title: Femoral insertion site of the graft used to replace the medial patellofemoral ligament influences the ligament dynamic changes during knee flexion and the clinical outcome.
abstract: OBJECTIVE
  This study's purpose was to investigate how an ideal anatomic femoral attachment affects the dynamic length change pattern of a virtual medial patellofemoral ligament (MPFL) from an extended to a highly flexed knee position; to determine the relative length and length change pattern of a surgically reconstructed MPFL; and to correlate femoral attachment positioning, length change pattern, and relative graft length with the clinical outcome.
  
  
  METHODS
  Twenty-four knees with isolated nonanatomic MPFL reconstruction were analysed by three-dimensional computed tomography at 0°, 30°, 60°, 90°, and 120° of knee flexion. The lengths of the MPFL graft and a virtual anatomic MPFL were measured. The pattern of length change was considered isometric if the length distance changed <5 mm through the entire dynamic range of motion.
  
  
  RESULTS
  Knee flexion significantly affected the path lengths between the femoral and patellar attachments. The length of the anatomic virtual MPFL decreased significantly from 60° to 120°. Its maximal length was 56.4 ± 6.8 mm at 30°. It was isometric between 0° and 60°. The length of the nonanatomic MPFL with a satisfactory clinical result decreased during flexion from 0° to 120°. Its maximal length was 51.6 ± 4.6 mm at 0° of knee flexion. The lengths measured at 0° and 30° were isometric and statistically greater than the lengths measured at higher flexion degrees. The failed nonanatomic MPFL reconstructions were isometric throughout the dynamic range, being significantly shorter (27.1 ± 13.3 %) than anatomic ligaments.
  
  
  CONCLUSIONS
  The femoral attachment point significantly influences the relative length and the dynamic length change of the grafts during knee flexion-extension and graft isometry. Moreover, it influences the long-term outcome of the MPFL reconstructive surgery. A nonanatomic femoral fixation point should not be considered the cause of persistent pain and instability after MPFL reconstruction in all cases.
  
  
  METHODS
  III.
authors.affiliation: Hospital 9 de Octubre, Valencia, Spain. vicente.sanchis.alfonso@gmail.com.|Hospital Arnau de Vilanova, Valencia, Spain. vicente.sanchis.alfonso@gmail.com.
authors.forename: Vicente
authors.initials: V
authors.lastname: Sanchis-Alfonso
authors.affiliation: Department of Radiology, Hospital Universitario y Politécnico La Fe and GIBI230 IIS La Fe Research Group, Valencia, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Ramirez-Fuentes
authors.affiliation: Agoriaz Orthopedic Center, Riaz, Switzerland.
authors.forename: Erik
authors.initials: E
authors.lastname: Montesinos-Berry
authors.affiliation: Hospital Arnau de Vilanova, Valencia, Spain.
authors.forename: Julio
authors.initials: J
authors.lastname: Domenech
authors.affiliation: Department of Radiology, Hospital Universitario y Politécnico La Fe and GIBI230 IIS La Fe Research Group, Valencia, Spain.
authors.forename: Luis
authors.initials: L
authors.lastname: Martí-Bonmatí
mesh_terms: D000293:Adolescent; D000328:Adult; D001837:Body Weights and Measures; D005260:Female; D005269:Femur / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D021621:Imaging, Three-Dimensional; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D008023:Ligaments, Articular / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D008297:Male; D031222:Patellar Dislocation / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D057071:Patellofemoral Joint / Q000000981:diagnostic imaging* / Q000601:surgery; D016059:Range of Motion, Articular / Q000502:physiology; D014057:Tomography, X-Ray Computed; D019737:Transplants; D055815:Young Adult
keywords: 3D-CT; Anatomic reconstruction; Femoral attachment; Medial patellofemoral ligament; Patella