Results of Medial Patellofemoral Ligament Reconstruction in the Treatment of Patellar Dislocation
Abstract & Commentary
Synopsis: Reconstruction of the medial patellar ligaments with hamstring grafts improved stability following patella dislocation, but not without some complications.
Source: Drez D Jr., et al. Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation. Arthroscopy. 2001;17(3):298-306.
This study presents the results of medial patellofemoral and medial patellotibial ligament reconstruction using either autogenous hamstring graft (semitendinosus graft in 6 patients and semitendinosus and gracilis graft in 5 patients) or fascia lata graft (3 patients). Fifteen patients (10 men and 5 women) were included in this study. The patients’ average ages were 22 years (range, 14-52 years) at the time of surgery. All sustained an initial traumatic patellar dislocation, and 7 had subsequent multiple dislocations. One patient underwent lateral release as well as ligament reconstruction. The remaining patients underwent reconstruction only.
Reconstruction was accomplished by first harvesting the autologous graft material and finding its center. The center of the graft was then affixed to the superomedial border of the patella with a No. 2 nonabsorbable braided suture and a suture anchor, while the superior "arm" of the graft used to replace the medial patellofemoral ligament was sutured to the periosteum of the adductor tubercle with the knee in full extension and the inferior "arm" anchored to the tibial periosteum approximately 1.5 cm distal to the joint line, mimicking the medial patellotibial ligament.
At follow-up (mean, 31 months; range, 24-43 months), patients were assessed by a subjective self-assessment questionnaire, the Tegner evaluation, the Fulkerson functional knee score, and the Kujala questionnaire. Additionally, patients underwent physical examination and radiographic evaluation of the involved extremity.
On subjective evaluation, 93% of patients believed the procedure had improved their knee. The mean Fulkerson score for this group was 93 (range, 80-100); the mean Kujala score was 88.6 (range, 57-100); and the postoperative Tegner score averaged 6.7 compared with 6.8 preoperatively. Only 3 patients had a normal physical examination; 10 had patellofemoral crepitus; 1 had medial facet tenderness; 1 had medial patellar hypermobility; and 9 had some quadriceps atrophy. Drez and colleagues also reported that 4 out of 15 patients lost flexion when compared with the uninvolved knee.
Comment by Letha Y. Griffin, MD, PhD
In the last 5 years, there has been a heightened interest in the role of the medial patellofemoral ligament as a key stabilizing ligament of the patellofemoral joint. The medial patellotibial ligament is felt to function less effectively in this role. Prior to the late 1990s, most surgical procedures for recurrent dislocations of the patellar centered around releasing tight, lateral structures, and imbricating laxity in the vastus medialis obliquus muscle and superficial medial retinaculum, alone or in combination with a distal bony realignment procedure. The medial patellofemoral ligament was infrequently addressed.
It should be emphasized that this subset of patients consisted of a majority of males (10 males and 5 females) whose initial dislocation was traumatic in nature. All subjects had a normal quadriceps’ angle. These patients were not young teenage girls with marked hyper-mobile patellae and significant flattening of the trochlear groove who sustained dislocations with minimal traumatic events. In fact, Drez et al mention that they do not recommend medial patellofemoral ligament reconstruction alone in patients with an abnormal quadriceps angle. This point probably deserves greater emphasis than being buried in one of the last paragraphs of Drez et al’s discussion.
One should also note that the average follow-up time for patients in this study was only 31.5 months. One could question whether this is adequate time to assess the development of secondary degenerative changes due to abnormal patella tracking or increased patellofemoral forces following a stabilization procedure. Moreover, the fact that 4 of the 15 patients had a residual flexion loss is significant and needs further study before one would wish to recommend widespread adoption of this technique.
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