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Many aspects of medial patellofemoral reconstruction are still controversial

Issue: May 2014

ByLars Blond, MD

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Editor’s note: Members of the Patellofemoral Foundation review and add clinical perspective to recently published studies on the causes, prevention and treatment of patellofemoral disorders. The twice monthly blogs are edited by John P. Fulkerson, MD, and can be found on Healio.com/Orthopaedics. To read all the Patellofemoral Update blogs, click here.

A note from the editors:

This is the second part of this article. The first part appeared in the April issue of Orthopaedics Today Europe and discusses the femoral and patella/quadriceps attachment sites, trochlea dysplasia and other aspects of this surgery.

Several types of graft for MPFLR have been found useful. Perhaps the hamstrings are the most popular, followed by the superficial quadriceps graft, introduced by Steensen and colleagues. The adductor tendon, patella tendon, allografts as well as artificial graft have been found useful. Schoettle has advocated to use the gracilis tendon instead of the semitendinosus tendon simply because it is strong enough. The strength of the native MPFL approximates 208 N with a mean stiffness of 24 N.

Compared to the gracilis tendon, the semitendinosus tendon has more important function as a dynamic valgus stabilizer and ACL agonist and it is likely that it is important for the prevention of ACL ruptures. The superficial quadriceps tendon seems to be attractive since it reduces the patella site fixation problems and also it has a more flat structure and to a higher degree it mimics the native MPFL. The down side is the long scar in front of the knee. Fink and Storz have suggested a quadriceps tendon harvesting system to reduce this problem. The adductor magnus tendon as graft has also been advocated, however, I find that the proximal insertion is unfavorable.

My personal preferences for about 10 years have been the gracilis tendon with two anchors in the patella, double bundle and an interference screw in the femur. Lately, I have been encouraged by the study from Fulkerson and colleagues about MQTFL reconstruction, and after a few anatomical dissections, I must agree with the existence of the MQTFL structure. Therefore, we have now performed about twenty MQTFL reconstructions and the procedure is faster, cheaper and elegant, compared to the MPFL procedure with drilling or anchors into the patella and associated risk of complication such as fracture being avoided. I have observed two cases of patella stress fracture with anchors into the patella.

A little detail, conflicting with the observation from Fulkerson, is that in respect to the femoral insertion site, I have observed the isometric spot to be at same spot as the MPFL. With respect to the superficial quadriceps tendon, I have yet only used this in revision cases and found it useful. Based on the study by Mochizuki and colleagues, with a more fan-shaped configuration and the study by Victor and colleagues with the proximal part of the MPFL tight in extension and the distal part more tight in flexion, I have tried to fix the distal part of the gracilis graft at the patella site and the proximal part in the quadriceps tendon, and this seems to function well, and at least it gives a more fan-shaped configuration, compared to the superficial quadriceps graft.

Postoperative immobilization

To do or not do postoperative immobilization is the question. In one hand, we want to protect the graft with a brace. On the other hand, we want to avoid arthrofibrosis. Personally, I don’t use braces and this is based on the principle that the graft is a check rein to secure the patella and when placed isometric the tension is equal through range of motion. Since I don’t perform isolated reconstruction in the cases where more extensive forces can be expected, as in cases with increases in the tibial tubercle–trochlear groove distance or trochlear dysplasia, I believe the disadvantages of the brace outweigh the benefits.

There are many ways to fixate the graft and just like other reconstructive surgery, it is a matter of preferences and economy. Anchors, interference screw, periosteal sutures, docking technique and bone tunnels have been described as well as direct suture into the distal quadriceps tendon. A study from Berard and colleagues have focused tunnel widening and it seems that patella alta and higher degrees of trochlear dysplasia predispose to this phenomenon, however, the clinical relevance is unknown.

Conclusion

As you maybe have realized after reading this, many aspects of medial PF reconstruction are still controversial. As Matthew Bollier stated in his Patellofemoral Update blog, “only precise patient outcome instruments and long-time follow-up can help us to distinguish between right and wrong.”

Remember, and this especially applies to MPFL surgery that “there is nothing so bad you can’t make it worse than it was before surgery.” Medial patellofemoral reconstruction surgery should be reserved for orthopaedic surgeons with particular interest and understanding in the PF joint.

• References:
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• For more information:
• Lars Blønd, MD, is a consultant surgeon, Koege University Hospital and chief surgeon, Teres Medical Group, Copenhagen, and President of the Danish Society of Sports Medicine. He can be reached at Ortopaedkirurgisk afdeling, Koege Universitets Sygehus, Lykkebaekvej 1, DK-4600, Denmark; email: lars-blond@dadlnet.dk or www.larsblond.com.

Disclosure: Blønd has no relevant financial disclosures.