Safe Drilling Paths in the Distal Femoral Epiphysis for Pediatric Medial Patellofemoral Ligament Reconstruction

2016 ◽  
Vol 45 (5) ◽  
pp. 1085-1089 ◽  
Author(s):  
Cynthia V. Nguyen ◽  
Lutul D. Farrow ◽  
Raymond W. Liu ◽  
Allison Gilmore
Keyword(s):  
Computer Aided Design ◽  
Medial Patellofemoral Ligament ◽  
Sagittal Plane ◽  
Insertion Site ◽  
Attachment Site ◽  
Surgical Reconstruction ◽  
Skeletally Immature ◽  
Femoral Cartilage ◽  
Distal Femoral Epiphysis ◽  
Femoral Physis

Background: Anatomic surgical reconstruction of the medial patellofemoral ligament (MPFL) has been popularized for the treatment of recurrent patellar instability in the skeletally immature population. Previous anatomic studies have found that the femoral attachment point of the MPFL is very close to the distal femoral physis. Purpose: To establish the safe angles for drilling the distal femoral epiphysis for MPFL graft placement. Study Design: Descriptive laboratory study. Methods: A total of 23 cadaveric distal femoral epiphyses were scanned into high-resolution 3-dimensional images. Using computer-aided design, we identified and marked the femoral insertion site of the MPFL. Cylinders 8 mm in diameter were placed at varying angles to simulate the drill paths for placement of 6-mm interference screws with a 1-mm buffer. The distance from the MPFL footprint to where the tunnel first violated the physis, the intercondylar notch, or the distal cartilage was measured. We recorded the percentage of tunnels that caused violations before reaching 20 mm, the shortest length of a typical femoral tunnel socket. Results: Measurements indicated that 41% of tunnels angled distally less than 10° violated the physis, 40% of tunnels angled distally more than 10° but anteriorly less than 10° violated the notch, and 27% of tunnels angled distally and anteriorly more than 20° violated the distal femoral cartilage. At least 90% of the tunnels were safe at 20 mm when the drill was angled between 15° and 20° both anteriorly and distally. Conclusion: Because of the anatomy of the distal femoral physis, drilling into the epiphysis from the MPFL attachment site at improper trajectories risks damage to sensitive structures. Angling the drill to an acceptable degree distally and anteriorly leads to less risk to the physis and notch, respectively, but angling too much leads to risk to the distal femoral cartilage. Small variations in the sagittal plane were better tolerated than variations in the coronal plane, so we recommend that more attention be paid to the radiographic anteroposterior view intraoperatively. It is safest to angle the drill distally and anteriorly approximately 15° to 20° in each plane from the MPFL attachment site. Clinical Relevance: During drilling into the distal femoral epiphysis at the MPFL origin in skeletally immature patients, angling the drill appropriately 15° to 20° both distally and anteriorly minimizes damage to the physis, notch, and distal femoral cartilage.

Variation in the Medial Patellofemoral Ligament Origin in the Skeletally Immature Knee: An Anatomic Study

2017 ◽  
Vol 46 (2) ◽  
pp. 363-369 ◽  
Author(s):  
Kevin G. Shea ◽  
W. Duncan Martinson ◽  
Peter C. Cannamela ◽  
Connor G. Richmond ◽  
Peter D. Fabricant ◽  
...  
Keyword(s):  
Medial Patellofemoral Ligament ◽  
Anatomic Variation ◽  
Femoral Condyle ◽  
Age Groups ◽  
Surgical Reconstruction ◽  
Skeletally Immature ◽  
Computed Tomography Scans ◽  
The Mean ◽  
Femoral Physis ◽  
Patellar Stability

Background: The medial patellofemoral ligament (MPFL) is frequently reconstructed to treat recurrent patellar instability. The femoral origin of the MPFL is well described in adults but not in the skeletally immature knee. Purpose: To identify a radiographic landmark for the femoral MPFL attachment in the skeletally immature knee and study its relationship to the distal femoral physis. Study Design: Descriptive laboratory study. Methods: Thirty-six cadaveric specimens between 2 and 11 years old were dissected and examined (29 male and 7 female). Metallic markers were placed at the proximal and distal borders of the MPFL femoral origin footprint. Computed tomography scans with 0.625-mm slices in the axial, coronal, and sagittal planes were used to measure the maximum ossified height and ossified depth. The measurements were used to describe the position of the midpoint MPFL attachment with respect to the posterior-anterior and distal-proximal dimensions of the femoral condyle on the sagittal view and to describe the distance from the physis to the femoral origin of the MPFL. Results: In 23 of 36 specimens, the femoral origin of the MPFL was distal to the physis. Thirteen of the 36 specimens had an MPFL origin at or proximal to the physis, with a more proximal MPFL origin consistently seen in older specimens. The distance of the MPFL origin to the physis ranged from 15.1 mm distal to the physis to 8.3 mm proximal to the physis. The mean midpoint of the MPFL femoral origin was located 3.0 ± 5.5 mm distal to the physis for all specimens. For specimens aged <7 years, the mean MPFL origin was 4.7 mm distal to the physis, and for specimens aged ≥7 years, the mean MPFL origin was 0.8 mm proximal to the femoral physis. The MPFL origin was more proximal and anterior for those aged ≥7 years and more distal and posterior for those aged <7 years. Conclusion: Surgical reconstruction of the MPFL is a common treatment to restore patellar stability. There appears to be significant variability in the origin of the MPFL in skeletally immature specimens. This study demonstrated that the MPFL origin was more proximal and anterior with respect to the physis in the older age group. The MPFL origin footprint may be customized for different age groups. Clinical Relevance: This information shows anatomic variation of the MPFL origin with age, with older specimens having a footprint that was more proximal and anterior than younger specimens. Customization of the surgical technique might be considered based on patient age.

Relationship of the Medial Patellofemoral Ligament Origin on the Distal Femur to the Distal Femoral Physis: A Systematic Review

2020 ◽  
Vol 49 (1) ◽  
pp. 261-266 ◽  
Author(s):  
Kyle R. Sochacki ◽  
Kevin G. Shea ◽  
Kunal Varshneya ◽  
Marc R. Safran ◽  
Geoffrey D. Abrams ◽  
...  
Keyword(s):  
Systematic Review ◽  
Quality Assessment ◽  
Study Design ◽  
Medial Patellofemoral Ligament ◽  
Distal Femur ◽  
Assessment Tool ◽  
Risk Of Bias ◽  
Skeletally Immature ◽  
Quality Assessment Tool ◽  
Femoral Physis

Background: The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies. Purpose: To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants. Study Design: Systematic review. Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean ± SD. Categorical variable data were reported as frequency with percentage. Results: Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 ± 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 ± 2.4 mm. Conclusion: The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.

Comparison of Ligament Isometry and Patellofemoral Contact Pressures for Medial Patellofemoral Ligament Reconstruction Techniques in Skeletally Immature Patients

2020 ◽  
Vol 48 (14) ◽  
pp. 3557-3565
Author(s):  
Sheena R. Black ◽  
Kathleen N. Meyers ◽  
Joseph T. Nguyen ◽  
Daniel W. Green ◽  
Jacqueline M. Brady ◽  
...  
Keyword(s):  
Medial Patellofemoral Ligament ◽  
Pressure Sensors ◽  
Contact Forces ◽  
Mpfl Reconstruction ◽  
Equation Modeling ◽  
Trochlear Groove ◽  
Skeletally Immature ◽  
Patellar Kinematics ◽  
Femoral Physis ◽  
Skeletally Immature Patient

Background: Adult medial patellofemoral ligament (MPFL) reconstruction techniques are not appropriate for the skeletally immature patient given the proximity of the distal femoral physis. Biomechanical consequences of reconstructions aimed at avoiding the physis have not been adequately studied. Purpose: To quantify the biomechanical effects of MPFL reconstruction techniques intended for skeletally immature patients. Study Design: Controlled laboratory study Methods: Four MPFL reconstruction techniques were evaluated using a computationally augmented cadaveric model: (1) Schoettle point: adult-type reconstruction; (2) epiphyseal: socket distal to the femoral physis; (3) adductor sling: graft wrapped around the adductor tendon; (4) adductor transfer: adductor tendon transferred to patella. A custom testing frame was used to cycle 8 knees for each technique from 10° to 110° of flexion. Patellofemoral kinematics were recorded using a motion camera system, contact stresses were recorded using Tekscan pressure sensors, and MPFL length was computed using an inverse kinematics computational model. Change in MPFL length, patellar facet forces, and patellar kinematics were compared using generalized estimating equation modeling. Results: Schoettle point reconstruction was the most isometric, demonstrating isometry from 10° to 100°. The epiphyseal technique was isometric until 60°, after which the graft loosened with increasing flexion. The adductor sling and adductor transfer techniques were significantly more anisometric from 40° to 110°. Both grafts tightened with knee flexion and resulted in significantly more lateral patellar tilt versus the intact state in early flexion and significantly higher contact forces on the medial facet versus the epiphyseal technique in late flexion. Conclusion: In this cadaveric simulation, the epiphyseal technique allowed for a more isometric ligament until midflexion, when the patella engaged within the trochlear groove. The adductor sling and adductor transfer grafts became tighter in flexion, resulting in potential loss of motion, pain, graft stretching, and failure. Marginal between-condition differences in patellofemoral contact mechanics and patellar kinematics were observed in late flexion. Clinical Relevance: In the skeletally immature patient, using an epiphyseal type MPFL reconstruction with the femoral attachment site distal to the physis results in a more isometric graft compared with techniques with attachment sites proximal to the physis.

The Relationship of the Femoral Origin of the Anterior Cruciate Ligament and the Distal Femoral Physeal Plate in the Skeletally Immature Knee

2001 ◽  
Vol 29 (6) ◽  
pp. 781-787 ◽  
Author(s):  
Christopher T. Behr ◽  
Hollis G. Potter ◽  
George A. Paletta
Keyword(s):  
Anterior Cruciate Ligament ◽  
Sagittal Plane ◽  
Cruciate Ligament ◽  
Spatial Relationship ◽  
Skeletally Immature ◽  
Proliferative Zone ◽  
Anterior Cruciate ◽  
Femoral Physis ◽  
Relationship Of ◽  
Over The Top

We defined the anatomic relationship of the anterior cruciate ligament femoral origin to the distal femoral physis in the skeletally immature knee with use of 12 fresh-frozen human fetal specimens (ages, 20 to 36 weeks). Each specimen underwent magnetic resonance imaging, was dissected free of soft tissue, sectioned in the sagittal plane, and stained. The spatial relationship of 1) the epiphyseal side of the physeal proliferative zone to the nearest point of bony attachment of the anterior cruciate ligament and 2) the origin of the anterior cruciate ligament to the over-the-top position were measured. The same measurements were made in 13 skeletally immature knees (ages, 5 to 15 years). We found that the femoral origin of the fetal anterior cruciate ligament developed as a confluence of ligament fibers with periosteum at 20 weeks, vascular invasion into the epiphysis at 24 weeks, and establishment of a secure epiphyseal attachment by 36 weeks. In the fetus, the distance from the anterior cruciate ligament femoral origin to the epiphysis was 2.66 ± 0.18 mm (range, 2.34 to 2.94). There was no significant change in this distance in adolescent specimens (2.92 ± 0.68 mm; range, 2.24 to 3.62). The over-the-top position was at the level of the distal femoral physis.

scholarly journals Medial Patellofemoral Ligament Reconstruction and Nonanatomic Stabilization Techniques in Skeletally Immature Patients

Joints ◽  
2019 ◽  
Author(s):  
Carola Pilone ◽  
Davide Edoardo Bonasia ◽  
Federica Rosso ◽  
Umberto Cottino ◽  
Claudio Mazzola ◽  
...  
Keyword(s):  
Medial Patellofemoral Ligament ◽  
Patellofemoral Instability ◽  
High Recurrence Rate ◽  
Skeletally Immature ◽  
Anatomical Features ◽  
Children And Adolescent ◽  
Close Proximity ◽  
Surgical Options ◽  
Femoral Physis ◽  
The Relationship

AbstractPatellar instability is a common cause of knee disability in children and adolescent, with a high recurrence rate. When conservative treatment fails, surgical options should be considered. The femoral insertion of the medial patellofemoral ligament (MPFL) is in close proximity to the distal femoral growth plate and precautions should be taken to avoid injuries to the physis. Anatomical features of the MPFL complex, with focus on the relationship between femoral MPFL attachment and femoral physis, are discussed together with surgical tips to avoid injuries to the growth plates. The aim of this article is to review the recent literature regarding MPFL reconstruction and other stabilization techniques for patellofemoral instability in skeletally immature patients, focusing on the different surgical options available. These can be classified as anatomical versus nonanatomical, proximal versus distal realignments, or based on the graft used: free graft and pedicled graft (quadriceps, patellar tendon, hamstring, and adductor magnus).

Anatomic Reconstruction of the Medial Patellofemoral Ligament in Children and Adolescents With Open Growth Plates

2012 ◽  
Vol 41 (1) ◽  
pp. 58-63 ◽  
Author(s):  
Manfred Nelitz ◽  
Jens Dreyhaupt ◽  
Heiko Reichel ◽  
Julia Woelfle ◽  
Sabine Lippacher
Keyword(s):  
Medial Patellofemoral Ligament ◽  
Trochlear Dysplasia ◽  
Patellofemoral Instability ◽  
Activity Score ◽  
Anatomic Reconstruction ◽  
Skeletally Immature ◽  
Kujala Score ◽  
Open Growth Plates ◽  
Femoral Physis ◽  
Open Growth

Background: Recurrent lateral patellar dislocation is a common knee injury in the skeletally immature adolescent. Because of the open physis, operative therapy in children is challenging. This study presents the outcomes of a minimally invasive technique for anatomic reconstruction of the medial patellofemoral ligament (MPFL) in children that respects the distal femoral physis. Hypothesis: Anatomic reconstruction of the MPFL in children that maintains the distal femoral physis will prevent redislocation, preserve the distal femoral physis, and improve knee function. Study Design: Case series; Level of evidence, 4. Methods: Twenty-one consecutive patients with patellofemoral instability and open growth plates underwent anatomic reconstruction of the MPFL that maintained the distal femoral growth plate. Preoperative radiographic examination included AP and lateral views to assess patella alta and limb alignment. Magnetic resonance imaging was performed to evaluate trochlear dysplasia and tibial tubercle–trochlear groove (TT-TG) distance. Evaluation included preoperative and postoperative physical examination, Kujala score, and Tegner activity score. Results: The average age at the time of operation was 12.2 years (range, 10.3-13.9). The average follow-up after operation was 2.8 years after surgery (range, 2.0-3.6). No recurrent dislocation occurred, but 2 patients with high-grade trochlear dysplasia still had a positive apprehension sign. The Kujala score significantly improved from 72.9 (range, 37-87) preoperatively to 92.8 (range, 74-100) postoperatively ( P < .01). The Tegner activity score decreased, but not significantly, from 6.0 (range, 3-9) preoperatively to 5.8 (range, 3-9) postoperatively ( P = .48). Conclusion: Anatomic reconstruction of the MPFL that respects the distal femoral physis in skeletally immature patients is a safe and effective technique for the treatment of patellofemoral instability and allows patients to return to sports without redislocation of the patella.

Anatomic and Biomechanical Properties of Flat Medial Patellofemoral Ligament Reconstruction Using an Adductor Magnus Tendon Graft: A Human Cadaveric Study

2021 ◽  
pp. 036354652110095
Author(s):  
Danko Dan Milinkovic ◽  
Christian Fink ◽  
Christoph Kittl ◽  
Petri Silanpää ◽  
Elmar Herbst ◽  
...  
Keyword(s):  
Medial Patellofemoral Ligament ◽  
Biomechanical Properties ◽  
Mpfl Reconstruction ◽  
Maximum Elongation ◽  
Skeletally Immature ◽  
Femoral Insertion ◽  
Adductor Tubercle ◽  
Adductor Magnus ◽  
Load To Failure ◽  
The Mean

Background: In contrast to the majority of existing techniques for reconstruction of the medial patellofemoral ligament (MPFL), the technique described in this article uses the adductor magnus muscle tendon to gain a flat, broad graft, leaving its distal femoral insertion intact, and does not require drilling within or near the femoral physis. It also allows for soft tissue patellar fixation and could facilitate anatomic MPFL reconstruction in skeletally immature patients. Purpose: To evaluate the anatomic and structural properties of the native MPFL and the adductor tendon (AT), followed by biomechanical evaluation of the proposed reconstruction. Study Design: Descriptive laboratory study. Methods: The morphological and topographical features of the AT and MPFL were evaluated in 12 fresh-frozen cadaveric knees. The distance between the distal insertion of the AT on the adductor tubercle and the adductor hiatus, as well as the desired length of the graft, was measured to evaluate this graft’s application potential. Load-to-failure tests were performed to determine the biomechanical properties of the proposed reconstruction construct. The construct was placed in a uniaxial testing machine and cyclically loaded 500 times between 5 and 50 N, followed by load to failure, to measure the maximum elongation, stiffness, and maximum load. Results: The mean ± SD length of the AT was 12.6 ± 1.5 cm, and the mean distance between the insertion on the adductor tubercle and adductor hiatus was 10.8 ± 1.3 cm, exceeding the mean desired length of the graft (7.5 ± 0.5 cm) by 3.3 ± 0.7 cm. The distal insertion of the AT was slightly proximal and posterior to the insertion of the MPFL. The maximum elongation after cyclical loading was 1.9 ± 0.4 mm. Ultimately, the mean stiffness and load to failure were 26.2 ± 7.6 N/mm and 169.7 ± 19.2 N, respectively. The AT graft failed at patellar fixation in 2 of the initially tested specimens and at the femoral insertion in the remaining 10. Conclusion: The described reconstruction using the AT has potential for MPFL reconstruction. The AT graft presents a graft of significant volume, beneficial anatomic topography, and adequate tensile properties in comparison with the native MPFL following the data from previously published studies. Clinical Relevance: Given its advantageous anatomic relationship as an application that avoids femoral drilling and osseous patellar fixation, the AT may be considered a graft for MPFL reconstruction in skeletally immature patients.

Posterior Cruciate Ligament Femoral Insertion Site Characteristics: Importance for Reconstructive Procedures

2002 ◽  
Vol 30 (5) ◽  
pp. 643-651 ◽  
Author(s):  
Etienne A. Mejia ◽  
Frank R. Noyes ◽  
Edward S. Grood
Keyword(s):  
Articular Cartilage ◽  
Posterior Cruciate Ligament ◽  
Cruciate Ligament ◽  
Insertion Site ◽  
Femoral Shaft ◽  
Surgical Reconstruction ◽  
Anatomic Study ◽  
Reconstructive Procedures ◽  
Femoral Attachment ◽  
Site Characteristics

Background: Previous descriptions of the insertion site of the posterior cruciate ligament are inadequate. Hypothesis: More than one reference system is required to adequately represent the anatomy of the femoral attachment. Study Design: Descriptive anatomic study. Methods: Twelve cadaveric specimens were evaluated by using two measurement methods relative to the femoral articular cartilage margin and two methods relative to the intercondylar femoral roof. Results: Reference lines perpendicular to the articular cartilage best defined the 12- and 1-o'clock positions, and those perpendicular to the articular cartilage or parallel to the femoral shaft best defined the 2-, 3-, and 4-o'clock positions. The angle of the proximal attachment to the roof was 88° ± 5.5°. The posterior cruciate ligament was a continuum of fibers rather than two distinct bundles, and its attachment showed variability in shape and thickness, extending past the midline in the notch (11:21 ± 15 minutes to 4:12 ± 20 minutes, right knee). Conclusions: More than one measurement system is required to accurately describe the femoral origin of the posterior cruciate ligament. Clinical Relevance: Accurate assessment of the anatomy is crucial for successful surgical reconstruction of the posterior cruciate ligament femoral attachment.

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