66. Sherman JO, Snyder ME, Weitzman JJ, Jona JZ, Fillis DA, O’Donnell B, 75.
75. Rescorla FJ, Morrison AM and Engles D. Hirschsprung’s Disease Evaluation of
Carcassonne M and Swenson O. A 40-year multinational retrospective study of 880
Swenson’s procedure. Journal of Pediatric Surgery 1989; 24: 833–838.
67. Smith VV. Isolated intestinal neuronal dysplasia. A descriptive histological entity?
In: Hadziselimvic F, Herzog B. (eds): Inflammatory Bowel Disease and Morbus
Hirschsprung’s Disease. Dordrecht: The Netherlands, Kluwer Academic 1993; 18:
203–214.
68. Fortuna RS, Weber TR and Tracy TF. Critical analysis of the operative treatment of
Hirschsprung’s Disease. Archives of Surgery 1996; 131: 520–525.
69. Marty TL, Seo T and Matlak ME. Gastrointestinal function after surgical correc-
tion of Hirschsprung’s Disease: Long-term follow up in 135 patients. Journal of
Pediatric Surgery 1995; 30: 655–658.
70. Sarioglu A, Tanyel C and Senocak ME. Complications of the two major operations
of Hirschsprung’s disease: a single centre experience. The Turkish Journal of
Pediatrics 2001; 43: 219–222.
71. Coakes SJ and Steed L. SPSS: Analysis without Anguish (Version 10.0 for
Windows). John Wily & Sons Australia: Brisbane, 2001.
72. Livaditis A. Hirschsprung’s Disease: Long-term results of the original Duhamel
operation. Journal of Pediatric Surgery 1981; 16: 484–486.
73. Sherman JO, Snyder ME and Weitzman, JJ. A 40-year multinational retrospective
study of 880 Swenson’s procedure. Journal of Pediatric Surgery 1989; 24: 833–838.
74. Ludman L, Spitz L and Tsuji H. Hirschsprung’s disease: functional and psycholog-
ical follow up comparing total colonic and rectosigmoid aganglionosis. Archives
Disease in Childhood 2002; 86: 348–351.
REVIEW ARTICLES
Why Do Orthopaedic Surgeons Ignore the Medial Patellofemoral
Ligament?
R. Kaba,1 S. Mashru1 and P. Sooriakumaran2
1
Department of Medicine, Guy’s, King’s & St. Thomas’ School of Medicine, King’s College London, UK
2
Royal Surrey County Hospital, Egerton Road, Guildford, UK
Correspondence to: Dr Prasanna Sooriakumaran, Lecturer in Surgery, Level A, Royal Surrey County Hospital,
Egerton Road, Guildford GU2 7XX, UK
Abstract
The medial patellofemoral ligament (MPFL) is a condensation of the
medial capsule of the knee joint. In the past two decades dissection
studies have shown that it extends from the superomedial border of
the patella to the femoral epicondyle, at or immediately above the
adductor tubercle. MRI and operative studies have revealed that it is
almost invariably damaged by lateral patellofemoral dislocation.
Current surgical management of such dislocations may involve imbri-
cating the torn medial capsule and parapatellar retinaculum back
onto the medial border of the patella. If the medial patellofemoral
ligament is torn at or near the femoral attachment, as the latest MRI
and operative studies demonstrate it frequently is, then this medial
reefing procedure will not be successful in restoring normal anatomy
and function. Here we review the anatomy and function of the MPFL,
its role in patellar dislocation and as well as surgical treatment for
patellar dislocation.
Introduction
Previous anatomical dissections and functional testing of the medial
patellar retinacular structures have suggested that the medial
patellofemoral ligament (MPFL) is a band of retinacular tissue con-
necting the femoral medial epicondyle to the medial edge of the
patella.1 However anatomists and some orthopaedic are also divided
as to its existence as a distinct entity,2 whilst proponents of its exis-
tence give varying opinions as regards to its clinical significance.3,4
We have previously demonstrated the existence of this ligament
through cadaveric dissections5 this in contrast to others who have
reported it in only 35% of specimens.2 Here we systematically review
the current body of knowledge regarding its clinical significance.
Anatomy of the Medial Patellofemoral Ligament
The MPFL was initially described by Kaplan, but not named.2
Anatomical dissections have revealed several components that
International Journal of Surgery • Volume 2 • Issue 2 • 2004
mortality and long-term functions in 260 cases. Archives of Surgery 1992; 127:
934–942.
76. Hsu WM and Chen CC. Clinical and manometric evaluation of postoperative fae-
cal soiling in patients with Hirschsprung’s disease. Journal Formos Medical
Association 1999; 98: 410–414.
77. Mishalany HG and Woolley MM. Postoperative Functional and Manometric
Evaluation of Patients with Hirschsprung’s Disease. Journal of Pediatric Surgery
1987; 22: 443–446.
78. Tariq GM, Breton RJ and Wright VM. Complications of endorectal pull-through
for Hirschsprung’s disease. Journal Pediatric Surgery 1991; 26: 1202–1206.
79. Bai Y, Chen H and Hao J. Long-term outcome and quality of life after the Swenson
procedure for Hirschsprung’s Disease. Journal of Pediatric Surgery 2002; 37:
639–642.
80. Langer JC, Fitzgerald PG, Winthrop AL, Srinathan SK, Foglia RP, Skinner MA,
Ternberg JL and Lau GYP. One-stage versus two stage Soave Pull-Through for
Hirschsprung’s Disease in the first year of life. Journal of Pediatric Surgery 1996;
31: 33–37.
81. Pierro A, Fasoli L, Kiely EM, Drake D and Spitz L. Staged-Pull-Through for
Rectosigmoid Hirschsprung’s Disease is not safer than Primary-Pull Through.
Journal of Pediatric Surgery 1997; 32: 505–509.
82. Santos MC, Giacomantonio JM and Lau HYC. Primary Swenson Pull-Through
Compared with Multiple-Staged Pull-Through in the Neonate. Journal of Pediatric
Surgery 1999; 34: 1079–1081.
International Journal of Surgery 2004; 2: 101–103
make up the medial retinacular complex, which provides stability to
the medial aspect of the knee and the patella.6–8 Warren and
Marshall et al,7 divided the medial retinacular complex into three
primary layers:
Layer 1: crural fascia,
Layer 2: superficial medial collateral ligament (SMCL) and other
structures,
Layer 3: capsule of the knee joint and the deep medial ligament.
Within layers two and three, condensations of fibres form the liga-
ments of the medial retinacular complex. Within layer two, the
medial retinacular complex ligaments form an inverted triangle.
Spritzer et al.,9 described that a central split within this inverted
triangle helps define three separate ligaments:
(a) the medial patellofemoral ligament,
(b) the patellotibial ligament and
(c) the superficial medial collateral ligament (SMCL).
Warren and Marshall et al.,7 and Feller et al,10 placed the MPFL into
the second of three layers, below the deep fascia and superficial to the
joint capsule, along with the SMCL. The MPFL has been described to
be a thin fascial band approximately 53mm (range 45–64mm) long,11
that links the medial epicondyle of the femur to the proximal part of
the supero-medial border of the patella. We found that the appearance
and bulk of the MPFL varied from knee to knee, being extremely thin
in some cases. The MPFL has also been visualized on axial MR
images as a low signal intensity band-like structure of variable thick-
ness that is located just deep to the VMO muscle.12
We found that the femoral attachment of the MPFL to be at
the adductor tubercle, close to the attachment of the SMCL and
101
adductor magnus tendon. The femoral attachment has also been
described as the anterior part of the medial epicondyle,10 the poste-
rior part of the medial epicondyle,13 and the MCL.14 This variation
shows that the MPFL femoral attachment is not a clearly delineated
feature due to convergence of a number of structures and tissue lay-
ers towards the medial epicondyle.
The MPFL provides an attachment to the posterior fibres of the
VMO. Their close association also suggests that these two structures
may often be damaged together, and it has been reported that the
VMO is often torn gradually in a proximal direction from the femoral
attachment to the adductor magnus tendon.15 Thus MPFL repair (dis-
cussed later) should include reattachment of the VMO distally to the
adductor magnus tendon, thereby maintaining its correct transverse
orientation that is important for patellar stability.1
Function of the MPFL
The MPFL has a mean tensile strength of 208 N,1 and biomechani-
cal studies have advocated that the MPFL is the primary passive
restraint that resists lateral translation of the patella.1 The increased
obliquity of the vastus medialis obliquus (VMO) fibres onto the
patella (55–70 degrees) as compared with the vastus lateralis
(22–45 degrees) and the increased height of the lateral femoral
condyle are important in the mechanism of patellar stabilization.8
Nomura et al.,16 measured the increase in laxity resulting from sec-
tioning the MPFL, at a range of angles of knee flexion. In cadaver
knees with the quadriceps tensed to 10 N and a lateral displacing
force of 10 N applied to the patella, they found, in the intact knee,
the patella was displaced approximately 6 mm laterally, while cut-
ting the MPFL allowed the displacement to increase to 13 mm. In
support of this Hautamaa et al,3 also found, a mean patellar lateral
displacement of 9 mm increased to 14 mm following the removal of
the MPFL. Nomura et al,17 proved that isolated sectioning of the
MPFL greatly increased the lateral shift of the patella between 20⬚
to 90⬚ of knee flexion, even with the other medial patellar stabiliz-
ers intact, providing further evidence that the MPFL is the primary
medial stabiliser of the patella. They also found that patellar lateral
laxity was restored to normal by repair of the MPFL, suggesting
that the MPFL has clinical significance with regards to surgical
treatment of patellar dislocation.
Role of the MPFL in Patellar Dislocation
Lance et al,18 defined patellar dislocation as the complete dis-
placement of the patella from the bony trochlear sulcus of the distal
articular surface of femur. This can occur in patients with ligamen-
tous laxity, particularly if associated with patellar sublaxity.7
Patellar dislocation occurs commonly in sportsmen, and results
from a valgus force causing the femur to rotate internally on a fixed
foot and tibia.18 Contraction of quadriceps also contributes to com-
plete dislocation of the patella out of the trochlear sulcus.18 Much
less commonly, dislocation can occur due to a blow to the outside
of the knee.18
A major consequence of complete patellar dislocation is medial
retinacular complex injury.9 The MPFL, being a component liga-
ment of the medial retinacular complex, is often torn6 and there
have been many documented MR images of MPFL injury.12
Spritzer et al,9 documented MR images showing that the medial
retinacular tears occur adjacent to the patellar insertion and Sallay
et al19 reported that tears of the femoral insertion of the MPFL were
seen in 15 of 16 knees (94%) on MRI, and open surgical explo-
ration revealed tears of the MPFL from the femur in the same num-
bers of cases.
Nomura et al4 found that, from 18 cases of acute patellar disloca-
tion and 49 cases of chronic patellar dislocation, MPFL injuries
could be categorised into 2 groups: an avulsion tear type (39%
cases) and a substantial tear type (61%). The chronic cases were in
3 groups: those with loose femoral attachment (18% of cases),
102
those with scar formation (60%) and those with no ligament
(22%). An avulsion tear type is a detachment injury to the deep
layer of the MPFL at its femoral attachment with no actual rupture
of the ligament itself. The substantial tear type is a complete
rupture of the MPFL and again is in immediate vicinity of femoral
attachment. Scar formation occurred in chronic dislocations in
the body of the MPFL near its femoral attachment. There are 2
reported reasons for MPFL injury occurring at the femoral attach-
ment.16 Firstly, the width and thickness of the MPFL becomes nar-
rower and thinner as it approaches the femoral attachment making
it prone to substantial tear type injury. Secondly, the area of
femoral attachment is very small and so this is a morphologically
and anatomically weak area.
Courneya et al20 also found femoral avulsion of the MPFL in 17/20
patients taken to surgery; all surgically confirmed tears were also
seen on MR imaging. The femoral tear resulted in significant patellar
instability; the patella was freely subluxable and could be dislocated
on physical examination in many cases. For this reason surgical treat-
ment should involve repair of the MPFL, reconstructing its femoral
attachment.
Surgical Treatment of Patellar Dislocation
Traditional treatments for patellar dislocation have recurrence rates
of up to 44%.21 It has also been reported that 20–30% of patients
experience symptoms of instability whether treated operatively or
non-operatively.22 Conservative treatment includes rest, bracing the
knee in a cast and muscle strengthening exercises. Over 100 proce-
dures have been described for surgical treatment of patellar insta-
bility;22 the majority of which realign the knee extensor mechanism
by manipulating the quadriceps angle to reduce the forces causing
lateralisation of the patella under quadriceps loading. Proximal
realignment procedures manipulate the insertions of components
into the patella and distal realignment procedures relocate the tibial
tubercle.23
Typically, proximal realignment involves imbricating the VMO
and/or the superficial medial retinaculum. However, the VMO and
superficial medial retinaculum contribute only as minor restraints
to lateral displacement of the patella.24 This procedure does not
address the ligamentous injury and Scuderi et al,23 report a recur-
rence incidence of 25% of dislocation with proximal realignment
treatment. Distal realignment procedures include transplantation of
the tibial tubercle and the patellar tendon attachment to a more dis-
tal and medial position, but this can cause chondromalacia24 or
osteoarthritis21 of the patella and weakening of the quadriceps.24
Again, distal realignment fails to address the medial ligamentous
injury and recurrence rates are high.
Primary MPFL repair may either be done acutely or after a period
of initial healing. Repair has been described at either the patellar
insertion of the damaged MPFL or insertion at its adductor tubercle
origin. MR imaging may be of value to identify the type of injury
(midsubtance or avulsion).4 Avulsion may be addressed easily with
an anchor whereas mid-substance injury in the chronic situation
may not be possible to repair due to an inability to identify the
MPFL structure or due to substantial scarring.20 In such circum-
stances, reconstruction may be required. Reconstruction may also
be needed in patients with patella alta or trochlear dysplasia, in
which the MPFL is structurally deficient.24
Gomes et al,25 performed 30 MPFL reconstructions using a poly-
ester ligament as the graft material performing closed lateral release
through a lateral incision and reporting 96% ‘good’ or ‘excellent’
results in 23 patients who did not have significant chondral lesions,
83% of whom had an excellent outcome at an average follow-up of
39 months. Erasmus et. al,26 used hamstrings as the graft material
and showed correction of lateral patellar subluxaton when compar-
ing pre- and post-operative computed tomography images.
Avikainen et al,27 reconstructed the MPFL using an adductor mag-
International Journal of Surgery • Volume 2 • Issue 2 • 2004
nus tenodesis in 14 knees; only one patient suffered recurrent dis-
locations. Nomura et al,17 reported 27 reconstructions using a
Leeds-Keio ligament in 24 patients, at an average of 5.9 years fol-
low-up, 55% of patients had excellent results, 41% had good results
and one patient had an episode of recurrent instability. Hence,
reconstruction of the MPFL has shown to be a successful method to
deal with patellar dislocation.
Conclusion
The medial patellofemoral ligament (MPFL) is a condensation of
the medial capsule of the knee joint. It extends from the superome-
dial border of the patella to the femoral epicondyle, at or immedi-
ately above the adductor tubercle. Biomechanical studies have
shown that the MPFL is the primary passive restraint protecting
against lateral dislocation of the patella. MR images of soft tissue
edema and MPFL injury patterns suggest that the majority of
MPFL injuries occur proximally, near or at the femoral attachment
site adjacent to the adductor tubercle. Conventional surgical tech-
niques do not restore its normal anatomy.
Our systematic review suggests that following acute transient dislo-
cation of the patella, those patients with disruption of the MPFL
may benefit from primary surgical repair of the ligament which
should result in a lower rate of recurrent dislocation as compared to
the current conservative or surgical treatments used that are being
used. Further research is required to evolve the best method for
MPFL reconstruction with particular emphasis on discovering the
precise location of the femoral attachment of the MPFL.
Acknowledgments
We would like to thank the technical staff at GKT Medical School for
use of the cadavers and dissection room facilities, and Mr Richard
Pusey, Former Consultant Orthopaedic Surgeon at Basildon Hospital,
for his help with the preparation of this work.
Conflicting Interests – None declared.
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Does Laparoscopic Surgery Offer Adequate Clearance In Rectal
Cancer? – A Discussion
S. Purkayastha,1 O. Aziz,1 T. Athanasiou,2 P. Paraskevas3 and A. Darzi1
1
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Academic Department of Surgery, Imperial College London, UK
Correspondence to: Mr Sanjay Purkayastha, Department of Surgery, St. Mary’s Hospital, London W2 1NY, UK
Abstract
Currently in the UK, the national institute of clinical excellence
(NICE), only advocates laparoscopic surgery for rectal cancer as part
of commissioned clinical trials. Laparoscopic teaching, training and
techniques have evolved greatly and offer many benefits to patients,
whilst remaining technically demanding to surgeons still on the slope
of the learning curve. Can such minimally invasive techniques be
used with the same results as open surgery in the treatment of rectal
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International Journal of Surgery 2004; 2: 103–106
to shed some light on such questions and briefly review some of the
literature. If laparoscopic anterior resections and abdominoperineal
resections achieve the same results as open procedures, then should
these techniques be more widely taught and practised? Surely the
peri-operative cost of these laparoscopic procedures does not over
shadow the potential outcome from much less traumatic surgery?
Introduction
Bowel cancer is the third commonest malignancy in the UK.1 Rectal
cancer (RC) is the commonest large bowel tumour, accounting for
approximately 40% of tumours.2 The incidence of rectal cancer
103