Die Rekonstruktion des medialen patellofemoralen Ligaments mit der getunnelten Semitendinosussehne

OBJECTIVE: Stabilization of the patella by reconstruction of the medial patellofemoral ligament. INDICATIONS: Chronic recurrent lateral dislocation or subluxation of the patella. Habitual lateral dislocation of the patella. CONTRAINDICATIONS: Primary dislocation of the patella. Genu valgum with a Q-angle > 15 degrees . Status following semitendinosus tendon transfer to reconstruct the anterior cruciate ligament. Joint infection. Neurogenic instability, ischiocrural muscle deficiency. SURGICAL TECHNIQUE: Division of the distal insertion of the semitendinosus muscle at the pes anserinus. Subligamentous tunneling at the proximal insertion of the medial collateral ligament. The distal end of the semitendinosus tendon is transferred through the subligamentous tunnel to the medial patellar margin. Fixation of the tendon to the medioproximal patellar margin by passing it through an oblique transpatellar drill hole. RESULTS: The patella was stabilized by dynamic reconstruction of the medial patellofemoral ligament in 14 patients with chronic recurrent or habitual lateral patellar dislocation. Ten patients were available for clinical follow-up assessment at an average of 13 months (8-27 months) postoperatively. The postoperative Kujala Index (maximum 100 points) increased on average from 56 to 95 points.     

Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children

We investigated the clinical outcome of a reconstructive procedure of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in four children (6 knees), with a minimum follow-up of four years. The technique involves transfer of the tendon of semitendinosus to the patella using the posterior one-third of the femoral insertion of the medial collateral ligament as a pulley. There was no recurrence of dislocation after surgery. The mean Kujala score at follow-up was 96.3 points. Radiological assessment showed that the congruence angle, the tilt angle and the lateral shift radio were restored to normal. The lateral and medial stress shift ratios and the Insall-Salvati ratio remained abnormal. We conclude that this technique can be recommended for the treatment of habitual or recurrent patellar dislocation in children, although hypermobility and patella alta are not fully corrected.     

复发性髌骨脱位治疗中内侧髌股韧带重建术的研究进展

复发性髌骨脱位是引起青少年膝关节功能障碍的常见疾病,其定义为髌骨脱位发生两次及两次以上,是一种骨科及运动医学临床常见的疾病。复发性髌骨脱位的病因有很多,但归根结底,髌骨在活动中所处的异常力学环境是引起不稳的根本原因。研究发现内侧髌股韧带被认为是限制髌骨向外脱位最重要的软组织结构,因而重建内侧髌股韧带对成功治疗复发性髌骨脱位起着重要的作用。但复发性髌骨脱位往往是一个多因素引起的临床问题,除了纠正软组织的异常外,骨性结构的异常也是一个不容忽视的问题。本文对近年来对内侧髌股韧带的解剖、生物力学、手术技巧、治疗结果及术后并发症的研究情况进行了综述。     

关节镜辅助下小切口重建内侧髌股韧带治疗创伤性复发性髌骨脱位

目的探讨关节镜辅助下小切口同种异体肌腱重建内侧髌股韧带(MPFL)治疗创伤性复发性髌骨脱位的临床效果。方法回顾性分析自2006年1月～2010年4月共收治28例创伤性复发性髌骨脱位,所有患者在第一次脱位均为膝关节外伤所致,伤后患膝明显肿胀及髌骨脱位-复位感,此后出现髌骨脱位3次以上者。手术方法:先行关节镜检查,髌骨外侧支持带紧张者行松解术,关节镜监视下调整MFPL的张力并于其解剖止点以同种异体肌腱重建MFPL,术后接受正规功能康复锻炼。结果术后平均随访26个月(12～36个月)。重建术后无髌骨再次脱位发生,髌股关节稳定。术前、术后均采用Lysholm和Kujala膝关节评分标准,手术前后评分差异有统计学意义(P<0.05)。结论选择适当的病例,重建内侧髌股韧带是治疗创伤性复发性髌骨脱位的有效方法。     

A new minimally invasive surgical technique for medial retinaculum repair following traumatic patellar dislocation

A new surgical method is introduced offering a less invasive approach to reattach the medial retinaculum following acute patellar dislocation. This retrospective analysis comprised 12 cases of medial retinacular repair in 10 patients. The surgical technique achieved reinforced reattachment of the torn region of the medial retinaculum for improved patellar support and stabilization. During follow-up, no recurrent patellar dislocations occurred, except where one patient reported a subjective feeling of patellar dislocation. The average Kujala score for our sample group after 2 years was 89.2. A plethora of methods are described in the literature to repair a tear to the medial patellofemoral ligament, which attaches at the superomedial patella. However, it is our contention that traumatic patellar dislocation invariably results in osteochondral avulsion at the inferomedial patella, refuting medial patellofemoral ligament involvement, and, rather, implicating the inferior aspect of the deep layer of medial retinaculum. Our surgical technique enables stable fixation of the region, decreasing the rate of recurrent dislocations. No grafts are used, permitting tendinous and ligamentous anatomy to remain intact. We further postulate that performing a CT examination preoperatively may reduce time between diagnosis and surgery, in addition to locating fracture sites more precisely.     

Delayed proximal repair and distal realignment after patellar dislocation

Twenty athletes with distal malalignment who sustained unilateral traumatic patellar dislocation remained impaired by chronic instability. Surgery was performed at a mean age of 18 years. Posttraumatic attenuation of the medial patellofemoral ligament was repaired near the margin of the patella in 10 knees and avulsion or attenuation posterior to the vastus medialis obliquus in 10 knees. Advancement of the medial patellomeniscal ligament at the margin of the patella and normalization of the Q angle to 10 degrees by tibial tubercle osteotomy were performed in each knee. Distal lateral retinacular release without release of the normal vastus lateralis tendon was performed. Results were judged according to Turba et al, and activity levels were evaluated per guidelines of the International Knee Documentation Committee. Eighteen (90%) patients achieved good or excellent results and were unimpaired at a minimum of 24 months. Two patients achieved fair subjective results with some impairment in vigorous activity. There was no recurrent instability. Radiographically, the mean preoperative patellofemoral congruence angle improved from 20 degrees to 0 degree. Athletes who sustain an initial traumatic patellar dislocation after physeal closure and in whom conservative management fails can be treated successfully by repair of the medial patellofemoral ligament at the site of disruption and advancement of the medial patellomeniscal ligament combined with correction of an elevated Q angle.     

Why do orthopaedic surgeons ignore the medial patellofemoral ligament?

The medial patellofemoral ligament (MPFL) is a condensation of the medial capsule of the knee joint. In the past two decades dissection studies have shown that it extends from the superomedial border of the patella to the femoral epicondyle, at or immediately above the adductor tubercle. MRI and operative studies have revealed that it is almost invariably damaged by lateral patellofemoral dislocation. Current surgical management of such dislocations may involve imbricating the torn medial capsule and parapatellar retinaculum back onto the medial border of the patella. If the medial patellofemoral ligament is torn at or near the femoral attachment, as the latest MRI and operative studies demonstrate it frequently is, then this medial reefing procedure will not be successful in restoring normal anatomy and function. Here we review the anatomy and function of the MPFL, its role in patellar dislocation and as well as surgical treatment for patellar dislocation.     

Trochleoplasty and medial patellofemoral ligament reconstruction for recurrent patellar dislocation

We report a case of recurrent patellar dislocation with high-grade trochlear dysplasia which persisted despite two previous operations. We did a Dejour''s sulcus deepening trochleoplasty, medial patellofemoral ligament reconstruction, and lateral retinacular release. Trochleoplasty and medial patellofemoral ligament reconstruction is required in patients with high grade trochlear dysplasia.     

A minimally invasive medial patellofemoral ligament arthroscopic reconstruction

The medial patellofemoral ligament reconstruction is recognized as a good choice for patients with recurrent patellar dislocation. Most techniques of the medial patellofemoral ligament reconstruction are open surgeries. Recently, we present a minimally invasive medial patellofemoral ligament arthroscopic reconstruction technique as a possible alternative method for recurrent patellar dislocation. The aim of the study was to describe a safe and effective technique to perform medial patellofemoral ligament reconstruction. The graft was prepared in shape to “Y.” Two 5-mm incisions were made in the skin above the medial edge of the patella. Two docking bone tunnels were drilled from medial edge to the center of the patella, mimicking the wide patellar insertion of the medial patellofemoral ligament, and a bone tunnel was made at the femoral insertion site. Two free ends of the graft were fixed into the patellar tunnels by lateral cortical suspension, and the folded end was fixed into the femoral tunnel by bioabsorbable interference screw. Average patellar tilt and the congruence angle were 30.7° ± 7.5° and 52.7° ± 7.3° and were reduced to 12.8° ± 0.9° and 2.3° ± 11.5° after treatment. The Kujala score was increased from 63.0 ± 9.0 to 91.0 ± 7.0. The minimally invasive medial patellofemoral ligament arthroscopic reconstruction in this paper seems to be helpful to increase safe of operation and treatment effect and reduce complications.     

Chronische patellofemorale Instabilit?t

Chronic patellofemoral instability may lead to pain and early osteoarthrosis. Recurrent dislocations of the patella, lateral subluxation and chronic dislocation are summarized under this generic term. There are five different factors which may be responsible of the development of chronic patellofemoral instability: 1) elongation of the medial patellofemoral ligament (MPFL), 2) patella alta, 3) increased distance between tibial tuberosity and trochlea groove (TTTG) distance, 4) trochlea dysplasia and 5) torsional malalignment. To rule out these factors clinical examination, radiological diagnostics (luxation, subluxation in the Defilée view, trochlea morphology, patella alta) and magnetic resonance imaging (MRI) of TTTG distance and trochlea morphology are crucial. The indications of operative treatment are chronic pain with subluxation, chronic dislocation and recurrent dislocation. Currently the former frequently and universally used lateral release is only indicated in cases of subluxation and positive tilt. Biomechanical studies have shown that a lateral release will otherwise increase patellofemoral instability. The choice of the surgical technique depends on the factors underlying patellofemoral instability, the conditions of growth plate and cartilage damage. Among the different surgical options proximal and distal realignment procedures are differentiated. In cases of MPFL elongation and mild passive instability a medial reefing might be successful. In cases of MPFL elongation, high passive instability up to 30° of flexion (with or without trochlear dysplasia) MPFL reconstruction may be the treatment of choice. A trochleoplasty is rarely indicated. This treatment may be considered in cases of high grade trochlea dysplasia and passive instability at more than 30° of flexion. If the TTTG distance is increased (>20 mm) or in cases of patella alta distal realignment with tibial tubercle transfer should be considered. This operation might also be useful in the presence of lateral cartilage damage as an anteromedialization of the patella.     

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.     

关节镜辅助下手术治疗成人习惯性髌骨脱位

目的评价关节镜辅助下治疗成人（骨骺发育成熟患者）髌骨习惯性脱位的临床疗效。方法在关节镜辅助下,应用改良Maquet术及内侧髌股韧带解剖重建术治疗成年人习惯性髌骨脱位8例,年龄16～32岁,平均为21.5岁;术后通过平均20.6个月（15～28个月）的随访,了解膝关节脱位复发、Q角改变情况,并采用Lysholm评分评估患肢整体功能康复情况。结果所有病例均未发生再脱位,且疼痛均明显减轻。手术前后Q角分别为（20.6±3.5）°和（12±1.2）°（P〈0.01）,伸膝力线均有所改善。术前和术后Lysholm膝关节功能评分为（52.00±11.25）分和（86.06±9.62）分（P〈0.05）,所有患者的运动能力均较术前有一定改善。结论在关节镜辅助下手术治疗成人习惯性髌骨脱位,术后膝关节功能恢复,主客观疗效均较满意。     

A technique for reconstruction of the medial patellofemoral ligament

Additional medial patellofemoral ligament reconstruction was performed successfully on six consecutive patients with recurrent dislocation of the patella because of residual patellar instability after medial transfer of the tibial tubercle. A technique for medial patellofemoral ligament reconstruction is described, and complications and postoperative management are discussed. The reconstruction was performed using a double strand hamstring tendon graft in five patients and iliotibial allograft in one. Good stabilization of the patella was achieved in all six patients, resulting in improved confidence in higher levels of activity. The satisfactory outcome of additional medial patellofemoral ligament reconstruction suggests the possibility that the procedure may be part of the optional procedure in proximal realignment for recurrent dislocation of the patella.     

Editorial Commentary: From Lateral Release and Medial Plication to Complex Medial Patellofemoral Ligament Reconstruction Techniques: Medial Quadriceps Tendon Femoral Ligament Reconstruction Is the Most Anatomic Repair

Patella instability and dislocation are common in younger patients, and 1 in 5 patients are at risk of recurrent dislocations. Conservative treatment should be considered for first dislocations unless other concomitant injuries are present. Historically, lateral patella release and medial plication techniques were used for repair but have been superseded by medial patellofemoral ligament reconstruction. Overconstraint is a potential problem and often related to nonanatomic femoral tunnel position and graft tension, which could result in increased patellar contact pressures and graft failure. The medial quadriceps tendon–femoral ligament reconstruction technique (MQTFL) avoids patellar tunnels without the risk of patella fracture. When comparing medial patellofemoral ligament, MQTFL, and the combination of both techniques in a cadaver model, MQTFL resulted in less constraint with no differences for patellar contact pressures. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair.     

内侧髌股韧带重建术治疗复发性髌骨脱位的疗效研究

目的探讨游离肌腱移植重建内侧髌股韧带的手术方法及治疗复发性髌骨脱位的疗效。方法自2006年6月至2012年7月收治复发性髌骨脱位患者共40例（47膝）,男10例（12膝）,女30例（35膝）,年龄7～51岁,平均19．4岁。全部经膝关节镜检最后确诊,其中43膝采用游离自体半腱肌,4膝采用异体肌腱,通过髌骨双隧道移植重建内侧髌股韧带,镜下动态调整移植肌腱的张力,使髌股关节对合达到正常,并用挤压螺钉将肌腱游离端固定在股骨止点。其中8例（10膝）同时行髌韧带止点内移术。结果有36例（42膝）患者获得随访,随访时间3—70个月,平均随访23个月。临床疗效评价包括髌骨主观稳定性评估、Lysholm膝关节评分及Insall疗效标准（1976年）。术后髌骨外推试验和恐惧试验均为阴性。手术前后Lysholm评分术前平均为（63．1±9．1）分,术后评分为（87．1±6．4）分,手术前后的差异有统计学意义（t=21．7,P〈0．05）。按Insall疗效标准,优良率为85．7％。结论采用以游离肌腱重建MPFL为主的综合术式治疗复发性髌骨脱位,手术效果满意。     

Bilateral recurrent discloation of the patella associated with below knee amputation: A case report

Background  

Recurrent dislocation of the patella in patients with below knee amputation is a known entity. Abnormally high-riding patella (patella alta) and medial patellofemoral ligament insufficiency in these patients predisposes them to patellar instability. The established treatment of this problem is surgical realignment.     

Editorial Commentary: The “F” in MPFL (Medial Patellofemoral Ligament) Reconstruction—How Should We Fix It and Does It Matter?

Our understanding of the medial patellofemoral complex anatomy has evolved significantly over the past several decades, and this has informed our current surgical approach to management of lateral patellar instability. Medial patellofemoral ligament reconstruction remains the gold standard for decreasing the risk of secondary patellar dislocation and returning patients to active physical function. However, concerns about isometry, overconstraint, secondary arthrosis, and surgical-site morbidity remain with femoral socket fixation, particularly when patella alta, rotational malalignment, or hypermobility is present. Medial patellofemoral ligament reconstruction with soft-tissue fixation, on either the patellar or femoral side, may mitigate some of these risks by offering a more dynamic checkrein to lateral translation. However, longer-term studies are required to determine comparative efficacy with varying surgical techniques, and the ideal graft tension and degree of knee flexion during fixation have not yet been determined.     

Treatment of chronic patellar dislocation with a modified Elmslie-Trillat procedure

Background This paper describes a modification of the Elmslie-Trillat procedure that is usually performed in severe cases of habitual or recurrent patellar instability. Methods Eighteen knees (7 men and 8 women) treated for recurrent or habitual patellar dislocation were evaluated clinically and radiographically at a mean follow-up of 5 years (range 24 months to 9 years). The mean age at follow-up was 26.3 years (range 17–44 years). The IKDC and Kujala and Tegner scores were used for the clinical evaluation. Anteroposterior, lateral and Merchant views were done for radiographic monitoring. When the patella was still unstable during dynamic evaluation after execution of the Elmslie-Trillat procedure, the medial third of the patellar tendon was isolated and harvested with a corresponding 1 cm long and 0.5 cm wide bone plug, maintaining its insertion to the inferior medial side of the patella. This ligament was medialized and put under tension, trying to find a medial insertion that guaranteed patellar stability throughout the full range of motion. Results IKDC classified 11 knees as A (normal), 4 knees as B (almost normal), 2 knees as C (abnormal) and 1 knee as D (severely abnormal). The Kujala score showed excellent results in 16 knees, 1 fair and 1 poor knee. The mean Tegner score rose from 2 preoperatively to 5 at follow-up. The poor knee presented an over-correction of the congruence angle on radiography. On follow-up radiographs, the parameters were almost completely corrected. Statistical analysis showed a significant correction of radiograph parameters, and significantly worse results in patients who underwent trochleoplasty. Conclusion The technique described tries to achieve a dynamic stability of the patella throughout the full range of motion in severe patellar instability where the Elmslie-Trillat procedure is insufficient. No recurrence of patellar instability has been observed. The stability must be obtained with dynamic control in the initial degrees of flexion, trying to avoid an excessive patellar medialization.     

Editorial Commentary: As Nature Intended: Will Inclusion of the Medial Patellotibial Ligament Create a Better Medial Patellofemoral Complex Reconstruction?

The medial patellofemoral complex, composed predominantly of the medial patellofemoral ligament, plays an important role in patellar tracking and stability. Medial patellofemoral ligament reconstruction is accordingly one of the most broadly applied surgical techniques for treating patellar instability. Orthopaedic research has demonstrated that surgeries that restore native anatomy are often more effective. The medial patellotibial ligament clearly serves an important supporting role in patellar tracking and stability, particularly in early flexion, and its inclusion in medial soft-tissue reconstructions more closely restores native patella tracking. Whether reconstructions incorporating the medial patellotibial ligament will translate to improved outcomes remains unclear.     

Editorial Commentary: The Best Medial Patellofemoral Reconstruction May Include Components of Both Quadriceps and Patellar Attachments

Given different functions of the medial quadriceps tendon–femoral ligament and medial patellofemoral ligament components of the proximal medial patellar restraints, reconstructions to the midpoint of the medial patellofemoral ligament and medial quadriceps tendon–femoral ligament are probably optimal, combining the benefits of both in surgical treatment of recurrent patella instability.