Widespread Implementation of Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Maintains Functional Outcomes at Midterm to Long-Term Follow-up While Decreasing Complication Rates: A Systematic Review

doi:10.1016/j.arthro.2014.12.029

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 31, Issue 7, July 2015, Pages 1372-1380

https://doi.org/10.1016/j.arthro.2014.12.029 Get rights and content

Purpose

Our primary purpose was to evaluate whether complications have increased or functional outcomes have changed as medial patellofemoral ligament (MPFL) reconstruction has been adopted by more surgeons at more institutions over recent years. Our secondary purpose was to further define the complication profile of MPFL reconstruction.

Methods

A systematic review of the literature was performed on January 12, 2014, using the keywords “medial patellofemoral ligament reconstruction,” “patellar instability reconstruction,” “patellofemoral ligament reconstruction,” and “MPFL.” Articles meeting our inclusion criteria were reviewed. Outcome measures, functional failures, complications, graft choice, and surgical technique were recorded and analyzed.

Results

Thirty-four articles met our exclusion and inclusion criteria and were reviewed. Nineteen articles were “new” additions to the literature, whereas 15 had previously been reported on in prior analyses (“old”). The 19 new articles reported a statistically significant decrease in functional failure rates, from 9.55% in older studies to 4.77% in more recent studies (P < .001). The major complication rate dropped from 2.01% to 0.46% in the newer studies (P = .005), and the minor complication rate decreased from 6.53% to 4.00% (P = .06). Postoperative Kujala scores did not show a statistically significant change between newer and older publications (89.0 [SD, 3.7] and 89.4 [SD, 4.9], respectively; P = .55). Comparing results by fixation type, as well as by graft choice, showed no statistically significant differences in terms of outcomes or complication profile.

Conclusions

With nearly twice the number of medical centers performing reconstruction of the MPFL and outcomes reported on nearly double the number of patients in recent years, functional outcomes remain favorable as complication and failure profiles are improving. Furthermore, despite a wide array of fixation techniques, as well as multiple options for graft constructs, there are no statistically or clinically significant differences in functional outcomes over time. This finding highlights the efficacy and adoptability of MPFL reconstruction for the treatment of recurrent patellar instability.

Level of Evidence

Level IV, systematic review of mixed-level studies.

Section snippets

Methods

A systematic review of the literature was performed using the Medline, Embase, Scopus, and Web of Science databases. The purpose was to identify publications describing results of isolated MPFL reconstruction. The search was performed on January 12, 2014, and included publications that appeared in the literature as far back as 1992. The inclusion criteria were as follows: (1) The study must describe a technique for MPFL reconstruction in patients with chronic patellar instability with or

Results

Of the 34 publications included in this review, 15 had already been cited in prior systematic reviews whereas the remaining 19 represented new contributions to the literature. Of the 19 new studies, 18 were published by medical centers that had not previously reported outcomes with this procedure (31 total centers included) and represented an additional 621 patients and 650 knees (of 1,015 patients and 1,048 knees in total).

A comparison of our results by date of publication is shown in Table 4.

Discussion

The purpose of this review was to evaluate the midterm to long-term functional outcomes of the various surgical techniques that are in use for reconstruction of the MPFL. Surely, knowledge gained from early studies, refined techniques, and improvements in the rehabilitation process over recent years have affected the outcomes for the better; however, with the adoption of these new techniques across increasingly large physician and patient populations, it is necessary to consider whether the

Conclusions

References (59)

G.L. Camanho et al.
Conservative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella
Arthroscopy
(2009)
J.E. Gomes
Comparison between a static and a dynamic technique for medial patellofemoral ligament reconstruction
Arthroscopy
(2008)
E. Nomura et al.
Correlation of MR imaging findings and open exploration of medial patellofemoral ligament injuries in acute patellar dislocations
Knee
(2002)
E. Marteau et al.
Gracilis tendon transfer associated with distal alignment for patella alta with recurrent dislocations: An original surgical technique
Orthop Traumatol Surg Res
(2011)
J.L. Ellera Gomes
Medial patellofemoral ligament reconstruction for recurrent dislocation of the patella: A preliminary report
Arthroscopy
(1992)
J.L. Ellera Gomes et al.
Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: A follow-up study
Arthroscopy
(2004)
L.F. Ma et al.
Medial retinaculum plasty versus medial patellofemoral ligament reconstruction for recurrent patellar instability in adults: A randomized controlled trial
Arthroscopy
(2013)
G.L. Camanho et al.
Medial patellofemoral ligament reconstruction: A novel technique using the patellar ligament
Arthroscopy
(2007)
D. Drez et al.
Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation
Arthroscopy
(2001)
E. Nomura et al.
A mid-term follow-up of medial patellofemoral ligament reconstruction using an artificial ligament for recurrent patellar dislocation
Knee
(2000)

E. Nomura et al.

Hybrid medial patellofemoral ligament reconstruction using the semitendinous tendon for recurrent patellar dislocation: Minimum 3 years’ follow-up

Arthroscopy

(2006)

Y. Toritsuka et al.

Dual tunnel medial patellofemoral ligament reconstruction for patients with patellar dislocation using a semitendinosus tendon autograft

Knee

(2011)

B. Fisher et al.

Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: A systematic review including rehabilitation and return-to-sports efficacy

Arthroscopy

(2010)

T. Watanabe et al.

Visual analong scale assessment after medial patellofemoral ligament reconstruction with or without tibial tubercle transfer

J Orthop Sci

(2008)

U.M. Kujala et al.

Scoring of patellofemoral disorders

Arthroscopy

(1993)

P. Vavken et al.

Treating patella instability in skeletally immature patients

Arthroscopy

(2013)

H. Mäenpää et al.

Patellar dislocation. The long-term results of nonoperative management in 100 patients

Am J Sports Med

(1997)

H. Mäenpää et al.

Recurrence after patellar dislocation. Redislocation in 37/75 patients followed for 6-24 years

Acta Orthop Scand

(1997)

M. Petri et al.

Operative vs conservative treatment of traumatic patellar dislocation: Results of a prospective randomized controlled clinical trial

Arch Orthop Trauma Surg

(2013)

D. Dejour et al.

Osteotomies in patello-femoral instabilities

Sports Med Arthrosc Rev

(2007)

D.C. Fithian et al.

Epidemiology and natural history of acute patellar dislocation

Am J Sports Med

(2004)

T.O. Smith et al.

Operative versus non-operative management of patellar dislocation. A meta-analysis

Knee Surg Sports Traumatol Arthrosc

(2011)

M. Lind et al.

Reconstruction of the medial patellofemoral ligament for treatment of patellar instability

Acta Orthop

(2008)

C.S. Ahmad et al.

The docking technique for medial patellofemoral ligament reconstruction: Surgical technique and clinical outcome

Am J Sports Med

(2009)

A. Panagopoulos et al.

MPFL reconstruction for recurrent patella dislocation: A new surgical technique and review of the literature

Int J Sports Med

(2008)

S.M. Desio et al.

Soft tissue restraints to lateral patellar translation in the human knee

Am J Sports Med

(1998)

T. Conlan et al.

Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee

J Bone Joint Surg Am

(1993)

P.I. Sallay et al.

Acute dislocation of the patella. A correlative pathoanatomic study

Am J Sports Med

(1996)

M. Deie et al.

Medial patellofemoral ligament reconstruction fixed with a cylindrical bone plug and a grafted semitendinosus tendon at the original femoral site for recurrent patellar dislocation

Am J Sports Med

(2011)

Cited by (112)

Adding Lateral Retinacular Release to Medial Patellofemoral Ligament Reconstruction Fails to Demonstrate Clinical Benefit Compared With Isolated Medial Patellofemoral Ligament Reconstruction
2024, Arthroscopy, Sports Medicine, and Rehabilitation
To compare functional outcomes and failure rates between medial patellofemoral ligament (MPFL) reconstructions with and without lateral retinacular release (LRR) at minimum 1-year follow up.
A retrospective review identified consecutive patients from 2013 to 2019 at a single center who met all of the following inclusion criteria: at least 1 confirmed patellar dislocation, patellar tilt (evidenced by tight retinaculum on operative examination or patellar tilt on radiographs), underwent either MPFL reconstruction alone or combined with LRR, had available preoperative documentation and imaging, and were at least 1 year out of surgery. Patients were excluded if they had previous surgery to the ipsilateral limb or had any concomitant procedure performed. Demographics and preoperative imaging were evaluated. Failure rates and functional outcome scores were obtained including Kujala, Patient-Reported Outcomes Measurement Information System, International Knee Documentation Committee, Single Assessment Numeric Evaluation, and Knee injury and Osteoarthritis Outcome Scores. Clinical failure was defined as revision MPFL reconstruction on the affected knee or at least 1 instance of postoperative patellar dislocation.
A total of 18 patients underwent isolated MPFL reconstruction (mean follow-up = 29.3 ± 8.3 months, range = 15.1-42.8 months), and 31 underwent MPFL reconstruction combined with LRR (mean follow up = 36.0 ± 11.3 months, range = 14.0-51.9 months). At final follow-up, there were no statistical differences between the isolated MPFL and MPFL combined with LRR cohorts for any of the functional outcome scores (P > .05 for all). At the time of final follow-up, no patients who underwent isolated MPFL and 19.3% (n = 6) or patients undergoing MPFL combined with LRR experienced clinical failure (P = .073), as defined by subsequent patellar dislocation or revision MPFL reconstruction. Of these, 2 patients underwent revision MPFL reconstructions with distal tubercle transfer for borderline abnormal TT:TG (i.e., >15 mm).
MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up. In addition, there were no differences in rates of achieving MCID between both groups
Level III, retrospective cohort study.
Is combined MPFL reconstruction and tubercule tibial osteotomy superior to isolated reconstruction? A systematic review and meta-analysis
2023, Journal of Clinical Orthopaedics and Trauma
There is no consensus for management of patellar instability, even in the case of malalignment. The purpose of the review is to evaluate outcomes in the literature of MPFL reconstruction with and without tibial tubercle osteotomy.
Two databases PubMed and Scopus were searched for studies comparing MPFL reconstruction with and without concomitant tibial tuberosity osteotomy. PRISMA guidelines were followed. Data on functional outcomes via Kujala score, redislocation rates and return to sport rates were reported.
9 studies included data from 806 knees: 463 submitted to isolated MPFL reconstruction, and 343 submitted to the combined surgery. Patients submitted to the combined procedure had all TT-TG values superior to 18, while the ones with isolated reconstruction had more heterogeneous values, varying between 13 and 20 mm. 77.78% of the studies reported on postoperative Kujala scores, with a mean value of 83.53 in patients who underwent MPFL reconstruction alone and 83.72 in those who underwent the combined procedure. The mean difference between the two groups was −0.83, with the improvement of the score statistically significant in 22.22% of the studies, regardless of the surgery. Concerning redislocation rate, odds ratio comparing both procedures was 0.84 (p = 0.67).
The principal finding is that the MPFL reconstruction with or without TTO resulted in similar functional outcomes, assessed by the Kujala score, and low complications concerning recurrent patellar dislocation. More robust literature is needed in the setting of a high TT-TG distance.
IV.
A Patella-Sided Tensioning Technique for Medial Patellofemoral Ligament Reconstruction
2023, Arthroscopy Techniques
Reconstruction of the medial patellofemoral ligament (MPFL) is a common procedure for treatment of recurrent patellofemoral instability. Over the last two decades, multiple surgical techniques for MPFL reconstruction have been described with no clear consensus on a superior reconstruction technique. Appropriate graft tensioning is one of the most important factors for a successful MPFL reconstruction. Overtensioning of the MPFL graft can lead to patellofemoral joint overload and undertensioning can lead to recurrent instability. Current literature demonstrates descriptions of MPFL reconstruction with final graft tensioning performed off of the femoral side. We describe a technique in this article for performing final graft tensioning from the patellar side, which gives the surgeon an option for intraoperative tension adjustments after evaluating patellar tracking.
Clinical outcomes of medial patellofemoral ligament reconstruction using FiberTape and knotless SwiveLock anchors
2022, Knee
We aimed to prospectively investigate the clinical outcomes of medial patellofemoral ligament (MPFL) reconstruction using polyester high-strength suture tape with knotless anchors.
Forty-three patients (65 knees) were followed for at least 1 year postoperatively, with 27 patients (43 knees) followed for 2 years postoperatively. All patients underwent MPFL reconstruction using polyester high-strength suture tape (FiberTape®; Arthrex) with knotless anchors (SwiveLock®; Arthrex). Repeated dislocation and residual patellar apprehension signs were recorded, and congruence and tilting angles were measured. Changes in Knee Injury and Osteoarthritis Outcome Scale (KOOS) scores and their associations with the preoperative tibial tubercle–trochlear groove (TT-TG) distance were analyzed.
No repeat dislocations (0%) were observed. One (2.4%) residual positive patellar apprehension sign was noted. The mean tilting angle decreased from 24.8° to 10.7° (P < 0.001), and the mean congruence angle decreased from 24.9° to 4.3° (P < 0.001). At 2 years follow up, all KOOS subscales had improved: pain (92.0 ± 12.9), symptoms (90.2 ± 11.9), activities of daily living (95.7 ± 7.3), sports activity (85.7 ± 16.9), quality of life (87.7 ± 12.9), and patellofemoral (89.0 ± 9.6) outcomes. KOOS subscale scores improved regardless of the preoperative TT-TG distance (21.1 ± 3.5 mm; range, 13.8–29.9 mm).
MPFL reconstruction using FiberTape and knotless SwiveLock anchors was performed without sacrificing autologous tissue. No recurrent patellar dislocation was observed during the 2-year follow up period. All KOOS subscale scores improved using FiberTape and SwiveLock anchors in MPFL reconstruction.
Tape Augmentation Does Not Affect Mid-Term Outcomes of Medial Patellofemoral Ligament Reconstruction in Skeletally Mature Adolescent Patients
2022, Arthroscopy, Sports Medicine, and Rehabilitation
To evaluate mid-term outcomes after medial patellofemoral ligament (MPFL) reconstruction with and without tape augmentation in the skeletally mature adolescent population.
All patients under age 18 with recurrent patellar instability treated with surgery at a single institution by a single surgeon from January 2013 through June 2017 were identified by current procedural terminology codes. Inclusion criteria were (1) primary MPFL reconstruction, (2) minimum 3 years’ follow-up, (3) skeletal maturity. Exclusion criteria were (1) bilateral MPFL reconstruction using different techniques on each knee, (2) prior surgery for patellar instability. Chart and imaging review was completed. Patients were contacted to complete a questionnaire, which included the International Knee Documentation Committee (IKDC) form.
Fifty-one of 92 eligible patients completed questionnaires. Two patients were excluded. Twenty patients underwent 23 non-augmented MPFL reconstructions; 29 patients underwent 33 augmented MPFL reconstructions. Group demographics were similar. At 4.9 ± 1.2 years follow-up, mean IKDC scores were 77.4 and 79.4 in the nonaugmentation and augmentation groups, respectively. Significantly fewer patients in the augmentation group experienced further injury to their ipsilateral knee compared to the non-augmentation group (6% vs 30%, P = .019). Fewer knees in the augmentation group developed recurrent subjective instability or dislocation after initial surgery requiring surgical correction compared to knees in the nonaugmentation group, although this difference was not significant (6% vs 17%, P = 0.181). Overall patient-reported outcomes were similar between the 2 groups.
There were no significant differences in patient-reported outcomes after MPFL reconstruction with or without tape augmentation. Tape augmentation significantly decreased the risk of subsequent ipsilateral knee injuries, although it did not show a significant difference in recurrent dislocations.
IV, therapeutic case series.
Adding a tibial tubercle osteotomy with anteromedialisation to medial patellofemoral ligament reconstruction does not impact patient-reported outcomes in the treatment of patellar instability
2022, Journal of ISAKOS
An isolated medial patellofemoral ligament (MPFL) reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient-reported outcomes.
A retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, gender, and follow-up time. Recurrent instability (including redislocation and subluxation), visual analogue scale (VAS) score, Kujala score, and satisfaction were evaluated.
There were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow-up time. The mean age was 25.0 years, 76.3% were female, and the mean follow-up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p = 0.311) or revision surgeries (10.2% vs. 10.2%) between groups.
Matched patients undergoing MPFLR with TTO compared with isolated MPFLR demonstrate no statistically significant difference in patient-reported outcomes, levels of pain, and satisfaction postoperatively. Furthermore, the addition of a TTO does not increase the risk of further surgery or complications.
III, retrospective comparative study.

View all citing articles on Scopus

: See commentary on page 1381

: The authors report that they have no conflicts of interest in the authorship and publication of this article.

View full text

Systematic ReviewWidespread Implementation of Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Maintains Functional Outcomes at Midterm to Long-Term Follow-up While Decreasing Complication Rates: A Systematic Review

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Results

Discussion

Conclusions

Arthroscopy

Arthroscopy

Knee

Orthop Traumatol Surg Res

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Knee

Arthroscopy

Knee

Arthroscopy

J Orthop Sci

Arthroscopy

Arthroscopy

Patellar dislocation. The long-term results of nonoperative management in 100 patients

Am J Sports Med

Recurrence after patellar dislocation. Redislocation in 37/75 patients followed for 6-24 years

Acta Orthop Scand

Operative vs conservative treatment of traumatic patellar dislocation: Results of a prospective randomized controlled clinical trial

Arch Orthop Trauma Surg

Osteotomies in patello-femoral instabilities

Sports Med Arthrosc Rev

Epidemiology and natural history of acute patellar dislocation

Am J Sports Med

Operative versus non-operative management of patellar dislocation. A meta-analysis

Knee Surg Sports Traumatol Arthrosc

Reconstruction of the medial patellofemoral ligament for treatment of patellar instability

Acta Orthop

The docking technique for medial patellofemoral ligament reconstruction: Surgical technique and clinical outcome

Am J Sports Med

MPFL reconstruction for recurrent patella dislocation: A new surgical technique and review of the literature

Int J Sports Med

Soft tissue restraints to lateral patellar translation in the human knee

Am J Sports Med

Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee

J Bone Joint Surg Am

Acute dislocation of the patella. A correlative pathoanatomic study

Am J Sports Med

Medial patellofemoral ligament reconstruction fixed with a cylindrical bone plug and a grafted semitendinosus tendon at the original femoral site for recurrent patellar dislocation

Am J Sports Med

Systematic Review
Widespread Implementation of Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Maintains Functional Outcomes at Midterm to Long-Term Follow-up While Decreasing Complication Rates: A Systematic Review