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Femoral tunnel malposition is the most common indication for revision medial patellofemoral ligament reconstruction with promising early outcomes following revision reconstruction: a systematic review

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of this study was to identify the causes of failure of previous medial patellofemoral ligament reconstruction (MPFL-R), and to furthermore report the surgical techniques available for MPFL revision surgery.

Methods

Four databases [PubMed, Ovid (MEDLINE), Cochrane Database, and EMBASE] were searched until September 29, 2020 for human studies pertaining to revision MPFL. Two reviewers screened the literature independently and in duplicate. Methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria, or the CAse REport guidelines (CARE), where appropriate.

Results

Fourteen studies (one level II, one level III, two level IV, ten level V) were identified. This search resulted in a total of 76 patients with a mean age (range) of 22 (14–39) years. The patients were 75% female with a mean (range) time to revision of 24.1 (1–60) months and mean (range) follow-up of 36.2 (2–48) months. The most common indication for revision surgery was malpositioning of the femoral tunnel (38.1%), unaddressed trochlear dysplasia (18.4%), patellar fracture (11.8%). Femoral tunnel malposition was typically treated via revision MPFL-R with quadriceps tendon or semitendinosus autograft and may retain the primary graft if fixation points were altered. Unaddressed trochlear dysplasia was treated with deepening trochleoplasty with or without revision MPFL-R, and patella fracture according to the nature of the fracture pattern and bone quality. Though generally, outcomes in the revision scenario across all indications were inferior to those post-primary procedure, overall, revision patients demonstrated positive improvements in pain and instability symptoms. Transverse patella fractures treated with debridement and filling with demineralized bone matrix if required with further fixation according to the fracture pattern.

Conclusion

The most common causes of MPFL failure in literature published to date, in order of decreasing frequency, are: malposition of the femoral tunnel, unaddressed trochlear dysplasia, and patellar fracture. Although surgical techniques of revision MPFL-R to manage these failures were varied, promising outcomes have been reported to date. Larger prospective comparative studies would be useful to clarify optimal surgical management of MPFL-R failure at long-term follow-up.

Level of evidence

IV.

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Abbreviations

LRR:

Lateral retinacular release

MPFL:

Medial patellofemoral ligament

MPFL-R:

Medial patellofemoral ligament reconstruction

TBW:

Tension bang wiring

TTTG:

Tibial tuberosity to trochlear groove

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Funding

No funding was provided for this study.

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Authors and Affiliations

  1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

    Madison Walker & Larissa Maini

  2. Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West 4E14, Hamilton, ON, L8N 3Z5, Canada

    Jeffrey Kay, Mahmoud Almasri & Darren de SA

  3. Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

    Ali Siddiqui

  4. Mercy Health—Cincinnati SportsMedicine and Orthopaedic Center, Cincinnati, OH, USA

    Mahmoud Almasri

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  1. Madison Walker
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  2. Larissa Maini
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Contributions

MW participated in the design of the study, carried out the systematic review, extracted data, and drafted the manuscript. LM extracted data and drafted the manuscript. JK was the third reviewer for any disagreements, participated in the manuscript design and revised the manuscript. Author AS participated in the systematic review of articles. Author MA participated in the revision of the manuscript. DdS conceived of the study, participated in study design, and in the revision of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Darren de SA .

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167_2021_6603_MOESM1_ESM.pdf

Additional file1 (PDF 162 KB) “Reasons for failure with treatments and outcomes [4, 13, 27, 48]”. Description of data: Primary surgical procedures and their associated reasons for failure, along with treatment techniques and reported outcomes.

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Walker, M., Maini, L., Kay, J. et al. Femoral tunnel malposition is the most common indication for revision medial patellofemoral ligament reconstruction with promising early outcomes following revision reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 30, 1352–1361 (2022). https://doi.org/10.1007/s00167-021-06603-x

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