellar tendon or hamstring graft anterior cruciate ligament reconstructions in patients aged above 50 years

Background:

The treatment of anterior cruciate ligament (ACL) injury consists of arthroscopic ACL reconstruction with patellar tendon or hamstring graft. Satisfactory results have been reported so far in the younger age group. Dilemma arises regarding the suitability of ACL reconstruction in patients aged 50 years and above. This retrospective analyses the outcome of ACL reconstruction in patients aged 50 years and above.

Materials and Methods:

55 patients aged 50 years and above presented to our institution with symptomatic ACL tear and were managed with arthroscopic reconstruction with patellar tendon/hamstring graft. 22 patients underwent ACL reconstruction with bone- patellar tendon-bone graft and the remaining 33 with a hamstring graft. Evaluation of functional outcome was performed using International Knee Documentation Committee (IKDC) and Lysholm scoring in the preoperative period, at the end of 1 year and at the final followup. Radiographic evaluation was performed using the Kellgren–Lawrence grading system.

Results:

The mean preoperative IKDC score was 39.7 ± 3.3. At the end of 1-year following the operation, the mean IKDC score was 73.6 ± 4.9 and at the final followup was 67.8 ± 7.7. The mean preoperative Lysholm score was 40.4 ± 10.3. At the end of 1-year following the intervention, the mean Lysholm score was 89.7 ± 2.1 and at final followup was 85.3 ± 2.5. Overall, 14 out of 42 patients who underwent radiographic assessment showed progression of osteoarthritis changes at the final followup after the intervention.

Conclusion:

In our study, there was a statistically significant improvement in the IKDC and Lysholm scores following the intervention. There was a slight deterioration in the scores at the final followup but the overall rate of satisfaction was still high and most of the patients were able to do their routine chores and light exercises suitable for their age group. Around one-third of patients show progression of radiographic changes in the postoperative period and this requires long term evaluation.     

Midterm results of combined patellofemoral and patellotibial ligaments reconstruction in recurrent patellar dislocation

Purpose

To report the midterm results of mini-invasive anatomical no hardware combined reconstruction of the medial patellofemoral ligament (MPFL) and medial patellotibial (MPTL) using single semitendinosus tendon autograft.

Materials and methods

A prospective study was performed on 33 cases with recurrent patellar dislocation treated with combined MPFL and MPTL reconstruction by a described Relay Technique. Evaluation was focusing on return to previous level of activity, range of motion, apprehension, overall patient satisfaction and scoring with VAS, Cincinnati, Kujala’s, Lysholm scores. Radiological evaluation was based on congruence and tilting angles. Four cases were lost to follow-up and excluded from the study, so the study included 29 patients.

Results

The mean VAS had improved from 6.3 to 1.8. Cincinnati score increased from 50 ± 7.1 (range, 38–60) to 88 ± 6 (range, 76–100). The mean Kujala score increased from 36.6 ± 6 (range, 22–48) to 90.6 ± 7 (range, 78–100). The mean Lysholm score increased from 51.9 ± 4.7 (range, 42–59) to 89.5 ± 5.6 (range, 78–98). The congruence angle improved from 11.93° to ?6.48°, and the patellar tilt angle from 10.9° to 2.45°. All improvements were statistically significant. Only one case reported unsatisfaction, and 96.4 % were satisfied and returned to previous activity. No single recurrence was reported.

Conclusion

Combined anatomical MPFL and MPTL reconstruction with semitendinosus (ST) autograft using mini-invasive Relay Technique is safe, and its midterm results show significant clinical and radiological improvements with 96.4 % patient satisfaction and nil rate of recurrence.

Level of evidence

Therapeutic case series, Level IV.     

“Basket weave technique” for medial patellofemoral ligament reconstruction: Clinical outcome of a prospective study

Background:

Bone tunneling and implants with rigid fixations for medial patellofemoral ligament (MPFL) reconstruction are known to compromise results and are avoidable, especially in skeletally immature subjects. This study was to assess if these deficiencies were overcome with the technique devised by the author which avoids implants and bone tunnels. Results were assessed for complication rate and outcome.

Materials and Methods:

Fifty six knees of recurrent lateral patellar dislocation were treated in the past 49 months by MPFL reconstruction. Thirty nine were female and 17 male knees. The mean age was 20.6 years (range 9-48 years). Mean followup was 26 months. Five knees had previously failed stabilization procedures. Thirty one cases had Dejours Type A or B and 12 had Type C trochlear dysplasia. Arthroscopy was performed for associated injuries and loose bodies. Seven knees required loose body removal. Five knees underwent lateral retinacular release. Four knees had tibial tuberosity transfer. One knee had an associated anterior cruciate ligament reconstruction. An anatomical MPFL reconstruction was performed using hamstring autograft without the need for intraoperative fluoroscopy. Only soft tissue fixation was necessary with this newly devised technique and suturing. A rapid rehabilitation protocol was implemented with monthly followup until normalcy and 6 monthly thereafter.

Results:

All achieved full range of motion and normal mediolateral stability. There was no recurrence of dislocation. No major surgery related complications. One patella fracture at 8 months was due to a fall developed terminal restriction of flexion. Those in sports could return to their sporting activities (Tegner 1–9). Cases with osteochondral fractures had occasional pain that subsided in 1 year. Mean Kujala score improved from 64.3 to 99.69 with KOOS score near normal in all.

Conclusion:

This new method of MPFL reconstruction gives excellent results. It avoids complications related to bone tunneling and implants. It is a safe, effective, reliable and reproducible technique.     

Anterior knee pain following BPTB graft harvest. Reality or overhyped

Introduction

The patellar tendon graft has long been the gold standard for ACL reconstruction. Recently semitendinosus and gracilis tendons graft have been used increasingly. We hypothetise that the Bone-Patella Tendon-Bone graft is a good and economical graft for the Indian population with no adverse effects of anterior knee pain or patellar tendon shortening. We believe that the early squatting and cross-legged sitting causes early and constant stretching of the tendon in our patients. This is responsible for the lesser incidences of adverse effects in the Indian population.

Cross-cultural adaptation and validation of the Italian versions of the Kujala,Larsen, Lysholm and Fulkerson scores in patients with patellofemoral disorders

Background

The Kujala, Fulkerson, Larsen and Lysholm questionnaires have been demonstrated to be reliable and sensitive in assessing patients with patellofemoral pathology. The purpose of this study is to translate and cross-culturally adapt into Italian the English versions of the Kujala, Fulkerson, Larsen and Lysholm questionnaires, and undertake reliability and validity evaluations of the Italian versions of these scores in patients with patellofemoral pathology.

Materials and methods

The cross-cultural adaptation process was carried out following the simplified Guillemin criteria. The questionnaires were administered to 63 patients with either patellar instability or painful patella syndrome. To assess the validity of the questionnaires, they were compared with the Oxford knee score. The questionnaires were administered to a subsample of 33 patients 5 days later to assess test–retest reliability.

Results

The interclass coefficient correlation was 0.96 for the Kujala score, 0.92 for the Larsen score, 0.96 for the Lysholm score, 0.94 for the Fulkerson score (P < 0.01), and 0.83 for the Oxford score. Pearson’s correlation was0.96 between the Kujala and Oxford scores, 0.90 between the Larsen and Oxford scores, 0.94 between the Lysholm and Oxford score, and 0.93 between the Fulkerson and Oxford scores. Responsiveness, calculated by standardized response mean, was 1.2, and effect size was 1.4.

Conclusions

The Italian versions of the Kujala, Larsen, Lysholm and Fulkerson scoring systems were shown to be equivalent to their English versions and demonstrated good validity, reliability and responsiveness to surgical treatment of patellofemoral pathology. To the best of the authors’ knowledge, this is the first attempt to adapt four of the most common patellofemoral-specific scoring scales to the Italian language.

Level of evidence

Level II.

     

Does the Utilization of Allograft Tissue in Medial Patellofemoral Ligament Reconstruction in Pediatric and Adolescent Patients Restore Patellar Stability?

Background

Medial patellofemoral ligament (MPFL) reconstruction is one of several surgical procedures used to treat patellofemoral instability. Use of allograft tissue can preserve autogenous tissue and may be preferable in patients with connective tissue disorders or ligamentous laxity. Although there are successful reports in adults, it is unclear if the use of allograft tissue in MPFL reconstruction can restore patellofemoral stability in children and adolescents.

Questions/purposes

(1) Does allograft tissue in MPFL reconstruction in pediatric and adolescent patients restore patellar stability? (2) What complications were associated with allograft MPFL reconstructions in children and adolescents?

Methods

Between June 2012 and August 2015, one surgeon (NKP) performed 26 MPFL reconstructions in 23 patients with gracilis allograft for traumatic patellar instability. Of those, 25 (96%) were available for followup more than 1 year later (mean, 24 months; range, 12–44 months). During this time, the surgeon suggested reconstruction to patients who had recurrent dislocation or subluxation after 6 weeks of bracing, physical therapy, and activity modification if they were noted to have a torn or attenuated MPFL on MRI. During that period, this was the only surgical technique the surgeon used to treat traumatic patellar instability. Patients undergoing concurrent bony procedures were ineligible for inclusion. The mean age of the patients in the series was 16.0 (± 2) years. Age, sex, skeletal maturity, presence of trochlear dysplasia, and additional arthroscopic procedures at the time of reconstruction were collected. Postoperative notes and imaging were reviewed for presence of complications defined as recurrent dislocation, recurrent subluxations, fractures, infection, or arthrofibrosis. These complications were identified by chart review by the senior surgeon (NKP) and study personnel (EH) not involved in clinical care of the patients or by patient-reported complications. Recurrent subluxation or dislocation was patient-reported at the time of the clinic visit or followup phone/email contact. Fractures were defined as any cortical disruption in the femur or patella that required treatment (change in postoperative protocol), infection requiring treatment (antibiotics and/or return to the operating room), or arthrofibrosis (stiffness that necessitated a change in the postoperative protocol or manipulation under anesthesia).

Results

Ninety-two percent (23 of 25) of patients reported no further instability episodes after MPFL reconstruction. Sixteen percent (four of 25) of patients had complications: two repeat episodes of patellar instability, one patella fracture, and one symptomatic hardware requiring interference screw removal. No patients developed arthrofibrosis or infection.

Conclusions

In this small case series, we found that MPFL reconstruction using allograft tissue in children and adolescents resulted in a low risk of recurrent instability, perhaps comparable to what has been published by others who have used autograft tissue. Longer followup is needed, because in some orthopaedic applications, allograft ligaments have been observed to attenuate over time. Future studies might compare these techniques using patient-reported outcomes scores as well as use a control group of patients with autograft tissue.

Level of Evidence

Level IV, therapeutic study.

     

改良髌骨双骨道法自体股薄肌腱重建髌骨内侧支持带治疗复发性髌骨脱位

目的探讨改良髌骨双骨道法自体股薄肌腱重建髌骨内侧支持带（medial patellofemoral ligament,MPFL）治疗复发性髌骨脱位的临床效果,同时探讨解剖高危因素对术后效果的影响。方法2007年1月-2010年2月,对36例髌骨复发性脱位（单侧31例,双侧5例）采用改良髌骨双骨道法自体股薄肌腱重建MPFL,在髌骨内上缘由后内向前外向髌骨内1／2表面平行钻2个3．5mm骨道,将股薄肌腱引过骨道,将股薄肌腱的两游离端拉入股骨内侧骨道,屈膝30。位可吸收螺钉固定。对所有患者的Beighton评分,Q角,Insall指数,滑车发育不良分级,胫骨结节一滑车沟距离（TT—TG）等进行测量。临床评分采用Kujala,Lysholm和Tegner评分,同时调查患者的满意度。结果32例对手术的效果非常满意,3例满意,1例不满意。Kujala、Lysholm、Tegner评分分别由术前（64．34-15．0）、（65．1±18．6）、（3．2±1．1）分显著提高到术后（92．4±9．2）分（t=4．657,P=0．002）,（92．0±10．1）分（t=3．936,P=0．006）和（5．2±1．0）分（t=6．633,P=0．001）。80．6％（29／36）的患者在术后6—8个月恢复到受伤前的运动水平。1例术后1年再次髌骨脱位。97．6％（40／41）的膝关节存在股骨滑车发育不良,Beighton评分（5．2±2．5）分,Insall指数为1．22±0．14,Q角（13．6±3．9）°,TT-TG值（13．7±4．4）mm,与功能评分无相关性（P〉0．05）。结论自体股薄肌腱改良髌骨双骨道法重建MPFL是一种可靠安全经济的手术方法。高危解剖因素如高位髌骨、滑车发育不良、关节松弛等情况广泛存在于髌骨复发性脱位的患者中,虽未发现其严重程度会直接影响手术效果,但当复合因素存在时,仅重建MPFL的软组织手术可能不足以完全防止髌骨脱位复发。     

Medial patellofemoral ligament anatomy: is it a predisposing factor for lateral patellar dislocation?

Purpose

Because the medial patellofemoral ligament (MPFL) is the primary restraint to lateral dislocation of the patella, we aimed, in this controlled study, to verify whether the MPFL with different measurements could be considered another predisposing factor for patellar dislocation.

Methods

A group of 100 consecutive individuals without the criteria for patellar dislocation (trochlear dysplasia, patella alta and lateral patellar tilt) was recruited as a control group and underwent magnetic resonance imaging (MRI) study and another group of 50 patients with patellar instability. Femoral condyles, interepicondylar distance, length and thickness of the MPFL were measured.

Results

In the control group, the MPFL was 38–60 mm long. Individuals with patellar instability who had no episode of patellar dislocation had a 4.11-mm longer ligament than controls (p = 0.032), while patients with instability with a previous history of dislocation had a 13.54-mm longer MPFL than controls (p < 0.001). Thickness of the MPFL at the patellar insertion was lower in individuals with patellar instability with a history of dislocation (p < 0.001). An instability coefficient (IC) less than 1.3 indicates that the MPFL is insufficient.

Conclusions

Individuals with patellar instability and previous patellar dislocation present with longer MPFL when compared to controls, and an associated IC less than 1.3 can be considered a predisposing factor for patellar dislocation. Treatment of patellar instability is a challenge, and it is difficult to identify what is the predisposing factor. This study has verified the measurements of the MPFL for the first time and presents values of thickness and length that can be considered as indications for surgical reconstruction.Level of evidence: III.     

Neglected patellar tendon ruptures—a simple modified reconstruction using hamstrings tendon graft

Purpose

We hereby describe a cost effective and simple anatomical reconstruction without requirement for allograft or implants for neglected chronic patellar tendon injuries. This has been validated in seven patients with an average follow up of greater than three years resulting in good outcome.

Methods

Seven patients (six males, one female) of mean age 41.8 years (range up to 57 years) presented with neglected patellar tendon injury. The time since injury ranged between three months and three years (average nine months). Active extension was not possible in three patients, and four patients had an extensor lag between 40° and 80° (average 62.5°). Four patients had quadriceps strength of grade 2/5 and three patients had grade 3/5. All patients had severe functional limitation with an average IKDC score of 46.8 (range 39–57). They all underwent patellar tendon reconstruction using hamstrings tendon autograft.

Results

Postoperatively with a mean follow up of 40.7 months (range 31–52 months), all patients had a stable knee with mean flexion of 125° (range 120°–130°) and without any extension lag. Quadriceps power was regained in five cases to 5/5 and in two cases to 4/5. With an improvement in the IKDC score to 86.8 (range 80–92), excellent outcome was noted in five patients and good outcome in two patients. The average postoperative Lysholm score was 92.4 (range 89–95) and the average Kujala score was 94.5 (range 92–97).

Conclusion

Patellar tendon reconstruction using hamstrings autograft for neglected patellar tendon injuries provides good stability and excellent outcome. Compared to previous techniques described, our technique is unique in being cost effective and a simple anatomical reconstruction without the requirement for allograft or implants.     

Medial reefing versus medial patellofemoral ligament reconstruction for patellar instability

The standard surgical treatment for patellar instability has been lateral release and medial reefing proximally, with a Roux-Goldthwaite tendon transfer distally. More recently, reconstruction of the medial patellofemoral ligament (MPFL) has become popular. The aim of this study was to determine whether MPFL reconstruction improved the functional outcomes over patients treated with medial reefing. A group of 28 knees in 25 patients treated with a MPFL reconstruction were identified and matched for age and gender with 28 operated knees in 27 patients treated with a medial reefing. Clinical assessment included pre-operative and 1 year Kujala scores. Radiological assessment used the Dejour protocol. The two groups were comparable with respect to gender, age, pre-operative Kujala score, type of trochlear dysplasia, tibial tubercle–trochlear groove distance and patellar tilt angle. It was concluded that although there was better patellar tracking at 1 year with an MPFL reconstruction compared to medial reefing, there was no significant functional improvement as measured by the Kujala score.     

Preliminary results of two surgical techniques in the treatment of recurrent patellar dislocation

Purpose

Recurrent patellar dislocation is defined as a dislocation occurring more than once. There is no consensus as to the choice of operative technique for recurrent dislocation in adolescents. Recently, great importance has been attributed to MPFL reconstruction. The aim of this study is to evaluate the value of MPFL reconstruction (group A) in adolescents by comparing MPFL reconstruction with combined soft tissue proximal and distal alignment (group B).

Methods

MPFL reconstruction by means of Avikainen’s technique was performed on 32 knees. Another 33 knees were subject to the techniques combining retinacular plasty, vastus medialis advancement, and Roux-Goldthwait procedure. The results were assed clinically (Lyscholm scale and the Kujala Anterior Knee Pain Scale) and using X-rays (axial and lateral knee view). Isokinetic assessment of the quadriceps and hamstring was performed.

Results

No statistically significant differences between the two groups were observed regarding the Lyscholm and Kujala scales, the presence of redislocation (9.3 % for group A versus 12.1 % for group B), apprehension test, abnormal patellofemoral angle, abnormal Caton index (p?>?0.05). A statistically significant difference between the groups was observed regarding the rate of pain complaints, the incidence of an abnormal congruence angle, patellar medialization and deficits in the peak torque of the hamstring between the two angular velocities (p?<?0.05).

Conclusions

The redislocation rates risk is similar in both groups. However, a lower incidence of pain complaints in the group of patients with MPFL reconstruction favours the use of MPFL reconstruction as the first choice technique.Level of evidence: III

     

Reconstruction of the medial patellofemoral ligament using a longitudinal patellar tunnel technique

Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean: 7.3). Reconstruction was performed using either the gracilis or semitendinosus tendon autograft. The Tegner activity score improved overall from 3 to 4.4 at follow-up and the mean follow-up Kujala score was 87 (range: 55–100). No patella redislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft using a longitudinal tunnel technique provided good post-operative stability restoring the primary soft tissue restraint to pathological lateral patellar displacement with no complications of post-operative patellar fracture.     

Arthroscopic anatomical double bundle anterior cruciate ligament reconstruction: A prospective longitudinal study

Background:

Single bundle anterior cruciate ligament (ACL) reconstruction has been the current standard of treatment for ACL deficiency. However, a significant subset of patients continue to report residual symptoms of instability with a poor pivot control. Cadaveric biomechanical studies have shown double bundle (DB) ACL reconstructions to restore the knee kinematics better. This study evaluates the outcome of DB ACL reconstruction.

Materials and Methods:

30 consecutive patients who underwent anatomic DB ACL reconstruction were included in this prospective longitudinal study. There were all males with a mean age of 25 ± 7.45 years. All patients were prospectively evaluated using GeNouRoB (GNRB) arthrometer, functional knee scores (International Knee Documentation Committee [IKDC] and Lysholm) and postoperative magnetic resonance imaging (MRI) for comparing the graft orientation and footprint of the reconstructed ACL with that of the normal knee.

Results:

The average followup was 36.2 months. At the time of final followup the mean Lysholm score was 93.13 ± 3.31. As per the objective IKDC score, 26 patients (86.6%) were in Group A while 4 patients (13.3%) were in Group B. The mean differential anterior tibial translation by GNRB, arthrometer was 1.07 ± 0.8 mm (range 0.1-2.3 mm). All cases had a negative pivot shift test. MRI scans of operated and the contralateral normal knee showed the mean sagittal ACL tibial angle coronal ACL tibial angle and tibial ACL footprint to be in accordance with the values of the contralateral, normal knee.

Conclusion:

The study demonstrates that DB ACL reconstruction restores the ACL anatomically in terms of size and angle of orientation. However, long term studies are needed to further substantiate its role in decreasing the incidence of early osteoarthritic changes compared to the conventional single bundle reconstructions.