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Tharnmanularp S, Nimura A, Tsutsumi M, Norose M, Tsukada S, Akita K. Medial patellofemoral ligament is a part of the vastus medialis obliquus and vastus intermedius aponeuroses attaching to the medial epicondyle. Knee Surg Sports Traumatol Arthrosc 2022; 30:3742-3750. [PMID: 35523877 PMCID: PMC9568457 DOI: 10.1007/s00167-022-06984-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/11/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE This study aimed to investigate the bony surface characteristic of the femoral attachment of the medial patellofemoral ligament (MPFL) and the correlation between the relevant layered structures, including muscular aponeurosis and the joint capsule, which contribute to patellofemoral joint (PFJ) stability. METHODS The morphology of the medial aspect of the medial condyle using micro-computed tomography and analysed cortical bone thickening in 24 knees was observed. For the macroscopic and histological analyses, 21 and 3 knees were allocated, respectively. The Kruskal-Wallis one-way analysis of variance test with Dunn post hoc testing was performed for statistical analysis. RESULTS At the level of the adductor tubercle, there were no significant differences in cortical bone thickness. At the level of the medial epicondyle (MEC), cortical bone thickness was considerably greater than that in other areas of the medial condyle (mean ± standard deviation, 0.60 ± 0.20 mm; p < 0.0001). Macroscopic analysis revealed that the deep aponeurosis of the vastus medialis obliquus and the tendinous arch of the vastus intermedius distally formed the composite membrane and adjoined to the joint capsule to firmly attach to MEC, which was located at 41.3 ± 5.7 mm posterior and 14.2 ± 3.1 mm superior to the joint cartilage. Histological analysis showed a composite membrane and adjoining capsule attached to MEC via fibrocartilage. CONCLUSION MPFL could be interpreted as part of the deep aponeurosis of the vastus medialis obliquus (VMO) and the tendinous arch of the vastus intermedius, which combined with the joint capsule to attach to MEC. The cortical bone thickening indicated that the tensile stresses were loaded on MEC in aged cadavers. Involvement of VMO and vastus intermedius aponeuroses in restored graft of MPFL could utilise the dynamic stability of surrounding muscles to mimic a native structure.
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Affiliation(s)
- Suthasinee Tharnmanularp
- grid.265073.50000 0001 1014 9130Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Masahiro Tsutsumi
- grid.265073.50000 0001 1014 9130Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan ,grid.440914.c0000 0004 0649 1453Inclusive Medical Science Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan
| | - Mio Norose
- grid.265073.50000 0001 1014 9130Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sachiyuki Tsukada
- grid.265073.50000 0001 1014 9130Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiichi Akita
- grid.265073.50000 0001 1014 9130Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Akça MÇ, Akalın Y, Çevik N, Şahin İG, Avcı Ö, Öztürk A. Joint line reestablishment in revision total knee arthroplasty. Arthroplasty 2020; 2:27. [PMID: 35236461 PMCID: PMC8796396 DOI: 10.1186/s42836-020-00046-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background In this study, the traditional “Anatomical Landmark-Distance Method (AL-DM)” in the formation of joint line (JL) was compared with “Adductor Tubercle-Ratios method” (AT-RM), and the effect of reestablishment of JL on clinical and functional outcomes were evaluated. Materials and methods 16 revision total knee arthroplasties (rTKAs) were performed by using “AT-RM” (group 1) and 16 rTKA by using “AL-DM” (group 2) in our clinic between 2015 and 2018. The data were prospectively collected and a total of 32 knees of 31 patients were analyzed. At the final follow-up, knee functions were evaluated by using Knee Society Score (KSS) knee and function, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, Short Form-36 (SF-36) questionnaires and physical examinations. Results Postoperative flexion arc was higher in Group 1. KSS knee and function scores were better in group 1. In group1, JL was reestablished successfully in all revision rTKAs in terms of ATJL and the tibial tubercle TT-JL ratios. The improvement in KSS knee and function scores and WOMAC scores were also better in group 1. Measurements showed that the improvement in KSS scores increased as AT-JL and TT-JL distances approached the calculated values. Conclusion “AT-RM” was shown to be superior to the traditional distance method in terms of JL reestablishment. Functional results and patient satisfaction increased when JL was reestablished.
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Affiliation(s)
- Mustafa Çınar Akça
- Research and Training Hospital Clinic of Orthopaedics and Traumatology, Health Sciences University Bursa YuksekIhtisas, 16310, Yildirim, Bursa, Turkey
| | - Yavuz Akalın
- Research and Training Hospital Clinic of Orthopaedics and Traumatology, Health Sciences University Bursa YuksekIhtisas, 16310, Yildirim, Bursa, Turkey
| | - Nazan Çevik
- Research and Training Hospital Clinic of Orthopaedics and Traumatology, Health Sciences University Bursa YuksekIhtisas, 16310, Yildirim, Bursa, Turkey
| | - İsmail Gökhan Şahin
- Clinic of Orthopaedics and Traumatology, Turkish Ministry of Health, Edirne Sultan 1 Murat State Hospital, Edirne, Turkey
| | - Özgür Avcı
- Research and Training Hospital Clinic of Orthopaedics and Traumatology, Health Sciences University Bursa YuksekIhtisas, 16310, Yildirim, Bursa, Turkey
| | - Alpaslan Öztürk
- Research and Training Hospital Clinic of Orthopaedics and Traumatology, Health Sciences University Bursa YuksekIhtisas, 16310, Yildirim, Bursa, Turkey.
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Yeh KT, Chen IH, Wang CC, Wu WT, Liu KL, Peng CH. The adductor tubercle can be a radiographic landmark for joint line position determination: an anatomic-radiographic correlation study. J Orthop Surg Res 2019; 14:189. [PMID: 31238953 PMCID: PMC6592006 DOI: 10.1186/s13018-019-1221-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 06/04/2019] [Indexed: 01/09/2023] Open
Abstract
Background The adductor tubercle (AT) has been used intraoperatively as a landmark to evaluate the joint line position in knee arthroplasty. The purpose of this study was to determine whether the AT could be clearly identified on radiographic imaging as well as if the AT to joint line distance could be accurately measured for use as a radiographic landmark. Methods The distance from the AT to the joint line was measured on each of 78 knees during total knee arthroplasty. Next, the AT was marked with a metal marker for radiographic analysis. On the postoperative radiograph, the location of the AT was determined by tracing the metal marker. Subsequently, the radiographic joint line distance (RJLD) was measured and compared with the intraoperative joint line distance (IJLD) to test the agreement of the measurements. Results Location analysis indicated that the inflection point on the radiographic contour of the distal femur was the predicted location for the AT. The mean IJLD was 45 ± 3 mm and the RJLD was 45 ± 4 mm. The intraclass correlation coefficient was used to evaluate the inter-rater reliability between the two methods; that coefficient was 0.751, indicating good agreement between them. Measurements on the radiograph were comparable to the intraoperative measurements of the operated knees. Conclusions In addition to being an intraoperative landmark, the AT may also be an eligible radiographic landmark for analyzing joint line level. The RJLD measurement may be obtained to plan the joint line position in knees with significant bone loss preoperatively and to follow up the results of surgery postoperatively.
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Affiliation(s)
- Kuang-Ting Yeh
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Zhongyang Rd., Sec. 3, Hualien, 97002, Taiwan.,School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
| | - Ing-Ho Chen
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Zhongyang Rd., Sec. 3, Hualien, 97002, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan.
| | - Chen-Chie Wang
- School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan.,Department of Orthopedics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, 23142, Taiwan
| | - Wen-Tien Wu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Zhongyang Rd., Sec. 3, Hualien, 97002, Taiwan.,School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
| | - Kuan-Lin Liu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Zhongyang Rd., Sec. 3, Hualien, 97002, Taiwan.,School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
| | - Cheng-Huan Peng
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Zhongyang Rd., Sec. 3, Hualien, 97002, Taiwan.,School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
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Krebs C, Tranovich M, Andrews K, Ebraheim N. The medial patellofemoral ligament: Review of the literature. J Orthop 2018; 15:596-9. [PMID: 29881201 DOI: 10.1016/j.jor.2018.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/06/2018] [Indexed: 11/20/2022] Open
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Chen IH, Wu WT, Wang CC, Liu KL, Yeh KT, Peng CH. An unambiguous technique for locating the adductor tubercle and using it to identify the joint line. Knee 2016; 23:960-963. [PMID: 27802923 DOI: 10.1016/j.knee.2016.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/13/2016] [Accepted: 05/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND If the adductor tubercle could be accurately located, it would be a useful landmark for identifying the joint line during knee arthroplasty. This study aimed to develop an intraoperative technique to improve its locating accuracy. METHODS Evaluation of bone specimens and cadaveric knees revealed that the proximal slope of the adductor tubercle (PSAT) turns from the medial surface vertically into the superior surface of the medial condyle, which forms a distinctive edge. This provided an ideal landmark that could be unambiguously engaged using a tipped instrument. Using the PSAT as a reference point, we measured the distance to the joint line (the proximal-distal condylar length; PDCL) in eight pairs of cadaveric knees, and evaluated the inter-observer variability. Next, we measured 120 knees undergoing total knee arthroplasty to test this technique in a normal population. Finally, we divided each PDCL by the respective anterior-posterior condylar length (APCL) to create a ratio that could predict the PDCL regardless of knee size. RESULTS The intra-class correlation coefficient (ICC) was 0.86 for the cadaveric measurements. The mean PDCL from the operated knees was 46mm (coefficient of variance (CV): eight percent). The mean PDCL/APCL ratio was 0.77 (CV: six percent). The high ICC and low CV indicated that using the PSAT was a reliable technique. CONCLUSION The PSAT is an ideal surgical landmark. The tipped instrument engagement technique with it may help to unambiguously locate the adductor tubercle in order to identify the joint line during knee arthroplasty.
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Affiliation(s)
- Ing-Ho Chen
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan.
| | - Wen-Tien Wu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chen-Chie Wang
- School of Medicine, Tzu Chi University, Hualien, Taiwan; Department of Orthopedics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Kuan-Lin Liu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuang-Ting Yeh
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Cheng-Huan Peng
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
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Iacono F, Raspugli GF, Filardo G, Bruni D, Zaffagnini S, Bignozzi S, Lo Presti M, Akkawi I, Neri MP, Marcacci M. The adductor tubercle: an important landmark to determine the joint line level in revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24:3212-3217. [PMID: 25761630 DOI: 10.1007/s00167-015-3556-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 02/24/2015] [Indexed: 01/16/2023]
Abstract
PURPOSE The restoration of the physiological femoro-tibial joint line (JL) is important to obtain a good outcome in revision total knee arthroplasty (RTKA). However, its assessment is challenging. The ratio of the distance between the adductor tubercle (AT) JL (ATJL) and the trans-epicondylar femoral width (FW) was proposed as a reliable method. The purpose of this study was to check whether this ratio is a reliable tool to restore the prosthetic JL height in challenging prosthetic revision cases. METHODS Twenty-one patients (mean age 65.8 years) were recruited. During surgery, FW was measured and ATJL distance was calculated using 0.53 (SD 0.03) as the ratio. After implant positioning, the obtained ATJL line was measured to verify the accuracy of the surgical procedure. Thirteen patients presented a healthy contralateral knee: a comparative radiograph examination was performed to verify the appropriateness of the restored JL height. RESULTS The intra-operatively calculated ATJL was not significantly different with respect to the measured ATJL obtained after prosthetic component implantation. The comparative analysis between the restored JL and the JL of the contralateral not operated knee was also not statistically significant, thus confirming the appropriateness of the restored JL height. CONCLUSIONS This study shows that the method which uses an AT to JL distance/FW ratio to determine the JL level, previously applied in primary TKA, is valid when using intra-operatively acquired measurements in RTKA. This is clinically relevant since it represents a reliable tool which helps surgeons to restore the JL level in challenging prosthetic revision cases. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Francesco Iacono
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy.
| | - Giovanni Francesco Raspugli
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Giuseppe Filardo
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Danilo Bruni
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Simone Bignozzi
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Mirco Lo Presti
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Ibrahim Akkawi
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Maria Pia Neri
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Maurilio Marcacci
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy.,Biomechanics and Technologic Innovation Laboratory and Nanobiotechnology Laboratory, Codivilla-Putti Research Center, Bologna University, Via di Barbiano 1/10, 40136, Bologna, Italy
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Sadaka C, Kabalan Z, Hoyek F, Abi Fares G, Lahoud JC. Joint line restoration during revision total knee arthroplasty: an accurate and reliable method. Springerplus 2015; 4:736. [PMID: 26640748 PMCID: PMC4661160 DOI: 10.1186/s40064-015-1543-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/18/2015] [Indexed: 11/10/2022]
Abstract
During revision total knee arthroplasty, the joint line is frequently malpositioned, due to the disappearance of the anatomical landmarks following previous interventions. This leads to decreased clinical outcome and increased risk of re-intervention. Many methods have been proposed to restore the joint line, but none of them has shown itself to be reliable. We describe an accurate and precise method to localize the exact position of the joint line which guarantees a better clinical knee score. The adductor tubercle (AT) is recognized to be the most reliable landmark used to localize the knee joint line (JL). The distance from the AT to the JL on antero-posterior radiographs (ATJL) and the femoral diameter (FD) on true lateral views were measured on 200 randomly selected normal knees. These measurements were tested for intra- and inter-observer differences. Then, the relationship between these two measurements was studied. A significant correlation and linear regression between FD and ATJL was found (p < 0.001), making the adductor tubercle a valid landmark to accurately position the prosthetic joint within 4 mm from the normal position. No significant difference was noted in the intra and inter-observer measurements (F test not significant). Sex was found to be an intervening variable (p ˂ 0.001). The correlation and regression between ATJL and FD had to be adjusted accordingly. Once the ATJL was determined preoperatively, the JL level is found during surgery by using a caliper that is held on the easily palpable AT. Knowing the femoral diameter, we can easily locate the joint line level surgically, using the adductor tubercle as a landmark. This method leads to better clinical outcomes and a reduced risk of re-intervention following revision total knee arthroplasty.
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Affiliation(s)
| | - Ziad Kabalan
- Holy Spirit University of Kaslik, Jounieh, Lebanon
| | - Fadi Hoyek
- Holy Spirit University of Kaslik, Jounieh, Lebanon
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