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Increased femoral anteversion is associated with inferior clinical outcomes after MPFL reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

This study aimed at investigating the influence of an increased femoral anteversion angle on clinical outcomes after medial patellofemoral ligament reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability. It was hypothesized that an increased femoral anteversion is associated with inferior clinical outcomes.

Methods

From 2014 to 2016, a total of 144 consecutive patients with recurrent patellar instability were treated with medial patellofemoral ligament reconstruction and combined tibial tubercle osteotomy. The femoral anteversion angle was measured using three-dimensional computed tomography scans. Patients were allocated into group A (femoral anteversion < 20°), group B (femoral anteversion 20°–30°) and group C (femoral anteversion > 30°) based on the value of the femoral anteversion angle. Routine radiography and CT examinations were performed to evaluate the patellar height, trochlear dysplasia, genu valgum, and tibial tuberosity–trochlear groove (TT–TG) distance. The patellar lateral shift distance assessed with stress radiography was used pre- and postoperatively to quantify medial patellofemoral ligament residual laxity under anaesthesia. Patient-reported outcomes (Kujala, IKDC, and Lysholm scores) and patellar maltracking (“J-sign”) were evaluated pre- and postoperatively. Finally, subgroup analysis was performed to investigate the influence of an increased femoral anteversion angle on the clinical and radiological outcomes.

Results

A total of 66 patients (70 knees) were included with a median follow-up time of 28 months (range 24–32). After a minimum of 2 years of follow-up, all patient-reported outcomes (Kujala, Lysholm, and IKDC scores) improved significantly, and subgroup analysis showed that group C had significantly lower Kujala scores (75 ± 8 vs. 84 ± 8, P13 = 0.003; 75 ± 8 vs. 82 ± 8, P23 = 0.030), Lysholm scores (81 ± 9 vs. 87 ± 7, P13 = 0.021) and IKDC scores (78 ± 6 vs. 85 ± 7, P13 = 0.001; 78 ± 6 vs. 84 ± 6, P23 = 0.005) than group A and group B. Twelve patients had a postoperative residual J-sign (17.1%), and significant differences were found between group C and group A regarding the rate of residual J-sign (32.1% vs. 4.8%, P13 = 0.003). Postoperatively, group C had a greater patellar lateral shift distance than group A (10 ± 4 vs. 6 ± 4 mm, P13 = 0.006) and group B (10 ± 4 vs. 6 ± 3 mm, P23 = 0.008). Additionally, patients with a residual J-sign demonstrated greater medial patellofemoral ligament laxity than patients without a residual J-sign (12 ± 4 vs. 9 ± 3 mm, P = 0.009).

Conclusion

Patients with an increased femoral anteversion angle (> 30°) had inferior postoperative clinical outcomes, including greater patellar laxity, a higher rate of residual J-sign and lower patient-reported outcomes after medial patellofemoral ligament reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability.

Level of evidence

III, retrospective cohort study.

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Funding

Funding was provided by Application of Clinical Features of Capital City of Science and Technology Commission, China, Beijing Special Subject (Grant No. Z181100001718106).

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Authors and Affiliations

  1. Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China

    ZhiJun Zhang, Hui Zhang, GuanYang Song, Tong Zheng, QianKun Ni & Hua Feng

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  1. ZhiJun Zhang
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  2. Hui Zhang
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  3. GuanYang Song
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  4. Tong Zheng
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Correspondence to Hua Feng.

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The authors declare that they have no conflict of interests.

Ethical approval

This study was approved by the ethics board of Beijing Jishuitan Hospital, China (IRB approval number: 01-07-2018).

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Zhang, Z., Zhang, H., Song, G. et al. 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 (2020). https://doi.org/10.1007/s00167-019-05818-3

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