Robotic-assisted MPFL reconstruction may yield improved outcomes vs. freehand technique
Key takeaways:
- Robotic-assisted MPFL reconstruction yielded improved tunnel positioning, better functional scores and less radiation exposure vs. freehand surgery.
- However, the differences were not clinically significant.
According to published results, robotic-assisted medial patellofemoral ligament reconstruction yielded more accurate femoral tunnel positioning, increased functional scores and less radiation exposure compared with a freehand technique.
However, both robotic-assisted and freehand MPFL reconstruction had similar rates for achievement of the minimal clinically important difference (MCID) for patient-reported outcomes (PROs).
Freehand surgery is the traditional technique that surgeons have used to implant grafts into the ideal insertion center during MPFL reconstruction, according to Xiaoyun Sheng, MD, and colleagues from Lanzhou University Second Hospital in China.
“Achieving this goal may require multiple fluoroscopies during operations, which increases radiation exposure,” Sheng and colleagues wrote. “Alternatively, the anatomical insertion point can be identified by freehand palpation, but this requires an enlarged incision and relies on extensive clinical surgical experience.”
Sheng and colleagues retrospectively analyzed data from 34 robotic-assisted MPFL reconstructions and 52 freehand MPFL reconstructions performed for chronic patellar dislocation between January 2020 and December 2023 at a single institution. Mean follow-ups occurred at 27 months for the robotic-assisted group and at 31 months for the freehand group.
Overall, no patients in either group had a patellar re-dislocation. Among the robotic-assisted group, median length of stay (LOS) was 7 days, median operation duration was 120 minutes and median number of fluoroscopies was 4.5. Among the freehand group, median LOS was 8 days, median operation duration was 110 minutes and median number of fluoroscopies was 9.
At follow-up, Sheng and colleagues found the robotic-assisted group had a shorter distance between the femoral tunnel and Schöttle’s point (2.57 mm vs. 5.58 mm), as well as increased Kujala and Lysholm scores at 1- and 2-year follow-ups compared with the freehand group. Sheng and colleagues noted both groups had significant improvements in Kujala and Lysholm scores preoperatively to postoperatively.
After MCID analysis, Sheng and colleagues found the robotic-assisted group and the freehand group had similar rates for achievement of the MCID for Kujala and Lysholm scores.
“These findings indicated that even though the robot-assisted group had statistically higher postoperative functional scores, no clinically significant differences were observed between the two groups,” Sheng and colleagues concluded.
Perspective
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This is an exciting area of study that applies technological advances to an area within patellofemoral surgery that is well known to require precision. However, it is important to remember the limitations of using radiographic guidance alone for femoral tunnel placement, due to inconsistent correlation with anatomic landmarks, inaccuracies that depend on knee positioning or field of view at the time of imaging and the posterior appearance of radiographic landmarks in knees with trochlear dysplasia.
While radiographic guidance is an important tool for femoral tunnel placement, optimal placement depends ultimately on the anatomy of the femur, as well as the isometric position to maintain minimal graft length changes throughout range of motion. In this study, the authors present promising results and highlight an important and novel advancement in MPFL reconstruction, and I look forward to future models that incorporate these other considerations that can make robotic assistance that much more powerful as a tool in the management of patellar instability.
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