Rev. bras. ortop. vol.51 número2

w w w . r b o . o r g . b r

Original

Article

Reconstruction

of

the

medial

patellofemoral

ligament

using

autologous

graft

from

quadriceps

tendon

to

treat

recurrent

patellar

dislocation

夽

Constantino

Jorge

Calapodopulos

,

Marcelo

Corvino

Nogueira

,

José

Martins

Juliano

Eustáquio

_,

_Constantino

_Jorge

_{Calapodopulos}

_Júnior

_,

Oreston

Alves

Rodrigues

a_{DepartmentofOrthopedicsandTraumatology,UniversidadeFederaldoTriânguloMineiro(UFTM),Uberaba,MG,Brazil}

b_{DepartmentofOrthopedicsandTraumatology,UniversidadedeUberaba(UNIUBE),Uberaba,MG,Brazil}

c_{HospitalRegionaldeSobradinho,Brasília,DF,Brazil}

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Articlehistory:

Received17February2014 Accepted29May2015

Availableonline6February2016

Keywords:

Patellofemoralligament Quadricepstendon Patellardislocation

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b

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t

Objective:Theobjectiveofthisstudywastoevaluatetheefficacyofthesurgicaltechnique usingthequadricepstendonasagraftinstaticreconstructionofthemedialpatellofemoral ligament.

Methods:Thiswasaprospectivecaseseriesstudyinwhichtheparticipantswere22patients withadiagnosisofrecurrentpatellardislocationwithoutanyotheranatomicalalterations thatrequiredsurgicaltreatment.Thefunctionalresultsfromthetechniquewereevaluated usingclinicaldataandtheLysholmquestionnaire,oneyearaftertheoperation.

Results:Itwasobservedthatthepatientswerepredominantlyfemale(86%)andunder21 yearsofage(73%),justlikeintheliterature.Atthefirstannualreturnafterthesurgery, therewasnosignificantpainonmediumefforts,nolossofrangeofmotionandapositive apprehensiontest.Accordingtothequestionnaireused,theresultsweregradedasgood.The patientswhoreportedhavingseverepainongreatereffortwereinvolvedin employment-relatedlegaldisputes.

Conclusion: Thistechniqueshowedlowmorbidityandgoodfunctionalresultsovertheshort term.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

WorkperformedattheUniversidadeFederaldoTriânguloMineiro(UFTM),Uberaba,MG,Brazil.

∗ _{Correspondingauthor.}

E-mail:mcorvino.ort@gmail.com(M.C.Nogueira).

http://dx.doi.org/10.1016/j.rboe.2016.01.012

188

Reconstruc¸ão

do

ligamento

patelofemoral

medial

com

enxerto

autólogo

do

tendão

quadricipital

no

tratamento

da

luxac¸ão

recidivante

da

patela

Palavraschave:

Ligamentopatelofemoral Tendãoquadricipital Luxac¸ãopatelar

r

e

s

u

m

o

Objetivo:Avaliaraeficáciadetécnicacirúrgicaqueusaotendãodoquadrícepscomoenxerto nareconstruc¸ãoestáticadoLPFM.

Métodos: Estudode sériedecasos,prospectivo,doqualparticiparam22 pacientescom odiagnósticodeluxac¸ãorecidivantedapatela,quenãoapresentavamoutrasalterac¸ões anatômicasquenecessitassemdetratamentocirúrgico.Osresultadosfuncionaisdatécnica foramavaliadospormeiodedadosclínicosedoquestionáriodeLysholm,comumanode pós-operatório.

Resultados: Observou-sepredomíniodepacientesdosexofeminino(86%)emenoresde 21 anos(73%),aexemplo doobservadonaliteratura.Noprimeiroretornoanualapósa cirurgia,nãohouvedorsignificativaaosmédiosesforc¸os,perdadeamplitudedemovimento epositividadedostestesdeapreensão.Segundooquestionárioempregado,osresultados foramgraduadoscomobons.Aquelesqueinformaramdorintensaaosmaioresesforc¸os apresentavampendênciastrabalhistas.

Conclusão: Atécnicaapresentadamostrou,emcurtoprazo,baixamorbidadeebons result-adosfuncionais.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Acute dislocationof the patella isa common event, espe-ciallyamongadolescentsandyoungadults,withhigherrates among females.1 _{It can be triggered bytraumatic or} non-traumaticevents. In the lattercases, it is associated with significantanatomicalalterationsofthekneeextensor mech-anism.Thereisnoconsensusregardingtheidealtreatment afterthefirstoccurrenceofdislocation,mainlybecauseonly 30%ofthepatientspresentanewepisode.2_{However,incases} ofrecurrentdislocation(twoormoreepisodes),thetreatment isessentiallysurgicalandhastheaimofcorrectingthe pre-disposingfactors.Amongthese,reconstructionofthemedial patellofemoralligament(MPFL)isconsideredtobethemost importantprocedure,3_{especiallyafterkneeinjury.}

TheMPFLactsasthemainligamentrestrictinglateral dis-placementofthepatellaatknee flexionofbetween0◦ _and

30◦_.4_{Becauseofitsbiomechanicalproperties,itisessentialfor} controllingthenormalkinematicsofthepatellofemoraljoint.5 Duringthefirstepisodeoftraumaticpatellardislocation,this anatomicalstructurebecomespartiallyortotally torn.This injuryisconsideredtobeanessentialfactorenabling devel-opmentofrecurrentdislocation.6

Thefirstreportsofthisreconstructionweremadeby Sug-amunaetal.,7 _{in1990,whousedtendonautografts,andby} ElleraGomes,whousedsyntheticgrafts.8_{Intheliterature,} dif-ferentsurgicaltechniqueshavebeendescribed,withoptions forstaticanddynamicreconstruction,but noneofthem is consideredtobethegoldstandard.9

Surgicalproceduresusingaportionoftheextensor mech-anismasagraftinstaticreconstructionoftheMPFL,through tendontransfer,asdescribedbyCamanhoetal.10_forthe patel-lartendon,andbySteensenetal.11_{forthequadricepstendon,} areeasilyreproducibleandhavelowmorbidity.

Theobjectiveofthisstudywastoevaluatetheshort-term resultsfromMPFLreconstructioninpatientswithrecurrent patellardislocation,bymeansofatechniqueusingafragment fromthequadricepstendonasagraft.

Materials

and

methods

This was a prospective case series. Theparticipants were 22 patientsofbothsexeswho hadadiagnosis ofrecurrent patellar dislocation.Theyunderwentsurgicaltreatmentfor MPFLreconstructionatHospitaldeClínicas,Federal Univer-sityoftheTriânguloMineiro(UFTM),inUberaba,MinasGerais, betweenJanuary2008andSeptember2013.Theparticipants signedafreeandinformedconsentstatement.

Table1–Lysholmquestionnaire.Translationvalidated forthePortugueselanguage.

Claudication(5points) Pain(25points)

Never=5

Mildorperiodic=3 Severeandconstant=0

None=25

Mildorperiodicduringphysical effort=20

Greaterpainduringorafter walking>2km=10 Graterpainduringorafter walking<2km=5 Constant=0

Weight-bearing(5points) Edema(10points)

None=5

Withstickorcrutch=2 Impossible=0

None=10

Withheavyexercise=6 Withordinaryexercise=3 Constant=0

Locking(15points) Goingupstairs(10points)

Nolockingorfeelingof this=15

Feelingbutwithout locking=10 Occasional=6 Frequent=2 Jointlockedduring examination=0

Noproblem=10 Slightlyimpaired=6 Onestepatatime=3 Impossible=0

Instability(25points) Squatting(5points)

Never=25

Rarelyduringphysical effort=20

Frequentlyduring effort=15

Occasionallyduring dailyactivities=10 Frequentlyduringdaily activities=5

Ateachstep=0

Noproblem=5 Slightlyimpaired=4

Notpossiblebeyond90degrees=2 Impossible=0

Totalscore:

Scoring:excellent:95–100;good:84–94;fair:65–83;poor≤64.

Theexclusioncriteriaforthestudyweredefinedafter clini-calevaluation,radiologicalevaluation(radiography,computed

tomography and magneticresonance imaging) and

arthro-scopicevaluation.Thefollowingpatientswereexcluded:those withgenuvalgum,previoussurgeryinthesameknee, abnor-malityofjointrangeofmotion(ROM),Qanglegreaterthan 20◦_{,trochlearanglegreaterthan145}◦_{,TT-TGdistancegreater}

than20mm,highpatella(greaterthan1.2,asassessedusing theInsall-Salvatiindex),patellardysplasiaofgradeIV orV

accordingtotheWibergclassification,12_{cartilaginousinjuryof} gradeIII_orIV_{accordingtotheOuterbridgeclassification}13_and meniscaland/orligamentinjurieswithindicationsforrepair orreconstruction.

Oneyearaftertheoperation,thepatientswereevaluatedby meansofclinicalparameters(pain,ROMandpatellar instabil-itytest)andthroughapplicationoftheLysholmquestionnaire, asvalidated forthe Portuguese language14 _{(Table 1). Their} intensityofpainwasinvestigatedbymeansofavisualanalog scaleandwasgradedasmild(scoresfrom0to3),moderate(3 to7)orsevere(7to10).15_{ROMwasinvestigatedusingamanual} goniometerandinstability,bymeansoftheapprehensiontest. Assessmentsmadebypatientswhowereoffworkbecauseof thesurgicalprocedurewereusedascomplementarydatafor thisstudy.

Fig.1–Surgicalincisiononthesuperomedialfaceofthe patella,ofapproximately50mm.

Thedatagatheredweresubsequentlyplaceinan inven-toryinanelectronicdatabase,throughvalidationbymeansof doubledataentry(typing).Toanalyzetheresults,descriptive statisticalprocedureswereused.

This study was approved by the Ethics Committee for HumanResearchofUFTM(protocol2567/13).

Surgical

technique

The patientswere positioned on a standardsurgical table, in dorsal decubitus, and underwent spinal anesthesia. A pneumatictourniquetwasusedroutinelyinthissurgical pro-cedure. Firstly,aninventory ofthe jointwas performedby meansofarthroscopy,inordertodiagnoseandtreatany pos-siblecartilagelesions.

Asurgicalincisionwasmadeatthelevelofthemedialedge ofthepatella,50mmproximallytoitsupperedge,andthiswas continueddistallyuntilreachingthepatellarlevel. Layer-by-layerdissectionwasperformeddowntotheperitendon,which wasincisedvertically(Fig.1).

The segment corresponding to the medial third of the quadricepstendon,withawidthofapproximately10mmand lengthof50mm,wassectionedwithpreservationofthe dis-talportioninsertedinthepatella(Fig.2).Thetendonsegment

190

Fig.3–Incisiononthemedialfaceoftheknee,of approximately20mm(arrow).

waspreparedwithsuturingusingabsorbablethread(Vycril® 1.0mm)inanchoredrunningstitchesatitsfreeend.

After graft preparation, the second stage of the proce-durebegan.Averticalincision wasmadeintheskinofthe medialfaceoftheknee,betweenthemedialepicondyleand the tubercle of the adductor, of around 20mm in length (Fig.3).

Sincetheintentionwasthatthegraftshouldpassalong thenormalanatomicalpath,fromits origintothepointof fixationinthedistalfemur(Nomura’spoint),16_throughthe secondlayerofWarrenandMarshall,17_{anincisionwasmade} inthemedialretinaculumandthislayerwasexploredasfar asthesuperomedialedgeofthepatella(Fig.4).

Thegraftwaspassedintoplacemediallyandthenneeded tobefixedtothefemur,atthepointcorrespondingtoits orig-inalinsertion(Nomura’spoint).Thiswaslocatedwiththeaid ofanimageintensifyingdevice(Fig.5).

Ananchorwasinsertedatthislocation(Fig.6)andthegraft wasfixedwhilethekneewasflexedat30◦_{,withthepatella}

centeredatthetrochlea.Afterdefinitivefixation,thejointROM andpatellarstabilityoverthekneeflexionrangeof0–30◦_were

tested.

Fig.4–Transferofthegrafttoitsfixationpointonthe distalfemur,underthevastusmedialismuscle.

Fig.5–*Nomura’spoint:fixationofthemedial

patellofemoralligamentinthedistalfemur(ME=medial epicondyle,AM=insertionoftheadductormagnus).

Results

Twenty-twopatientswithaconditionofcurrentdislocationof thepatellaparticipatedinthisstudy.Theywereagedbetween 15and48yearsand73%wereundertheageof21years.Female patients predominated (86%)and the left legwas affected morefrequently (59%).Theworst scoresfrom the Lysholm questionnairewereamongtheolderparticipants(Table2).The meanlengthofpostoperativefollow-upwas30months,with arangefrom12to52months.Therewerenocomplications relatingtothesurgicalwound.

Basedonthequestionnaireused,59%ofthepatients pre-sentedgoodorexcellentresults,27.2%fairresultsand13.8%

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Patient Sex Age Side Employment-law

issues

Limping Weight-bearing Locking Instability Pain Swelling Goingup stairs

Squatting TOTAL SCORE

1 F 16 L N 5 5 10 25 20 10 10 4 89

2 F 18 R N 3 5 15 25 20 10 10 4 92

3 F 15 R N 5 5 10 20 20 6 6 2 74

4 F 21 R N 3 5 15 20 20 6 10 4 83

5 M 21 L N 5 5 15 25 20 10 10 5 95

6 F 20 L N 5 5 20 20 25 6 4 5 80

7 F 21 L N 5 5 15 20 25 10 10 5 95

8 F 18 R N 5 5 10 25 20 10 3 4 82

9 F 19 L N 5 5 10 20 20 10 10 4 84

10 F 39 L Y 5 5 10 15 10 3 6 2 56

11 F 19 R N 5 5 15 25 25 10 10 4 99

12 F 40 L Y 5 5 6 25 10 0 3 2 56

13 M 19 L N 5 5 10 25 20 10 10 5 90

14 F 28 R N 5 5 15 25 25 10 10 5 100

15 F 18 L N 5 5 15 25 25 10 10 2 97

16 F 26 R N 3 5 15 25 20 10 10 5 93

17 F 18 R N 5 5 10 25 20 10 3 2 80

18 F 28 L N 3 5 15 20 20 6 10 4 83

19 F 48 L Y 5 5 10 15 10 3 6 4 58

20 F 20 R N 5 5 15 25 25 10 10 2 97

21 M 19 L N 5 5 15 20 20 10 10 4 89

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Table3–Resultsfrompatient’sscoresintheLysholm questionnaire.

Lysholmscore Numberof

patients

%ofthe patients

Excellent 06 27.2

Good 07 31.8

Regular 06 27.2

Poor 03 13.8

poorresults(Table3).Alltheparticipantswhoclassifiedtheir resultsaspoorreportedthattheyexperiencedseverepainin thepatellofemoraljointonmakingmajoreffort.However,they hademployment-lawissuesduringtheperiodevaluated.The finalmeanscoreforthequestionnairewas84.6,whichwas gradedasagoodresult.

Intheclinicalevaluationoneyearaftertheoperation,none ofthepatientssaidthattheyhadanymoderateorseverepain uponmakingmediumeffortinvolvingthepatellofemoraljoint orthelocationofinsertionoftheanchorinthedistalfemur,as shownbythevisualanalogscale.Therewasnodeficitofjoint ROMandallthepatientshadnegativeresultsfromthe appre-hensiontest.In16casesinwhichanevaluationatleast30 monthsaftertheoperationwaspossible,theclinicalresults, theclinicalresultsremainedsimilar.

Discussion

Independentofthe etiology ofrecurrent dislocationofthe patella, this isapathological condition that mostlyaffects youngadultsandwomen,1 _{asalsoobservedinthepresent} study.Bothinpost-traumaticandinnon-traumaticcasesin whichconservativetreatmentischosen,instabilitygenerally becomesrecurrentandinmostcases,anatomicalalterations associatedwithtearingoftheMPFLareseen.Aprevious ran-domizedprospectivestudyinwhichpatientswithtraumatic dislocation ofthe patella were evaluated showed that the resultswerebetteraftersurgicaltreatmentthanafter conser-vativetreatment.18

Theparticipantsinthepresentstudydidnotpresentany anatomicalalterations withindicationsforcomplementary orthopedicproceduresthathavebeendevelopedfortreating recurrentdislocationofthepatella.19_{Mostofthesetechniques} havetheaimofrealigningtheextensormechanismand reduc-ingthe lateralizationofthepatella whenthequadricepsis putintoaction.Distalrealignmentprocedures(forcaseswith TT-TGdistancesgreaterthan20mmorcasesofhighpatella) consistofmedializationand/ordistalizationoftheanterior tibialtuberosity.Proximalrealignmentproceduresdependon quadricepscontraction tokeepthe patella inthetrochlear groove. Both of these have shown limited clinical results. However,intactpassivestabilizerssuchastheMPFLhavean importantroleindependentofthemisalignment,withresults thatare more effectivethan those from proximalor distal realignmentprocedures.20

TheMPFLcontributesapproximately50–70%ofthe restric-tiononlateraltranslationofthepatella.Thus,itisthemost importantstabilizerofthe patellaand itsreconstruction is theprimaryprocedureincasesofrecurrentluxation.20_Several surgicaltechniqueshavebeendescribed,withdifferenttypes

ofgrafts(artificialligament,patellartendon,quadriceps ten-donorflexortendons)andfixationmethods(bonetunnelin thepatellaandscrewinthefemur;suturinginthepatellaand Endobuttoninthefemur;andanchorinthepatellaandscrew inthefemur,amongothers).21_{Recentsystematicreviewshave} shownthatreconstructionoftheMPFLisaneffective proce-durewithalowrateofrecurrenceofpatellarinstabilityand good functional and subjectiveresults, independent ofthe surgicaltechnique.22

Themethodusingthequadricepstendonasthegraftis commonamongsurgicalproceduresontheknee.Itpresents theadvantagesthatthegraftiseasilyobtainedgraft,nobone tunnelsareneededand,becausethepatellarboneinsertionis maintained,thereismoreeconomicaluseofsurgicalfixation materials.However,italsopresentsvariationsregardingthe thicknessofthegraft(partial ortotal),thetendonsegment usedandthepathfollowedbetweenthesuperomedialsurface ofthepatellaandthemedialfemoralcondyle(subcutaneous orbelowthevastusmedialismuscle).11,23

Thetechniquedescribedhere,inwhichagraftfromthefull thicknessofthemiddlethirdofthequadricepstendonwas used, presentedsatisfactoryefficacy,witharesultthatwas classified asgood accordingtothescorefrom the Lysholm questionnaire. Asdescribed here, it enables the surgeryto belessaggressiveand,becauseoftheanatomicalpathused andbecauseonlyoneextremityiskeptfree,adequate func-tionality for performing routine activities is ensured. This questionnairewaschosenbecauseofitsreliabilityforknee lig-amentinjuriesandbecauseitcontainstheitem“instability”, whichisimportantforevaluatingtheresultsfromasurgical techniqueforligamentreconstruction.

Inrelationtotheclinicalresultsoneyearafterthe oper-ation, no diminution of joint range of motion or positive apprehensiontestswasobserved.Noneofthepatientssaid that they had any moderate or severe pain in the region ofthepatellofemoraljointatrestoruponmakingmedium effort. Among the patients who continued to be followed up,thegoodresultsweremaintained.In13.8%ofthecases, thepatientsreportedexperiencinggreaterpainduringmore intensiveeffort(suchaswalkingformorethan2km). How-ever,theseparticipants,whoweretheoldestparticipantsin thestudy,hademployment-lawissuesandthereforeprobably wishedtoobtainsomeformofsecondaryadvantagethrough thedisease.

The homogenous population obtained for this study, without the presenceofsevere femoropatellar dysplasiaor associatedlesions,makestheresultsmorereliable.Thereisa needforlongfollow-upofthesepatients,sincesome compli-cationsmayonlyhaveemergedaftertheperiodstudied.Pain consequenttojointdegenerationcanbehighlightedamong these,causedbyincreasedmedialretropatellarforce.Given thelowmorbidityandtheresultsthatwereobservedoverthe shortterm,thistechniquecanbequalifiedasagoodoption forMPFLreconstructionsurgery.

Conclusion

reproducibletechnique,withlowmorbidity,whichpresents goodshort-termresultsfortreatingrecurrentdislocationof thepatella.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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