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Pediatric MPFL Reconstruction and Outcomes Eric Wall, MD

Pediatric MPFL Reconstruction and Outcomes Eric Wall, MD. Cincinnati Children’s Hospital. MPFL Reconstruction Indications. Alone Traumatic Patellar Dislocation (best indication) Recurrent Patellar Dislocation (with/without laxity)

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Pediatric MPFL Reconstruction and Outcomes Eric Wall, MD

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  1. Pediatric MPFL Reconstruction and Outcomes Eric Wall, MD Cincinnati Children’s Hospital Eric Wall Pediatric MPFLR

  2. MPFL Reconstruction Indications Alone • Traumatic Patellar Dislocation (best indication) • Recurrent Patellar Dislocation (with/without laxity) Adjunctive (along with quadricepsplasty, lateral release, VMO transfer, quad lengthening, MPTL, etc) • Neuromuscular • Syndromic • Congenital/Fixed Eric Wall Pediatric MPFLR

  3. MPFL Pre-hab • Obtain ROM • Effusion elimination • Quad strengthening • E stim • Straight leg raise Gait train Quad/Ham co-contraction Eric Wall Pediatric MPFLR

  4. Patient Positioning Use standard radiolucent OR table Move patient distal on table so that heels are just off the foot of the table Place tourniquet on upper thigh Use paint roller at foot of the table as a bump to set knee flexion at about 45-60 degrees. [Blue straight arrow] Bump up ipsilateral hip so that knee will balance without flopping into internal or external rotation [Blue curved arrows] Eric Wall Pediatric MPFLR

  5. Dissection Elevate a periosteal flap off the medial patella down to the point where grayish-yellow fat is observed Dissect medially in the fatty layer that is beneath the medial retinaculm and just outside the joint synovium Palpate the bottom of the pouch with finger or a metzenbaum scissors near the medial epicondyle *If you puncture the gossamer synovium into the joint, just dissect a little more superficial Eric Wall Pediatric MPFLR

  6. Beath Pin Placement Start a short beath pin just distal to the physis on AP fluoroscopy, and at the bottom of the medial retinacular pouch identified with a finger or scissors. Confirm the femoral pin start point with cross table lateral fluoro. Because the physeal sparing pin is starting slightly distal to Schottle’s point, you should maintain isometry by moving pin slightly anterior to Schottle’s point. This will keep the graft isometric with the patella in extension and with patella at 90 degees during full flexion Aim beath pin slightly anterior and distal as you drill the pin. This will help avoid the notch, and the cupped physis on the AP view Do not initially pass the pin past the opposite cortex because it will harpoon the IT band and make it difficult to test isometry in full flexion. Eric Wall Pediatric MPFLR

  7. Femoral Tunnel Tunnel and fixation should be distal to the physis, Tunnel pin should point distally to follow the cupped physis (blue straight arrow) Eric Wall Pediatric MPFLR

  8. Pediatric Schottle’s To keep the graft isometric from full knee extension to full flexion… Because Schottle’s point (blue circle/lines) should be moved slightly distal to avoid the open growth plate. Consequently it should also be moved slightly anterior to Schottle’s pointto maintain equal graft length from full extension to full flexion (yellow curved arrow) If you test isometry by running a large test suture around your femoral guide pin and through patella tunnel (or other patella fixation), if the patella pulls medial as you extend knee from flexion to full extension, the graft is too tight in extension, and the femoral guide pin needs to be moved slightly anterior. As illustrated in Shea 2017 for children >7 yo Eric Wall Pediatric MPFLR

  9. Patella Fixation This illustrates a single patellar tunnel to minimize the risk of patella fracture. Drill a 3.5mm x 1cm tunnel thought the medial patella just superior to the patella equator, and join it with a 2nd 3.5mm tunnel through the anterior cortex (blue arrow). Use small 3.5-4.0 mm wide curettes to smooth out the isthmus between the two tunnels and make sure the graft passes easily. Tunnel should be placed in the proximal 2/3 of the patella in the coronal plane (Shea 15) Eric Wall Pediatric MPFLR

  10. Patella Graft Isometry Draw a #5 suture through the patellar tunnel and loop it around the beath pin. Test isometry at 45-60 degrees flexion. If the graft is too tight in extension and the patella pulls medially in full extension, the tunnel is too posterior and the pin needs to be moved anteriorly If the graft is too tight in flexion, then the pin needs to be positioned more posteriorly. The physis limits the pin from being moved more proximally into its anatomic position. Pull the graft thought the tunnel and Krackow stitch the ends together. Measure the free ends of the doubled graft diameter for the femoral tunnel size Eric Wall Pediatric MPFLR

  11. Patella graft loop 4mm diameter hamstring graft looped through a tunnel in the medial patella. Doubled hamstring graft looped thorough 4mm diameter medial-anterior patella tunnel Femur socket guide pin

  12. Femoral Socket Drilling Ream the femoral socket to the same diameter graft size to a select the equal diameter bio-composite screw that has a length of 30 mm. Overdrill the length of the socket by 20-30 mm to make sure the graft does not bottom out in the socket before it is taut. CAUTION: Place interference screw guide pin in socket before drawing graft into socket. Eric Wall Pediatric MPFLR

  13. Graft Passage After drilling the femoral tunnel pass the graft under the medial retinaculum and out the femoral tunnel incision. *Make sure to place the interference screw guide pin in the femoral socket before seating the graft in the socket. Place the pin far posterior in the socket. Eric Wall Pediatric MPFLR

  14. Screw Placement To avoid cutting the graft, use an absorbable or biocomposite interference screw. Place the knee in 45-60 degrees of flexion. Pull the slack out of the graft and tension with only about 3-5 pounds of pressure. Place the screw over the posteriorly positioned guide pin. Eric Wall Pediatric MPFLR

  15. MPFL Reconstruction Advantages • No Lateral release • Extrasynovial tunnel to medial epicondyle (pain) • Immediate WBAT with accelerated rehab • Cosmetic incisions • Eliminates J-sign • Few failures Eric Wall Pediatric MPFLR

  16. MPFL Complications • Patella fracture • ST interference screw cuts graft • Stiffness (↑ w/ acute OC repair) • Femur guide pin in PF joint or peroneal nerve • Not for congenital, NM, syndromic dislocation • Growth plate damage and non-isometry Eric Wall Pediatric MPFLR

  17. MPFL Rehab Consensus • 4-6 months (similar to ACL) • RTS: Biodex, Hop, IKDC, PQL • Dynamic sports activity..cut, twist, land, shift • Apprehension eliminated • Good biomechanics on double/single leg landing Eric Wall Pediatric MPFLR

  18. Knee angle for tensioning • 45-60 deg (Shah 2012 recommends >60 deg) Eric Wall Pediatric MPFLR

  19. Femoral fixation point • Pediatric Schottle Point (Shea 2017) Immature > 7 y/o Fixation point slightly distal and anterior to adult Schottle’s point Eric Wall Pediatric MPFLR

  20. Graft Choices (Auto ≈ Allo) • Allograft • 23/25 Allograft patients without recurrence. (Hohn E 2016) • Systematic review showed autograft had better outcomes than allograft, but failure rate similar. (Weinberger JM 2016) • More study needed (Fabricant P 2017) Eric Wall Pediatric MPFLR

  21. Fixation thought bone tunnel weakest. Lenscrow S 2013 Fixation though bone tunnel strongest. Russo F 2016 Suture vs Bone fixation…Shah 12 showed trend toward slightly more complications with bone tunnels, but higher recurrence of instability/apprehensionwith suture fixation Double limb better than single limb graft (Weisenberger 16) Patella Fixation Technique Controversial

  22. Patella or Femur fixation 1st? Tensioning via femur seems easier than patella so fix to patella first and tension thought the femur. Equal strength of graft pullout with loop (A) or free ends (B) of graft going into femur tunnel. Russo F 2016 Eric Wall Pediatric MPFLR

  23. Patella Fracture Avoid trans-osseous tunnels (Vavken 13 showed patella fractures occur in 0.4% of cases) If use medial bone tunnel in patella… Keep 3.5mm-4mm diameter and short < 10mm long from medial border (not transosseous) Trans-osseous patella tunnel Eric Wall Pediatric MPFLR

  24. OUTCOMES • Askenberger 2018 found that MPFL repair vs non-op treatment gave fewer recurrent dislocations, but equal outcomes • Bryant J 2018 found that MPFL repair gave fewer recurrent dislocations and fewer complications than MPFL reconstruction. • Vavken P 13 No clear evidence that surgery better than non-op for 1st dislocation, but in recurrent dislocation, MPFL reconstruction most successful treatment. • Nelitz M 13 showed 21 patients with >2 year f/u after MPFL reconstruction showed no recurrence of dislocation and dramatic improvement in their Kujala score. • Hohn E 2016 showed 2/25 with recurrent patellar dislocation with allograft MPFL • Gao and Fabricant 2018 Recommend standard outcomes, TTTG, CD, pre and postop findings, peds validated PROMs, activity scale • Palmu S 2008 68% recurrence in adolescents with traditional stabilization including medial reef, lateral release, VMO advancement (not MPFL reconstruction) • Nwachukwu B 2016 Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review Eric Wall Pediatric MPFLR

  25. Outcomes 2 Shah JN 2012 A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Schneider 2016 in meta analysis of primarily isolated MPFL studies showed post-op Kujala 86, recurrent instability 1%, apprehension sign 4%, reoperation 3%, Tegner 5.7 Goyal D. 2013 Medial patellofemoral ligament reconstruction: the superficial quad technique. Excellent results in 32 patietns mean age of 25 with 3 yrs mean f/u using quad turndown technique CsintalanR, Fithian D et.al. 2013 MPFL reconstruction for the treatment of patellofemoral instability. 56 knees with mean fu 4.3 yrs, mean age 24 yrs. Isolated MPFL. No recurrent patellar dislocations, 6 subluxations Good IKDC (76.3) and Tegner (5.6) scores Ahmad CS, 2009. The docking technique for medial patellofemoral ligament reconstruction: surgical technique and clinical outcome at mean fu of 31 months. 20 patient with MPFL had no recurrence of dislocation/subluxation. IKDC 82, Kujala, Tegner, Lysholm all good . Eric Wall Pediatric MPFLR

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