Hevesi Mario, Sivasundaram Lakshmanan, Meeker Zachary D, Kaiser Joshua T, Yanke Adam B, Cole Brian J
Midwest Orthopaedics at Rush, Chicago, Illinois, USA.
Video J Sports Med. 2023 Jan 24;3(1):26350254221131588. doi: 10.1177/26350254221131588. eCollection 2023 Jan-Feb.
Patellofemoral anatomy allows for substantial freedom of motion. Medial patellofemoral ligament (MPFL) tears occur in up to 96% of lateral patellar dislocations. Risk factors for subsequent instability include maltracking and increased tibial tubercle to trochlear groove (TT-TG) distance.
Medial patellofemoral ligament reconstruction (MPFLR) with concurrent tibial tubercle osteotomy (TTO) is indicated in patients with recurrent dislocation or unresolved apprehension. Concurrent TTO should be considered for TT-TGs 15-20 mm depending on overall clinical picture and risk factors. We strongly consider TTO for TT-TGs ≥20 mm and for revision procedures.
Following diagnostic arthroscopy, a midline incision is made from the inferior patellar pole to 3 cm beyond the tibial tubercle. The anterior compartment is incised and retracted laterally. An osteotomy guide is affixed to the tibia and an osteotomy cut is made with a saw, leaving a small bridge of periosteum distally. The osteotomy is competed proximally with osteotomes, then medialized and held in place with two 4.5-mm screws. An incision is made on the superomedial patella and two 0.045 inch guidewires are placed at the MPFL insertion and overdrilled with a 3.5-mm drill. A 22-cm semitendinosus allograft is prepared and fixed to the patella using two 3.5-mm anchors. An incision is made over the medial epicondyle and a 2.4-mm beath pin is placed at Schöttle point. Isometry is confirmed and the pin is overdrilled with a 6-mm reamer. The allograft is passed just superficial to capsule from the peripatellar incision to the medial incision, docked into the femur, and secured with a 6-mm interference screw at 30° of flexion after confirmation of appropriate graft length.
Studies have demonstrated improved outcomes for patients undergoing MPFLR + TTO compared with isolated MPFL in the setting of maltracking and increased TT-TG distance. In addition, a recent meta-analysis demonstrated no negative effect of concurrent TTO on return to sport timeline.
DISCUSSION/CONCLUSION: MPFLR with concurrent TTO is effective, with surgical correction of underlying maltracking and satisfactory return to sport. Consideration to MPFL + TTO should be given to patients with recurrent instability and pathologically increased TT-TG.The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
髌股关节解剖结构允许较大的活动自由度。内侧髌股韧带（MPFL）撕裂在外侧髌骨脱位中发生率高达96%。后续不稳定的危险因素包括轨迹不良和胫骨结节至滑车沟（TT-TG）距离增加。
对于复发性脱位或持续存在恐惧的患者，建议行内侧髌股韧带重建（MPFLR）并同期进行胫骨结节截骨术（TTO）。根据整体临床表现和危险因素，对于TT-TG为15 - 20 mm的患者应考虑同期TTO。对于TT-TG≥20 mm的患者以及翻修手术，我们强烈建议行TTO。
诊断性关节镜检查后，从髌骨下极至胫骨结节远侧3 cm做正中切口。切开前侧间室并向外侧牵开。将截骨导向器固定于胫骨，用锯进行截骨，在远侧保留一小段骨膜桥。截骨近端用骨刀完成，然后向内侧移位，并用两枚4.5 mm螺钉固定。在髌骨上内侧做切口，在MPFL止点处置入两根0.045英寸导丝，并用3.5 mm钻头扩孔。准备一条22 cm的半腱肌异体移植物，用两枚3.5 mm锚钉固定于髌骨。在内侧髁上做切口，在Schöttle点置入一根2.4 mm的导针。确认等长后，用6 mm扩孔钻扩孔。将异体移植物从髌周切口经关节囊浅面穿过至内侧切口，引入股骨，确认移植物长度合适后，在屈膝30°时用一枚6 mm挤压螺钉固定。
研究表明，在轨迹不良和TT-TG距离增加的情况下，与单纯MPFL重建相比，接受MPFLR + TTO的患者预后更好。此外，最近的一项荟萃分析表明，同期TTO对恢复运动的时间线没有负面影响。
讨论/结论：MPFLR同期TTO是有效的，可手术纠正潜在的轨迹不良，并能使患者满意地恢复运动。对于复发性不稳定和TT-TG病理性增加的患者，应考虑行MPFL + TTO。作者证明已获得本出版物中出现的任何患者的同意。如果个体可识别，作者已随本投稿附上患者的豁免声明或其他书面批准形式以供发表。
