Research progress in femoral tunnel positioning points of medial patellofemoral ligament reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Yan ^1,2 ,  LI Yanlin ^1,2 , LIU Dejian ^1,2 , WANG Guoliang ^1,2

1. Kunming Medical University, Kunming Yunnan, 650000, P.R.China;
2. Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China;

Corresponding author：

LI Yanlin, Email: 852387873@qq.com

Keywords：

Medial patellofemoral ligament; femoral tunnel; anatomy; location point

DOI：

10.7507/1002-1892.202006059

Video：

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Objective To review the research progress of location methods and the best femoral insertion position of medial patellofemoral ligament (MPFL) reconstruction of femoral tunnel, and provide reference for surgical treatment.Methods The literature about femoral insertion position of the MPFL reconstruction in recent years was extensively reviewed, and the anatomical and biomechanical characteristics of MPFL, as well as the advantages and disadvantages of femoral tunnel positioning methods were summarized.Results The accurate establishment of the femoral anatomical tunnel is crucial to the success of MPFL reconstruction. At present, there are mainly two kinds of methods for femoral insertion: radiographic landmark positioning method and anatomical landmark positioning method. Radiographic landmark positioning method has such advantages as small incision and simple operation, but it can not be accurately positioned for patients with severe femoral trochlear dysplasia. It is suggested to combine with the anatomical landmark positioning method. These methods have their own advantages and disadvantages, and there is no unified positioning standard. In recent years, the use of three-dimensional design software can accurately assist in the MPFL reconstruction, which has become a new trend.Conclusion Femoral tunnel positioning of the MPFL reconstruction is very important. The current positioning methods have their own advantages and disadvantages. Personalized positioning is a new trend and has not been widely used in clinic, its effectiveness needs further research and clinical practice and verification.

Citation： ZHANG Yan, LI Yanlin, LIU Dejian, WANG Guoliang. Research progress in femoral tunnel positioning points of medial patellofemoral ligament reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(2): 258-264. doi: 10.7507/1002-1892.202006059 Copy

1.	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.
2.	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.
3.	Sanchis-Alfonso V, Ramirez-Fuentes C, Montesinos-Berry E, et al. Does radiographic location ensure precise anatomic location of the femoral fixation site in medial patellofemoral ligament surgery? Knee Surg Sports Traumatol Arthrosc, 2016, 24(9): 2838-2844.
4.	Tanaka MJ. Variability in the patellar attachment of the medial patellofemoral ligament. Arthroscopy, 2016, 32(8): 1667-1670.
5.	Sanchis-Alfonso V, Ramirez-Fuentes C, Montesinos-Berry E, et al. 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. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2433-2441.
6.	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.
7.	Kruckeberg BM, Chahla J, Moatshe G, et al. Quantitative and qualitative analysis of the medial patellar ligaments: An anatomic and radiographic study. Am J Sports Med, 2018, 46(1): 153-162.
8.	Kita K, Tanaka Y, Toritsuka Y, et al. 3D computed tomography evaluation of morphological changes in the femoral tunnel after medial patellofemoral ligament reconstruction with hamstring tendon graft for recurrent patellar dislocation. Am J Sports Med, 2017, 45(7): 1599-1607.
9.	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.
10.	Viste A, Chatelet F, Desmarchelier R, et al. Anatomical study of the medial patello-femoral ligament: landmarks for its surgical reconstruction. Surg Radiol Anat, 2014, 36(8): 733-739.
11.	Kernkamp WA, Wang C, Li C, et al. The medial patellofemoral ligament is a dynamic and anisometric structure: An in vivo study on length changes and isometry. Am J Sports Med, 2019, 47(7): 1645-1653.
12.	Tanaka MJ, Chahla J, Farr J, et al. Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction. Knee Surg Sports Traumatol Arthrosc, 2019, 27(8): 2537-2550.
13.	Pérez-Prieto D, Capurro B, Gelber PE, et al. The anatomy and isometry of a quasi-anatomical reconstruction of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2420-2423.
14.	Aframian A, Smith TO, Tennent TD, et al. Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy. Knee Surg Sports Traumatol Arthrosc, 2017, 25(12): 3755-3772.
15.	Kang HJ, Wang F, Chen BC, et al. Functional bundles of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc, 2010, 18(11): 1511-1516.
16.	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.
17.	Sanchis-Alfonso V, Montesinos-Berry E, Ramirez-Fuentes C, et al. Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies. World J Orthop, 2017, 8(2): 115-129.
18.	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.
19.	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.
20.	Camp CL, Krych AJ, Dahm DL, et al. Medial patellofemoral ligament repair for recurrent patellar dislocation. Am J Sports Med, 2010, 38(11): 2248-2254.
21.	McCarthy M, Ridley TJ, Bollier M, et al. Femoral tunnel placement in medial patellofemoral ligament reconstruction. Iowa Orthop J, 2013, 33: 58-63.
22.	Schöttle 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.
23.	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.
24.	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.
25.	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.
26.	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.
27.	Steensen Robert N, Dopirak Ryan M, McDonald William G. The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med, 2004, 32: 1509-13.
28.	LaPrade RF, Engebretsen AH, Ly TV, et al. The anatomy of the medial part of the knee. J Bone Joint Surg (Am), 2007, 89(9): 2000-2010.
29.	Oka S, Matsushita T, Kubo S, et al. Simulation of the optimal femoral insertion site in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2014, 22(10): 2364-2371.
30.	Herschel R, Hasler A, Tscholl PM, et al. Visual-palpatory versus fluoroscopic intraoperative determination of the femoral entry point in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2545-2549.
31.	Redfern J, Kamath G, Burks R. Anatomical confirmation of the use of radiographic landmarks in medial patellofemoral ligament reconstruction. Am J Sports Med, 2010, 38(2): 293-297.
32.	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.
33.	Monllau JC, Masferrer-Pino À, Ginovart G, et al. Clinical and radiological outcomes after a quasi-anatomical reconstruction of medial patellofemoral ligament with gracilis tendon autograft. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2453-2459.
34.	Thaunat M, Erasmus PJ. Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2009, 17(5): 480-483.
35.	Chatterton A, Nielsen TG, Sørensen OG, et al. Clinical outcomes after revision surgery for medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2018, 26(3): 739-745.
36.	Wijdicks CA, Griffith CJ, LaPrade RF, et al. Radiographic identification of the primary medial knee structures. J Bone Joint Surg (Am), 2009, 91(3): 521-529.
37.	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.
38.	Zhang XC, Xie G, Zhang CY, 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.
39.	李常辉. 内侧髌股韧带的解剖学特征和起止点足印的解剖学研究及临床意义. 青岛: 青岛大学, 2017.
40.	张勇, 程飚, 杨林. 关节镜辅助下内侧髌股韧带重建术治疗髌骨脱位股骨侧止点定位方法研究. 中国修复重建外科杂志, 2020, 34(10): 1233-1237.
41.	雷鸣鸣, 华强. 两种股骨隧道定位法内侧髌股韧带重建术比较. 中国矫形外科杂志, 2019, 27(16): 1461-1466.
42.	Hiemstra LA, Kerslake S, Lafave M. Medial patellofemoral ligament reconstruction femoral tunnel accuracy: Relationship to disease-specific quality of life. Orthop J Sports Med, 2017, 5: 2325967116687749.
43.	Blatter SC, Fürnstahl P, Hirschmann A, et al. Femoral insertion site in medial patellofemoral ligament reconstruction. Knee, 2016, 23(3): 456-459.
44.	柯晋, 肖进, 马立敏, 等. 3D 打印技术辅助个性化截骨模板在轻中度拇外翻外科治疗中的应用. 中国数字医学, 2020, 15(7): 102-104.
45.	罗树林, 尹峰, 刘铮, 等. 3D 打印导板在关节镜下膝前交叉韧带重建中的临床应用. 同济大学学报 (医学版), 2020, 41(1): 90-94.
46.	van Duren BH, Lebe M, Davies DC, et al. Proof-of-concept prototype drill-guide for use in medial patello-femoral ligament (MPFL) reconstruction surgery. J Med Eng Technol, 2019, 43(1): 1-7.
47.	Fritz B, Fucentese SF, Zimmermann SM, et al. 3D-printed anatomic models of the knee for evaluation of patellofemoral dysplasia in comparison to standard radiographs and computed tomography. Eur J Radiol, 2020, 127: 109011.

1. 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.
2. 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.
3. Sanchis-Alfonso V, Ramirez-Fuentes C, Montesinos-Berry E, et al. Does radiographic location ensure precise anatomic location of the femoral fixation site in medial patellofemoral ligament surgery? Knee Surg Sports Traumatol Arthrosc, 2016, 24(9): 2838-2844.
4. Tanaka MJ. Variability in the patellar attachment of the medial patellofemoral ligament. Arthroscopy, 2016, 32(8): 1667-1670.
5. Sanchis-Alfonso V, Ramirez-Fuentes C, Montesinos-Berry E, et al. 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. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2433-2441.
6. 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.
7. Kruckeberg BM, Chahla J, Moatshe G, et al. Quantitative and qualitative analysis of the medial patellar ligaments: An anatomic and radiographic study. Am J Sports Med, 2018, 46(1): 153-162.
8. Kita K, Tanaka Y, Toritsuka Y, et al. 3D computed tomography evaluation of morphological changes in the femoral tunnel after medial patellofemoral ligament reconstruction with hamstring tendon graft for recurrent patellar dislocation. Am J Sports Med, 2017, 45(7): 1599-1607.
9. 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.
10. Viste A, Chatelet F, Desmarchelier R, et al. Anatomical study of the medial patello-femoral ligament: landmarks for its surgical reconstruction. Surg Radiol Anat, 2014, 36(8): 733-739.
11. Kernkamp WA, Wang C, Li C, et al. The medial patellofemoral ligament is a dynamic and anisometric structure: An in vivo study on length changes and isometry. Am J Sports Med, 2019, 47(7): 1645-1653.
12. Tanaka MJ, Chahla J, Farr J, et al. Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction. Knee Surg Sports Traumatol Arthrosc, 2019, 27(8): 2537-2550.
13. Pérez-Prieto D, Capurro B, Gelber PE, et al. The anatomy and isometry of a quasi-anatomical reconstruction of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2420-2423.
14. Aframian A, Smith TO, Tennent TD, et al. Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy. Knee Surg Sports Traumatol Arthrosc, 2017, 25(12): 3755-3772.
15. Kang HJ, Wang F, Chen BC, et al. Functional bundles of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc, 2010, 18(11): 1511-1516.
16. 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.
17. Sanchis-Alfonso V, Montesinos-Berry E, Ramirez-Fuentes C, et al. Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies. World J Orthop, 2017, 8(2): 115-129.
18. 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.
19. 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.
20. Camp CL, Krych AJ, Dahm DL, et al. Medial patellofemoral ligament repair for recurrent patellar dislocation. Am J Sports Med, 2010, 38(11): 2248-2254.
21. McCarthy M, Ridley TJ, Bollier M, et al. Femoral tunnel placement in medial patellofemoral ligament reconstruction. Iowa Orthop J, 2013, 33: 58-63.
22. Schöttle 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.
23. 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.
24. 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.
25. 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.
26. 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.
27. Steensen Robert N, Dopirak Ryan M, McDonald William G. The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med, 2004, 32: 1509-13.
28. LaPrade RF, Engebretsen AH, Ly TV, et al. The anatomy of the medial part of the knee. J Bone Joint Surg (Am), 2007, 89(9): 2000-2010.
29. Oka S, Matsushita T, Kubo S, et al. Simulation of the optimal femoral insertion site in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2014, 22(10): 2364-2371.
30. Herschel R, Hasler A, Tscholl PM, et al. Visual-palpatory versus fluoroscopic intraoperative determination of the femoral entry point in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2545-2549.
31. Redfern J, Kamath G, Burks R. Anatomical confirmation of the use of radiographic landmarks in medial patellofemoral ligament reconstruction. Am J Sports Med, 2010, 38(2): 293-297.
32. 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.
33. Monllau JC, Masferrer-Pino À, Ginovart G, et al. Clinical and radiological outcomes after a quasi-anatomical reconstruction of medial patellofemoral ligament with gracilis tendon autograft. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2453-2459.
34. Thaunat M, Erasmus PJ. Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2009, 17(5): 480-483.
35. Chatterton A, Nielsen TG, Sørensen OG, et al. Clinical outcomes after revision surgery for medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2018, 26(3): 739-745.
36. Wijdicks CA, Griffith CJ, LaPrade RF, et al. Radiographic identification of the primary medial knee structures. J Bone Joint Surg (Am), 2009, 91(3): 521-529.
37. 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.
38. Zhang XC, Xie G, Zhang CY, 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.
39. 李常辉. 内侧髌股韧带的解剖学特征和起止点足印的解剖学研究及临床意义. 青岛: 青岛大学, 2017.
40. 张勇, 程飚, 杨林. 关节镜辅助下内侧髌股韧带重建术治疗髌骨脱位股骨侧止点定位方法研究. 中国修复重建外科杂志, 2020, 34(10): 1233-1237.
41. 雷鸣鸣, 华强. 两种股骨隧道定位法内侧髌股韧带重建术比较. 中国矫形外科杂志, 2019, 27(16): 1461-1466.
42. Hiemstra LA, Kerslake S, Lafave M. Medial patellofemoral ligament reconstruction femoral tunnel accuracy: Relationship to disease-specific quality of life. Orthop J Sports Med, 2017, 5: 2325967116687749.
43. Blatter SC, Fürnstahl P, Hirschmann A, et al. Femoral insertion site in medial patellofemoral ligament reconstruction. Knee, 2016, 23(3): 456-459.
44. 柯晋, 肖进, 马立敏, 等. 3D 打印技术辅助个性化截骨模板在轻中度拇外翻外科治疗中的应用. 中国数字医学, 2020, 15(7): 102-104.
45. 罗树林, 尹峰, 刘铮, 等. 3D 打印导板在关节镜下膝前交叉韧带重建中的临床应用. 同济大学学报 (医学版), 2020, 41(1): 90-94.
46. van Duren BH, Lebe M, Davies DC, et al. Proof-of-concept prototype drill-guide for use in medial patello-femoral ligament (MPFL) reconstruction surgery. J Med Eng Technol, 2019, 43(1): 1-7.
47. Fritz B, Fucentese SF, Zimmermann SM, et al. 3D-printed anatomic models of the knee for evaluation of patellofemoral dysplasia in comparison to standard radiographs and computed tomography. Eur J Radiol, 2020, 127: 109011.

Chinese Journal of Reparative and Reconstructive Surgery

Research progress in femoral tunnel positioning points of medial patellofemoral ligament reconstruction

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