Does degree of trochlear dysplasia and position of femoral tunnel influence outcome after medial patellofemoral ligament reconstruction?

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 management 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 determined. Radiographs were analyzed to evaluate congruence angle, lateral patellofemoral angle, patellar height, trochlear dysplasia, 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 tunnels 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.

Knee joint functional range of movement prior to and following total knee arthroplasty measured using flexible electrogoniometry.

The functional ranges of movement of the knee were investigated in a group of patients with knee osteoarthritis (n = 42, mean age 70 years) before, 4 months and at 18-24 months after total knee arthroplasty and then compared with age matched normal subjects (n = 20, mean age 67 years). Flexible electrogoniometry was used to record the maximum flexion-extension angle, the minimum flexion-extension angle and flexion-extension excursions of both knees during eleven functional activities along with the active and passive knee joint range of motion measured using a manual goniometer. Over the eleven functional activities the patients pre-operatively exhibited 28% less knee joint excursion than normal age matched subjects. By 18-24 months following total knee arthroplasty only 2% of this deficit was recovered. Statistically this recovery was only significant in level walking, slope ascent and slope descent. A greater range of movement was measured in a non-weight bearing position than was used in weight bearing functional activity. It is concluded that total knee arthroplasty gives rise to little improvement in knee motion during functional activities and that functional range of movement of the knee remains limited when compared to normal knee function for a minimum of 18 months following operation.