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Neri T, Parker DA, Putnis S, Klasan A, Trombert-Paviot B, Farizon F, Philippot R. Clinical and Radiological Predictors of Functional Outcome After Isolated Medial Patellofemoral Ligament Reconstruction at Midterm Follow-up. Am J Sports Med 2019; 47:1338-1345. [PMID: 30943374 DOI: 10.1177/0363546519831294] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Isolated medial patellofemoral ligament reconstruction (iMPFLR) is increasingly used for the surgical treatment of recurrent patellofemoral instability. PURPOSE The purpose of this study was to identify the clinical and radiological predictors that can significantly influence the functional outcomes after an iMPFLR. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 107 patients (112 ligament reconstructions) who underwent iMPFLR were evaluated with a mean ± SD follow-up of 59 ± 33 months (range, 12-123 months). Functional International Knee Documentation Committee (IKDC) and Kujala scores were assessed preoperatively and every 12 months. Radiological assessment of patellar height and tilt (Laurin angle, Merchant angle, Maldague classification) and computed tomography (CT) scan measurement of patellar tilt (contracted and relaxed quadriceps) and tibial tubercle-trochlear groove distance were performed preoperatively and at 6 months. Femoral tunnel position was assessed following the criteria formulated by Schöttle. The amount of femoral tunnel widening was measured by means of 3-dimensional CT scan at 6 months. Predictors were determined from univariate and multivariate regression analyses integrating clinical and radiological criteria pre- and postoperatively. The dependent variable was defined as the difference between pre- and postoperative scores. RESULTS Between pre- and postoperative measurement at last follow-up, a significant improvement for IKDC and Kujala functional scores was observed (Kujala: 57 ± 11.3 to 87 ± 12.9, P < .001; IKDC: 47.8 ± 13.1 to 79 ± 15.8, P < .001). Demographics (age, body mass index, sex), dislocation characteristics (number of dislocations, time between first dislocation and surgery, age at first dislocation, mechanism of first dislocation, knee side), clinical data (frontal limb alignment, hyperlaxity, recurvatum, pre- and postoperative range of motion), and complications (quadriceps atrophy, complex regional pain syndrome) did not influence functional scores. The predictors of lower improvement in functional scores included small correction of the patellar tilt reported on the CT scan measurement, malpositioning of the femoral tunnel, and a widening of this tunnel near the medial cortex. Malpositioning of the femoral tunnel was correlated with tunnel widening, and patients with anterior and proximal malpositioning experienced stiffness in flexion. CONCLUSION Overall, iMPFLR demonstrated good outcomes. Predictors influencing the functional results were identified. Less improvement in clinical outcome was reported for patients with a high preoperative patellar tilt and only a small correction in tilt and for those who had femoral tunnel malpositioning, which was correlated with tunnel widening.
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Affiliation(s)
- Thomas Neri
- Department of Orthopaedic Surgery, University Hospital of Saint Étienne, Saint Étienne, France
- EA 7424-Interuniversity Laboratory of Human Movement Science, University Lyon-University Jean Monnet, Saint Étienne, France
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | | | - Sven Putnis
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | - Antonio Klasan
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | | | - Frederic Farizon
- Department of Orthopaedic Surgery, University Hospital of Saint Étienne, Saint Étienne, France
- EA 7424-Interuniversity Laboratory of Human Movement Science, University Lyon-University Jean Monnet, Saint Étienne, France
| | - Remi Philippot
- Department of Orthopaedic Surgery, University Hospital of Saint Étienne, Saint Étienne, France
- EA 7424-Interuniversity Laboratory of Human Movement Science, University Lyon-University Jean Monnet, Saint Étienne, France
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Neri T, Parker DA, Beach A, Gensac C, Boyer B, Farizon F, Philippot R. Medial patellofemoral ligament reconstruction with or without tibial tubercle transfer is an effective treatment for patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 2019; 27:805-813. [PMID: 30167754 DOI: 10.1007/s00167-018-5102-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The hypotheses were that medial patellofemoral ligament reconstruction (MPFLr) would improve the long-term symptoms of patellofemoral Instability (PFI) and control patellar tilt, based on computed tomography (CT), and that the addition of a TT transfer, when it is necessary, would not deteriorate the outcome. The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of a large series of MPFLr, either isolated or associated with a TT transfer. METHODS From 133 MPFLr with a minimum of 4 years postoperatively, three groups were defined: isolated MPFLr, MPFLr with tibial tubercle (TT) medialisation or MPFLr with TT medialisation and distalisation. IKDC and Kujala scores were evaluated. Patellar tilt was evaluated on the patient's preoperative and the last available radiograph, and on CT scan measurements performed preoperatively and at 6-month postoperatively. RESULTS The mean follow-up was 6.3 ± 1.7 years [4.1-10.3] and four patients reported recurrent patellar dislocation. Between pre and postoperative at last follow-up a significant improvement in IKDC and Kujala functional scores was observed (P < 0.01), with no difference between the three groups. Regarding patellar tilt, there were significant decreases in Laurin and Merchant angles and an improvement of the Maldague stage (P < 0.01). The CT analysis of patellar tilt also demonstrates a significant improvement of the patella tilt (P < 0.01). The control of the patella tilt was correlated with a good functional result (P < 0.01). CONCLUSION The MPFLr, whether isolated or associated with a TT transfer, provides good long-term clinical and radiological outcomes with a low rate of recurrence. The addition of a TT transfer, when necessary, results in the same good outcomes. This article provides a guide for surgeons evaluating PFI to choose the most appropriate procedure. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Thomas Neri
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France. .,EA 7424, Inter-University Laboratory of Human Movement Science, University Lyon, University Jean Monnet Saint Etienne, Saint-Étienne, France. .,Sydney Orthopaedic Research Institute, Sydney, Australia.
| | | | - Aaron Beach
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | - Clara Gensac
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France
| | - Bertrand Boyer
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France
| | - Frederic Farizon
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France.,EA 7424, Inter-University Laboratory of Human Movement Science, University Lyon, University Jean Monnet Saint Etienne, Saint-Étienne, France
| | - Remi Philippot
- Department of Orthopaedic Surgery, Service de Chirurgie orthopédique, Centre Hospitalo Universitaire de Saint-Étienne, University Hospital of Saint Etienne, Hôpital Nord, 42055, Saint-Étienne Cedex 2, France.,EA 7424, Inter-University Laboratory of Human Movement Science, University Lyon, University Jean Monnet Saint Etienne, Saint-Étienne, France
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Lamotte A, Neri T, Kawaye A, Boyer B, Farizon F, Philippot R. Medial patellofemoral ligament reconstruction for patellar instability following total knee arthroplasty: A review of 6 cases. Orthop Traumatol Surg Res 2016; 102:607-10. [PMID: 27317639 DOI: 10.1016/j.otsr.2016.03.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 03/02/2016] [Accepted: 03/15/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patellar instability is a frequent cause of total knee arthroplasty (TKA) failure. In cases of post-arthroplasty patellar instability, the medial structures may be damaged. The objective of this study was to study the effectiveness of medial patellofemoral ligament (MPFL) reconstruction. We hypothesized that MPFL reconstruction will effectively realign the patella, making it a viable treatment option for managing post-arthroplasty patellar instability. MATERIAL AND METHODS In this retrospective study of six patients treated by four different surgeons, patients were included if they had a recurring or permanent patellar dislocation after undergoing TKA. Patients were excluded if the patellar instability was painful but did not result in dislocation. Each patient underwent MPFL reconstruction using the gracilis; additional procedures could be performed depending on the diagnosis. One patient required TKA revision because of an abnormally rotated femoral implant. The main outcome measure was the non-recurrence of the dislocation. The IKDC and Kujala functional scores, joint range of motion and patellar tilt on X-rays were analyzed preoperatively and at the last follow-up. RESULTS At a mean follow-up of 23 months (6-46), none of the patients experienced a recurrence of the patellar dislocation. Only one patient had no improvements in the functional outcome scores. The patellar tilt was reduced in all patients. CONCLUSION MPFL reconstruction-in isolation or with femoral component revision-is effective at treating post-arthroplasty patellar instability. It has its place in the treatment of patellar dislocation following TKA and its indications must be based on exact analysis of the reasons for the instability. LEVEL OF EVIDENCE IV - Retrospective cohort study.
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Affiliation(s)
- A Lamotte
- Service d'orthopédie et traumatologie, CHU de Saint-Étienne, 42000 Saint-Étienne, France.
| | - T Neri
- Service d'orthopédie et traumatologie, CHU de Saint-Étienne, 42000 Saint-Étienne, France; Laboratoire de physiologie de l'exercice, EA 4338, 42000 Saint-Étienne, France
| | - A Kawaye
- Service d'orthopédie et traumatologie, centre hospitalier du Forez, 42600 Montbrison, France
| | - B Boyer
- Service d'orthopédie et traumatologie, CHU de Saint-Étienne, 42000 Saint-Étienne, France
| | - F Farizon
- Service d'orthopédie et traumatologie, CHU de Saint-Étienne, 42000 Saint-Étienne, France; Laboratoire de physiologie de l'exercice, EA 4338, 42000 Saint-Étienne, France
| | - R Philippot
- Service d'orthopédie et traumatologie, CHU de Saint-Étienne, 42000 Saint-Étienne, France; Laboratoire de physiologie de l'exercice, EA 4338, 42000 Saint-Étienne, France
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Carnesecchi O, Neri T, Di Iorio A, Farizon F, Philippot R. Results of anatomic gracilis MPFL reconstruction with precise tensioning. Knee 2015; 22:580-4. [PMID: 26021832 DOI: 10.1016/j.knee.2015.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 11/25/2014] [Accepted: 01/14/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The medial patellofemoral ligament (MPFL) is the most commonly injured structure in patients with objective patellar instability. The objective of this study was to prospectively evaluate the clinical and radiographic results of MPFL reconstruction in 50 patients with chronic patellar instability. METHODS Fifty patients with chronic patellar instability, aged 15-39 years, were included. The MPFL was reconstructed using a free gracilis autograft tendon. Two anchors were used for patellar fixation, and femoral fixation was achieved with an interference screw placed into a tunnel between the adductor tubercle and medial epicondyle. The graft was tensioned to 10 N with the knee in 30° flexion. IKDC and Kujala scores were assessed pre- and post-operatively. Patellar tilt was measured from CT scans with the quadriceps relaxed and contracted, both pre- and post-operatively. RESULTS The follow-up period was 7 to 44 months (mean: 25 months, SD 10.3). The mean raw IKDC score increased from 51.5 preoperatively to 71.7 at last follow-up, the mean overall IKDC score increased from 38.5 to 61.7 and the Kujala score increased from 48.3 to 82.4. On CT scans, the mean patellar tilt went from 24° to 16.2° with the quadriceps relaxed and 27.7° to 18.1° in contraction. No recurrent dislocation was observed. CONCLUSION This technique of MPFL reconstruction provided significant improvements in IKDC and Kujala scores and significant reduction in patellar tilt. No recurrent dislocations were observed during the study period.
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Affiliation(s)
- Olivier Carnesecchi
- Laboratory of Exercise Physiology (LPE EA 4338), Lyon University, Saint-Etienne, France; Department of Orthopaedic Surgery, University Hospital Center of Saint-Etienne, France.
| | - T Neri
- Department of Orthopaedic Surgery, University Hospital Center of Saint-Etienne, France
| | - A Di Iorio
- Department of Orthopaedic Surgery, University Hospital Center of Saint-Etienne, France
| | - F Farizon
- Department of Orthopaedic Surgery, University Hospital Center of Saint-Etienne, France
| | - R Philippot
- Laboratory of Exercise Physiology (LPE EA 4338), Lyon University, Saint-Etienne, France; Department of Orthopaedic Surgery, University Hospital Center of Saint-Etienne, France
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Neri T, Philippot R, Carnesecchi O, Boyer B, Farizon F. Medial patellofemoral ligament reconstruction: clinical and radiographic results in a series of 90 cases. Orthop Traumatol Surg Res 2015; 101:65-9. [PMID: 25530480 DOI: 10.1016/j.otsr.2014.09.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 07/31/2014] [Accepted: 09/01/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Among the numerous techniques available, medial patellofemoral ligament (MPFL) reconstruction is increasingly used for the surgical treatment of objective patellar instability. The main objective of the present study was to assess efficacy in preventing recurrence of patellar dislocation and in correcting radiographic patellar tilt. The study hypothesis was that MPFL reconstruction, isolated or with associated bone surgery, by restoring "favorable" graft anisometry, provides a good trade-off between patellar stability and absence of postoperative stiffness. MATERIALS AND METHODS Eighty-seven patients (90 reconstructions) presenting with objective patellar instability were prospectively included. The standardized procedure comprised MPFL reconstruction using the gracilis tendon. Femoral fixation used an interference screw in a blind tunnel between the adductor magnus tubercle and the medial epicondyle; patellar fixation used 2 anchors. Complementary distal bone graft was associated in 21 patients due to a preoperative tibial tubercle-trochlear groove (TT-TG) distance exceeding 20mm or to patella alta. Functional IKDC and Kujala scores and radiographic measurement of patellar tilt and femoral tunnel position were assessed preoperatively and at end of follow-up. RESULTS Mean follow-up was 24.3months (range, 6-49months). Three patients showed recurrence of patellar dislocation. Mean Kujala score rose from 53.88 preoperatively to 86.24 postoperatively, and mean real IKDC score from 45.15 to 73.92 (P<0.001). Patellar tilt decreased significantly between pre- and postoperative X-ray (P<0.001). DISCUSSION MPFL gracilis reconstruction provides good clinical results and good radiologic correction of patellar tilt, making it a technique of choice in the treatment of objective patellar instability. LEVEL OF EVIDENCE Level IV. Retrospective case series study.
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Affiliation(s)
- T Neri
- Service d'orthopédie et traumatologie, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raimond, 42270 Saint-Priest en Jarez, France.
| | - R Philippot
- Service d'orthopédie et traumatologie, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raimond, 42270 Saint-Priest en Jarez, France; Laboratoire de physiologie de l'exercice, EA 4338, CHU de Saint-Etienne, 25, boulevard Pasteur, 42023 Saint-Étienne, France
| | - O Carnesecchi
- Service d'orthopédie et traumatologie, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raimond, 42270 Saint-Priest en Jarez, France
| | - B Boyer
- Service d'orthopédie et traumatologie, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raimond, 42270 Saint-Priest en Jarez, France
| | - F Farizon
- Service d'orthopédie et traumatologie, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raimond, 42270 Saint-Priest en Jarez, France
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Guilbert S, Chassaing V, Radier C, Hulet C, Rémy F, Chouteau J, Chotel F, Boisrenoult P, Sebilo A, Ferrua P, Ehkirch FP, Bertin D, Dejour D. Axial MRI index of patellar engagement: a new method to assess patellar instability. Orthop Traumatol Surg Res 2013; 99:S399-405. [PMID: 24268843 DOI: 10.1016/j.otsr.2013.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to define a new index to measure lateral patellar displacement (LPD) using nuclear magnetic resonance imaging (MRI), an axial index of engagement of the patella (AEI) obtained from two different axial MRI views then to validate its use in a prospective series of patients presenting an objective patellar instability (OPI). MATERIALS AND METHODS One hundred and thirty-five patients with OPI and no history of surgery of the patella were included in a prospective study organized by the French Society of Arthroscopy performed between June 2010 and August 2012. All patients underwent axial and sagittal MRI. The AEI was obtained by projecting predefined patellar and trochlear landmarks (cartilaginous landmarks) on 2 different axial MRI views (one trochlear and one patellar). The results were compared with a series of controls (n=45). RESULTS The preoperative AEI of the patella was 0.94 ± 0.09 for the control group and 0.84 ± 0.16 for OPI group (P=0.000016). The AEI could be obtained in 100% of the cases if it was measured on 2 MRI views while it could not be measured in 38.5% of the cases if the measurement was only obtained from one MRI view or whenever the widest part of the patella was not across from the femoral trochlea. The AEI did not significantly depend on dysplasia or the presence of a supratrochlear spur. The lowest AIE values were associated with trochlear dysplasia with a supratrochlear spur (P=0.0023) and a more prominent trochlea (P=0.0016). The AEI was correlated with patellar tilt (P<0.000001) and TT-TG on MRI (P<0.000001). DISCUSSION AEI is a new index to measure LPD. It can be obtained in all cases because it is obtained from two different MRI views. The normal value is close to 1. It can be used to measure patellar instability on the axial plane in patients with OPI, especially in the most severe cases.
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Affiliation(s)
- S Guilbert
- Pôle Santé Oréliance, Maison des consultations, 551, avenue Jacqueline-Auriol, 45770 Saran, Orléans, France.
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Simoni P, Jamali S, Albert A, Totterman S, Schreyer E, Tamez-Peña JG, Zobel BB, Miezentseva VA, Gillet P. Minimum joint space width (mJSW) of patellofemoral joint on standing "skyline" radiographs: test-retest reproducibility and comparison with quantitative magnetic resonance imaging (qMRI). Skeletal Radiol 2013; 42:1573-82. [PMID: 23974466 DOI: 10.1007/s00256-013-1701-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 07/15/2013] [Accepted: 07/22/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the intraobserver, interobserver, and test-retest reproducibility of minimum joint space width (mJSW) measurement of medial and lateral patellofemoral joints on standing "skyline" radiographs and to compare the mJSW of the patellofemoral joint to the mean cartilage thickness calculated by quantitative magnetic resonance imaging (qMRI). MATERIALS AND METHODS A couple of standing "skyline" radiographs of the patellofemoral joints and MRI of 55 knees of 28 volunteers (18 females, ten males, mean age, 48.5 ± 16.2 years) were obtained on the same day. The mJSW of the patellofemoral joint was manually measured and Kellgren and Lawrence grade (KLG) was independently assessed by two observers. The mJSW was compared to the mean cartilage thickness of patellofemoral joint calculated by qMRI. RESULTS mJSW of the medial and lateral patellofemoral joint showed an excellent intraobserver agreement (interclass correlation (ICC) = 0.94 and 0.96), interobserver agreement (ICC = 0.90 and 0.95) and test-retest agreement (ICC = 0.92 and 0.96). The mJSW measured on radiographs was correlated to mean cartilage thickness calculated by qMRI (r = 0.71, p < 0.0001 for the medial PFJ and r = 0.81, p < 0.0001 for the lateral PFJ). However, there was a lack of concordance between radiographs and qMRI for extreme values of joint width and KLG. Radiographs yielded higher joint space measures than qMRI in knees with a normal joint space, while qMRI yielded higher joint space measures than radiographs in knees with joint space narrowing and higher KLG. CONCLUSIONS Standing "skyline" radiographs are a reproducible tool for measuring the mJSW of the patellofemoral joint. The mJSW of the patellofemoral joint on radiographs are correlated with, but not concordant with, qMRI measurements.
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Affiliation(s)
- Paolo Simoni
- Diagnostic Imaging Departement, Domanine du Sart Tilman, CHU de Liège, Bât. 35, 4000, Liège, Belgium,
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