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Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents using a pedicled quadriceps tendon graft shows favourable results at a minimum of 2-year follow-up

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

In adults, reconstruction of the medial patellofemoral ligament (MPFL) has shown good results. Treatment for recurrent patellar instability in children and adolescents with open growth plates, however, requires alternative MPFL reconstruction techniques. This study presents the outcomes of a minimally invasive technique for anatomic reconstruction of the MPFL in children using a pedicled superficial quadriceps tendon graft, hardware-free patellar graft attachment, and anatomic femoral fixation that spares the distal femoral physis.

Methods

Twenty-five consecutive patients with patellofemoral instability and open growth plates underwent anatomic reconstruction of the MPFL using a pedicled superficial quadriceps tendon graft. Preoperative radiographic examination included AP and lateral views to assess patella alta and limb alignment. Magnetic resonance imaging was performed to evaluate trochlear dysplasia and tibial tubercle–trochlear groove distance. Evaluation included pre- and post-operative physical examination, Kujala score, visual analog scale (VAS), and Tegner activity score.

Results

The average age at the time of operation was 12.8 years (9.5–14.7). The average follow-up after operation was 2.6 years (2.0–3.4). No recurrent dislocation occurred. Twenty patients were very satisfied (80%), four patients were satisfied (16%), and one patient was partially satisfied with the surgical procedure (4%). No patient was dissatisfied. The median Kujala score significantly improved from 63 (44–81) preoperatively to 89 (77–100) post-operatively (P < 0.01), and the median VAS score improved significantly from 4 (1–7) to 1 (0–4) (P < 0.01). The Tegner activity score increased, but not significantly, from 4 (3–8) preoperatively to 5 (3–8) post-operatively (non-significant).

Conclusion

The described technique for MPFL reconstruction with a pedicled quadriceps tendon is a safe and effective technique with good clinical results and allows patients to return to sports without redislocation of the patella. It might therefore be a valuable alternative to more extensive procedures in paediatric and adolescent patients.

Level of evidence

Prospective study, Level III.

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References

  1. Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220

    Article  CAS  PubMed  Google Scholar 

  2. Bollier M, Fulkerson J, Cosgarea A, Tanaka M (2011) Technical failure of medial patellofemoral ligament reconstruction. Arthroscopy 27:1153–1159

    Article  PubMed  Google Scholar 

  3. Brown GD, Ahmad CS (2008) Combined medial patellofemoral ligament and medial patellotibial ligament reconstruction in skeletally immature patients. J Knee Surg 21:328–332

    Article  PubMed  Google Scholar 

  4. Buchanan G, Torres L, Czarkowski B, Giangarra CE (2016) Current concepts in the treatment of gross patellofemoral instability. Int J Sports Phys Ther 11:867–876

    PubMed  PubMed Central  Google Scholar 

  5. Buckens CF, Saris DB (2010) Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. Am J Sports Med 38:181–188

    Article  PubMed  Google Scholar 

  6. Deie M, Ochi M, Sumen Y, Yasumoto M, Kobayashi K, Kimura H (2003) Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children. J Bone Joint Surg Br 85:887–890

    Article  CAS  PubMed  Google Scholar 

  7. Dejour D, Le Coultre B (2007) Osteotomies in patello-femoral instabilities. Sports Med Arthrosc Rev 15:39–46

    Article  PubMed  Google Scholar 

  8. Elias JJ, Cosgarea AJ (2006) Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. Am J Sports Med 34:1478–1485

    Article  PubMed  Google Scholar 

  9. Fink C, Veselko M, Herbort M, Hoser C (2014) MPFL reconstruction using a quadriceps tendon graft: part 2: operative technique and short term clinical results. Knee 21:1175–1179

    Article  PubMed  Google Scholar 

  10. Goyal D (2013) Medial patellofemoral ligament reconstruction: the superficial quad technique. Am J Sports Med 41:1022–1029

    Article  PubMed  Google Scholar 

  11. Herbort M, Hoser C, Domnick C (2014) MPFL reconstruction using a quadriceps tendon graft: part 1: biomechanical properties of quadriceps tendon MPFL reconstruction in comparison to the Intact MPFL. A human cadaveric study. Knee 21:1169–1174

    Article  PubMed  Google Scholar 

  12. Howells NR, Barnett AJ, Ahearn N, Ansari A, Eldridge JD (2012) Medial patellofemoral ligament reconstruction: a prospective outcome assessment of a large single centre series. J Bone Joint Surg Br 94:1202–1208

    Article  CAS  PubMed  Google Scholar 

  13. Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101:101–104

    Article  CAS  PubMed  Google Scholar 

  14. Kita K, Tanaka Y, Toritsuka Y, Amano H, Uchida R, Takao R, Horibe S (2015) Factors affecting the outcomes of double-bundle medial patellofemoral ligament reconstruction for recurrent patellar dislocations evaluated by multivariate analysis. Am J Sports Med 43:2988–2996

    Article  PubMed  Google Scholar 

  15. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9:159–163

    Article  CAS  PubMed  Google Scholar 

  16. Lind M, Enderlein D, Nielsen T, Christiansen SE, Faunø P (2016) Clinical outcome after reconstruction of the medial patellofemoral ligament in paediatric patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 24:666–671

    Article  PubMed  Google Scholar 

  17. Lippacher S, Dreyhaupt J, Williams SR, Reichel H, Nelitz M (2014) Reconstruction of the medial patellofemoral ligament: clinical outcomes and return to sports. Am J Sports Med 42:1661–1668

    Article  PubMed  Google Scholar 

  18. Lippacher S, Dejour D, Elsharkawi M, Dornacher D, Ring C, Dreyhaupt J, Reichel H, Nelitz M (2012) Observer agreement on D. Dejour’s trochlear dysplasia classification. A comparison of the true lateral radiographs to axial MR images. Am J Sports Med 40:837–843

    Article  PubMed  Google Scholar 

  19. Lippe J, Armstrong A, Fulkerson JP (2012) Anatomic guidelines for harvesting a quadriceps free tendon autograft for anterior cruciate ligament reconstruction. Arthroscopy 28:980–984

    Article  PubMed  Google Scholar 

  20. Nelitz M, Dornacher D, Dreyhaupt J, Reichel H, Lippacher S (2011) The relation of the distal femoral physis and the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 19:2067–2071

    Article  CAS  PubMed  Google Scholar 

  21. Nelitz M, Dreyhaupt J, Reichel H, Woelfle J, Lippacher S (2013) Anatomical reconstruction of the medial patellofemoral ligament in children and adolescents with open growth-plates: surgical technique and clinical outcome. Am J Sports Med 41:58–63

    Article  PubMed  Google Scholar 

  22. Nelitz M, Williams SR (2014) Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents using a pedicled quadriceps tendon graft. Arthrosc Tech 28:e303–e308

    Article  Google Scholar 

  23. Nguyen CV, Farrow LD, Liu RW, Gilmore A (2016) Safe drilling paths in the distal femoral epiphysis for pediatric medial patellofemoral ligament reconstruction. Am J Sports Med. doi:10.1177/0363546516677795

    Google Scholar 

  24. Noyes FR, Albright JC (2006) Reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon. Arthroscopy 22:22:904.e1–22:904.e7

    Article  Google Scholar 

  25. Parikh SN, Nathan ST, Wall EJ, Eismann EA (2013) Complications of medial patellofemoral ligament reconstruction in young patients. Am J Sports Med 41:1030–1038

    Article  PubMed  Google Scholar 

  26. Park MS, Chung CY, Lee KM, Lee SH, Choi IH (2010) Which is the best method to determine the patellar height in children and adolescents? Clin Orthop Relat Res 468:1344–1351

    Article  PubMed  Google Scholar 

  27. Schiphouwer L, Rood A, Tigchelaar S, Koëter S (2017) Complications of medial patellofemoral ligament reconstruction using two transverse patellar tunnels. Knee Surg Sports Traumatol Arthrosc 25:245–250

    Article  PubMed  Google Scholar 

  28. Schneider DK, Grawe B, Magnussen RA, Ceasar A, Parikh SN, Wall EJ, Colosimo AJ, Kaeding CC, Myer GD (2016) Outcomes after isolated medial patellofemoral ligament reconstruction for the treatment of recurrent lateral patellar dislocations: a systematic review and meta-analysis. Am J Sports Med 44:2993–3005

    Article  PubMed  PubMed Central  Google Scholar 

  29. Schoettle 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

    Article  Google Scholar 

  30. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C (2012) A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 40:1916–1923

    Article  PubMed  PubMed Central  Google Scholar 

  31. Shea KG, Styhl AC, Jacobs JC Jr, Ganley TJ, Milewski MD, Cannamela PC, Anderson AF, Polousky JD (2016) The relationship of the femoral physis and the medial patellofemoral ligament in children: a cadaveric study. Am J Sports Med 44:2833–2837

    Article  PubMed  Google Scholar 

  32. Sillanpää PJ, Mäenpää HM, Arendt EA (2010) Treatment of lateral patella dislocation in the skeletally immature athlete. Oper Tech Sports Med 18:83–92

    Article  Google Scholar 

  33. Steensen RN, Dopirak RM, Maurus PB (2005) A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy 21:365–370

    Article  PubMed  Google Scholar 

  34. Tanaka MJ, Bollier MJ, Andrish JT, Fulkerson JP, Cosgarea AJ (2012) Complications of medial patellofemoral ligament reconstruction: common technical errors and factors for success: AAOS exhibit selection. J Bone Joint Surg Am 94:e87

    Article  PubMed  Google Scholar 

  35. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

    Google Scholar 

  36. Vavken P, Wimmer MD, Camathias C, Quidde J, Valderrabano V, Pagenstert G (2013) Treating patella instability in skeletally immature patients. Arthroscopy 29:1410–1422

    Article  PubMed  Google Scholar 

  37. Wagner D, Pfalzer F, Hingelbaum S, Huth J, Mauch F, Bauer G (2013) The influence of risk factors on clinical outcomes following anatomical medial patellofemoral ligament (MPFL) reconstruction using the gracilis tendon. Knee Surg Sports Traumatol Arthrosc 21:318–324

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. MVZ Oberstdorf, Orthopaedic Specialty Clinic, Teaching Hospital of the University of Ulm, Trettachstrasse 16, 87561, Oberstdorf, Germany

    Manfred Nelitz & Sean Robert March Williams

  2. Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany

    Jens Dreyhaupt

Authors
  1. Manfred Nelitz
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  2. Jens Dreyhaupt
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Correspondence to Manfred Nelitz.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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All patients gave their informed consent to participate in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

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Nelitz, M., Dreyhaupt, J. & Williams, S.R.M. Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents using a pedicled quadriceps tendon graft shows favourable results at a minimum of 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 26, 1210–1215 (2018). https://doi.org/10.1007/s00167-017-4597-4

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