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MPFL reconstruction with TTT yielded successful outcomes in treatment of patellar instability
BARCELONA, Spain — Results presented at the EFORT Annual Congress showed patients with patellar instability who underwent medial patellofemoral ligament reconstruction combined with tibial tuberosity transfer experienced successful outcomes, even with high-grade trochlea dysplasia.
Varun Dewan , MBChB, MRCS, MSc, and colleagues collected patient demographics, mechanism of injury, time to surgery, presence of trochlea dysplasia, postoperative complications, return to sport and recurrence of instability among 64 patients who underwent medial patellofemoral ligament (MPFL) reconstruction with tibial tuberosity transfer (TTT) from 2009 to 2015 under the care of a single surgeon. Patients had an average age of 22.5 years and follow-up to 7 years, with a mean follow-up of 3.5 years, according to Dewan.
“We found that the majority had high grades of dysplasia and only one patient had no evidence of any dysplasia,” Dewan said in his presentation here.
He noted 63 patients had no further instability following surgery, as well as a negative postoperative patella apprehension test. Dewan said 40 patients experienced dislocation during sports. Of these patients, two-thirds were able to return to the same level of sport prior to surgery.
“Two patients experienced recurrence in their symptoms,” Dewan said. “One patient required a further reconstruction of their MPFL and one patient experienced a dislocation following high flexion injury, which was managed conservatively successfully.”
Results showed no statistical significance with the presence of trochlear dysplasia and recurrence in patella symptoms, according to Dewan. – by Casey Tingle
Reference:
Gudipati S, et al. Paper 2447. Presented at: EFORT Annual Congress; May 30-June 1, 2018; Barcelona, Spain.
Disclosure: Dewan reports no relevant financial disclosures.
Perspective
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These are impressive results indeed—63/64 stable at follow-up. If all patients in the series had documented lateral patella tracking, then the approach of correcting alignment and reconstructing the medial patellofemoral complex (MPFC-Tanaka) is most appropriate; and effective also in my experience.
Most important is to individualize. Many patients with recurrent lateral patella instability, however, have trochlea dysplasia without structural lateral tracking such that medial reconstruction alone is sufficient. MPFL and/or medial quadriceps tendon-femoral ligament (MQTFL) (proximal components of the MPFC) reconstruction are effective in preventing recurrent patella instability in such patients.
Correction of functional and structural lateral tracking in patients with patella instability is appropriate based on documented lateral tracking, using assessment of gait, femoral torsion, tibial tuberosity-trochlear groove, tibial tubercle-PCL, patella alta, Maldague lateral views, Merchant axial radiographs at 30° knee flexion and sometimes mid-patella transverse CT at 15°, 30° and 45° knee flexion. One may then understand whether to move a tibial tubercle medially, anteromedially and/or distally. Establishing optimal patella tracking by TTT followed by MPFC (MPFL or MQTFL) reconstruction to restore medial support is effective and optimal for specific, documented structural tracking and alignment abnormalities. When alignment is satisfactory, only proximal MPFC reconstruction is needed.
The goals of patella stabilization surgery are balanced tracking, optimal loading of articular cartilage and anatomically accurate retinacular support around the patella. I believe the authors confirm this.