Abstract
Purpose
The purpose of this study was to evaluate and compare clinical and radiological outcomes between isolated medial patellofemoral ligament reconstruction (MPFLR) and MPFLR combined with derotational distal femoral osteotomy (DDFO) for patellar dislocation with increased femoral anteversion (FA).
Methods
Between 2014 and 2019, 36 patients who underwent isolated MPFLR and 31 patients who underwent MPFLR combined with DDFO were retrospectively included. Clinical outcomes included physical examinations, functional outcomes (Kujala, Lysholm, International Knee Documentation Committee (IKDC), and Banff Patella Instability Instrument (BPII) scores), activity level (Tegner activity score and return to sports), complications, and patellar re-dislocation rate. Radiological outcomes included patella tilt angle, patellar congruence angle, and patella–trochlear groove distance.
Results
All clinical outcomes improved significantly in both groups, but the DDFO group had significantly better postoperative scores than the MPFLR group (Kujala: 85.1 ± 7.7 vs. 80.5 ± 8.4, P = 0.023; Lysholm: 86.8 ± 8.2 vs. 81.9 ± 9.1, P = 0.026; IKDC: 86.2 ± 10.0 vs. 81.7 ± 8.1, P = 0.045; and BPII: 68.0 ± 12.5 vs. 62.3 ± 10.0, P = 0.039). Both groups achieved successful return to sports (90.3% vs. 91.7%). No re-dislocation or major complications occurred. Radiological outcomes improved significantly in both groups, but the DDFO group had better outcomes (P < 0.05). The tibial tubercle–trochlear groove distance was only improved after DDFO from 17.0 ± 2.3 mm to 15.1 ± 2.0 mm (P = 0.001).
Conclusion
Both isolated MPFLR and MPFLR combined with DDFO yielded satisfactory clinical and radiological outcomes in the treatment of patellar dislocation with increased FA. However, combined DDFO had better outcomes and should be considered a priority.
Level of evidence
Level III.
Similar content being viewed by others
Availabilty of data and materials
The data used or analyzed during the current study are available from the corresponding author on reasonable request.
Code availability
No code was generated or used during the study.
Abbreviations
- LPD:
-
Lateral patellar dislocation
- TT-TG:
-
Tibial tubercle–trochlear groove
- MPFL:
-
Medial patellofemoral ligament
- MPFLR:
-
Medial patellofemoral ligament reconstruction
- FA:
-
Femoral anteversion
- TTO:
-
Tibial tubercle osteotomy
- DDFO:
-
Derotational distal femoral osteotomy
- BMI:
-
Body mass index
- ROM:
-
Range of motion
- CT:
-
Computer tomography
- IKDC:
-
International Knee Documentation Committee
- BPII:
-
Banff Patella Instability Instrument
- PCL:
-
Posterior condylar line
- PTA:
-
Patella tilt angle
- PCA:
-
Patellar congruence angle
- PTG:
-
Patella–trochlear groove
- ICC:
-
Intraclass correlation coefficient
References
Basso M, Arnaldi E, Tamini J, Bruno AAM (2021) Medial patellofemoral ligament reconstruction with autologous gracilis tendon: clinical and radiological outcomes at a mean 6 years of follow up. Knee 33:252–259
Biedert RM (2020) Combined deepening trochleoplasty and supracondylar external rotation osteotomy for recurrent patellar instability in patients with trochlear dysplasia and increased femoral antetorsion. Knee 27:1158–1166
Biedert RM (2021) Reflections on rotational osteotomies around the patellofemoral joint. J Clin Med 10(3):474
Blanke F, Watermann K, Haenle M, Feitenhansl A, Camathias C, Vogt S (2020) Isolated medial patellofemoral ligament reconstruction can be an effective procedure in patellofemoral instability with risk factors. J Knee Surg 33:992–997
Cao Y, Zhang Z, Shen J, Song G, Ni Q, Li Y et al (2022) Derotational distal femoral osteotomy yields satisfactory clinical outcomes in pathological femoral rotation with failed medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 30:1809–1817
Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26
Deng X, Li L, Li Z, Liu J (2021) Clinical application of femoral derotation osteotomy combined with medial patellofemoral ligament reconstruction for patellar dislocation with excessive femoral internal torsion. Asian J Surg 44:891–893
Dong Z, Xu C, Yan L, Liu J, Wang F (2022) Isolated medial patellofemoral ligament reconstruction is valid to stabilize patellofemoral joint but uncertain to reduce patellar height in setting of lateral patellar dislocation and patella alta. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-022-04429-x
Franciozi CE, Ambra LF, Albertoni LJ, Debieux P, Rezende FC, Oliveira MA et al (2017) Increased femoral anteversion influence over surgically treated recurrent patellar instability patients. Arthroscopy 33:633–640
Frings J, Krause M, Akoto R, Frosch KH (2019) Clinical results after combined distal femoral osteotomy in patients with patellar maltracking and recurrent dislocations. J Knee Surg 32:924–933
Gobbi RG, Demange MK, de Ávila L, Araújo Filho J, Moreno RA, Gutierrez MA et al (2017) Patellar tracking after isolated medial patellofemoral ligament reconstruction: dynamic evaluation using computed tomography. Knee Surg Sports Traumatol Arthrosc 25:3197–3205
Hao K, Feng A, Kong L, Wang F (2022) Quality of life following medial patellofemoral ligament reconstruction combined with medial tibial tubercle transfer in patients with recurrent patellar dislocation: a retrospective comparative study. J Orthop Surg Res 17(1):416
Hefti F, Müller W, Jakob RP, Stäubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234
Hiemstra LA, Kerslake S, Lafave MR, Heard SM, Buchko GM, Mohtadi NG (2013) Initial validity and reliability of the Banff Patella Instability Instrument. Am J Sports Med 41:1629–1635
Iacobescu G, Cirstoiu C, Cursaru A, Anghelescu D, Stanculescu D (2020) Correlation between patellar tilt angle, femoral anteversion and tibial tubercle trochlear groove distance measured by computer tomography in patients with non-traumatic recurrent patellar dislocation. Maedica (Bucur) 15:174–180
Kaiser P, Schmoelz W, Schöttle PB, Heinrichs C, Zwierzina M, Attal R (2019) Isolated medial patellofemoral ligament reconstruction for patella instability is insufficient for higher degrees of internal femoral torsion. Knee Surg Sports Traumatol Arthrosc 27:758–765
Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9:159–163
Lysholm J, Gillquist J (1982) Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 10:150–154
Moreland CM, Shaw KA, Burks R, Baird M, Hattaway J, Parada SA et al (2021) Primary medial patellofemoral ligament reconstruction in military servicemembers: Can we reliably restore preinjury function and stability. Orthop J Sports Med 9:23259671211013336
Nelitz M, Williams RS, Lippacher S, Reichel H, Dornacher D (2014) Analysis of failure and clinical outcome after unsuccessful medial patellofemoral ligament reconstruction in young patients. Int Orthop 38:2265–2272
Noonan B, Cooper T, Chau M, Albersheim M, Arendt EA, Tompkins M (2022) Rotational deformity-when and how to address femoral anteversion and tibial torsion. Clin Sports Med 41(1):27–46
Pappa N, Flanigan DC, Long J, Dorweiler M, Fowler B, Duerr R, Dibartola AC, Kaeding CK, Magnussen RA (2022) Influence of patellofemoral anatomy on outcomes of isolated medial patellofemoral ligament reconstruction for recurrent patellar instability. Orthop J Sports Med 10(6):23259671221104416
Peng J, Xiao F, Zhu J, Shen C, Li Y, Han X, Cui Y, Chen X (2022) Characteristics of the patellofemoral joint of patients with DDH and the effects of Bernese periacetabular osteotomy on the patellofemoral joint. BMC Musculoskelet Disord 23(1):337
Qiao Y, Zhang X, Xu J, Xu C, Zhao S, Zhao J (2022) Internal torsion of the knee: an embodiment of lower-extremity malrotation in patients with patellar instability. J Bone Joint Surg Am 104(13):1179–1187
Fyllos A, Klontzas ME, Chytas D, Mitrousias V, Banios K et al (2021) Surgical and radiological anatomy of the medial patellofemoral ligament: a magnetic resonance imaging and cadaveric study. Diagnostics (Basel) 11(11):2076
Salsich GB, Perman WH (2007) Patellofemoral joint contact area is influenced by tibiofemoral rotation alignment in individuals who have patellofemoral pain. J Orthop Sports Phys Ther 37:521–528
Schlumberger M, Schuster P, Hofmann S, Mayer P, Immendörfer M, Mayr R, Richter J (2021) Midterm results after isolated medial patellofemoral ligament reconstruction as first-line surgical treatment in skeletally immature patients irrespective of patellar height and trochlear dysplasia. Am J Sports Med 49(14):3859–3866
Schöttle PB, Schmeling A, Rosenstiel N, Weiler A (2007) Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 35:801–804
Scorcelletti M, Reeves ND, Rittweger J, Ireland A (2020) Femoral anteversion: significance and measurement. J Anat 237(5):811–826
Shatrov J, Vialla T, Sappey-Marinier E, Schmidt A, Batailler C, Lustig S, Servien E (2022) At 10 year minimum follow-up, one-third of patients have patellofemoral arthritis after isolated medial patellofemoral ligament reconstruction using gracilis tendon autograft. Arthroscopy. https://doi.org/10.1016/j.arthro.2022.07.021
Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49
Tian G, Yang G, Zuo L, Li F, Wang F (2020) Femoral derotation osteotomy for recurrent patellar dislocation. Arch Orthop Trauma Surg 140:2077–2084
Wang HJ, Song YF, Ma Y, Lin L, Wang J, Wang YJ, Liu Y, Lu W, Wang F, Yu JK (2022) Higher pathologic threshold of increased tibial tuberosity-trochlear groove distance should be considered for taller patients. Knee Surg Sports Traumatol Arthrosc 30(11):3760–3766
Zhang QH, Zhang Y, He RX, Guo HM, Wang XG (2022) Anatomical characteristics and potential gene mutation sites of a familial recurrent patellar dislocation. BMC Med Genomics 15(1):176
Zhang YQ, Zhang Z, Wu M, Zhou YD, Tao SL, Yang YL et al (2022) Medial patellofemoral ligament reconstruction: a review. Medicine (Baltimore) 101(1):e28511
Zhang Z, Cao Y, Song G, Li Y, Zheng T, Zhang H (2021) Derotational femoral osteotomy for treating recurrent patellar dislocation in the presence of increased femoral anteversion: a systematic review. Orthop J Sports Med 9(11):23259671211057130
Zhang Z, Song G, Li Y, Zheng T, Ni Q, Feng H et al (2021) Medial patellofemoral ligament reconstruction with or without derotational distal femoral osteotomy in treating recurrent patellar dislocation with increased femoral anteversion: a retrospective comparative study. Am J Sports Med 49:200–206
Zhang Z, Zhang H, Song G, Wang X, Zhang J, Zheng T et al (2020) A high-grade J sign is more likely to yield higher postoperative patellar laxity and residual maltracking in patients with recurrent patellar dislocation treated with derotational distal femoral osteotomy. Am J Sports Med 48:117–127
Zhang Z, Zhang H, Song G, Zheng T, Feng H (2020) A pre-operative grade 3 J-sign adversely affects short-term clinical outcome and is more likely to yield MPFL residual graft laxity in recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 28:2147–2156
Zhang Z, Zhang H, Song G, Zheng T, Ni Q, Feng H (2020) Increased femoral anteversion is associated with inferior clinical outcomes after MPFL reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc 28:2261–2269
Acknowledgements
The authors would like to acknowledge the Department of Imaging of our hospital for their technical supports.
Funding
The authors did not receive support from any organization for the submitted work.
Author information
Authors and Affiliations
Contributions
FW contributed to the conceptualization and project administration of the study. KH and YN contributed significantly to the study design, data collection and parameter measurements. LK performed patient selection and statistical analysis. The first draft of the manuscript was written by KH and YN. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no competing interests to declare that are relevant to the content of this article.
Ethical approval
Institutional review board approval was obtained from the ethics committee of Third Hospital of Hebei Medical University. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Consent to publish
Patients signed informed consent regarding publishing their data and photographs.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Hao, K., Niu, Y., Kong, L. et al. Medial patellofemoral ligament reconstruction combined with derotational distal femoral osteotomy yields better outcomes than isolated procedures in patellar dislocation with increased femoral anteversion. Knee Surg Sports Traumatol Arthrosc 31, 2888–2896 (2023). https://doi.org/10.1007/s00167-022-07264-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-022-07264-0