Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-2990-9

KNEE

Bilateral medial patellofemoral ligament reconstruction in high-level athletes Yuichi Kuroda • Takehiko Matsushita • Tomoyuki Matsumoto • Yohei Kawakami Masahiro Kurosaka • Ryosuke Kuroda



Received: 2 July 2013 / Accepted: 3 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014

Abstract This report presents two cases of high-level athletes with bilateral patellar dislocations who were able to return to their preinjury level of activity after bilateral medial patellofemoral ligament (MPFL) reconstruction, without any major complications. Patient 1 was a 19-year-old male volleyball player for a top-level college volleyball team, and patient 2 was a 24-year-old woman who was a member of a national-level adult softball team. MPFL reconstruction could be an effective treatment for bilateral patellar dislocation in high-level athletes. Level of evidence V. Keywords Medial patellofemoral ligament  Recurrent patellar dislocation  Sports  Athletes  Bilateral

Introduction Patellar instability, such as recurrent patellar dislocations, often causes a significant reduction in the patient’s activity level. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the main restraint protecting against lateral patellar displacement [1, 3, 7, 9], and disruption of the MPFL frequently occurs after traumatic patellar dislocation. Therefore, reconstruction of the MPFL has become an accepted surgical technique for the restoration of patellofemoral stability in patients with recurrent patellar dislocation, and successful clinical outcomes have been reported [2, 4, 22].

However, there have been few reports on the return of athletes to sports after MPFL reconstruction. Furthermore, detailed information on the patients’ levels of sports activity has not been well described in previous reports [18]; the efficacy of MPFL reconstruction in high-level athletes remains unknown. Here, in consideration of this question, we present two cases of high-level athletes (Tegner activity level 8) with bilateral patellar dislocations who were able to return to preinjury levels of sports activity after MPFL reconstruction. Surgical techniques Details of our surgical technique were described previously [11, 12]. Briefly, the semitendinosus tendon was harvested, and a lateral release was performed, intra-articularly, with a radiofrequency device, if needed. Two suture anchors were inserted into the patella. A guidewire was then placed between the medial epicondyle and the adductor tubercle so that the length change pattern between the anchors and the insertion point showed a slightly longer pattern during extension and a shorter pattern during deep flexion. A drill hole was then created over the guidewire. The doubled semitendinosus tendon was inserted into the drilled hole and fixed with an interference screw. The free ends of the graft were fixed to the patella with Ethibond sutures (Ethicon, Sommerville, NJ, USA) that were attached to the suture anchors. Case reports

Y. Kuroda  T. Matsushita (&)  T. Matsumoto  Y. Kawakami  M. Kurosaka  R. Kuroda Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan e-mail: [email protected]

Case 1: A volleyball player for a top-level college volleyball team (Tegner activity level 8) A 15-year-old male sustained an injury to his left knee when he landed during a volleyball game. He was

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diagnosed with patellar dislocation and an osteochondral fracture of the patella. As a result, he underwent lateral retinacular release and osteosynthesis at another hospital. After the operation, he experienced several incidents of patellar dislocation. Thus, he was referred from the initial hospital to the Kobe University Hospital at the age of 19 years. He had maintained a full range of motion, and his apprehension sign was positive. A skyline view of his left knee showed severe trochlear dysplasia (sulcus angle, 173.6°; Dejour classification of trochlear dysplasia, type D [5]). MPFL reconstruction was performed on the left knee. Although he returned to volleyball within 6 months, he injured his right knee in the same manner and returned to Kobe University Hospital. The skyline view of the right knee also showed trochlear dysplasia (sulcus angle, 177.0°; Dejour classification of trochlear dysplasia, type C) (Fig. 1a). A surgical treatment, similar to that performed on his left knee, was performed on his right knee. Postoperatively, partial weight bearing with a knee brace was started on the day after surgery, as tolerated. After 1 week, the knee brace was removed, and range of motion exercises was started. Full weight bearing was permitted at 3 weeks, and jogging was permitted at 3 months. He partially re-joined volleyball practices, mainly basic training, 4 months postoperatively. At 6 months, he returned to a preinjury level of sports activity. He did not complain of pain or swelling, and no further

Fig. 1 Case 1, a 19-year-old man. a A postoperative skyline view radiograph of both knees at 30° of knee flexion. b Lateral radiographic views of both knees. One of the suture anchors in the left knee was mistakenly inserted out of the patella during the surgery. The suture anchor did not cause any obvious symptoms

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dislocations occurred, in either knee, as of the last (1 year) postoperative follow-up. Additionally, his Kujala score improved from 70 (preoperatively) to 100 (postoperatively); his postoperative Lysholm score was 100. Case 2: A catcher for an adult, semiprofessional softball team (Tegner activity level 8) A 24-year-old woman visited Kobe University Hospital complaining of instability in both knees. She had experienced her first traumatic patellar dislocation when she was 14 years-old, during a softball game. After the first dislocation, she experienced several patellar dislocations over the following 10 years. The patient had a full range of motion in both knees and her apprehension signs were positive in both knees. The sulcus angles were 141.7° and 142.1° in the skyline views of both knees. Computed tomography (CT) showed a hypoplastic, flat-shaped groove in both knees (Fig. 2a). Surgical intervention was performed on both knees using a method similar to that used in the first patient, but lateral release was not performed. Similar postoperative rehabilitation was performed, as in the first case, during the first 3 months. Jogging and throwing were permitted 3 months after surgery; batting was permitted at 6 months, and catcher-specific training was permitted at 7 months. She was able to return to a preinjury level of sports activity 10 months

Knee Surg Sports Traumatol Arthrosc Fig. 2 Case 2, a 24-year-old woman. a A preoperative axial view of computed tomography of both knees. b A postoperative, lateral view radiograph of both knees

postoperatively. Over a 2-year follow-up period, the patient did not experience any patellar dislocations and both patella tracked stably on the grooves in both knees. Her Kujala score improved from 90 (preoperatively) to 100 (postoperatively), with a postoperative Lysholm score of 100.

Discussion The most important finding of the present study was that MPFL reconstruction could be an effective treatment, even for high-level athletes with bilateral patellar dislocations. Patients with recurrent patellar dislocations do not often play sports; therefore, there have been few reports on the return of athletes to sports after MPFL reconstructions. Ronga et al. [18] examined the efficacy of MPFL reconstructions in patients with recurrent patellar dislocations, including among patients who played sports. They reported that 9 of 28 patients returned to preinjury levels of

sports activity after MPFL reconstructions, suggesting that MPFL reconstructions are effective treatments for patients playing sports. However, their study targeted patients who had unilateral patellar dislocations, without any anatomic predisposing factors, and the efficacy of MPFL reconstructions in highly active patients with predisposing factors was not clarified. In the current study, both patients had bilateral patellar dislocations with anatomic predisposing factors. To the best of our knowledge, reports have not been published concerning patients with bilateral patellar dislocations and anatomic predisposing factors, who have been able to return to preinjury levels of sports activity. Both of the present patients had trochlear dysplasia, which is a major risk factor for patellar instability [6]. One of the main concerns in treating patients who have predisposing factors is the recurrence of patellar instability. Patellar instability and the recurrence of patellar dislocations can be caused by the re-tearing of a graft or graft elongation, and it can occur at the graft insertion site [13]. In our MPFL reconstruction method, we used a

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semitendinosus tendon graft. The graft was anchored using a suture anchor and an interference screw on the patellar and femoral sides, respectively. Mountney et al. [13] reported that the mean tensile strength of the native MPFL was approximately 208 N, which is relatively weak compared with the other graft materials, including the semitendinosus tendon [17]. They also reported that the strength of a reconstruction with a suture anchor technique was 142 N and that a blind-tunnel tendon graft reconstruction, with an interference screw, was 126 N. On the other hand, Lenschow et al. [10] reported that the maximum failure load of the suture anchor technique was 401.5 N. Because the techniques they used were different from our techniques, the strength of our technique is currently unknown. However, our fixation technique appears strong enough to resist the high forces that occur during sports activities. Whether correction of bony abnormalities should be performed for patients with bony predisposing factors remains controversial [15, 21, 23]. Some reports advocate correction of boney abnormalities such as trochleoplasty and tibial tuberosity transfer, combined with MPFL reconstruction [14, 19]. On the other hand, most previous clinical outcomes involving isolated MPFL reconstructions have been favourable [12, 20]. The present cases suggest that osseous surgery may not be necessary when performing MPFL reconstructions, which are effective in broad populations of patients with patellar instability. However, MPFL reconstructions are uncommon among high-level athletes with severe bony predisposing factors, such as in the first case. In addition, the patient was only followed up for 1 year, postoperatively, meaning that additional cases with longer follow-up times are needed to completely address this issue. Several authors have reported complications associated with MPFL reconstructions. Parikh et al. [16] reported that complications occurred in 16.2 % of MPFL reconstructions in young patients with patellar instabilities. Shah et al. [20] reviewed the complications associated with MPFL reconstructions for recurrent patellar dislocations and reported that femoral tunnels have been reported to be critical for successful MPFL reconstructions. Since femoral tunnel positioning was determined after finding an optimal length change graft pattern, the radiographic tunnel positions vary slightly among the operated knees (Figs. 1b, 2b). Therefore, the length change pattern of the graft seems to be important for obtaining successful MPFL reconstruction outcomes. Fisher et al. [8] comprehensively reviewed the efficacy of MPFL reconstructions, including rehabilitation and return-to-sports, in patients with recurrent patellar dislocations. They reported that quadriceps dysfunction was the most common complication. However, both of the patients described in this report regained quadriceps

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function. Generally, high-level athletes have better ability to control their muscles and greater basal muscle power, before surgery, than do non-athletes. Therefore, this might have contributed to the good recovery of our two patients.

Conclusions In conclusion, two high-level athletes with bilateral, recurrent, patellar dislocations underwent MPFL reconstructions. They were able to return to preinjury levels of sports activity, indicating that MPFL reconstructions may be effective treatments for these types of recurrent dislocations, even in high-level athletes. Conflict of interest The authors have no conflicts of interest to declare in this report.

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Bilateral medial patellofemoral ligament reconstruction in high-level athletes.

This report presents two cases of high-level athletes with bilateral patellar dislocations who were able to return to their preinjury level of activit...
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