Lateral Patellofemoral Ligament Reconstruction: A Biomechanical Comparison of 2 Techniques

Abstract

Background: The importance of maintaining lateral patellar stabilizing structures has been demonstrated by the presence of iatrogenic medial patellar instability after lateral retinacular release (LRR) procedures. In patients with medial patellar instability, lateral patellofemoral ligament (LPFL) reconstruction has been clinically shown to restore patellar stability while improving patient-reported outcomes. However, the biomechanics associated with different LPFL reconstruction techniques remain largely unknown. Purpose: To (1) investigate whether LPFL reconstruction restores medial patellar translation compared with the intact state after LRR and (2) evaluate for any biomechanical differences between soft tissue and osseous LPFL reconstruction techniques. Study Design: Controlled laboratory study. Methods: A total of 7 knees were included in the final analysis. The knees were dissected, and the tibia and femur were potted. An eye screw was then placed at the midpoint of the patella perpendicular to the medial surface. A custom jig was constructed to allow for a 1-kg load to be applied to the quadriceps muscle. Medial patellar displacement was investigated at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of knee flexion using a tensile testing machine with a 20-N medial force applied to the patella. Medial patellar displacement was assessed in 4 states: intact, LRR, soft tissue LPFL reconstruction (inserted through incisions in the iliotibial band, quadriceps tendon, and patellar tendon), and osseous LPFL reconstruction. Results: The LRR group had significantly greater medial patellar translation compared with the intact group throughout flexion ( P < .01 to P = .029). The soft tissue LPFL reconstruction group demonstrated significantly greater medial patellar translation at 30° ( P = .020) and 45° ( P = .025) compared with the intact group, with less translation compared with the LRR group at all degrees of knee flexion except for 45° ( P = .065). The osseous LPFL reconstruction group demonstrated significantly greater medial patellar translation compared with the intact group at 30° of flexion ( P = .036), with significantly less translation compared with the LRR group from 0° to 30° ( P < .01 to P = .013). The soft tissue LPFL reconstruction group (15.94 ± 2.55 mm) demonstrated significantly greater medial patellar translation at 10° of flexion compared with the osseous LPFL reconstruction group (14.16 ± 2.34 mm) ( P = .033). Conclusion: Soft tissue LPFL reconstruction led to significantly greater medial patellar translation at 30° and 45° compared with the intact state, while osseous LPFL reconstruction produced significantly greater translation only at 30°. Both the soft tissue and the osseous reconstruction techniques resulted in comparable medial patellar translation at all degrees of knee flexion except for 10°, in which osseous reconstruction was more similar to the intact state. Clinical Relevance: Compared with LRR, soft tissue LPFL reconstruction was able to restore stability against medial patellar translation at most degrees of knee flexion, while osseous LPFL reconstruction did not provide adequate stabilization beyond 30° of flexion. While the LPFL does appear to have osseous insertions, soft tissue reconstruction functioned more similarly to the intact state after LRR.

Quadriceps Muscle and Medial Retinaculum Combinate Effects on Patellar Instability during Knee Flexion

“…The study of patellofemoral joint stability has been the subject of much research, focusing on the interaction of various factors, including quadriceps muscle forces, retinacular structures, tibial rotation, and articular geometry [31,32]. Some authors have extended the analysis of Q-angle [33,34], quadriceps tension imbalances [35] and retinacular releases on patellar kinematics and contact patterns [36]. Others have examined the role of tibial rotation and the correlation between patellar tracking and femoral and patellar topography [37][38][39].…”