Advertisement

International Orthopaedics

, Volume 38, Issue 11, pp 2265–2272 | Cite as

Analysis of failure and clinical outcome after unsuccessful medial patellofemoral ligament reconstruction in young patients

  • Manfred Nelitz
  • Robert Sean Williams
  • Sabine Lippacher
  • Heiko Reichel
  • Daniel Dornacher
Original Paper

Abstract

Purpose

Reconstruction of the medial patellofemoral ligament (MPFL) has become a popular procedure for patients with patellofemoral instability. Nevertheless, complication rates of up to 26 % have been reported. This study presents the analysis of failure and clinical outcome of subsequent revision surgery in young patients following unsuccessful medial patellofemoral ligament reconstruction.

Methods

Nineteen consecutive patients with unsuccessful MPFL reconstruction underwent revision surgery. Pre-operative assessment included physical examination, radiographs and magnetic resonance imaging to assess the MPFL graft, trochlear dysplasia, tibial tubercle–trochlear groove (TT-TG) distance, patella alta and femoral tunnel positioning. Evaluation also included the detection of cartilage injuries as well as visual analog scale (VAS), knee function scores and patient satisfaction. Each complication was analysed and an appropriate revision procedure was performed according to the identified technical or untreated anatomical risk factor.

Results

The average age at the time of the index operation was 20.2 years (range, 16–27 years). The average age at the time of the primary MPFL reconstruction was 18.4 years (range, 15–25). Three main reasons for failure after MPFL reconstruction could be identified: failure to consider additional risk factors, intra-operative technical errors and inappropriate patient selection. In five patients severe trochlear dysplasia and in two patients concomitant excessive femoral anteversion as additional risk factors were detected. Seven patients experienced medial retinacular pain with limited flexion due to technical errors caused in three patients by anterior placement of the femoral tunnel and in four others by overtensioning of the MPFL graft. Four patients with patellofemoral pain were found to have ICRS grade III or IV cartilage injuries. The median postoperative Kujala scores improved from 57 (34 – 73) pre-operatively to 83 (49 – 94), the median knee function improved from 5 (range, 2 – 6) pre-operatively to 8 (range, 3 – 10). Median VAS scores improved from 4 (2 – 7) to 2 (0 – 5). A total of 78.9 % of patients were satisfied or very satisfied, 15.8 % were partially satisfied and one patient (5.3 %) was not satisfied with the result after revision surgery.

Conclusion

Failure to consider additional risk factors, technical intra-operative errors and inappropriate patient selection were identified as reasons for revision surgery after MPFL reconstruction. Identifying the potential causes of failure can help to treat and possibly prevent future complications.

Keywords

Complication Patellofemoral instability Medial patellofemoral ligament Pain 

References

  1. 1.
    Ahmad CS, Brown GD, Stein BS (2009) The docking technique for medial patellofemoral ligament reconstruction: surgical technique and clinical outcome. Am J Sports Med 37:2021–2027PubMedCrossRefGoogle Scholar
  2. 2.
    Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220PubMedCrossRefGoogle Scholar
  3. 3.
    Amis AA, Oguz C, Bull AM, Senavongse W, Dejour D (2008) The effect of trochleoplasty on patellar stability and kinematics: a biomechanical study in vitro. J Bone Joint Surg (Br) 90:864–869CrossRefGoogle Scholar
  4. 4.
    Bicos J, Fulkerson JP, Amis A (2007) Current concepts review: the medial patellofemoral ligament. Am J Sports Med 35:484–492PubMedCrossRefGoogle Scholar
  5. 5.
    Bollier M, Fulkerson J, Cosgarea A, Tanaka M (2011) Technical failure of medial patellofemoral ligament reconstruction. Arthroscopy 27:1153–9PubMedCrossRefGoogle Scholar
  6. 6.
    Brittberg M, Winalski CS (2003) Evaluation of cartilage injuries and repair. J Bone Joint Surg Am 85(Suppl 2):58–69PubMedGoogle Scholar
  7. 7.
    Buckens CF, Saris DB (2010) Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. Am J Sports Med 38:181–188PubMedCrossRefGoogle Scholar
  8. 8.
    Christiansen SE, Jacobsen BW, Lund B, Lind M (2008) Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes. Arthroscopy 24:82–87PubMedCrossRefGoogle Scholar
  9. 9.
    Elias JJ, Cosgarea AJ (2006) Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. Am J Sports Med 34:1478–1485PubMedCrossRefGoogle Scholar
  10. 10.
    Dejour D, Le Coultre B (2007) Osteotomies in patellofemoral instabilities. Sports Med Arthrosc 15:39–46PubMedCrossRefGoogle Scholar
  11. 11.
    Dejour H, Walch G, Nove-Josserand L, Guier CH (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26PubMedCrossRefGoogle Scholar
  12. 12.
    Diederichs G, Köhlitz T, Kornaropoulos E, Heller MO, Vollnberg B, Scheffler S (2013) Magnetic resonance imaging analysis of rotational alignment in patients with patellar dislocations. Am J Sports Med 41:51–7PubMedCrossRefGoogle Scholar
  13. 13.
    Fisher B, Nyland J, Brand E, Curtin B (2010) Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy. Arthroscopy 26:1384–1394PubMedCrossRefGoogle Scholar
  14. 14.
    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) 94:1202–1208CrossRefGoogle Scholar
  15. 15.
    Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101:101–104PubMedCrossRefGoogle Scholar
  16. 16.
    Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9:159–163PubMedCrossRefGoogle Scholar
  17. 17.
    Lippacher S, Reichel H, Nelitz M (2010) Patellar fracture after patellar stabilization. Orthopade 39:516–518Google Scholar
  18. 18.
    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 42:1661–68Google Scholar
  19. 19.
    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 41:58–63PubMedCrossRefGoogle Scholar
  20. 20.
    Nelitz M, Dreyhaupt J, Lippacher S (2013) Combined trochleoplasty and medial patellofemoral ligament reconstruction for recurrent patellar dislocations in severe trochlear dysplasia: a minimum 2-year follow-up study. Am J Sports Med 41:1005–12PubMedCrossRefGoogle Scholar
  21. 21.
    Nelitz M, Lippacher S (2013) Arthroscopic evaluation of trochlear dysplasia as an aid in decision making for the treatment of patellofemoral instability. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-013-2586-9 Google Scholar
  22. 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 3(2):e303–308PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Ntagiopoulos PG, Byn P, Dejour D (2013) Midterm results of comprehensive surgical reconstruction including sulcus-deepening trochleoplasty in recurrent patellar dislocations with high-grade trochlear dysplasia. Am J Sports Med 41:998–1004PubMedCrossRefGoogle Scholar
  24. 24.
    Parikh SN, Nathan ST, Wall EJ, Eismann EA (2013) Complications of medial patellofemoral ligament reconstruction in young patients. Am J Sports Med 41:1030–8PubMedCrossRefGoogle Scholar
  25. 25.
    Parikh S, Noyes FR (2011) Patellofemoral disorders: role of computed tomography and magnetic resonance imaging in defining abnormal rotational lower limb alignment. Sports Health 3:158–169PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Ronga M, Oliva F, Longo UG, Testa V, Capasso G, Maffulli N (2009) Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 37:1735–1742PubMedCrossRefGoogle Scholar
  27. 27.
    Ruwe PA, Gage JR, Ozonoff MB, DeLuca PA (1992) Clinical determination of femoral anteversion: a comparison with established techniques. J Bone Joint Surg Am 74:820–830PubMedGoogle Scholar
  28. 28.
    Schoettle PB, Schmeling A, Rosenstiel N, Weiler A (2007) Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 35:801–804CrossRefGoogle Scholar
  29. 29.
    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 40:1916–23PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Staheli LT, Corbett M, Wyss C (1985) Lower extremity rotational problems in children: normal values to guide management. J Bone Joint Surg Am 67:39PubMedGoogle Scholar
  31. 31.
    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:e87PubMedCrossRefGoogle Scholar
  32. 32.
    Thaunat M, Erasmus PJ (2009) Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 17:480–483PubMedCrossRefGoogle Scholar
  33. 33.
    Tomczak RJ, Guenther KP, Rieber A (1997) MR Imaging measurement of the femoral antetorsional angle as a new technique: comparison with CT in children and adults. Am J Roentgenol 168:791–794CrossRefGoogle Scholar
  34. 34.
    Utting MR, Mulford JS, Eldridge JD (2008) A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability. J Bone Joint Surg (Br) 90:180–185CrossRefGoogle Scholar
  35. 35.
    Von Knoch F, Böhm T, Bürgi ML, Von Knoch M, Bereiter H (2006) Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia. J Bone Joint Surg (Br) 88:1331–1335CrossRefGoogle Scholar
  36. 36.
    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 21:318–24PubMedCrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2014

Authors and Affiliations

  • Manfred Nelitz
    • 1
  • Robert Sean Williams
    • 1
  • Sabine Lippacher
    • 2
  • Heiko Reichel
    • 2
  • Daniel Dornacher
    • 2
  1. 1.Clinics Kempten/OberallgäuTeaching Hospital of the University of UlmOberstdorfGermany
  2. 2.Department of Orthopaedic SurgeryUniversity of UlmUlmGermany

Personalised recommendations