MPFL revision surgery linked with improved quality of life
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Despite significant restrictions prior to revision surgery for medial patellofemoral ligament reconstruction failure, published results showed significant improvements in patient-reported quality of life after revision surgery.
Peter Balcarek, MD, and colleagues assessed patient-reported quality of life before and after revision surgery for failed MPFL reconstruction among 25 patients using the Banff Patella Instability Instrument 2.0 (BPII 2.0) score and a numerical analog scale for patellofemoral pain and subjective knee joint function. Researchers matched the study group by surgical procedure, predisposing factors, sex, age and follow-up time to a control group of 50 patients who underwent identical patellar stabilizing procedures.
Results showed an increase in the BPII 2.0 score from approximately 28.6 points preoperatively to 68.7 points postoperatively in the study group and from approximately 43.8 points preoperatively to 75.5 points postoperatively in the control group. Although the study group had significantly lower BPII 2.0 scores before revision surgery compared with the control group, researchers noted no significant differences in the scores between the two groups postoperatively. Researchers also found 92% and 84% of patients in the study and control groups, respectively, achieved the minimally clinically important difference (MCID) reported for the BPII 2.0 score. Both groups had significant improvements in patellofemoral pain and subjective knee joint function without any significant difference between them at final follow-up, according to results.
“The results obtained from this study indicate that disease-specific patient-reported QoL, subjective knee joint function and patellofemoral pain improved significantly in both primary and revision cases, yielding satisfactory results in both groups,” Balcarek told Healio Orthopedics. “Although the reported QoL in the study group was significantly worse prior to revision surgery, the postoperative BPII 2.0 scores were not significantly different between the groups, and a similar number of patients crossed the MCID when compared to the control group without previous interventions. The results indicate the importance of anatomical predisposing factors for both patellofemoral stability and functionality and indicate the need for their surgical correction, at least in patients with MPFL reconstruction failure and previously uncorrected risk factors.”
Perspective
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I was interested to read the article by Felix Zimmermann, MD, and colleagues evaluating outcomes of revision surgery after failed isolated MPFL reconstruction. There is limited literature on the subject, and this area of study gets at the question of when is isolated MPFL reconstruction enough and when do we need to consider concomitant procedures. This question continues to be not fully answered, but this study does shed some further light on the subject, specifically that revision surgery after failed MPFL reconstruction can be successful, especially if paired with concomitant procedures to address anatomic patellofemoral risk factors.
Not surprisingly in a small study like this, the study group is a heterogeneous population where only eight of 25 revisions involved MPFL reconstruction alone and the remaining procedures had a variety of concomitant bony procedures. Only 60% of the revision surgeries were for recurrent instability, so there were many reasons for failure of the primary surgery. There is also not a lot of information on how the control group was chosen.
Despite limitations such as these, this study does demonstrate that patients can improve after revision surgery. In my estimation, perhaps the biggest takeaway is that it highlights the importance of considering the anatomy risk factors when performing revision surgery, but by virtue of the failures and subsequent response to revision surgery, it also highlights the importance of considering the anatomy risk factors the first time around. Although we lack clarity on how to approach the complexities of patellofemoral care and the many associated anatomy risk factors, it is clear that the care of patellofemoral instability patients requires a comprehensive and versatile approach to treatment.
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