The American Journal of Sports

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Does Degree of Trochlear Dysplasia and Position of Femoral Tunnel Influence Outcome After Medial
Patellofemoral Ligament Reconstruction?
Graeme P. Hopper, William J. Leach, Brian P. Rooney, Colin R. Walker and Mark J. Blyth
Am J Sports Med 2014 42: 716 originally published online January 23, 2014
DOI: 10.1177/0363546513518413

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Does Degree of Trochlear Dysplasia
and Position of Femoral Tunnel
Influence Outcome After Medial
Patellofemoral Ligament Reconstruction?
Graeme P. Hopper,*y MBChB, William J. Leach,z FRCS, Brian P. Rooney,z FRCS,
Colin R. Walker,§ FRCS, and Mark J. Blyth,y FRCS
Investigation performed at Glasgow Royal Infirmary, Glasgow, Scotland, UK

Background: The medial patellofemoral ligament (MPFL) is the main restraining force against lateral patellar displacement. It is
disrupted after patellar subluxation or dislocation. Reconstruction of the MPFL is frequently performed when nonoperative man-
agement fails and the patient experiences recurrent patellar dislocation.
Purpose: To determine the relationship between the degree of trochlear dysplasia and femoral tunnel position and outcome after
MPFL reconstruction.
Study Design: Case series; Level of evidence, 4.
Methods: A total of 68 patients (72 knees) with recurrent dislocation of the patella underwent MPFL reconstruction. The mean
follow-up was 31.3 months (range, 13-72 months). Clinical and functional outcomes were recorded using the Kujala, Lysholm,
and Tegner scores. Postoperative complications, participation in sporting activity, and overall patient satisfaction were deter-
mined. Radiographs were analyzed to evaluate congruence angle, lateral patellofemoral angle, patellar height, trochlear dyspla-
sia, trochlear boss height, and position of the femoral tunnel.
Results: The mean Kujala, Lysholm, and Tegner scores postoperatively were 76.2, 73.8, and 3.6, respectively (n = 61). The mean
congruence angle (n = 30) improved from 22.5° to 1.0° postoperatively (P = .000038), the lateral patellofemoral angle (n = 30)
improved from 7.4° to 7.8° postoperatively (P = .048), and the patellar height (n = 46) using the Caton-Deschamps method
improved from 1.1 to 1.0 postoperatively (P = .000016). Mild trochlear dysplasia grade A/B was found in 89% of patients (n =
54), and 11% of patients (n = 7) had severe grade C/D dysplasia. The mean distance from the anatomic insertion of the MPFL
to the center of the tunnel was 9.3 mm (range, 0.5-28.2 mm), with 71.7% thought to be within 10 mm of the anatomic position
defined by Schottle (n = 46). When patients with high-grade trochlear dysplasia were excluded, anatomically placed femoral tun-
nels demonstrated significantly better clinical scores than did tunnels not placed anatomically (Kujala score, P = .028; Lysholm
score, P = .012). A multivariate logistic regression analysis also demonstrated that the distance of the femoral tunnel from the
anatomic position predicted clinical outcome (Kujala score, P = .043; Lysholm score, P = .028). All of the patients with severe
trochlear dysplasia (n = 7) suffered from recurrent dislocations postoperatively, compared with only 9.3% of patients (n = 5)
with mild trochlear dysplasia (P = .0001). Four patients had patellar fractures postoperatively. Of patients with mild dysplasia,
83% were either very satisfied or satisfied with the outcome of their surgery compared with only 57% with severe dysplasia
(P = .05). Of patients with mild trochlear dysplasia, 56% returned to sport postoperatively compared with only 43% of patients
with severe trochlear dysplasia (P = .526).
Conclusion: This study demonstrates the importance of restoration of the anatomic insertion point of the MPFL when performing
MPFL reconstruction and proposes that this procedure should not be performed in isolation in patients with high-grade trochlear
dysplasia.
Keywords: patellofemoral instability; recurrent dislocation; medial patellofemoral ligament reconstruction

The medial patellofemoral ligament (MPFL) is the main force.4,7,16 It originates at the posterior aspect of the medial
restraining force against lateral patellar displacement, epicondyle and inserts along the superomedial border of
providing 50% to 60% of the total medial restraining the patella.12 It is often disrupted after patellar subluxa-
tion or dislocation, with Nomura21 reporting damage to
the MPFL in 96% of patients with patellar dislocation.
Three systematic reviews of MPFL reconstruction have
The American Journal of Sports Medicine, Vol. 42, No. 3
DOI: 10.1177/0363546513518413 been published recently. Buckens and Saris2 concluded
Ó 2014 The Author(s) that there is growing evidence that MPFL reconstruction

716
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Vol. 42, No. 3, 2014 Outcome After MPFL Reconstruction 717

leads to excellent functional outcome, and Fisher et al13 con-

cluded that the procedure is likely to improve the patient’s
ability to perform activities of daily living. Despite the
numerous techniques described, no single technique has
been shown to be superior to any other. In addition, there
have been few long-term follow-up studies, and the numbers
in most of these series were small.k Importantly, Shah
et al30 reviewed 25 articles and reported a 26.1% complica-
tion rate with MPFL reconstruction. These complications
included patellar fractures, clinical instability, loss of knee
flexion, wound complications, and pain.
A limited number of studies have undertaken radiologic
assessment after MPFL reconstruction. Nomura et al22-24
demonstrated a significant reduction in both the congru-
ence angle and patellar height postoperatively. In particu-
lar, there are limited data on the effect of the degree of
trochlear dysplasia. Steiner et al31 evaluated patients
with patellar instability in association with trochlear dys-
plasia but found no difference in clinical outcome with dif- Figure 1. The anatomic insertion site of the medial patello-
ferent degrees of dysplasia. femoral ligament.
Schottle et al28 described the anatomic insertion site in
the femur of the medial patellofemoral ligament in a radio- magnetic resonance imaging scans (superimposed axial
logic study of 8 cadaveric knees. This point is 1.3 mm ante- images) and radiographs. Gracilis (n = 48), semitendinosus
rior to the posterior cortex extension and 2.5 mm distal to (n = 15), and gracilis plus semitendinosus (n = 9) autografts
a perpendicular line intersecting the posterior medial con- were used for the reconstructions. This was a retrospective
dyle (Figure 1). Servien et al29 analyzed 29 femoral tunnel case series, and mean follow-up was 31.3 months (range,
positions using this radiologic landmark and found 19 tun- 13-72 months). The mean age at the time of surgery was
nels to be in an anatomic position, 5 in a proximal position, 23.9 years (range, 14-46 years); 18 patients were male, and
and 5 in a proximal and anterior position. However, they 50 patients were female.
did not find any correlation between clinical outcome and
nonanatomic position of the femoral tunnel.
The aims of this study were to determine the clinical and Surgical Technique
functional success rate of MPFL reconstruction with vary-
ing degrees of trochlear dysplasia and to determine the All procedures were carried out by the 4 senior authors
effect of femoral tunnel placement on outcome after MPFL (W.J.L., B.P.R., C.R.W., and M.J.B.) in 3 large teaching hos-
reconstruction. We hypothesized that failure of MPFL pitals. Ipsilateral hamstring tendon autografts were used
reconstruction would be associated with high-grade troch- throughout. Graft fixation on the patellar side was achieved
lear dysplasia and nonanatomic femoral tunnel placement. with interference screw fixation in a bony tunnel at the mid-
point of the medial patella border. The isometric point on
the femur was then identified before femoral tunnel drilling
MATERIALS AND METHODS and interference screw fixation in most cases (61/72 cases).
The isometric point was determined by placing a pin at the
Patients proposed tunnel entrance on the femur and then taking the
knee through a range of motion. If the graft was tight in
From January 2006 to January 2011, a total of 68 consecu- flexion, then the pin would be placed more posterior and dis-
tive patients (72 knees) with recurrent dislocation of the tal until the isometric point was identified. Radiologic
patella underwent MPFL reconstruction; 22 of the 72 opera- screening was not used intraoperatively for identifying fem-
tions (30.6%) included a tibial tubercle osteotomy. The indica- oral tunnel position. In 11 of the 72 cases, a suture anchor
tion for an adjunct tibial tubercle osteotomy was was used for femoral fixation. The graft was tensioned
a preoperative tibial tuberosity–trochlear groove (TTTG) dis- under arthroscopic visualization with medialization until
tance of greater than 17 mm or significant patella alta the patella was in the center of the trochlea.
(Caton-Deschamps ratio .1.2) as determined by preoperative The tibial tubercle osteotomy involved medializing the
tubercle to create a TTTG distance of about 10 mm with
k
References 1, 3, 5, 8, 9, 11, 15, 18, 22-27, 31, 33, 34, 37. distalization as required to create a normal patellar height.

*Address correspondence to Graeme P. Hopper, MBChB, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, Scotland G4 0SF, UK (e-mail:
hopperg@[Link]).
y
Royal Infirmary, Glasgow, Scotland, UK.
z
Glasgow Western Infirmary, Glasgow, Scotland, UK.
§
Southern General Hospital, Glasgow, Scotland, UK.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

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718 Hopper et al The American Journal of Sports Medicine

TABLE 1
Clinical Outcome Measures Comparing
Mild and Severe Trochlear Dysplasiaa

Mild Severe
Trochlear Trochlear Mean
Dysplasia Dysplasia Difference
(n = 54) (n = 7) (95% CI) P Value

Mean Kujala score 79.7 50.4 29.3 .0001

(20.8-37.8)
Mean Lysholm score 77.2 47.3 29.9 .0001
(18.0-41.8)
Mean Tegner score 3.9 2.3 1.6 .027
(0.3-3.0)

a
Mild trochlear dysplasia was defined as Dejour grades A and B;
severe trochlear dysplasia was defined as Dejour grades C and D.
CI, confidence interval.

Figure 2. Measurement of trochlear boss height.

TABLE 2
Patient Satisfaction and Return to Sport
Clinical and Functional Evaluation Comparing Mild and Severe Trochlear Dysplasiaa
Postoperative clinical and functional outcomes were Mild Severe
recorded using the Kujala, Lysholm, and Tegner Trochlear Trochlear
scores.19,32 In addition, postoperative complications includ- Dysplasia Dysplasia
ing patellar fracture and recurrent dislocation were (n = 54) (n = 7) P Value
recorded. Patients were also assessed for participation in
Recurrent dislocation, % 7.4 100 .0001
sporting activities and their level of overall satisfaction Return to sport, % 56 43 .526
with the procedure. Data were analyzed according to Satisfaction, % NA
whether the patient had mild (Dejour grades A or B) or Very satisfied 32 14
severe (Dejour grades C or D) trochlear dysplasia. Data Satisfied 51 43
were collated retrospectively by the authors from case Unsure 6 14
notes, postal questionnaires, and telephone interviews. Unsatisfied 11 28

a
Mild trochlear dysplasia was defined as Dejour grades A and B;
Radiographic Evaluation severe trochlear dysplasia was defined as Dejour grades C and D.
NA, not applicable.
Plain digital radiographs performed preoperatively were
used to evaluate trochlear dysplasia and trochlear boss
height, both using true lateral radiographs. Trochlear dys- distance from the mean anatomic insertion site of the
plasia was graded by the Dejour classification,6 which clas- medial patellofemoral ligament described by Schottle
sifies dysplasia as A (crossing sign), B (crossing sign and et al28 to the center of the femoral tunnel on postoperative
supratrochlear spur), C (crossing sign and double contour), true lateral radiographs using a digital measuring tool.
or D (crossing sign, double contour, and supratrochlear Grafts were described as anatomic if the center of the fem-
spur). The trochlear boss height is a measurement of the oral tunnel was within 10 mm of the radiological landmark
size of the dome-shaped trochlea and was measured by for the femoral origin of the MPFL.
a line drawn from the most anterior point of the dome per-
pendicular to a line drawn as an extension of the anterior Data Analysis
femoral cortex on a true lateral radiograph (Figure 2).
Plain digital radiographs (lateral and skyline at 45° Descriptive statistics were calculated. Comparison of pre-
flexion) performed preoperatively and postoperatively at operative and postoperative radiograph measurements
3 months were used to assess congruence angle, lateral were calculated using a paired Student t test. The correla-
patellofemoral angle, and patellar height using the tion of clinical outcomes and radiographic parameters were
Caton-Deschamps method, which is the ratio of the dis- calculated using a Student t test. Fisher exact test or chi-
tance between the distal edge of the articular surface of square tests were used to compare male and female
the patella and the anterosuperior angle of the tibial pla- patients, use of a tibial tubercle osteotomy, and return to
teau to the length of the articular surface of the patella.36 sport. An analysis of variance was used to compare intra-
Plain digital radiographs performed postoperatively surgeon results and to compare graft types. Correlation
were used to evaluate the femoral tunnel placement cre- between clinical outcome and femoral tunnel position and
ated for the MPFL reconstruction. We measured the trochlear dysplasia was determined using Pearson

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Vol. 42, No. 3, 2014 Outcome After MPFL Reconstruction 719

TABLE 3
Clinical Outcome Measures
Comparing Different Variablesa

P Value
Variable Kujala Score Lysholm Score Tegner Score

TTO .197 .248 .279

Sex .065 .073 .063
Surgeon .543 .572 .655
Graft .130 .055 .674

a
TTO, tibial tubercle osteotomy.

correlation. Statistical analysis was carried out using

SPSS software (version 19.0; IBM Corp, Armonk, New
York, USA). Significance was set at P \ .05 for all tests.

RESULTS
Preoperative radiographs were available in 61 of 72 knees
(84.7%) to evaluate the preoperative trochlear boss height
and trochlear dysplasia. The mean trochlear boss height
was 3.7 6 1.6 mm (range, 0-7.3 mm). Fifty-four (89%) knees
had trochlear dysplasia grade A or B (low grade), and 7 (11%)
knees had trochlear dysplasia grade C or D (high grade).
The clinical results are summarized in Table 1. A high
failure rate was seen in patients with high-grade trochlear
dysplasia (Dejour grades C and D), with a 100% rate of
recurrent dislocations (all 7 patients). Only 5 (9.3%) of
the 54 patients with milder degrees of trochlear dysplasia
developed recurrent dislocations (P = .0001). Better return
to sport and higher patient satisfaction were also seen in
patients with milder dysplasia (Table 2). Figure 3. (A) Anatomically positioned tunnel. (B) Nonana-
Analysis of the clinical data was performed separately tomically positioned tunnel.
for patients undergoing a tibial tubercle osteotomy and
compared with data from patients undergoing MPFL
reconstruction in isolation; however, no statistically signif- TABLE 4
icant differences were established. Furthermore, no signif- Clinical Outcome Scores for Patients With Mild
icant differences were found between male and female Trochlear Dysplasia: Distance of the Femoral Tunnel
patients or between different surgeons (Table 3). Position From the Anatomic Position
Forty-six of 72 knees (63.9%) had radiographs of suffi-
cient standard to evaluate the postoperative femoral tun- Femoral Tunnel Position
From Anatomic Position
nel placement. The mean distance from the anatomic
insertion of the MPFL to the center of the femoral tunnel \10 mm .10 mm
was 9.3 6 5.9 mm (range, 0.5-28.2 mm). Thirty-three of (n = 29) (n = 11) P Value
46 knees (71.7%) were considered to be anatomic, and 13
Median Kujala score (range) 89 57 .028
of 46 knees (28.3%) were considered to be nonanatomic.
(8-100) (23-92)
Examples of anatomic and nonanatomic tunnel positions Median Lysholm score (range) 90 61 .012
are demonstrated in Figure 3. (8-100) (18-90)
When patients with high-grade trochlear dysplasia are
excluded, the importance of the placement of the femoral
tunnel is clarified, with fewer recurrent dislocations and
higher clinical scores in the anatomically placed femoral
tunnels (\10 mm) (Table 4; Figures 4 and 5), particularly six of 72 knees (63.9%) had lateral radiographs of sufficient
if the complication of patellar fracture is avoided. quality available to compare the preoperative versus post-
Thirty of 72 knees (41.7%) had skyline radiographs operative patellar height using the Caton-Deschamps
available to compare the preoperative and postoperative method. A summary of the preoperative and postoperative
congruence and the lateral patellofemoral angles. Forty- radiographic evaluation is displayed in Table 5.

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720 Hopper et al The American Journal of Sports Medicine

TABLE 5
Radiographic Outcomes

Preoperative Postoperative
n Mean SD Range Mean SD Range P Value

Congruence angle, deg 30 22.5 19.0 –1.2 to 82.6 1.0 20.1 –35.3 to 61.5 .000038
Lateral patellofemoral angle, deg 30 7.4 4.1 –4.1 to 19.2 7.8 4.7 –5.9 to 17.1 .048
Patellar height 46 1.1 0.2 0.6 to 1.6 1.0 0.2 0.6 to 1.4 .000016

Figure 4. Correlation between the Kujala score and the dis- Figure 5. Correlation between the Lysholm score and the
tance of the femoral tunnel position from the anatomic posi- distance of the femoral tunnel position from the anatomic
tion in patients with mild dysplasia. position in patients with mild dysplasia.

Recurrent dislocations were associated with not only Complications

increased trochlear boss height (P \ .001) and more
severe grades of trochlear dysplasia (P \ .001) but also Four knees (5.6%) had postoperative patellar fractures (Fig-
nonanatomic femoral tunnel placement (P = .018). No dif- ure 6). A transverse tunnel had been drilled but was found
ferences were found between recurrent dislocators and to be placed anteriorly in every case. As a result, a 4.5-mm
nondislocators in terms of congruence angle (P = .121), single oblique tunnel was used, with care taken to avoid
lateral patellofemoral angle (P = .375), or patellar height anterior placement in the patients later in the series (Figure
(P = .460). 7). All 4 knees underwent open reduction and internal fixa-
Of the 12 knees suffering recurrent dislocations, 6 with tion with either tension band wiring or screw fixation. No
high-grade dysplasia have since undergone a trochleoplasty further adverse events have been reported in these patients.
procedure with no subsequent dislocations of the patella. Two knees had tibial tuberosity avulsion fractures, which
One knee with mild trochlear dysplasia had a revision were managed nonoperatively, and 1 knee had a tight
MPFL reconstruction with no subsequent dislocations of reconstruction requiring further release.
the patella. The remaining 5 knees are currently being
treated nonoperatively with regular follow-up.
Multivariate logistic regression analysis was also per- DISCUSSION
formed to identify radiographic parameters (congruence
angle, lateral patellofemoral angle, patellar height, troch- Acute patellar dislocation is most common in young
lear dysplasia, trochlear boss height, and position of the female patients, and several factors predispose to recur-
femoral tunnel) that predict postoperative clinical outcome rent dislocations, including patella alta, trochlear dyspla-
(Kujala, Lysholm, and Tegner scores). Distance of the fem- sia, and hyperlaxity.14,17,20 Reconstruction of the MPFL is
oral tunnel from the anatomic position was the only signif- frequently performed when nonoperative management
icant factor found (Kujala score, P = .043; Lysholm score, fails and the patient experiences recurrent patellar dislo-
P = .028). cations. The procedure aims to restore normal patellar

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Vol. 42, No. 3, 2014 Outcome After MPFL Reconstruction 721

Figure 6. Postoperative patellar fracture.

stability by incorporating a graft from the medial aspect

of the patella to the insertion site of the MPFL, recon-
structing the ligament. Various MPFL reconstruction pro-
cedures with a range of grafts and different fixation
methods have been described in the literature, and
reported outcomes are encouraging.{ The procedure is
often combined with a realignment of the distal extensor
mechanism where there is associated lateralization of
the tibial tubercle, with distalization where there is Figure 7. (A) Transverse tunnel showing anterior placement.
patella alta. (B) Oblique tunnel showing ideal placement.
Our current study has demonstrated that isolated
MPFL reconstruction is not a suitable option for patients
with severe trochlear dysplasia (grades C and D). We the tension side of the patella. Intraoperative radiologic
have used 3 clinical outcome measures to determine the screening might also help to alleviate this potentially seri-
success of surgery, Kujala, Lysholm, and Tegner scores, ous complication.
with all 3 measures showing significantly lower postopera- The importance of femoral tunnel placement has been
tive scores in patients with severe trochlear dysplasia. This highlighted in a recent biomechanical study by Elias and
concurs with a recent study by Wagner et al,35 who demon- Cosgarea10 involving computational knee models in which
strated a negative relationship between degrees of troch- they demonstrated that small errors in graft length (3 mm
lear dysplasia and outcome scores. Complication rates shorter) and position (5 mm proximal) can adversely affect
were also unacceptably high in patients with severe the patellofemoral force distribution. Their analysis indi-
dysplasia in our study, with 100% of cases suffering recur- cated that proximal malpositioning of the graft leads to
rent dislocation, in contrast to just 7.4% of patients with increased tension, and the use of a short graft leads to an
mild trochlear dysplasia (grades A and B). increase in medial pressure of more than 50%.
In patients with mild trochlear dysplasia, both Kujala There are several limitations associated with this retro-
and Lysholm scores were significantly greater if the femoral spective study. First, there are no preoperative clinical and
tunnel had been placed within 10 mm of the anatomic inser- functional scores for comparison with the postoperative
tion point. Previous work by Servien et al29 did not find any scores. Preoperative and postoperative radiographs were
correlation between femoral tunnel placement and clinical not available for all of the patients, either because they
outcome; however, Servien et al used a cutoff of just had not been performed or they were technically inade-
7 mm, which we believe to have been too strict. In our expe- quate. Finally, the heterogeneous nature of the grafts
rience, femoral tunnel placement up to 10 mm from the ana- used and the femoral fixation employed limit some of the
tomic position results in consistently good clinical outcome. conclusions that can be drawn.
We concur with the recommendation of Servien et al for the
routine use of intraoperative fluoroscopy to improve the
reproducibility of the femoral tunnel placement.
Four knees had postoperative patellar fractures in this CONCLUSION
study. In all of these patients, technical errors were to
In this study, we report the clinical, functional, and radio-
blame, with the patellar tunnel placed too anteriorly on
graphic results of 68 patients (72 knees) undergoing MPFL
reconstruction in our region for recurrent dislocation of the
{
References 1, 3, 5, 8, 9, 11, 15, 18, 22-27, 31, 33, 34, 37. patella. Clinical and functional outcome scores and

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722 Hopper et al The American Journal of Sports Medicine

radiographic parameters are comparable with those in 15. Gomes JE. Comparison between a static and dynamic technique for
published series of MPFL reconstructions. High rates of medial patellofemoral ligament reconstruction. Arthroscopy.
2008;24(4):430-435.
failure were seen in patients with Dejour grades C and D
16. Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM.
dysplasia, and we suggest that MPFL reconstruction Medial soft tissue restraints in lateral patellar instability and repair.
should not be performed in isolation in patients with Clin Orthop Relat Res. 1998;349:174-182.
severe dysplasia. 17. Hawkins RJ, Bell RH, Anisette G. Acute patellar dislocations: the nat-
In patients with mild dysplasia (Dejour grades A and B), ural history. Am J Sports Med. 1986;14(2):117-120.
a correlation was found between clinical outcome and fem- 18. Howells NR, Barnett AJ, Ahearn N, Ansari A, Eldridge JD. Medial
oral tunnel placement, demonstrating the importance of patellofemoral ligament reconstruction: a prospective outcome
assessment of a large single centre series. J Bone Joint Surg Br.
restoration of the anatomic insertion point of the MPFL 2012;94(9):1202-1208.
when performing this procedure. Intraoperative radiologic 19. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka
screening may help improve the accuracy of femoral tunnel O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2):159-163.
placement. 20. McManus F, Rang M, Heslin DJ. Acute dislocation of the patella in
children: the natural history. Clin Orthop Relat Res. 1979;139:88-91.
21. Nomura E. Classification of lesions of the medial patello-femoral lig-
ament in patellar dislocation. Int Orthop. 1999;23(5):260-263.
ACKNOWLEDGMENT 22. Nomura E, Horiuchi Y, Kihara M. A mid-term follow-up of medial
patellofemoral ligament reconstruction using an artificial ligament
The authors thank Dr Iain Anthony and Dr Julie Wells for for recurrent patellar dislocation. Knee. 2000;7(4):211-215.
their contributions to this work. 23. Nomura E, Inoue M. Hybrid medial patellofemoral ligament recon-
struction using the semitendinosus tendon for recurrent patellar dislo-
cation: minimum 3 years’ follow-up. Arthroscopy. 2006;22(7):787-793.
24. Nomura E, Inoue M, Kobayashi S. Long-term follow-up and knee
REFERENCES osteoarthritis change after medial patellofemoral ligament recon-
struction for recurrent patellar dislocation. Am J Sports Med.
1. Ahmad CS, Brown GD, Stein BS. The docking technique for medial 2007;35(11):1851-1858.
patellofemoral ligament reconstruction: surgical technique and clini- 25. Panni AS, Alam M, Cerciello S, Vasso M, Maffulli N. Medial patellofe-
cal outcome. Am J Sports Med. 2009;37(10):2021-2027. moral ligament reconstruction with a divergent patellar transverse 2-
2. Buckens CF, Saris DB. Reconstruction of the medial patellofemoral tunnel technique. Am J Sports Med. 2011;39(12):2647-2655.
ligament for treatment of patellofemoral instability: a systematic 26. Ronga M, Oliva F, Longo UG, Testa V, Capasso G, Maffulli N. Iso-
review. Am J Sports Med. 2010;38(1):181-188. lated medial patellofemoral ligament reconstruction for recurrent
3. Christiansen SE, Jacobsen BW, Lund B, Lind M. Reconstruction of patellar dislocation. Am J Sports Med. 2009;37(9):1735-1742.
the medial patellofemoral ligament with gracilis tendon autograft in 27. Schottle PB, Fucentese SF, Romero J. Clinical and radiological out-
transverse patellar drill holes. Arthroscopy. 2008;24(1):82-87. come of medial patellofemoral ligament reconstruction with
4. Conlan T, Garth WP Jr, Lemons JE. Evaluation of the medial soft- a semitendinosus autograft for patellar instability. Knee Surg Sports
tissue restraints of the extensor mechanism of the knee. J Bone Joint Traumatol Arthrosc. 2005;13(7):516-521.
Surg Am. 1993;75(5):682-693. 28. Schottle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic
5. Cossey AJ, Paterson R. A new technique for reconstructing the landmarks for femoral tunnel placement in medial patellofemoral lig-
medial patellofemoral ligament. Knee. 2005;12(2):93-98. ament reconstruction. Am J Sports Med. 2007;35(5):801-804.
6. Dejour D, Le Coultre B. Osteotomies in patello-femoral instabilities. 29. Servien E, Fritsch B, Lustig S, et al. In vivo positioning analysis of
Sports Med Arthrosc. 2007;15(1):39-46. medial patellofemoral ligament reconstruction. Am J Sports Med.
7. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral 2011;39(1):134-139.
patellar translation in the human knee. Am J Sports Med. 30. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann
1998;26(1):59-65. C. A systematic review of complications and failures associated with
8. Dopirak R, Adamany D, Bickel B, Steensen R. Reconstruction of the medial patellofemoral ligament reconstruction for recurrent patellar
medial patellofemoral ligament using a quadriceps tendon graft: dislocation. Am J Sports Med. 2012;40(8):1916-1923.
a case series. Orthopedics. 2008;31(3):217. 31. Steiner TM, Torga-Spak R, Teitge RA. Medial patellofemoral ligament
9. Drez D Jr, Edwards TB, Williams CS. Results of medial patellofemoral reconstruction in patients with lateral patellar instability and trochlear
ligament reconstruction in the treatment of patellar dislocation. dysplasia. Am J Sports Med. 2006;34(8):1254-1261.
Arthroscopy. 2001;17(3):298-306. 32. Tegner Y, Lysholm J. Rating systems in the evaluation of knee liga-
10. Elias JJ, Cosgarea AJ. Technical errors during medial patellofemoral lig- ment injuries. Clin Orthop Relat Res. 1985;198:43-49.
ament reconstruction could overload medial patellofemoral cartilage: 33. Thaunat M, Erasmus PJ. The favourable anisometry: an original con-
a computational analysis. Am J Sports Med. 2006;34(9):1478-1485. cept for medial patellofemoral ligament reconstruction. Knee.
11. Ellera Gomes JL, Stigler Marczyk LR, Cesar de Cesar P, Jungblut CF. 2007;14(6):424-428.
Medial patellofemoral ligament reconstruction with semitendinosus 34. Toritsuka Y, Amano H, Mae T, et al. Dual tunnel medial patellofemoral
autograft for chronic patellar instability: a follow-up study. Arthros- ligament reconstruction for patients with patellar dislocation using
copy. 2004;20(2):147-151. a semitendinosus tendon autograft. Knee. 2011;18(4):214-219.
12. Feller JA, Feagin JA Jr, Garrett WE Jr. The medial patellofemoral lig- 35. Wagner D, Pfalzer F, Hingelbaum S, Huth J, Mauch F, Bauer G. The
ament revisited: an anatomical study. Knee Surg Sports Traumatol influence of risk factors on clinical outcomes following anatomical
Arthrosc. 1993;1(3-4):184-186. medial patellofemoral ligament (MPFL) reconstruction using the graci-
13. Fisher B, Nyland J, Brand E, Curtin B. Medial patellofemoral ligament lis tendon. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):318-324.
reconstruction for recurrent patellar dislocation: a systemic review 36. Walch G, Dejour H. Radiology in femoro-patellar pathology. Acta
including rehabilitation and return-to-sports efficacy. Arthroscopy. Orthop Belg. 1989;55(3):371-380.
2010;26(10):1384-1394. 37. Watanabe T, Muneta T, Ikeda H, Tateishi T, Sekiya I. Visual analog
14. Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, White scale assessment after medial patellofemoral ligament reconstruc-
LM. Epidemiology and natural history of acute patellar dislocation. tion: with or without tibial tubercle transfer. J Orthop Sci.
Am J Sports Med. 2004;32(5):1114-1121. 2008;13(2):32-38.

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