Restricted accessResearch articleFirst published online 2020-12
Patient-Reported Outcomes After Revision Surgery for Failed Medial Patellofemoral Ligament Reconstruction: A Matched-Pair Analysis Including Correction of Predisposing Factors
Complications and the need for revision surgery after medial patellofemoral ligament reconstruction (MPFLR) are evident in the current literature. However, there is a shortage of clinical data evaluating the results of revision surgery in individual patients after failed MPFLR.
Purpose:
To investigate the results of tailored revision surgery for failed MPFLR, including the correction of predisposing factors.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Between August 2015 and March 2019, 25 patients (male:female, n = 9:16; mean ± SD age, 25.9 ± 6.5 years) underwent revision surgery for failed MPFLR (study group). The Banff Patella Instability Instrument 2.0 (BPII 2.0) and a numerical analog scale (0-10) for patellofemoral pain and subjective knee joint function were used to assess patient-reported quality of life before and after revision surgery. The control group of 50 patients (male:female, n = 18:32; age, 22.8 ± 4.3 years) who underwent identical patellar-stabilizing procedures was matched 1:2 by the surgical procedure, predisposing factors, sex, age, and follow-up time.
Results:
Evaluation was performed postoperatively at a mean 27.8 ± 14.0 months (range, 12-54 months) in the study group and 26.1 ± 11.2 months (range, 12-56 months) in the control group (P = .55). The BPII 2.0 score increased from 28.6 ± 17.9 points to 68.7 ± 22.3 points (P < .0001) in the study group and from 43.8 ± 22.5 points to 75.5 ± 21.4 points (P < .0001) in the control group from preoperatively to postoperatively, respectively. Before revision surgery, the BPII 2.0 scores in the study group were significantly inferior to those in the control group (P = .0026). At the final follow-up, the BPII 2.0 score in the study group was not significantly lower (P = .174), and a similar number of patients in the study group and the control group achieved the minimally clinically important difference (P = .49). Patellofemoral pain and subjective knee joint function improved significantly in both groups (P < .0001, P < .0001), without any significant difference between them at the final follow-up (P = .85, P = .86).
Conclusion:
Revision surgery for MPFLR failure, including the correction of major anatomic risk factors, yielded a significant improvement in patient-reported quality-of-life outcome measures. Patients with failed MPFLR, however, were significantly more restricted before revision surgery than patients without previous interventions when evaluated with the BPII 2.0.
ArendtEAAskenbergerMAgelJTompkinsMA.Risk of redislocation after primary patellar dislocation: a clinical prediction model based on magnetic resonance imaging variables. Am J Sports Med. 2018;46(14):3385-3390.
2.
BalcarekPOberthürSHopfensitzS, et al. Which patellae are likely to redislocate?Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2308-2314.
3.
BalcarekPRadeboldTSchulzXVogelD.Geometry of torsional malalignment syndrome: trochlear dysplasia but not torsion predicts lateral patellar instability. Orthop J Sports Med. 2019;7(3):2325967119829790.
4.
BalcarekPRehnSHowellsNR, et al. Results of medial patellofemoral ligament reconstruction compared with trochleoplasty plus individual extensor apparatus balancing in patellar instability caused by severe trochlear dysplasia: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2017;25(12):3869-3877.
5.
BalcarekPWaldeTA.Accuracy of femoral tunnel placement in medial patellofemoral ligament reconstruction: the effect of a nearly true-lateral fluoroscopic view. Am J Sports Med. 2015;43(9):2228-2232.
6.
BartschALubbertsBMummeMEgloffCPagenstertG.Does patella alta lead to worse clinical outcome in patients who undergo isolated medial patellofemoral ligament reconstruction? A systematic review. Arch Orthop Trauma Surg. 2018;138(11):1563-1573.
7.
BecherCAttalRBalcarekP, et al. Successful adaption of the Banff Patella Instability Instrument (BPII) 2.0 into German. Knee Surg Sports Traumatol Arthrosc. 2018;26(9):2679-2684.
8.
BelkinNSMeyersKNRedlerLHMaherSNguyenJTShubin SteinBE.Medial patellofemoral ligament isometry in the setting of patella alta. Arthroscopy. Published online February5, 2020. doi:10.1016/j.arthro.2020.01.035
9.
CatonJDeschampsGChambatPLeratJLDejourH.Les rotules basses: a propos de 128 observations. Rev Chir Orthop Reparatrice Appar Mot. 1982;68(5):317-325.
10.
ChattertonANielsenTGSørensenOGLindM.Clinical outcomes after revision surgery for medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26(3):739-745.
11.
DejourDLe CoultreB.Osteotomies in patello-femoral instabilities. Sports Med Arthrosc Rev. 2007;15(1):39-46.
12.
EricksonBJNguyenJGasikKGruberSBradyJShubin SteinBE.Isolated medial patellofemoral ligament reconstruction for patellar instability regardless of tibial tubercle-trochlear groove distance and patellar height: outcomes at 1 and 2 years. Am J Sports Med. 2019;47(6):1331-1337.
13.
FisherBNylandJBrandECurtinB.Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy. Arthroscopy. 2010;26(10):1384-1394.
14.
FrancioziCEAmbraLFAlbertoniLJB, et al. Anteromedial tibial tubercle osteotomy improves results of medial patellofemoral ligament reconstruction for recurrent patellar instability in patients with tibial tuberosity–trochlear groove distance of 17 to 20 mm. Arthroscopy. 2019;35(2):566-574.
15.
FrancioziCEAmbraLFAlbertoniLJB, et al. Increased femoral anteversion influence over surgically treated recurrent patellar instability patients. Arthroscopy. 2017;33(3):633-640.
16.
FringsJKrauseMAkotoRFroschK-H.Clinical results after combined distal femoral osteotomy in patients with patellar maltracking and recurrent dislocations. J Knee Surg. 2019;32(9):924-933.
17.
HevesiMHeidenreichMJCampCL, et al. The recurrent instability of the patella score: a statistically based model for prediction of long-term recurrence risk after first-time dislocation. Arthroscopy. 2019;35(2):537-543.
18.
HiemstraLAKerslakeSALafaveMR.Influence of risky pathoanatomy and demographic factors on clinical outcomes after isolated medial patellofemoral ligament reconstruction: a regression analysis. Am J Sports Med. 2019;47(12):2904-2909.
19.
HiemstraLAKerslakeSLoewenMLafaveM.Effect of trochlear dysplasia on outcomes after isolated soft tissue stabilization for patellar instability. Am J Sports Med. 2016;44(6):1515-1523.
20.
HinterwimmerSImhoffABMinzlaffP, et al. Anatomical two-bundle medial patellofemoral ligament reconstruction with hardware-free patellar graft fixation: technical note and preliminary results. Knee Surg Sports Traumatol Arthrosc. 2013;21(9):2147-2154.
21.
HollidayCLHiemstraLAKerslakeSGrantJA.Relationship between anatomical risk factors, articular cartilage lesions, and patient outcomes following medial patellofemoral ligament reconstruction. Cartilage. Published online December26, 2019. doi:10.1177/19476035198 94728
22.
HolmeTJHenckelJHartshornKCobbJPHartAJ.Computed tomography scanogram compared to long leg radiograph for determining axial knee alignment. Acta Orthop. 2015;86(4):440-443.
23.
HopperGPLeachWJRooneyBPWalkerCRBlythMJ.Does degree of trochlear dysplasia and position of femoral tunnel influence outcome after medial patellofemoral ligament reconstruction?Am J Sports Med. 2014;42(3):716-722.
24.
KitaKTanakaYToritsukaY, et al. Factors affecting the outcomes of double-bundle medial patellofemoral ligament reconstruction for recurrent patellar dislocations evaluated by multivariate analysis. Am J Sports Med. 2015;43(12):2988-2996.
25.
KnochF vonBöhmTBürgiMLKnochM vonBereiterH.Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia: a 4- to 14-year follow-up study. J Bone Joint Surg Br. 2006;88(10):1331-1335.
26.
LafaveMRHiemstraLKerslakeS. Factor analysis and item reduction of the Banff Patella Instability Instrument (BPII): introduction of BPII 2.0. Am J Sports Med. 2016;44(8):2081-2086.
27.
MackayNDSmithNAParsonsNSpaldingTThompsonPSprowsonAP.Medial patellofemoral ligament reconstruction for patellar dislocation: a systematic review. Orthop J Sports Med. 2014;2(8):2325967114544021.
28.
MatsushitaTKurodaROkaSMatsumotoTTakayamaKKurosakaM.Clinical outcomes of medial patellofemoral ligament reconstruction in patients with an increased tibial tuberosity-trochlear groove distance. Knee Surg Sports Traumatol Arthrosc. 2014; 22(10):2438-2444.
29.
NelitzMWilliamsRSLippacherSReichelHDornacherD.Analysis of failure and clinical outcome after unsuccessful medial patellofemoral ligament reconstruction in young patients. Int Orthop. 2014;38(11):2265-2272.
30.
NelitzMWilliamsSRM. Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents using a pedicled quadriceps tendon graft. Arthrosc Techn. 2014;3(2):e303-e308.
31.
ParikhSNNathanSTWallEJEismannEA.Complications of medial patellofemoral ligament reconstruction in young patients. Am J Sports Med. 2013;41(5):1030-1038.
32.
PostWRFithianDC.Patellofemoral instability: a consensus statement from the AOSSM/PFF Patellofemoral Instability Workshop. Orthop J Sports Med. 2018;6(1):2325967117750352.
33.
PrevitaliDMilevSRPagliazziGFilardoGZaffagniniSCandrianC.Recurrent patellar dislocations without untreated predisposing factors: medial patellofemoral ligament reconstruction versus other medial soft-tissue surgical techniques—a meta-analysis. Arthroscopy. 2020;36(6):1725-1734.
34.
Sappey-MarinierESonnery-CottetBO’LoughlinP, et al. Clinical outcomes and predictive factors for failure with isolated MPFL reconstruction for recurrent patellar instability: a series of 211 reconstructions with a minimum follow-up of 3 years. Am J Sports Med. 2019;47(6):1323-1330.
35.
SchneiderDKGraweBMagnussenRA, et al. Outcomes after isolated medial patellofemoral ligament reconstruction for the treatment of recurrent lateral patellar dislocations: a systematic review and meta-analysis. Am J Sports Med. 2016;44(11):2993-3005.
36.
SeitlingerGScheureckerGHöglerRLabeyLInnocentiBHofmannS.Tibial tubercle-posterior cruciate ligament distance: a new measurement to define the position of the tibial tubercle in patients with patellar dislocation. Am J Sports Med. 2012;40(5):1119-1125.
37.
ServienEFritschBLustigS, et al. In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med. 2011;39(1):134-139.
38.
ShahJNHowardJSFlaniganDCBrophyRHCareyJLLattermannC.A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med. 2012;40(8):1916-1923.
39.
StupayKLSwartEShubin SteinBE.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. Arthroscopy. 2015;31(7):1372-1380.
40.
TestaEACamathiasCAmslerFHenlePFriederichNFHirschmannMT.Surgical treatment of patellofemoral instability using trochleoplasty or MPFL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017;25(8):2309-2320.
41.
WagnerDPfalzerFHingelbaumSHuthJMauchFBauerG.The influence of risk factors on clinical outcomes following anatomical medial patellofemoral ligament (MPFL) reconstruction using the gracilis tendon. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):318-324.
42.
ZhangZZhangHSongG, et al. A high-grade J sign is more likely to yield higher postoperative patellar laxity and residual maltracking in patients with recurrent patellar dislocation treated with derotational distal femoral osteotomy. Am J Sports Med. 2020;48(1):117-127.
43.
ZhangZZhangHSongGZhengTNiQFengH.Increased femoral anteversion is associated with inferior clinical outcomes after MPFL reconstruction and combined tibial tubercle osteotomy for the treatment of recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc. 2020;28(7):2261-2269.
44.
ZimmermannFLiebensteinerMCBalcarekP.The reversed dynamic patellar apprehension test mimics anatomical complexity in lateral patellar instability. Knee Surg Sports Traumatol Arthrosc. 2019;27(2):604-610.
