Research progress on femoral attachment positioning during medial patellofemoral ligament reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YAN Peng’an ¹ , LU Fan ^1,2,3 , CAI Yifan ¹ , YAN Zhenxing ¹ , WEI Yuqiao ¹ , SUN Chongxiao ¹ , GENG Bin ^1,2,3 ,  XIA Yayi ^1,2,3

1. Department of Orthopaedics , the Second Hospital of Lanzhou University, Lanzhou Gansu, 730030, P. R. China;
2. Orthopaedic Clinical Research Center of Gansu Province, Lanzhou Gansu, 730030, P. R. China;
3. Intelligent Orthopaedic Industry Technology Center of Gansu Province, Lanzhou Gansu, 730030, P. R. China;

Corresponding?author：

XIA Yayi, Email: xiayy@lzu.edu.cn

Keywords：

Patellar dislocation; medial patellofemoral ligament reconstruction; femoral attachment positioning; research progress

DOI：

10.7507/1002-1892.202405051

Video：

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Objective To review research progress on femoral attachment positioning during medial patellofemoral ligament (MPFL) reconstruction, so as to provide a reference for accurate positioning in clinic. Methods The literature at home and abroad on femoral attachment positioning during MPFL reconstruction was extensively reviewed and summarized. Results MPFL is the main ligament that restricts patellar outward migration, so MPFL reconstruction is the main treatment for patellar dislocation, but the accuracy of intraoperative femoral attachment positioning will significantly affect the effectiveness. At present, there are three main methods for femoral attachment positioning in MPFL reconstruction, including imaging positioning, bony landmark positioning, and new technology. Among them, the main imaging positioning method is the “Sch?ttle point” method, but it has high requirements for fluoroscopic positioning, and can only be accurately positioned under standard lateral fluoroscopy of the femur. The bony landmark positioning method mainly locates the femoral attachment by touching or dissecting the bony landmarks such as adductor tubercles and medial epicondyle of femur, but its disadvantages are that the positioning is not accurate enough, the intraoperative visual field exposure requirements are high, and a large incision is required. In order to avoid the problem that the simple bony landmark positioning method, in recent years, the combination of bony landmarks combined with arthroscopy, three-dimensional (3D) printing technology, and robot-assisted positioning methods have begun to be used in clinical practice. New technology localization methods have shown good results by preparing guides before operation, planning positioning paths in advance, or directly using robots to assist positioning during operation. Conclusion The accurate positioning of the femoral attachment in MPFL reconstruction is crucial, and the method of accurate and rapid intraoperative determination needs to be further improved and optimized. In the future, it is expected that the combination of computer image recognition correction technology and intraoperative position assistance will solve this problem.

Citation： YAN Peng’an, LU Fan, CAI Yifan, YAN Zhenxing, WEI Yuqiao, SUN Chongxiao, GENG Bin, XIA Yayi. Research progress on femoral attachment positioning during medial patellofemoral ligament reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(10): 1276-1282. doi: 10.7507/1002-1892.202405051 Copy

1.	Baer MR, Macalena JA. Medial patellofemoral ligament reconstruction: patient selection and perspectives. Orthop Res Rev, 2017, 9: 83-91.
2.	Patil S, Ahmad M, Patel M, et al. Cadaveric study to define the anatomy of the medial patellofemoral ligament (MPFL) and its variant patterns. Cureus, 2023, 15(5): e39333. doi: 10.7759/cureus.39333.
3.	Hopper GP, Leach WJ, Rooney BP, et al. Does degree of trochlear dysplasia and position of femoral tunnel influence outcome after medial patellofemoral ligament reconstruction? Am J Sports Med, 2014, 42(3): 716-722.
4.	Anbari A, Cole BJ. Medial patellofemoral ligament reconstruction: a novel approach. J Knee Surg, 2008, 21(3): 241-245.
5.	黃勇, 陳斐, 楊遠, 等. 內側髕股韌帶聯合髕脛韌帶重建治療髕骨不穩的研究進展. 中華骨與關節外科雜志, 2021, 14(1): 70-75.
6.	Maione A, Tradati D, Ferrua P, et al. Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome. Knee Surg Sports Traumatol Arthrosc, 2023, 31(7): 2810-2817.
7.	McCarthy M, Ridley TJ, Bollier M, et al. Femoral tunnel placement in medial patellofemoral ligament reconstruction. Iowa Orthop J, 2013, 33: 58-63.
8.	阿依丁·夏哈太, 張克遠, 劉陽. 內側髕股韌帶重建術后股骨隧道位置對膝關節功能的影響研究. 中國修復重建外科雜志, 2015, 29(8): 951-954.
9.	Tscholl PM, Ernstbrunner L, Pedrazzoli L, et al. The relationship of femoral tunnel positioning in medial patellofemoral ligament reconstruction on clinical outcome and postoperative complications. Arthroscopy, 2018, 34(8): 2410-2416.
10.	Bollier M, Fulkerson J, Cosgarea A, et al. Technical failure of medial patellofemoral ligament reconstruction. Arthroscopy, 2011, 27(8): 1153-1159.
11.	Anderson G, Diduch DR. Medial patellofemoral ligament reconstruction: tips and tricks to get it right. Clin Sports Med, 2022, 41(1): 89-96.
12.	Blatter SC, Fürnstahl P, Hirschmann A, et al. Femoral insertion site in medial patellofemoral ligament reconstruction. Knee, 2016, 23(3): 456-459.
13.	Stephen JM, Kaider D, Lumpaopong P, et al. The effect of femoral tunnel position and graft tension on patellar contact mechanics and kinematics after medial patellofemoral ligament reconstruction. Am J Sports Med, 2014, 42(2): 364-372.
14.	Cregar WM, Huddleston HP, Wong SE, et al. Inconsistencies in reporting risk factors for medial patellofemoral ligament reconstruction failure: a systematic review. Am J Sports Med, 2022, 50(3): 867-877.
15.	Walker M, Maini L, Kay J, et al. Femoral tunnel malposition is the most common indication for revision medial patellofemoral ligament reconstruction with promising early outcomes following revision reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2022, 30(4): 1352-1361.
16.	Ewald F, Klasan A, Putnis S, et al. After MPFL reconstruction, femoral tunnel widening and migration increase with poor tunnel positioning and are related to poor clinical outcomes. Knee Surg Sports Traumatol Arthrosc, 2023, 31(6): 2315-2322.
17.	Sch?ttle PB, Schmeling A, Rosenstiel N, et al. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med, 2007, 35(5): 801-804.
18.	Kay J, Memon M, Ayeni OR, et al. Medial patellofemoral ligament reconstruction techniques and outcomes: a scoping review. Curr Rev Musculoskelet Med, 2021, 14(6): 321-327.
19.	Hiemstra LA, Kerslake S, O’Brien CL, et al. Accuracy and learning curve of femoral tunnel placement in medial patellofemoral ligament reconstruction. J Knee Surg, 2017, 30(9): 879-886.
20.	Stephen JM, Lumpaopong P, Deehan DJ, et al. The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and nonanatomic attachments. Am J Sports Med, 2012, 40(8): 1871-1879.
21.	Zhang N, Jiang Z, Wen X, et al. The triangle zone as a femoral attachment location in medial patellofemoral ligament reconstruction: An in vivo three-dimensional analysis using an open MRI scanner. Knee, 2015, 22(6): 585-590.
22.	Jaecker V, Brozat B, Banerjee M, et al. Fluoroscopic control allows for precise tunnel positioning in MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2017, 25(9): 2688-2694.
23.	程峰, 殷振宇, 汪志芳, 等. 透射定位法在復發性髕骨脫位重建內側髕股韌帶中的應用. 中華關節外科雜志: 電子版, 2018, 12(6): 863-867.
24.	Emre TY, Cetin H, Selcuk H, et al. Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint. Arch Orthop Trauma Surg, 2024, 144(4): 1675-1684.
25.	Jaecker V, Neumann L, Shafizadeh S, et al. Radiographic images are inapplicable for a precise evaluation of the femoral tunnel position following MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2019, 27(11): 3432-3440.
26.	Koenen P, Shafizadeh S, Pfeiffer TR, et al. Intraoperative fluoroscopy during MPFL reconstruction improves the accuracy of the femoral tunnel position. Knee Surg Sports Traumatol Arthrosc, 2018, 26(12): 3547-3552.
27.	Sanchis-Alfonso V, Ramírez-Fuentes C, Montesinos-Berry E, et al. Radiographic location does not ensure a precise anatomic location of the femoral fixation site in medial patellofemoral ligament reconstruction. Orthop J Sports Med, 2017, 5(11): 2325967117739252. doi: 10.1177/2325967117739252.
28.	Ziegler CG, Fulkerson JP, Edgar C. Radiographic reference points are inaccurate with and without a true lateral radiograph: the importance of anatomy in medial patellofemoral ligament reconstruction. Am J Sports Med, 2016, 44(1): 133-142.
29.	Balcarek P, Walde TA. Accuracy of femoral tunnel placement in medial patellofemoral ligament reconstruction: the effect of a nearly true-lateral fluoroscopic view. Am J Sports Med, 2015, 43(9): 2228-2232.
30.	Zhang X, Xie G, Zhang C, et al. Comparation and evaluation of the accuracy of the sulcus localization method to establish the medial patellofemoral ligament femoral tunnel: a cadaveric and clinical study. BMC Musculoskelet Disord, 2019, 20(1): 53. doi: 10.1186/s12891-019-2439-x.
31.	Chen J, Xiong Y, Han K, et al. Computed tomography imaging analysis of the MPFL femoral footprint morphology and the saddle sulcus: evaluation of 1094 knees. Orthop J Sports Med, 2022, 10(2): 23259671211073608. doi: 10.1177/23259671211073608.
32.	Chen J, Han K, Jiang J, et al. Radiographic reference points do not ensure anatomic femoral fixation sites in medial patellofemoral ligament reconstruction: A quantified anatomic localization method based on the saddle sulcus. Am J Sports Med, 2021, 49(2): 435-441.
33.	張文豪, 易林, 張思平, 等. 基于解剖學鞍溝區確定股骨止點進行內側髕股韌帶重建治療髕骨脫位的早期療效分析. 生物骨科材料與臨床研究, 2024, 21(1): 90-93.
34.	Fujino K, Tajima G, Yan J, et al. Morphology of the femoral insertion site of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc, 2015, 23(4): 998-1003.
35.	Yoo YS, Chang HG, Seo YJ, et al. Changes in the length of the medial patellofemoral ligament: an in vivo analysis using 3-dimensional computed tomography. Am J Sports Med, 2012, 40(9): 2142-2148.
36.	Wang HJ, Song YF, Yan X, et al. Using anatomic landmarks to locate Sch?ttle’s point was accurate without fluoroscopy during medial patellofemoral ligament reconstruction. Arthroscopy, 2021, 37(6): 1902-1908.
37.	夏亞一, 耿彬, 孫重霄, 等. 一種針對于髕骨脫位的手術用股骨骨道定位器: CN202223001008.9. 2023-07-07.
38.	de Abreu-E-Silva GM, Buarque FAR, Dias TS, et al. Anatomical femoral tunnel positioning in the medial patellofemoral ligament reconstruction: is the free-hand technique accurate? Ann Transl Med, 2020, 8(15): 924. doi: 10.21037/atm-19-3925.
39.	Servien E, Fritsch B, Lustig S, et al. In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med, 2011, 39(1): 134-139.
40.	Belkin NS, Meyers KN, Redler LH, et al. Medial patellofemoral ligament isometry in the setting of patella alta. Arthroscopy, 2020, 36(12): 3031-3036.
41.	Izadpanah K, Meine H, Kubosch J, et al. Fluoroscopic guided tunnel placement during medial patellofemoral ligament reconstruction is not accurate in patients with severe trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc, 2020, 28(3): 759-766.
42.	Drapeau-Zgoralski V, Swift B, Caines A, et al. Lateral patellar instability. J Bone Joint Surg (Am), 2023, 105(5): 397-409.
43.	張召賀, 方禹舜, 李亞楠, 等. 機器人輔助定位股骨隧道在內側髕股韌帶重建術中的應用. 中華創傷骨科雜志, 2024, 26(1): 19-25.
44.	張勇, 程飚, 楊林. 關節鏡輔助下內側髕股韌帶重建術治療髕骨脫位股骨側止點定位方法研究. 中國修復重建外科雜志, 2020, 34(10): 1233-1237.
45.	鐘名金, 崔家鳴, 黃子榮, 等. 改良全關節鏡下內側髕股韌帶重建術治療復發性髕骨脫位的療效. 中華創傷雜志, 2023, 39(8): 695-702.
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1. Baer MR, Macalena JA. Medial patellofemoral ligament reconstruction: patient selection and perspectives. Orthop Res Rev, 2017, 9: 83-91.
2. Patil S, Ahmad M, Patel M, et al. Cadaveric study to define the anatomy of the medial patellofemoral ligament (MPFL) and its variant patterns. Cureus, 2023, 15(5): e39333. doi: 10.7759/cureus.39333.
3. Hopper GP, Leach WJ, Rooney BP, et al. Does degree of trochlear dysplasia and position of femoral tunnel influence outcome after medial patellofemoral ligament reconstruction? Am J Sports Med, 2014, 42(3): 716-722.
4. Anbari A, Cole BJ. Medial patellofemoral ligament reconstruction: a novel approach. J Knee Surg, 2008, 21(3): 241-245.
5. 黃勇, 陳斐, 楊遠, 等. 內側髕股韌帶聯合髕脛韌帶重建治療髕骨不穩的研究進展. 中華骨與關節外科雜志, 2021, 14(1): 70-75.
6. Maione A, Tradati D, Ferrua P, et al. Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome. Knee Surg Sports Traumatol Arthrosc, 2023, 31(7): 2810-2817.
7. McCarthy M, Ridley TJ, Bollier M, et al. Femoral tunnel placement in medial patellofemoral ligament reconstruction. Iowa Orthop J, 2013, 33: 58-63.
8. 阿依丁·夏哈太, 張克遠, 劉陽. 內側髕股韌帶重建術后股骨隧道位置對膝關節功能的影響研究. 中國修復重建外科雜志, 2015, 29(8): 951-954.
9. Tscholl PM, Ernstbrunner L, Pedrazzoli L, et al. The relationship of femoral tunnel positioning in medial patellofemoral ligament reconstruction on clinical outcome and postoperative complications. Arthroscopy, 2018, 34(8): 2410-2416.
10. Bollier M, Fulkerson J, Cosgarea A, et al. Technical failure of medial patellofemoral ligament reconstruction. Arthroscopy, 2011, 27(8): 1153-1159.
11. Anderson G, Diduch DR. Medial patellofemoral ligament reconstruction: tips and tricks to get it right. Clin Sports Med, 2022, 41(1): 89-96.
12. Blatter SC, Fürnstahl P, Hirschmann A, et al. Femoral insertion site in medial patellofemoral ligament reconstruction. Knee, 2016, 23(3): 456-459.
13. Stephen JM, Kaider D, Lumpaopong P, et al. The effect of femoral tunnel position and graft tension on patellar contact mechanics and kinematics after medial patellofemoral ligament reconstruction. Am J Sports Med, 2014, 42(2): 364-372.
14. Cregar WM, Huddleston HP, Wong SE, et al. Inconsistencies in reporting risk factors for medial patellofemoral ligament reconstruction failure: a systematic review. Am J Sports Med, 2022, 50(3): 867-877.
15. Walker M, Maini L, Kay J, et al. Femoral tunnel malposition is the most common indication for revision medial patellofemoral ligament reconstruction with promising early outcomes following revision reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2022, 30(4): 1352-1361.
16. Ewald F, Klasan A, Putnis S, et al. After MPFL reconstruction, femoral tunnel widening and migration increase with poor tunnel positioning and are related to poor clinical outcomes. Knee Surg Sports Traumatol Arthrosc, 2023, 31(6): 2315-2322.
17. Sch?ttle PB, Schmeling A, Rosenstiel N, et al. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med, 2007, 35(5): 801-804.
18. Kay J, Memon M, Ayeni OR, et al. Medial patellofemoral ligament reconstruction techniques and outcomes: a scoping review. Curr Rev Musculoskelet Med, 2021, 14(6): 321-327.
19. Hiemstra LA, Kerslake S, O’Brien CL, et al. Accuracy and learning curve of femoral tunnel placement in medial patellofemoral ligament reconstruction. J Knee Surg, 2017, 30(9): 879-886.
20. Stephen JM, Lumpaopong P, Deehan DJ, et al. The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and nonanatomic attachments. Am J Sports Med, 2012, 40(8): 1871-1879.
21. Zhang N, Jiang Z, Wen X, et al. The triangle zone as a femoral attachment location in medial patellofemoral ligament reconstruction: An in vivo three-dimensional analysis using an open MRI scanner. Knee, 2015, 22(6): 585-590.
22. Jaecker V, Brozat B, Banerjee M, et al. Fluoroscopic control allows for precise tunnel positioning in MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2017, 25(9): 2688-2694.
23. 程峰, 殷振宇, 汪志芳, 等. 透射定位法在復發性髕骨脫位重建內側髕股韌帶中的應用. 中華關節外科雜志: 電子版, 2018, 12(6): 863-867.
24. Emre TY, Cetin H, Selcuk H, et al. Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint. Arch Orthop Trauma Surg, 2024, 144(4): 1675-1684.
25. Jaecker V, Neumann L, Shafizadeh S, et al. Radiographic images are inapplicable for a precise evaluation of the femoral tunnel position following MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2019, 27(11): 3432-3440.
26. Koenen P, Shafizadeh S, Pfeiffer TR, et al. Intraoperative fluoroscopy during MPFL reconstruction improves the accuracy of the femoral tunnel position. Knee Surg Sports Traumatol Arthrosc, 2018, 26(12): 3547-3552.
27. Sanchis-Alfonso V, Ramírez-Fuentes C, Montesinos-Berry E, et al. Radiographic location does not ensure a precise anatomic location of the femoral fixation site in medial patellofemoral ligament reconstruction. Orthop J Sports Med, 2017, 5(11): 2325967117739252. doi: 10.1177/2325967117739252.
28. Ziegler CG, Fulkerson JP, Edgar C. Radiographic reference points are inaccurate with and without a true lateral radiograph: the importance of anatomy in medial patellofemoral ligament reconstruction. Am J Sports Med, 2016, 44(1): 133-142.
29. Balcarek P, Walde TA. Accuracy of femoral tunnel placement in medial patellofemoral ligament reconstruction: the effect of a nearly true-lateral fluoroscopic view. Am J Sports Med, 2015, 43(9): 2228-2232.
30. Zhang X, Xie G, Zhang C, et al. Comparation and evaluation of the accuracy of the sulcus localization method to establish the medial patellofemoral ligament femoral tunnel: a cadaveric and clinical study. BMC Musculoskelet Disord, 2019, 20(1): 53. doi: 10.1186/s12891-019-2439-x.
31. Chen J, Xiong Y, Han K, et al. Computed tomography imaging analysis of the MPFL femoral footprint morphology and the saddle sulcus: evaluation of 1094 knees. Orthop J Sports Med, 2022, 10(2): 23259671211073608. doi: 10.1177/23259671211073608.
32. Chen J, Han K, Jiang J, et al. Radiographic reference points do not ensure anatomic femoral fixation sites in medial patellofemoral ligament reconstruction: A quantified anatomic localization method based on the saddle sulcus. Am J Sports Med, 2021, 49(2): 435-441.
33. 張文豪, 易林, 張思平, 等. 基于解剖學鞍溝區確定股骨止點進行內側髕股韌帶重建治療髕骨脫位的早期療效分析. 生物骨科材料與臨床研究, 2024, 21(1): 90-93.
34. Fujino K, Tajima G, Yan J, et al. Morphology of the femoral insertion site of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc, 2015, 23(4): 998-1003.
35. Yoo YS, Chang HG, Seo YJ, et al. Changes in the length of the medial patellofemoral ligament: an in vivo analysis using 3-dimensional computed tomography. Am J Sports Med, 2012, 40(9): 2142-2148.
36. Wang HJ, Song YF, Yan X, et al. Using anatomic landmarks to locate Sch?ttle’s point was accurate without fluoroscopy during medial patellofemoral ligament reconstruction. Arthroscopy, 2021, 37(6): 1902-1908.
37. 夏亞一, 耿彬, 孫重霄, 等. 一種針對于髕骨脫位的手術用股骨骨道定位器: CN202223001008.9. 2023-07-07.
38. de Abreu-E-Silva GM, Buarque FAR, Dias TS, et al. Anatomical femoral tunnel positioning in the medial patellofemoral ligament reconstruction: is the free-hand technique accurate? Ann Transl Med, 2020, 8(15): 924. doi: 10.21037/atm-19-3925.
39. Servien E, Fritsch B, Lustig S, et al. In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med, 2011, 39(1): 134-139.
40. Belkin NS, Meyers KN, Redler LH, et al. Medial patellofemoral ligament isometry in the setting of patella alta. Arthroscopy, 2020, 36(12): 3031-3036.
41. Izadpanah K, Meine H, Kubosch J, et al. Fluoroscopic guided tunnel placement during medial patellofemoral ligament reconstruction is not accurate in patients with severe trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc, 2020, 28(3): 759-766.
42. Drapeau-Zgoralski V, Swift B, Caines A, et al. Lateral patellar instability. J Bone Joint Surg (Am), 2023, 105(5): 397-409.
43. 張召賀, 方禹舜, 李亞楠, 等. 機器人輔助定位股骨隧道在內側髕股韌帶重建術中的應用. 中華創傷骨科雜志, 2024, 26(1): 19-25.
44. 張勇, 程飚, 楊林. 關節鏡輔助下內側髕股韌帶重建術治療髕骨脫位股骨側止點定位方法研究. 中國修復重建外科雜志, 2020, 34(10): 1233-1237.
45. 鐘名金, 崔家鳴, 黃子榮, 等. 改良全關節鏡下內側髕股韌帶重建術治療復發性髕骨脫位的療效. 中華創傷雜志, 2023, 39(8): 695-702.
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Research progress on femoral attachment positioning during medial patellofemoral ligament reconstruction

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