w w w . r b o . o r g . b r
Original
article
Reconstruction
of
medial
patellofemoral
ligament
using
quadriceps
tendon
combined
with
reconstruction
of
medial
patellotibial
ligament
using
patellar
tendon:
initial
experience
夽
Betina
Bremer
Hinckel
∗,
Riccardo
Gomes
Gobbi,
Marcelo
Batista
Bonadio,
Marco
Kawamura
Demange,
José
Ricardo
Pécora,
Gilberto
Luis
Camanho
InstitutodeOrtopediaeTraumatologia,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil
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Articlehistory:
Received22February2015 Accepted19March2015 Availableonline13January2016
Keywords: Jointinstability
Patellofemoraljoint/surgery Patella
Orthopedicprocedures
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Objective:To describea surgical techniquefor anatomicalreconstructionofthe medial patellofemoralligamentusingthequadricepstendon,combinedwithreconstructionofthe medialpatellotibialligamentusingthepatellartendon;andtopresenttheinitialresults fromacaseseries.
Method:Theproposedtechniquewasusedonaseriesofcasesofpatientswithdiagnoses ofpatellofemoralinstabilityandindicationsforsurgicaltreatment,whowereattendedby theKneeGroupofHC-IOT,UniversityofSãoPaulo.Thefollowingwereevaluatedbefore andaftertheoperation:rangeofmotion(ROM),apprehensiontest,lateraltranslationtest, patellarinclinationtest,invertedJsign,subluxationuponextension,painfromcompression ofthepatellaandpainfromcontractionofthequadriceps.Aftertheoperation,thepatients wereaskedwhetheranynewepisodeofdislocationhadoccurred,whattheirdegreeof satisfactionwiththesurgerywas(onascalefrom0to10)andwhethertheywouldbe preparedtogothroughthisoperationagain.
Results:Sevenkneeswereoperated,insevenpatients,withameanfollow-upof5.46months (±2.07).Fourpatientswhopresentedapprehensionbeforetheoperationdidnotshowthis aftertheoperation.Thelateraltranslationtestbecamenormalforallthepatients,whilethe patellarinclinationtestremainedpositivefortwopatients.ThepatientswithaninvertedJ signcontinuedtobepositiveforthissign.Fivepatientswerepositiveforsubluxationupon extensionbeforetheoperation,butallpatientswerenegativeforthisaftertheoperation. Noneofthepatientspresentedanynewepisodeofdislocationofthepatella.Allofthem statedthattheyweresatisfied:fivegaveasatisfactionscoreof9andtwo,ascoreof10.All ofthemsaidthattheywouldundergotheoperationagain.Onlyonepatientpresenteda postoperativecomplication:dehiscenceofthewound.
夽
WorkperformedintheLaboratóriodeInvestigac¸ãoMédicadoSistemaMúsculo-Esquelético(LIM-41),DepartmentofOrthopedicsand Traumatology,SchoolofMedicine,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mails:betinahinckel@gmail.com,betinahinckel@me.com(B.B.Hinckel). http://dx.doi.org/10.1016/j.rboe.2015.03.012
Conclusion: Reconstructionofthemedialpatellofemoralligamentusingthequadriceps ten-don,combinedwithreconstructionofthemedialpatellotibialligamentusingthepatellar tendon,wastechnicallysafeandpresentedgoodobjectiveandsubjectiveclinicalresultsin thiscaseserieswithashortfollow-up.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Reconstruc¸ão
do
ligamento
patelofemoral
medial
com
tendão
quadricipital
combinada
com
patelotibial
medial
com
tendão
patelar:
experiência
inicial
Palavras-chave: Instabilidadearticular Articulac¸ão
patelofemoral/cirurgia Patela
Procedimentosortopédicos
r
e
s
u
m
o
Objetivo: Descrever técnicacirúrgica de reconstruc¸ãoanatômica do LPFMcom tendão quadricipitalcombinadacomareconstruc¸ãodoLPTMcomtendãopatelareapresentar osresultadosiniciaisemumasériedecasos.
Método: FoiaplicadaatécnicapropostaemumasériedecasosdepacientesdoGrupode JoelhodoHC-IOTdiagnosticadoscominstabilidadepatelofemoralecomindicac¸ãode trata-mentocirúrgico.Nopréepós-operatórioforamavaliados:amplitudedemovimento(ADM), testedaapreensão,testedatranslac¸ãolateral,testedainclinac¸ãopatelar,sinaldoJ inver-tido,subluxac¸ãoemextensão,doracompressãodapatelaedoracontrac¸ãodoquadríceps. Nopós-operatóriotambémfoiperguntadoaospacientessehouvenovoepisódiodeluxac¸ão, qualograudesatisfac¸ãocomacirurgia(escaladezeroa10)esepassariampelacirurgia novamente.
Resultados: Foramoperadossetejoelhosemsetepacienteseamédiadeseguimentofoi de5,46meses(±2,07).Tivemosquatropacientescomapreensãonopré-operatórioquenão tinhamapreensãonopós-operatório.Otestedetranslac¸ãolateralfoinormalizadoemtodos ospacientesenquantootestedainclinac¸ãopatelarpermaneceupositivoemdoispacientes. OspacientescomJinvertidopermaneceramcomosinalpositivo.Asubluxac¸ãoem exten-são,presentenopré-operatórioemcincopacientes,foinegativaemtodosnopós-operatório. Nenhumpacienteapresentounovoepisódiodeluxac¸ãodapatela.Todosresponderamestar satisfeitos.Cinco pacientesreferiramsatisfac¸ão9e doisreferiram10.Todaspassariam novamentepelacirurgia.Apenasumapacienteapresentoucomplicac¸ãopós-operatória, deiscênciadeferida.
Conclusão:Areconstruc¸ãocombinadadoLPFMcomtendãoquadricipitalcomareconstruc¸ão doLPTMcomtendãopatelarétecnicamenteseguraeapresentoubonsresultadosclínicos objetivosesubjetivosnestasériedecasodecurtoseguimento.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Lateraldislocationofthepatellaisresponsiblefor2–3%ofall kneeinjuriesandisthesecondbiggestcauseofhemarthrosis.1 The stability of the patellofemoral joint is maintained through complex interactions between active, passive and staticstabilizers.
Themedialligamentsresponsibleformaintainingthe sta-bilityofthepatellofemoraljointarethemedialpatellofemoral ligament, medial patellotibial ligament and medial patel-lomeniscalligament.
There have been many studies on the medial patellofemoral ligament (MPFL) and its anatomical and biomechanical characteristics.2–10 However, little is known
about the medial patellotibial ligament (MPTL)and medial patellomeniscalligament(MPML).2,3,5,6
Theinitialbiomechanicalstudies,inthe1990s,which eval-uatedthecontributionofthemedialligamentsinrestricting lateralizationofthepatellashowedthattheMPFLcontributed 50–60% of the medial restriction during the initial flexion (flexionofbetween0◦ and30◦).4–6 Thecontributionsofthe secondaryrestrictorshavevariedaccordingtothestudy:for the MPTLfrom 0%to 24%; and for the MPML from 8%to
38%.2,5,6 However, in amore recent study,Philippot et al.2
and92%inrelationtopatellarrotation.2 Inaclinicalstudy, Garthetal.11observedthatclinicalandarthroscopic sublux-ationwas presentinpatientswho onlyhadinjuriestothe MPML,when the knee was extended.Thus, the MPTLand MPMLare importantinmaintainingthenormalkinematics ofthepatellofemoraljointacrosstheentirerangeofmotion, andespeciallyathigherdegreesofflexion.
Surgicaltreatment usuallyconsists ofa combination of reconstruction of the injured MPFL with an adjuvant pro-cedureforimproving thealignment andcongruenceofthe patellofemoraljoint.Severaltypesofgraftforreconstructing the MPFL with good results have been described.12–14 It is importanttohavedifferenttypesofgraftwithsimilarresults inordertomakeitpossibletoindividualizethetreatmentand toperformrevisiononthereconstruction.
Inasystematicreviewonthecomplicationsarisingfrom reconstructionoftheMPFLalone,thecomplicationratefound was26.1%.Clinicalfailuresthatpresentedsubluxationor dis-location occurred in 3.7%ofthe cases. Alterations seen in physicalexaminations,such aspositive apprehensiontest, patellarhypermobilityorepisodesoffeelingsofinstabilityin thekneeoperated,occurredin8.3%ofthecases.Thus, objec-tiveorsubjectiveinstabilitypersistedin12%ofthecases.15 Weputforwardthehypothesisthat thissubluxationmight resultfromprogressiveslackeningoftheMPFLduetohigher stresssubsequenttoitsreconstruction.Reconstructionofone ofthesecondaryrestrictor ligaments(MPTL orMPML) may diminishthestressontheMPFLandimprovethefunctional results.TheMPTLmaydecreasetheangleofthequadriceps (Qangle), thus improving patellar excursionwithout caus-ingasmany changestothe kinematicsofthetibiofemoral jointaswould medializationosteotomyofthe anterior tib-ial tuberosity (ATT), which is the method used today for decreasingtheQangle.16Inchildren,whenitisnotpossible toperformosteotomytocorrectriskfactors,reconstruction of these secondary ligaments becomes even more impor-tant. Therehavebeen somedescriptions ofseries ofcases ofMPFLreconstructioncombinedwithMPTLreconstruction, withgoodresults.17–21SeriesofcasesofMPTLreconstruction usingthe patellar tendoncombined withprocedures other thanMPFL construction(lateral release ofthe retinaculum, advancement of the vastus medialis obliquus and medial retinaculum,andosteotomyoftheATT)alsoexist.22–24 The objectives ofthe present study were todescribe asurgical techniqueforanatomicalreconstructionoftheMPFLusingthe quadricepstendon,combinedwithreconstructionoftheMPTL usingthepatellartendon,and topresenttheinitialresults fromaseriesofcases.
Materials
and
methods
Thisstudywasapprovedbyourinstitution’sethicscommittee underthenumberCEP333/13,andallthepatientssigneda consentstatementinordertoparticipate.
Theproposedtechniquewasappliedtoaseriesofcases ofpatientsseenbytheKneeGroupofHospitaldasClínicas, InstituteofOrthopedicsandTraumatology(HC-IOT),whowere diagnosed as presenting patellofemoral instability with an
indicationforsurgicaltreatment.Allthepatientshadaclinical diagnosisofpatellardislocation,withatleasttwoepisodes.
TheindicationsforcombinedreconstructionoftheMPFL andMPTLwere:
- Subluxation inextension (lateral and proximal displace-mentofthepatellawithcontractionofthequadriceps,with thekneeextended).
- Instability inflexion(spontaneous dislocationor positive lateraltranslationtestwiththekneeflexed).
- Hyperextensionofthekneewithligamentlaxity.
- Opengrowthplateinassociationwithpredisposingfactors (increasedQangle,highpatellaandtrochleardysplasia).
Thefollowingwereevaluated beforeandafterthe oper-ation: range of motion (ROM), apprehension test, lateral translationtest,patellarinclinationtest,invertedJsign, sub-luxation in extension, pain on compression ofthe patella andpainoncontractionofthequadriceps.Thefollowing pre-disposingfactors wereevaluatedusingmagneticresonance imaging: Q angle (TT–TG: distance of the patellar tendon fromthetrochlearthroat);highpatella(modifiedInsall–Salvati index,Caton–Deschampsindexandlengthofthepatellar ten-don);andtrochleardysplasia(Dejourclassification).Afterthe operation,thepatientswereaskedwhethertherehad been anynewepisodeofdislocation;whattheirdegreeof satisfac-tionwiththesurgerywas(scalefrom0to10);andwhetherthey wouldundergotheoperationagain(yesorno).Thesurgical complicationswerealsoevaluated.
Surgicalreconstructiontechnique:
- Skinincisions:Twosmallanteriorincisions,eachmeasuring 2–3cm(minimallyinvasivetechnique),weremadeinorder toharvestquadricepsandpatellargrafts,andanincisionof 1–2cmwasmadeinthemedialepicondyleinordertoinsert theMPFLinthefemur.Whenadditionalprocedureswere indicatedandrequiredwiderexposure,ananteriorincision of8cmwasmade(opentechnique).
- Harvesting ofthe quadriceps graft (Figs. 1–3)12: An inci-sionof3cmwasmadeproximally tothe patella.Usinga scalpelblade, a strip of8mmin width from the medial portionofthequadricepstendoncontainingthesuperficial portionofthequadriceps(inrelationtotherectusfemoris) wascutout,whileits patellarinsertionwas maintained. The distal extremity of the graft was carefully partially detachedfromthepatella,asfarasthetransitionbetween theupperandmiddlethirdsofthepatellarheight.Two adju-vant stitcheswere made inthe periosteum using slowly absorbablethread,inordertomaintaintheinsertion. - Harvestingofthepatellargraft(Figs.1–3)13:Amedial
Fig.1–Illustrationofthegraftsharvestedfromthepatellar
andquadricepstendons.
- InsertionoftheMPFLinthefemur(Fig.4AandB):Thefree proximalendwasrotatedthrough90◦andwaspassedunder themedialretinaculumthroughtheincision.Theinsertion pointwasbetweenthemedialepicondyleandthetubercle oftheadductors,attheradiographicpoint.25A5-mmanchor was fixedatthis point. INpatients withanopengrowth plate,a3.5-mmanchorwasusedanditsinsertionwasin thedistalepiphysisofthefemur.26
- Insertion of theMPTL (Fig. 4A and B):Thefree endwas passed underthe medial reticulum toward the proximal tibia.A5-mmanchorwasfixedinthetibia,1.5–2.5cmbelow the jointline and1.5and 2.5cm mediallytothepatellar tendon,whichformedanangleof20–25◦ withthepatellar tendon.3,5Inpatientswithanopengrowthplate,a3.5-mm anchorwasused,withanangleof20–25◦inrelationtothe patellar tendon,fixedjustabove thegrowth plate,inthe proximalepiphysisofthetibia,sothatitstensioningwould be maintained duringgrowth. Sincethe insertion inthe tibialplateauwasclosetothegrowthplatescar,the fixa-tionofthegraftclosetothegrowthplatereconstitutedthe anatomyoftheMPTLwellinadulthood.
- Tensioningand fixationofthe grafts(Fig.4AandB):The patellartendonwasfirstlyfixedatthepointdescribedfor theMPTL.Thekneewaspositionedat90◦offlexion,which isthepositionofgreatesttensionandcontributionofthe MPTLtothelateralrestriction,2andalsoapositionatwhich
Fig.2–Graftsharvestedfromthepatellarandquadriceps
tendonsbymeansoftheopentechnique.
thepatellaiswellreducedbetweenthecondyles.TheMPTL wasplacedundertraction withsufficienttensionto con-tributetowardmaintainingthepatellainthisposition.It wasimportanttoplacethegraftundertensionsimilarto thatoftheremnantpatellartendon,sothattheycouldact synergistically over the entire rangeof motion. Overten-sioning of the tendon also needed to be avoided so as
Fig.3–Graftsharvestedfromthepatellarandquadriceps
Fig.4–(A)IllustrationofreconstructionoftheMPFLusingagraftfromthequadricepstendonandoftheMPTLusingagraft
fromthepatellartendon,inanteriorview.(B)IllustrationofreconstructionoftheMPFLusingagraftfromthequadriceps
tendonandoftheMPTLusingagraftfromthepatellartendon,inmediolateralview.
nottocauseanincreaseinpressureinthepatellofemoral compartment.27Thegraftwasthensuturedtotheanchor thathadpreviouslybeenfixedintheMPTL.Thekneewas then placedat 30◦ offlexion, such that the patella was positionedatthetrochlea.Thequadricepsgraftwasplaced undersufficienttraction tokeepthepatella atareduced position. Withthis degreeoftension, the patellaneeded tobecapableofmakingamediolateralexcursionofoneto twoquadrants,anditwasimportantthatthegraftwasnot overtensioned,forthereasonsmentionedearlier.28Lastly, twoorthreestitcheswereinsertedbetweenthequadriceps graftoftheMPFLandthevastusmedialis,fordynamism.
Additionalprocedures(shorteningofthepatellartendon, lateralretinacularrelease andstretchingofthequadriceps) wereperformedconcomitantlyinaccordancewiththe pre-disposingfactors.29
After the operation, the patients used immobilization in extension for walking, from the first postoperative day until completion of six weeksafter the operation. Passive movement was made throughphysiotherapy and at home underguidancefromaphysiotherapist,withprogressiononly limitedbypain.
Results
Sevenkneeswereoperated,insevenpatientsofmeanage15.4 years(allofthemfemale):sixrightkneesandoneleftknee.
Theevaluationonpredisposingfactorsandsurgical indi-cations is shown in Table 1. The mean length of the patellartendonwas47.57mm(±10.78mm).Twopatientshad lengths of more than 52mm. The mean for the modified Insall–Salvatiindexwas1.84(±0.31),andtwoofthepatients hadindexesabovenormalvalues(i.e.>2).Themeanforthe
Caton–Deschampsindexwas1.39 (±0.30),and fivepatients hadindexesabovenormalvalues(i.e.>1.2).ThemeanTT–TG distance was 1.6cm (±0.44cm), and four patients had val-uesgreaterthan1.5cm.Threepatientspresentedhigh-grade trochleardysplasia(B,C orD).Themainindicationsfor com-binedreconstructionoftheMPFLandMPTLweresubluxation inextension,opengrowth plateinassociationwith predis-posingfactorsandinstabilityinflexion,indecreasingorderof frequency(Table1).
In thepreoperativeevaluation, onlyonepatientdidnot haveacompleterangeofmotionandpresentedcontracturein flexion;fourhadapositiveapprehensiontest;allthepatients presentedabnormalitiesinthelateral translationtest;only one presented normal values in the patellar tilt test; two patientspresentedtheinvertedJsign;onlyonedidnothave subluxationinextension;fourhadpainuponcompressionof thepatella;andfourpresentedpainuponcompressionofthe quadriceps(Table2).
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:75–82
Table1–PredisposingfactorsandindicationsforcombinedreconstructionoftheMPFLandMPTL.
Patient Patellartendon length(mm)
Modified Insall–Salvati
index
Caton–Deschamps index
TT–TG distance(cm)
Dejour classification
Subluxation inextension
Instabilityin flexion
Hyperextension oftheknee withligament
laxity
Opengrowth plate
Associatedprocedures performed
1 48 1.9 1.4 1.2 A + + +
2 65 2.3 1.8 2.3 C + + + Shorteningofthepatellar
tendon
3 37 1.5 1 1.5 D + + + Stretchingofthelateral
retinaculum
4 40 1.7 1.4 1.9 A + +
5 46 1.8 1.4 1.1 A + +
6 59 2.2 1.7 1.3 A + + + + Lateralretinacularrelease
(arthroscopic)
7 38 1.5 1 1.9 B +(habitual) + Stretchingofthe
quadricepstendonandof thelateralretinaculum
Mean 47.57 1.84 1.39 1.60
MPFL,medialpatellofemoralligament;MPTL,medialpatellotibialligament. Surgicalindicationsinbold.
Table2–Clinicalevaluationbeforeandaftertheoperation.
Patient ROM(before) ROM(after) Apprehension test(before)
Apprehension test(after)
Lateraltranslation test(before)
Lateraltranslation test(after)
Patellartilttest (before)
Patellartilttest (after)
1 0–150 0–150 − − Altered Normal Normal Normal
2 10–140 10–140 + − Altered Normal Altered Normal
3 0–150 0–150 + − Altered Normal Altered Altered
4 0–150 0–150 + − Altered Normal Altered Normal
5 −10to140 −10to140 − − Altered Normal Altered Normal
6 −15to150 −10to140 + − Altered Normal Altered Normal
7 0–150 0–150 − − Altered Normal Altered Altered
Patient Jsign(before) Jsign(after) Subluxationin extension(before)
Subluxationin extension(after)
Painupon compressionofthe
patella(before)
Painupon compressionofthe
patella(after)
Painupon contractionofthe quadriceps(before)
Painupon contractionofthe quadriceps(after)
1 − − + − − + − +
2 + + + − + + + +
3 + + + − + − + −
4 − − + − + − + −
5 − − + − − − − −
6 − − + − − − − −
Noneofthepatientspresentedanynewepisodeofpatella dislocation. All ofthem said that theywere satisfied. Five patientsratedtheirsatisfactionas9andtwoas10.Allofthe patientssaidthattheywouldgothroughthesurgeryagain.
Onlyonepatient presentedany postoperative complica-tion,whichconsistedofdehiscenceofthewound.Thispatient requiredtwosurgicaldebridementproceduresandnew sutur-ingoftheskinandsubcutaneoustissue,forhealingtotake place.
Discussion
The technique described here has the advantages that it enablesanatomicalreconstructionoftheMPFLandMPTLand tensioningofthegraftsatdifferentdegreesofflexion,thereby respectingthefunctionofeachligament.Inaddition, main-tenanceof the patellarinsertion ofthe quadricepstendon andpatellartendonavoidstheneedtousesynthesis mate-rialatthesite,orperforation,whichpossiblywouldhaveled tofracturingofthepatella.15,30,31
Inreconstructionsdescribed previously,the distal inser-tionsoftheflexortendonsweremaintained.Thesedidnot coincidewiththeinsertionsofeithertheMPTLortheMPML. Thetibialinsertionoftheflexortendonswaslocatedat dis-tancesof41±6.6mmfromthetibialplateauand6.88±1mm medially to the patellar tendon. The MPTL was located between15 and 20mm mediallytothe patellar tendon, in adults.32Withfreedistalborders,thegraftcanbeplacedin ananatomical position. Inaddition, this allowstensioning oftheMPFLandMPTLreconstructionsatdifferentanglesof flexion.Becausethepositioninginpreviousdescriptionswas non-anatomical,onlyoneinstanceoftensioningoftheMPFL andMPTLatdifferentanglesofflexionwasdescribed.17
Furthermore,fixationoftheMPTLintheproximal epiph-ysisofthetibia,andnotintheproximalmetaphysisofthe tibia,reducestheriskofdistalmigrationofthegraftinsertion overthecourseofgrowth,whichwouldchangeitstensioning andfunctioning.33Theprincipleofinsertionintheepiphysis isanalogoustothatusedinreconstructingtheMPFL.26
ReconstructionoftheMPFLtogetherwiththeMPTL,using grafts fromflexortendons, hasalsoproduced provengood resultsinfivecaseseriestotaling74patients.17–21The differ-enceinourproposalliesonlyinthegraftsused.Useofgrafts fromthepatellarandquadricepstendonsforreconstructing theMPFLisalreadywellknownanddisseminated.Useofthe patellartendonforreconstructingthe MPTLalone hasalso beendescribed.22–24
In our initial series of cases, the patients presented improvements in various signs and symptoms of patellar instabilityandonlycaseofaminorcomplicationofthe oper-ative wound. We believe that this case was due touse of inappropriatesizingandtissuepull-backintheincision.None ofthepatientspresentedrecurrenceofthepatellardislocation andallofthemsaidthattheyweresatisfiedwiththeresult.
Thus,webelievethatournewproposalforcombinedMPFL reconstructionusingthequadricepstendonandMPTL recon-structionusingthepatellartendonistechnicallysafe,given thatitconsistsofproceduresandconceptsusedroutinelyby kneesurgeons.Inaddition, itsgood resultsare predictable,
basedonthecurrentevidencefromtheliterature.The tech-niquepresentedgoodobjectiveandsubjectiveclinicalresults intheseriesofthepresentstudy.
Themajorlimitation ofthisstudy isits shortfollow-up, giventhatinstabilitymayrecuratalaterstage.Forthisreason, wechosenottoincludetheKujalascore,whichmighthave indicated resultsthatwere unsatisfactory giventhat many ofthepatientsassessedwerestillundergoingrehabilitation. Thus,alongerfollow-upisnecessaryinordertohavea bet-terassessmentoftheresultsoveralongerperiod.Theaimof thisarticlewastopresentanewandalternativesurgical tech-niqueforcombinedreconstructionoftheMPFLandMPTLand itscomplicationandsuccessratesovertheshortterm.
Conclusion
CombinedreconstructionoftheMPFLusingthequadriceps tendonandoftheMPTLusingthepatellartendonis techni-callysafeandpresentedgoodobjectiveandsubjectiveclinical resultsinthisseriesofcaseswithashortfollow-up.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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