MPFL positioning on the femoral side

Transcription

1 MPFL positioning on the femoral side Stephen et al AJSM 2012 Prof Dr med Jacques Menetrey, MD, PhD Dr med Philippe Tscholl, MD Centre de médecine de l appareil moteur et du sport - HUG Swiss Olympic medical Center Unité d Orthopédie et Traumatologie du Sport (UOTS) Service de chirurgie orthopédique et traumatologie de l appareil moteur University Hospital of Geneva, Geneva Switzerland

2 Financial disclosure No conflict of interest to disclose

3 Post-operative results Ø No strong correlations between clinical outcomes and tunnel femoral positioning Ø Except if it s far out Servien et al Am J Sports Med 2012 Hopper et al Am J Sports Med 2014 Sanchis Alfonso et al KSSTA 2015

4 Post-operative results Ø Nonanatomic femoral tunnel positioning is associated with unfavorable outcomes! Amis et al Knee 2003 Elias et al Am J Sports Med 2006 Thaunat et al KSSTA 2009 Camp et al Am J Sports Med 2010

5 Post-operative results ü No recurrence of instability in 3-10% ü 25% of complications ü Up to 30% tunnel malpositioning ü Up to 30% with medial knee pain ü 12-30% loose 10 or more of flexion Steensen et al Am J Sports Med 2004 Servien et al Am J Sports med 2012 Shah et al Am J Sports Med 2012 Enderlein et al KSSTA 2015

6 And the solid science Stephen et al Am J Sports Med 2012

7 And the solid science ü The 40/50/60% rule Stephen et al Am J Sports Med 2012

8 Surgical orientation for femoral tunnel positioning in MPFL reconstruction n Radiological landmarks n Palpation n Isometry

9 Radiological landmarks Schöttle et al. Study on 8 cadaveric knees Relatively uniform femoral insertion site of the MPFL Schöttle et al Am J Sports Med 2007

10 Radiological landmarks the downside 1 Redfern et al seeking to confirm Schöttle s point Found difference of 5mm in the A-P and 7 mm proximal to distal Redfern et al Am J Sports Med 2010 «Bony architecture varies as a consequence of weight bearing activity undertaken by the patients. Therefore, the posterior femoral cortex may not represent a consistent anatomic landmark for use in determination of the femoral tunnel» Stephen et al Am J Sports Med 2012

11 Radiological landmarks -the downside 2 Barnett et al. Study on 10 cadaveric knees Relatively uniform femoral insertion site of the MPFL Barnett et al KSSTA 2012

12 Radiological landmarks - the downside 2 Barnett et al. Study on 10 cadaveric knees In accordance with Schoettle point Malrotation of 5-10 may lead to tunnel malplacement Ziegler et al Study on 10 cadaveric knees 4mm difference to Schoettle point 5 of malrotation causes 7-9mm points displacement Barnett et al KSSTA 2012 Ziegler et al Am J Sports Med 2016

13 Surgical anatomy The MPFL and its relation to: n n n n n VMO Quadriceps tendon Posteromedial capsule MCL prox insertion Adductor tubercle Nomura et al KSSTA 2005

14 Palpation (surface anatomy) AT The deep fibres attach 10mm fmpfl distal AT The superficial fibres are attached to the PMC 7mm proximal and 7mm anterior to the medial epicondyle Nomura et al KSSTA 2005 Victor et al Am J Sports Med 2009

15 Isometry «Non-isometric positioning may cause restricted patellar movement, loss of knee joint range of motion, increased medial patellofemoral joint contact pressures, graft failure, or recurrent dislocation. The native MPFL has previously been identified as «close to isometric» Stephen et al Am J Sports Med 2012

16 Testing isometry Along the entire ROM Most important no increase in tension in higher flexion Small laxity in extension can be tolerated Nomura et al KSSTA 2005 Victor et al Am J Sports Med 2009

17 Where is the dead zone? Beware not to be proximal or distal Stephen et al Am J Sports Med 2012

18 In conclusion Good surgical exposition Identification of the ME and the AT Palpation AT fmpfl K-wire Testing of the isometry Fixation with an interference screw NOT SURE, USE FLUO!!

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