Surgical techniques for medial Patellofemoral ligament reconstruction: a systematic review and meta-analysis of level I and II studies

Harjind Kahlon; Prushoth Vivekanantha; Benjamin Blackman; Dan Cohen; Tyler Mckechnie; Lily Park; Darren de Sa

doi:10.1007/s00167-023-07494-w

Surgical techniques for medial Patellofemoral ligament reconstruction: a systematic review and meta-analysis of level I and II studies

Knee Surg Sports Traumatol Arthrosc. 2023 Oct;31(10):4368-4378. doi: 10.1007/s00167-023-07494-w. Epub 2023 Jun 22.

Authors

Harjind Kahlon¹, Prushoth Vivekanantha², Benjamin Blackman³, Dan Cohen⁴, Tyler Mckechnie⁵, Lily Park⁵, Darren de Sa⁶

Affiliations

¹ Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
² Michael DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
³ Department of Medicine, Department of Surgery, University of Limerick, Limerick, Ireland.
⁴ Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada.
⁵ Division of General Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada.
⁶ Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada. darren.desa@medportal.ca.

PMID: 37347281
DOI: 10.1007/s00167-023-07494-w

Abstract

Purpose: To determine the most optimal surgical technique for medial patellofemoral ligament reconstruction (MPFLR).

Methods: Three databases MEDLINE, PubMed, and EMBASE were searched from inception to December 13^th, 2022, for level I or II studies comparing MPFLR techniques. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on patient-reported outcome measures were recorded. Quality assessment was carried out using the MINORS and Cochrane Risk of Bias assessment tools. Certainty of evidence was carried out with the GRADE assessment tool.

Results: Ten studies comprising 723 patients (723 knees) were included in this review. The weighted mean difference in Kujala, Lysholm, and IKDC scores comparing single- and double-tunnel patellar drilling techniques was 2.66 (95% CI -1.05-6.37, p = 0.16, I² = 0%) with moderate certainty, 0.78 (95% CI -9.02-10.58, p = 0.88, I² = 87%) with low certainty, and 1.71 (95% CI -2.43-5.86, p = 0.42, I² = 0%) with low certainty, respectively. Double-suture anchor patellar fixation demonstrated greater Kujala scores than transpatellar fixation (87.1 ± 2.8 vs 84.0 ± 3.8, p < 0.001) with moderate certainty. Y-shaped graft patellar fixation demonstrated superior Kujala scores to C-shaped graft patellar fixation (95.9 ± 4.7 vs 91.3 ± 9.7, p = 0.001) with moderate certainty. Augmentation of femoral fixation with polyester sutures demonstrated superior Kujala scores (97.8 ± 6.4. vs 88.0 ± 6.3, p < 0.005) with low certainty. Four-stranded grafts demonstrated greater Kujala scores than two-stranded grafts (93.5 ± 2.6 vs 91.6 ± 3.5, p = 0.01) with low certainty.

Conclusion: The optimal MPFLR surgical technique is likely to utilize a four-stranded graft using either endobutton, double-suture anchor, or transosseous suture patellar fixation with polyester suture augmented interference screw femoral fixation. Orthopedic surgeons can consider employing such a technique to improve patient outcomes by conferring greater graft stability, strength, and function. Level of evidence Level II.

Keywords: Fixation; Graft; MPFLR; Surgical technique; Tunnel-drilling.

Publication types

Meta-Analysis
Systematic Review
Review

MeSH terms

Humans
Knee Joint / surgery
Ligaments, Articular / surgery
Patellar Dislocation* / surgery
Patellofemoral Joint* / surgery
Polyesters

Substances

Polyesters