title: Effect of Medial Patellofemoral Ligament Reconstruction Method on Patellofemoral Contact Pressures and Kinematics.
abstract: There remains a lack of evidence regarding the optimal method when reconstructing the medial patellofemoral ligament (MPFL) and whether some graft constructs can be more forgiving to surgical errors, such as overtensioning or tunnel malpositioning, than others.
  
  
  
  The null hypothesis was that there would not be a significant difference between reconstruction methods (eg, graft type and fixation) in the adverse biomechanical effects (eg, patellar maltracking or elevated articular contact pressure) resulting from surgical errors such as tunnel malpositioning or graft overtensioning.
  
  
  
  Controlled laboratory study.
  
  
  
  Nine fresh-frozen cadaveric knees were placed on a customized testing rig, where the femur was fixed but the tibia could be moved freely from 0° to 90° of flexion. Individual quadriceps heads and the iliotibial tract were separated and loaded to 205 N of tension using a weighted pulley system. Patellofemoral contact pressures and patellar tracking were measured at 0°, 10°, 20°, 30°, 60°, and 90° of flexion using pressure-sensitive film inserted between the patella and trochlea, in conjunction with an optical tracking system. The MPFL was transected and then reconstructed in a randomized order using a (1) double-strand gracilis tendon, (2) quadriceps tendon, and (3) tensor fasciae latae allograft. Pressure maps and tracking measurements were recorded for each reconstruction method in 2 N and 10 N of tension and with the graft positioned in the anatomic, proximal, and distal femoral tunnel positions. Statistical analysis was undertaken using repeated-measures analyses of variance, Bonferroni post hoc analyses, and paired t tests.
  
  
  
  Anatomically placed grafts during MPFL reconstruction tensioned to 2 N resulted in the restoration of intact medial joint contact pressures and patellar tracking for all 3 graft types investigated (P > .050). However, femoral tunnels positioned proximal or distal to the anatomic origin resulted in significant increases in the mean medial joint contact pressure, medial patellar tilt, and medial patellar translation during knee flexion or extension, respectively (P < .050), regardless of graft type, as did tensioning to 10 N.
  
  
  
  The importance of the surgical technique, specifically correct femoral tunnel positioning and graft tensioning, in restoring normal patellofemoral joint (PFJ) kinematics and articular cartilage contact stresses is evident, and the type of MPFL graft appeared less important.
  
  
  
  The correct femoral tunnel position and graft tension for restoring normal PFJ kinematics and articular cartilage contact stresses appear to be more important than graft selection during MPFL reconstruction. These findings emphasize the importance of the surgical technique when undertaking this procedure.
authors.affiliation: Mechanical Engineering Department, Imperial College London, London, UK.
authors.forename: Joanna M
authors.initials: JM
authors.lastname: Stephen
authors.affiliation: Mechanical Engineering Department, Imperial College London, London, UK.
authors.forename: Christoph
authors.initials: C
authors.lastname: Kittl
authors.affiliation: Fortius Clinic, London, UK.
authors.forename: Andy
authors.initials: A
authors.lastname: Williams
authors.affiliation: Department of Sports Traumatology, Rizzoli Institute, Bologna, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Zaffagnini
authors.affiliation: Department of Sports Traumatology, Rizzoli Institute, Bologna, Italy.
authors.forename: Giulio Maria
authors.initials: GM
authors.lastname: Marcheggiani Muccioli
authors.affiliation: Gelenkpunkt, Innsbruck, Austria.
authors.forename: Christian
authors.initials: C
authors.lastname: Fink
authors.affiliation: Mechanical Engineering Department, Imperial College London, London, UK a.amis@imperial.ac.uk.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Amis
mesh_terms: D000328:Adult; D000368:Aged; D064591:Allografts / Q000706:statistics & numerical data; D001178:Arthroplasty / Q000379:methods*; D001696:Biomechanical Phenomena; D002102:Cadaver; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017847:Patellar Ligament / Q000601:surgery*; D057071:Patellofemoral Joint / Q000502:physiology* / Q000601:surgery; D011312:Pressure; D055815:Young Adult
keywords: contact pressures; gracilis; graft; medial patellofemoral ligament (MPFL) reconstruction; patellar instability; patellofemoral tracking; quadriceps tendon; surgery; tensor fasciae latae