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MPFL reconstruction using epiphyseal femoral socket can avoid injury in children with patellar instability
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According to study results, medial patellofemoral ligament reconstruction using an epiphyseal femoral socket with fluoroscopic guidance was an effective treatment for children with patellar instability that avoided physeal injury and subsequent growth disturbance.
“The take-home message is that the results of our paper demonstrate that patella stabilization surgery with [medial patellofemoral ligament] MPFL reconstruction can be performed safely and effectively in young patients with open growth plates,” study co-author Daniel W. Green, MD, from Hospital for Surgery, told Healio.com/Orthopedics.
Green and colleagues identified 54 knees in 49 skeletally immature patients who underwent physeal-sparing MPFL reconstruction. The mean age at time of surgery was 13.5 years. In all patients, a femoral socket distal to the femoral physis was used for graft fixation. Postoperative MRIs of the operative knee were used to assess physeal safety, and standing hip-to-ankle radiographs were used to assess development of the lower limb angular deformities and limb length discrepancy. Median radiographic follow-up was 2.2 years.
Results showed five patients had recurrent patellar instability at the most recent clinical follow-up. Of these, three patients underwent subsequent tibial tubercle osteotomy or revision MPFL reconstruction. Investigators noted the leg length between operated and nonoperated limbs was not statistically significantly different. The nonoperated and operated mechanical medial proximal tibial angle and mechanical lateral distal femoral angle measurement were not statistically significantly different. No evidence of physeal arrest was seen on postoperative MRI. The median distance from the physis to the socket at the aperture was 5.9 mm and was 7.1 mm from the physis to the distal end of the femoral socket. – by Monica Jaramillo
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Shital N. Parikh, MD
Medial patellofemoral ligament (MPFL) reconstruction has become a popular treatment option for recurrent patellar instability. In skeletally immature patients, the MPFL femoral attachment is in close proximity to the distal femoral physis, raising concerns about the possibility of iatrogenic injury to the physis and resultant growth disturbances. The authors, based on postoperative anteroposterior radiographs and coronal plane MRI, have demonstrated safety of their technique using an epiphyseal femoral socket and fluoroscopic guidance. Other reported methods of MPFL femoral attachment in skeletally immature patients include sutures, suture anchors, soft tissue pulleys or femoral tunnel with pull-through sutures, though safety of some of these methods have not been studied. Meticulous surgical technique, intraoperative fluoroscopy and adequate clinical and radiographic follow-up are imperative for safety of MPFL reconstruction in skeletally immature patients.
As the MFPL attachment point on the distal femur is medial and posterior, future studies on growth disturbances should also include range of motion and sagittal plane analysis. The single case report on distal femoral physeal arrest after MPFL reconstruction reported extension loss and flexion deformity of the distal femur which required an extension osteotomy. Such a deformity could be missed if growth disturbances are analyzed in a single plane, as in the current study.
Reference:
Seitlinger G, et al. Knee. 2017;doi:10.1016/j.knee.2017.02.003.
Cincinnati Children’s Hospital Medical Center
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