Skip to main content

Advertisement

SpringerLink
Log in

After MPFL reconstruction, femoral tunnel widening and migration increase with poor tunnel positioning and are related to poor clinical outcomes

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

Abstract

Purpose

Isolated MPFL reconstruction (iMPFLR) is increasingly used for the surgical treatment of treatment for recurrent patella dislocation. The purpose of this study was to evaluate the influence of tunnel widening and migration on clinical outcomes after iMPFL using a CT-scannographic analysis at 6 months postoperatively.

Methods

One hundred and sixty patients (91 females for 69 males) with an average age of 23 years [14–54] who underwent iMPFLR and had an evaluation scan at 6 months postoperatively were evaluated with a mean follow-up of 97 ± 89 months [12 to 166]. Functional International Knee Documentation Committee (IKDC) Score, Kujala score, and joint mobility were assessed preoperatively, at 6 months and at the latest follow-up. The IKDC and Kujala scores were expressed as the difference between pre- and postoperative scores (dIKDC and dKujala). The position of the femoral tunnel was assessed according to the Schöttle criteria on post-operative radiographic profiles. Tunnel widening (at three levels of measurement) and the migration of the center of the tunnel were studied on a CT-scan analysis at 6 months. Any correlation and regression between the evolution of the clinical scores and the measured scannographic parameters were investigated. The relationships between tunnel position and tunnel changes were also studied.

Results

Between pre- and post-op, the IKDC (45 ± 13 to 80 ± 15, p < 0.001) and Kujala (55 ± 11 to 87 ± 12, p < 0.001) scores were significantly improved. Patients with tunnel changes had decreased clinical and functional results at 6 months post-op of an iMPFLR (p < 0.001). These changes in the femoral tunnel, evidenced by a tunnel entrance widening and migration of the tunnel center, were related to an initial malposition of the tunnel (p < 0.001).

Conclusion

In iMPFLR, changes in the femoral tunnel, corresponding to dilatation and migration of the tunnel center, may occur. These changes are increased by the initial malpositioning of the femoral tunnel and are correlated with less good clinical and functional outcomes.

Level of evidence

Level IV.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

Data are available on request.

References

  1. de Abreu-E-Silva GM, Buarque FAR, Dias TS, Lei P, Bueno ELR, de Andrade MAP (2020) Anatomical femoral tunnel positioning in the medial patellofemoral ligament reconstruction: is the free-hand technique accurate? Ann Transl Med 8:924

    Article  PubMed  PubMed Central  Google Scholar 

  2. Aframian A, Smith TO, Tennent TD, Cobb JP, Hing CB (2017) Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy. Knee Surg Sports Traumatol Arthrosc 25:3755–3772

    Article  PubMed  Google Scholar 

  3. Amano H, Tanaka Y, Kita K, Uchida R, Tachibana Y, Yonetani Y, Mae T, Shiozaki Y, Horibe S (2019) Significant anterior enlargement of femoral tunnel aperture after hamstring ACL reconstruction, compared to bone-patellar tendon-bone graft. Knee Surg Sports Traumatol Arthrosc 27:461–470

    Article  PubMed  Google Scholar 

  4. Berard J-B, Magnussen RA, Bonjean G, Ozcan S, Lustig S, Neyret P, Servien E (2014) Femoral tunnel enlargement after medial patellofemoral ligament reconstruction: prevalence, risk factors, and clinical effect. Am J Sports Med 42:297–301

    Article  PubMed  Google Scholar 

  5. Chiang E-R, Chen K-H, Chih-Chang Lin A, Wang S-T, Wu H-T, Ma H-L, Chang M-C, Liu C-L, Chen T-H (2019) Comparison of tunnel enlargement and clinical outcome between bioabsorbable interference screws and cortical button-post fixation in arthroscopic double-bundle anterior cruciate ligament reconstruction: a prospective, randomized study with a minimum follow-up of 2 years. Arthroscopy 35:544–551

    Article  PubMed  Google Scholar 

  6. Dall’Oca C, Elena N, Lunardelli E, Ulgelmo M, Magnan B (2020) MPFL reconstruction: indications and results. Acta Biomed 91:128–135

    PubMed  PubMed Central  Google Scholar 

  7. Decante C, Geffroy L, Salaud C, Chalopin A, Ploteau S, Hamel A (2019) Descriptive and dynamic study of the medial patellofemoral ligament (MPFL). Surg Radiol Anat 41:763–774

    Article  PubMed  Google Scholar 

  8. Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41:1149–1160

    Article  PubMed  Google Scholar 

  9. Hiemstra LA, Kerslake S, Lafave M (2017) Medial Patellofemoral Ligament Reconstruction Femoral Tunnel Accuracy. Orthop J Sports Med 5:232596711668774

    Article  Google Scholar 

  10. Hiemstra LA, Kerslake SA, Lafave MR (2019) Influence of risky pathoanatomy and demographic factors on clinical outcomes after isolated medial patellofemoral ligament reconstruction: a regression analysis. Am J Sports Med 47:2904–2909

    Article  PubMed  Google Scholar 

  11. Hinckel BB, Gobbi RG, Demange MK, Pereira CAM, Pécora JR, Natalino RJM, Miyahira L, Kubota BS, Camanho GL (2017) Medial patellofemoral ligament, medial patellotibial ligament, and medial patellomeniscal ligament: anatomic, histologic, radiographic, and biomechanical study. Arthroscopy 33:1862–1873

    Article  PubMed  Google Scholar 

  12. Kita K, Tanaka Y, Toritsuka Y, Amano H, Uchida R, Shiozaki Y, Takao R, Horibe S (2017) 3D computed tomography evaluation of morphological changes in the femoral tunnel after medial patellofemoral ligament reconstruction with hamstring tendon graft for recurrent patellar dislocation. Am J Sports Med 45:1599–1607

    Article  PubMed  Google Scholar 

  13. Maione A, Tradati D, Ferrua P, Ricci M, Usellini E, Randelli PS, Berruto M (2022) Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07235-5

    Article  PubMed  Google Scholar 

  14. Neri T, Parker DA, Beach A, Gensac C, Boyer B, Farizon F, Philippot R (2019) Medial patellofemoral ligament reconstruction with or without tibial tubercle transfer is an effective treatment for patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 27:805–813

    Article  PubMed  Google Scholar 

  15. Neri T, Parker DA, Putnis S, Klasan A, Trombert-Paviot B, Farizon F, Philippot R (2019) Clinical and radiological predictors of functional outcome after isolated medial patellofemoral ligament reconstruction at midterm follow-up. Am J Sports Med 47:1338–1345

    Article  PubMed  Google Scholar 

  16. Philippot R, Chouteau J, Wegrzyn J, Testa R, Fessy MH, Moyen B (2009) Medial patellofemoral ligament anatomy: implications for its surgical reconstruction. Knee Surg Sports Traumatol Arthrosc 17:475–479

    Article  PubMed  Google Scholar 

  17. Putnis SE, Oshima T, Klasan A, Grasso S, Neri T, Fritsch BA, Parker DA (2021) Magnetic resonance imaging 1 year after hamstring autograft anterior cruciate ligament reconstruction can identify those at higher risk of graft failure: an analysis of 250 cases. Am J Sports Med 49:1270–1278

    Article  PubMed  Google Scholar 

  18. Sanchis-Alfonso V, Alastruey-López D, Ginovart G, Montesinos-Berry E, García-Castro F, Ramírez-Fuentes C, Monllau JC, Alberich-Bayarri A, Pérez MA (2019) Parametric finite element model of medial patellofemoral ligament reconstruction model development and clinical validation. J Exp Orthop 6:32

    Article  PubMed  PubMed Central  Google Scholar 

  19. Sanchis-Alfonso V, Ginovart G, Alastruey-López D, Montesinos-Berry E, Monllau JC, Alberich-Bayarri A, Pérez MA (2019) Evaluation of patellar contact pressure changes after static versus dynamic medial patellofemoral ligament reconstructions using a finite element model. JCM 8:2093

    Article  PubMed  PubMed Central  Google Scholar 

  20. Sanchis-Alfonso V, Ramirez-Fuentes C, Montesinos-Berry E, Domenech J, Martí-Bonmatí L (2017) Femoral insertion site of the graft used to replace the medial patellofemoral ligament influences the ligament dynamic changes during knee flexion and the clinical outcome. Knee Surg Sports Traumatol Arthrosc 25:2433–2441

    Article  PubMed  Google Scholar 

  21. Sanchis-Alfonso V, Ramírez-Fuentes C, Montesinos-Berry E, Elía I, Martí-Bonmatí L (2017) Radiographic location does not ensure a precise anatomic location of the femoral fixation site in medial patellofemoral ligament reconstruction. Orthop J Sports Med 5:232596711773925

    Article  Google Scholar 

  22. Sappey-Marinier E, Sonnery-Cottet B, O’Loughlin P, Ouanezar H, Reina Fernandes L, Kouevidjin B, Thaunat M (2019) Clinical outcomes and predictive factors for failure with isolated mpfl reconstruction for recurrent patellar instability: a series of 211 reconstructions with a minimum follow-up of 3 years. Am J Sports Med 47:1323–1330

    Article  PubMed  Google Scholar 

  23. 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

    Article  PubMed  Google Scholar 

  24. Schüttler K-F, Hoeger A, Heyse TJ, Figiel J, Timmesfeld N, Stein T, Ziring E, Efe T (2018) Femoral tunnel widening is associated with tunnel malposition but not with clinical failure after medial patellofemoral ligament reconstruction with a free gracilis tendon graft. Arch Orthop Trauma Surg

  25. Servien E, Fritsch B, Lustig S, Demey G, Debarge R, Lapra C, Neyret P (2011) In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med 39:134–139

    Article  PubMed  Google Scholar 

  26. 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 

  27. Shea KG, Martinson WD, Cannamela PC, Richmond CG, Fabricant PD, Anderson AF, Polousky JD, Ganley TJ (2018) Variation in the medial patellofemoral ligament origin in the skeletally immature knee: an Anatomic Study. Am J Sports Med 46:363–369

    Article  PubMed  Google Scholar 

  28. Stephen JM, Kaider D, Lumpaopong P, Deehan DJ, Amis AA (2014) The effect of femoral tunnel position and graft tension on patellar contact mechanics and kinematics after medial patellofemoral ligament reconstruction. Am J Sports Med 42:364–372

    Article  PubMed  Google Scholar 

  29. Tanaka MJ (2020) Femoral Origin anatomy of the medial patellofemoral complex: implications for reconstruction. Arthroscopy 36:3010–3015

    Article  PubMed  Google Scholar 

  30. Trinh TQ, Ferrel JR, Bentley JC, Steensen RN (2017) The Anatomy of the medial patellofemoral ligament. Orthopedics 40:e583–e588

    Article  PubMed  Google Scholar 

  31. Yue L, DeFroda SF, Sullivan K, Garcia D, Owens BD (2020) Mechanisms of bone tunnel enlargement following anterior cruciate ligament reconstruction. JBJS Rev 8:e0120

    Article  PubMed  Google Scholar 

  32. Zhang Z, Song G, Zheng T, Ni Q, Feng H, Zhang H (2021) The presence of a preoperative high-grade J-sign and femoral tunnel malposition are associated with residual graft laxity after MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 29:1183–1190

    Article  PubMed  Google Scholar 

  33. Zimmermann F, Börtlein J, Milinkovic DD, Balcarek P (2020) Patient-reported outcomes after revision surgery for failed medial patellofemoral ligament reconstruction: a matched-pair analysis including correction of predisposing factors. Am J Sports Med 48:3566–3572

    Article  PubMed  Google Scholar 

  34. Zimmermann F, Milinkovic DD, Börtlein J, Balcarek P (2022) Revision surgery for failed medial patellofemoral ligament reconstruction results in better disease-specific outcome scores when performed for recurrent instability than for patellofemoral pain or limited range of motion. Knee Surg Sports Traumatol Arthrosc 30:1718–1724

    Article  PubMed  Google Scholar 

Download references

Funding

Through this large cohort of 160 patients, with a mean follow-up of 97 months, we have shown the influence of the initial positioning of the tunnel on the clinical results, which are altered when the initial tunnel is poorly positioned. In addition, we have shown that initial tunnel malposition increases the dilatation and migration of the femoral tunnel.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University Hospital of Saint Étienne, CEDEX 2 42055, Saint Étienne, France

    Fabien Ewald, Frédéric Farizon, Rémi Philippot & Thomas Neri

  2. EA 7424-Interuniversity Laboratory of Human Movement Science, University Lyon-University Jean Monnet, Saint Étienne, France

    Frédéric Farizon, Rémi Philippot & Thomas Neri

  3. Johannes Kepler University Linz, Linz, Austria

    Antonio Klasan

  4. University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK

    Sven Putnis

Authors
  1. Fabien Ewald
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Antonio Klasan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sven Putnis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Frédéric Farizon
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Rémi Philippot
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Thomas Neri
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

FE: Investigation, writing original draft, editing. AK: Methodology, Reviewing. SP: Methodology, Reviewing. FF: Methodology, Reviewing. RP: Supervision, Reviewing. TN: Conceptualization, Supervision, Methodology, Reviewing.

Corresponding author

Correspondence to Fabien Ewald.

Ethics declarations

Conflict of interest

The authors did not receive grants or outside funding in support of their research or preparation of the manuscript. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Ethical approval

This study has been approved by an ethics committee.

Informed consent

Informed consent of each patient was collected at each inclusion.

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.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ewald, F., Klasan, A., Putnis, S. et al. After MPFL reconstruction, femoral tunnel widening and migration increase with poor tunnel positioning and are related to poor clinical outcomes. Knee Surg Sports Traumatol Arthrosc 31, 2315–2322 (2023). https://doi.org/10.1007/s00167-022-07277-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-022-07277-9

Keywords

Search

Navigation