Carl J. Shapiro Department of Orthopaedic Surgery, Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia.
Am J Sports Med. 2020 Jul;48(9):2252-2259. doi: 10.1177/0363546520930703. Epub 2020 Jun 18.
There is a lack of evidence regarding the optimum extensor-sided fixation method for medial patellofemoral ligament (MPFL) reconstruction. There is increased interest in avoiding patellar drilling via soft tissue-only fixation to the distal quadriceps, thus reconstructing the medial quadriceps tendon-femoral ligament (MQTFL). The biomechanical implications of differing extensor-sided fixation constructs remain unknown.
The null hypothesis was there would be no differences between traditional MPFL reconstruction and MQTFL reconstruction with respect to resistance to lateral translation, patellar position, or patellofemoral contact pressures.
Controlled laboratory study.
Nine adult knee specimens were mounted on a jig that applied static, physiologic loads to the quadriceps tendons. Patellar position and orientation, knee flexion angle, and patellofemoral pressure were recorded at 8 different flexion angles between 0° and 110°. Additionally, a lateral patellar excursion test was conducted wherein a load was applied directly to the patella in the lateral direction with the knee at 30° of flexion and subjected to 2-N quadriceps loads. Testing was conducted under 4 conditions: intact, transected MPFL, MQTFL reconstruction, and MPFL reconstruction. For MQTFL reconstruction, the surgical technique established by Fulkerson was employed. For MPFL reconstruction, a traditional technique was utilized.
The patellar excursion test showed no significant difference between the MQTFL and intact states with respect to lateral translation. MPFL reconstruction led to significantly less lateral translation ( < .05) than all other states. There were no significant differences between MPFL and MQTFL reconstructions with respect to peak patellofemoral contact pressure. MPFL and MQTFL reconstructions both resulted in increased internal rotation of the patella with the knee in full extension.
Soft tissue-only extensor-sided fixation to the distal quadriceps (MQTFL) during patella stabilization appears to re-create native stability in this time 0 cadaver model. Fixation to the patella (MPFL) was associated with increased resistance to lateral translation.
Evolving anatomic knowledge and concern for patellar fracture has led to increased interest in MQTFL reconstruction. Both MQTFL and MPFL reconstructions restored patellofemoral stability to lateral translation without increasing contact pressures under appropriate graft tensioning, with MQTFL more closely restoring native resistance to lateral translation at the time of surgery.
对于内侧髌股韧带（MPFL）重建的最佳伸肌侧固定方法，目前缺乏证据。人们越来越感兴趣的是通过仅对远端股四头肌进行软组织固定来避免髌骨关节钻孔，从而重建内侧股四头肌肌腱-髌韧带（MQTFL）。不同伸肌侧固定结构的生物力学意义尚不清楚。
如果传统的 MPFL 重建和 MQTFL 重建在抵抗外侧平移、髌骨关节位置或髌股关节接触压力方面没有差异，则零假设成立。
对照实验室研究。
将 9 个成人膝关节标本安装在一个夹具上，该夹具向股四头肌肌腱施加静态、生理负荷。在 0°至 110°的 8 个不同弯曲角度下记录髌骨关节位置和方向、膝关节弯曲角度和髌股关节压力。此外，还进行了外侧髌骨关节偏移测试，即在膝关节弯曲 30°时，直接向髌骨关节施加侧向力，并施加 2-N 的股四头肌负荷。测试在 4 种情况下进行：完整、MPFL 横断、MQTFL 重建和 MPFL 重建。MQTFL 重建采用 Fulkerson 建立的手术技术。对于 MPFL 重建，采用传统技术。
在外侧平移方面，髌骨关节偏移测试显示 MQTFL 与完整状态之间没有显著差异。与所有其他状态相比，MPFL 重建导致的外侧平移明显减少（<0.05）。在峰值髌股关节接触压力方面，MPFL 和 MQTFL 重建之间没有显著差异。MPFL 和 MQTFL 重建都导致膝关节完全伸直时髌骨关节内旋增加。
在这个 0 期尸体模型中，在髌骨关节稳定时仅对远端股四头肌进行软组织伸肌侧固定（MQTFL）似乎可以重建固有稳定性。固定在髌骨关节（MPFL）上与抵抗外侧平移的能力增加有关。
不断发展的解剖学知识和对髌骨关节骨折的关注导致了对 MQTFL 重建的兴趣增加。MQTFL 和 MPFL 重建都恢复了髌股关节的稳定性，防止了外侧平移，在适当的移植物张力下不会增加接触压力，MQTFL 在手术时更接近恢复对侧向平移的固有阻力。
