Open Access, Peer-reviewed
pISSN 1226-2102
eISSN 2005-8918
    J Korean Orthop Assoc. 2011 Dec;46(6):443-450. Korean.
    Published online Dec 29, 2011.
    https://doi.org/10.4055/jkoa.2011.46.6.443
    Copyright © 2011 by The Korean Orthopaedic Association
    Review

    Anatomical Reconstruction of the Medial Patellofemoral Ligament: Development of a Novel Procedure Based on Anatomical Dissection

    Hee Sung Lee, M.D., Jung Yun Choi, M.D.,* Jeong Ku Ha, M.D.,† Yong Seuk Lee, M.D.,‡ Jae Ho Yoo, M.D.,§ Min Kyu Kim, M.D.,* and Jin Goo Kim, M.D., Ph.D.†
      • Department of Orthopedic Surgery, Hanmi Hospital, Daegu, Korea.
      • *Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea.
      • †Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea.
      • ‡Department of Orthopedic Surgery, Gachon University Gil Hospital, Incheon, Korea.
      • §Department of Orthopedic Surgery, Seoul Sky Hospital, Seoul, Korea.
    • Correspondence to: Jin Goo Kim, M.D., Ph.D. Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University College of Medicine, 85, Jur-dong 2ga, Chung-gu, Seoul 100-032, Korea. TEL: +82-2-2270-0025, FAX: +82-2-2270-0048, Email: boram107@hanmail.net
    Received November 23, 2010; Accepted August 11, 2011.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    This paper reports a novel method for reconstructing the medial patellofemoral ligament (MPFL) using hamstring tendon autografts, based on the results of an anatomical study by cadaveric dissection. Five fresh frozen cadaveric knees were studied. MPFL was found present in all cases, and the average length was 54 mm (49.6-59.3 mm). The shape of the MPFL was triangular wherein the femoral attachment was narrow and the patellar attachment was relatively broad. The MPFL was less stiff and a weaker structure compared to the other ligaments. This study could refl ect a novel surgical technique for the MPFL reconstruction with its anatomical and biomechanical properties. The study population comprises of 9 patients (5 males and 4 females) who underwent primary MPFL reconstruction at our clinic between April 2008 and February 2010. The mean follow-up period was 17.6 months. The Kujala score improved signifi cantly from 51.1 points to 81.4 points (p<0.001), the Lysholm score improved signifi cantly from 47.8 points to 84.9 points (p<0.001) and the Tegner activity level improved signifi cantly from 2.9 to 5.1 (p<0.001). There was no case of recurrent dislocation and complications according to the short term follow-up results. Our novel soft tissue fixation method using double bundle reconstruction with hamstring tendon autografts would not only be an anatomic reconstruction but also would be effective for reconstruction of the MPFL.

    Keywords
    medial patellofemoral ligament; anatomy; patellar dislocation; reconstruction

    Figures

    Figure 1
    This photograph of the isolated medial patellofemoral ligament shows the femoral and patellar attachment sites of the MPFL and the anatomical relationship of medial knee structures. MPFL, medial patellofemoral ligament; sMCL, superficial medial collateral ligament; VMO, vastus medialis obliquus.

    Figure 2
    Schematic drawings show measurement parameters in the anatomical dissection study. A, length of patella; B, width of patella; C, distance from the superior pole of patella to the upper border of medial patellofemoral ligament; D, length of patellar insertion of medial patellofemoral ligament; E, distance from lower border of medial patellofemoral ligament to inferior pole of patella; F, length of femoral insertion of medial patellofemoral ligament; G, length of superior border of medial patellofemoral ligament; H, length of inferior border of medial patellofemoral ligament; Ip, thickness of medial patellofemoral ligament at patellar side; If, thickness of medial patellofemoral ligament at femoral side; J, length of patellar insertion of vastus medialis obliquus at medial patellofemoral ligament.

    Figure 3
    Our novel procedure of the medial patelofemoral ligament reconstruction. (A) Hamstring autograft is passed under the proximal insertion of superficial medial collateral ligament and suspended. (B) Autograft is passed through the tunnels of patella and tightened. (C) Both ends of autograft were stitched up securely to the soft tissue over the patella.

    Figure 4
    Schematic drawing shows our anatomical reconstruction of medial patellofemoral ligament.

    Figure 5
    A 44-year-old male slipped down and the patella was dislocated 1 month ago. (A) Pre-operative Merchant view: patella tilted laterally. (B) Pre-operative MR image: medial patella-femoral ligament is detached from its femoral insertion (white arrows). (C) Post-operative 8 months Merchant view: patella is reduced in the trochlear groove.

    Tables

    Table 1
    Result of Anatomical Dissection

    Table 2
    Demographic Data of Patients

    References

      1. Dandy DJ, Griffiths D. Lateral release for recurrent dislocation of the patella. J Bone Joint Surg Br 1989;71:121–125.
      1. Garth WP Jr, DiChristina DG, Holt G. Delayed proximal repair and distal realignment after patellar dislocation. Clin Orthop Relat Res 2000;(377):132–144.
      1. Myers P, Williams A, Dodds R, Bülow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Results, and its place in the management of patellofemoral instability. Am J Sports Med 1999;27:575–579.
      1. Post WR, Fulkerson JP. Distal realignment of the patellofemoral joint. Indications, effects, results, and recommendations. Orthop Clin North Am 1992;23:631–643.
      1. Scuderi G, Cuomo F, Scott WN. Lateral release and proximal realignment for patellar subluxation and dislocation. A long-term follow-up. J Bone Joint Surg Am 1988;70:856–861.
      1. Small NC, Glogau AI, Berezin MA. Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy 1993;9:63–67.
      1. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59–65.
      1. Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM. Medial soft tissue restraints in lateral patellar instability and repair. Clin Orthop Relat Res 1998;(349):174–182.
      1. Panagiotopoulos E, Strzelczyk P, Herrmann M, Scuderi G. Cadaveric study on static medial patellar stabilizers: the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2006;14:7–12.
      1. Tuxøe JI, Teir M, Winge S, Nielsen PL. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc 2002;10:138–140.
      1. Muneta T, Sekiya I, Tsuchiya M, Shinomiya K. A technique for reconstruction of the medial patellofemoral ligament. Clin Orthop Relat Res 1999;(359):151–155.
      1. Nomura E, Inoue M. Surgical technique and rationale for medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Arthroscopy 2003;19:E47.
      1. Noyes FR, Albright JC. Reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon. Arthroscopy 2006;22:904.e1–904.e7.
      1. Schöttle P, Schmeling A, Romero J, Weiler A. Anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft. Arch Orthop Trauma Surg 2009;129:305–309.
      1. Steensen RN, Dopirak RM, Maurus PB. A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy 2005;21:365–370.
      1. Sillanpää P, Mattila VM, Visuri T, Mäenpää H, Pihlajamäki H. Ligament reconstruction versus distal realignment for patellar dislocation. Clin Orthop Relat Res 2008;466:1475–1484.
      1. Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP. Anatomy and biomechanics of the medial patellofemoral ligament. Knee 2003;10:215–220.
      1. Feller JA, Feagin JA Jr, Garrett WE Jr. The medial patellofemoral ligament revisited: an anatomical study. Knee Surg Sports Traumatol Arthrosc 1993;1:184–186.
      1. Smirk C, Morris H. The anatomy and reconstruction of the medial patellofemoral ligament. Knee 2003;10:221–227.
      1. Arendt EA, Fithian DC, Cohen E. Current concepts of lateral patella dislocation. Clin Sports Med 2002;21:499–519.
      1. Elias JJ, Cosgarea AJ. Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. Am J Sports Med 2006;34:1478–1485.
      1. Ahmad CS, Brown GD, Stein BS. The docking technique for medial patellofemoral ligament reconstruction: surgical technique and clinical outcome. Am J Sports Med 2009;37:2021–2027.
      1. Sillanpää PJ, Mäenpää HM, Mattila VM, Visuri T, Pihlajamäki H. A mini-invasive adductor magnus tendon transfer technique for medial patellofemoral ligament reconstruction: a technical note. Knee Surg Sports Traumatol Arthrosc 2009;17:508–512.
      1. Schöttle PB, Hensler D, Imhoff AB. Anatomical double-bundle MPFL reconstruction with an aperture fi xation. Knee Surg Sports Traumatol Arthrosc 2010;18:147–151.
      1. Zhang L, Li Z, Liu J, Sun J, Ma J. Anatomical double bundle reconstruction of medial patellofemoral ligament with allograft tendon in patellar dislocations. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2010;24:100–103.
      1. LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am 2007;89:2000–2010.
      1. Bicos J, Fulkerson JP, Amis A. Current concepts review: the medial patellofemoral ligament. Am J Sports Med 2007;35:484–492.
      1. Zavras TD, Race A, Bull AM, Amis AA. A comparative study of 'isometric' points for anterior cruciate ligament graft attachment. Knee Surg Sports Traumatol Arthrosc 2001;9:28–33.
      1. Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin TM, Woo SL. Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med 2000;28:144–151.
      1. Race A, Amis AA. PCL reconstruction. In vitro biomechanical comparison of 'isometric' versus single and double-bundled 'anatomic' grafts. J Bone Joint Surg Br 1998;80:173–179.
      1. Parker DA, Alexander JW, Conditt MA, Uzodinma ON, Bryan WJ. Comparison of isometric and anatomic reconstruction of the medial patellofemoral ligament: a cadaveric study. Orthopedics 2008;31:339–343.
      1. Wang F, Chen BC, Kang HJ, Wang J, Liu H, Dong JT. Comparison of clinical results between an isometric and an anatomic technique for medial patellofemoral ligament reconstruction. Zhonghua Wai Ke Za Zhi 2010;48:891–895.
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    MeSH Terms
    Cadaver
    Dislocations
    Follow-Up Studies
    Humans
    Knee
    Ligaments
    Male
    Patellar Dislocation
    Tendons
    Tissue Fixation
    Metrics
    Share
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