Medial Patellofemoral Ligament Reconstruction Combined With Distal Realignment for Recurrent Dislocations of the Patella: 5-Year Results of a Randomized Controlled Trial

Abstract

Background: Tibial tubercle transfer (TTT) and medial patellofemoral ligament (MPFL) reconstruction have both shown, either in isolation or in combination, to provide improved patellofemoral joint (PFJ) stability. There are few studies that provide evidence that this remains true in the long term. Purpose: To compare the long-term results of patellar instability after TTT with and without MPFL reconstruction in 2 randomized groups. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 34 patients (36 knees) were randomized to 2 groups. The first group underwent lateral release (LR) and TTT for confirmed maltracking of the patella (control group). The second group underwent MPFL reconstruction in addition to TTT and LR (reconstruction group). Patients were followed up with validated questionnaires (Kujala score, Tegner activity score), a visual analog scale (VAS) assessing their insecurity, and a clinical assessment at a minimum of 5 years postoperatively. Participants also underwent quantitative computed tomography (CT) at 1 year for comparison. Two patients in the control group and 1 patient in the reconstruction group were lost to follow-up at 5 years. Results: There were no significant differences in the Kujala ( P = .75), Tegner ( P = .36), or VAS ( P = .75) scores at any time period. One patient in the control group sustained a patellar redislocation at 3 years. Five patients in the control group and 2 in the reconstruction group had functional failures and required reoperations; however, this was not statistically significant ( P = .30). There were no significant differences between groups in the time to return to school or work ( P = .65) or sports ( P = .38) after surgery. Overall patient satisfaction was higher in the reconstruction group compared with the control group ( P = .04), and quantitative CT scans showed that the reconstruction group had a statistically significant improvement in the mean patellar tilt (6° vs −8°, respectively; P = .03) and mean congruence angle (13° vs −11°, respectively; P = .03) in the quadriceps-contracted state compared with the control group. Conclusion: Reconstruction of the MPFL in addition to TTT and LR resulted in improved alignment parameters (congruence angle, patellar tilt angle) as well as patient satisfaction. The Kujala and Tegner scores were no different between the 2 groups at any time period. There was insufficient evidence to conclude that the addition of MPFL reconstruction to TTT results in fewer redislocations or reoperations. This study concludes that MPFL reconstruction improves PFJ alignment and patient satisfaction; however, further studies with larger patient numbers are required to satisfy its significance with respect to redislocation rates and functional scores in the long term.

The Outcomes of Isolated Distal Realignment Procedures in Patellofemoral Instability: A Systematic Review and Meta-analysis

“…Damasena et al conducted a randomized controlled trial and compared between patients who underwent tibial tubercle transfer with lateral release, and patients who underwent tibial tubercle transfer, lateral release, and medial patellofemoral ligament reconstruction. 21 Similarly, they found that there was no significant difference between the two groups in terms of the rates of patellofemoral dislocation, the pain score, the Kujala score, the Tegner scores, and the time taken to return to work or sports. 21 They went on to conclude that there was insufficient evidence to conclude that the addition of medial patellofemoral ligament reconstruction to tibial tubercle transfer would result in few redislocations or reoperations.…”

“…21 Similarly, they found that there was no significant difference between the two groups in terms of the rates of patellofemoral dislocation, the pain score, the Kujala score, the Tegner scores, and the time taken to return to work or sports. 21 They went on to conclude that there was insufficient evidence to conclude that the addition of medial patellofemoral ligament reconstruction to tibial tubercle transfer would result in few redislocations or reoperations. 21 With these, the current review has identified that isolated distal realignment procedures can lead to a significantly decreased rate of patellofemoral instability or maltracking and a significantly increased in number of patients with excellent or good outcomes postoperatively.…”

“…14 Two other studies have also compared between distal realignment procedures with or without additional proximal realignment procedures. 20,21 However, these studies were not included in the review because even the group without the additional proximal realignment procedures had other proximal realignment procedures. 20,21 Vivod et al compared between isolated proximal realignment procedures, isolated distal realignment procedures, and combined procedures.…”

“…20,21 However, these studies were not included in the review because even the group without the additional proximal realignment procedures had other proximal realignment procedures. 20,21 Vivod et al compared between isolated proximal realignment procedures, isolated distal realignment procedures, and combined procedures. 20 The patients with isolated distal procedures had an Elmslie-Trillat procedure with lateral release while the patients with combined procedures had a combination of tibial tubercle medialization, lateral release, medial reefing, and trocheoplasty.…”

“…21 They went on to conclude that there was insufficient evidence to conclude that the addition of medial patellofemoral ligament reconstruction to tibial tubercle transfer would result in few redislocations or reoperations. 21 With these, the current review has identified that isolated distal realignment procedures can lead to a significantly decreased rate of patellofemoral instability or maltracking and a significantly increased in number of patients with excellent or good outcomes postoperatively. In addition, comparisons between patients with and without additional proximal realignment procedures suggest that additional proximal realignment procedures do not definitely improve the outcomes of distal realignment procedures, and therefore should not be routinely performed in all patients undergoing distal realignment procedures.…”