Loading

Annals of Sports Medicine and Research

Excellent Results of Isolated MPFL Reconstruction in Patients with and without High Grade Trochlea Dysplasia

Review Article | Open Access Volume 8 | Issue 2 |
Article DOI :

  • 1. Department of Orthopedics and Sports Traumatology, Atos MediaPark Clinic, Germany
  • 2. Department of Trauma and Orthopedic Surgery, Reconstructive Surgery, Hand Surgery and Treatment Of Burns, Germany
  • 3. IFD Cologne, Im Mediapark 2, 50670 Cologne, Germany
  • 4. Ortho Sports Lab, Department of Orthopedics and Sports Traumatology, Wilhelm-Mevis-Platz 17, 50259 Pulheim, Germany
  • 5. Department of Trauma and Orthopedic Surgery, University of Witten/ Herdecke, Cologne Merheim Medical Center, Germany
+ Show More - Show Less
Corresponding Authors
Theresa Schäferhoff, Department of Orthopedics and Sports Traumatology, Atos MediaPark Clinic, Im Mediapark 3, 50670 Cologne, NRW, Germany, Tel: 49-170-9070002
Abstract

Introduction: Medial patellofemoral ligament (MPFL) reconstruction has become a well-established surgical technique to treat recurrent patellar dislocation. However, no golden standard exists so far to treat a patellofemoral instability. An additive trochleoplasty is recommended for patients with a high-grade trochlear dysplasia, that means a lateral trochlear inclination (LTI) of less than 11°.
The following study was to ascertain if an isolated MPFL reconstruction results in comparable results in patients with and without trochlea dysplasia. 
Methods: The study included 43 patients who underwent an MPFL reconstruction with a median age of 25.6 years and a median follow-up of 37.1 months. Patients were assessed by the International Knee Documentation Committee (IKDC), Tegner Activity, Lysholm and the visual analog scale (VAS) scores. On magnetic resonance imaging (MRI) LTI, Caton-Deschamps Index, tibial tuberosity to trochlear groove (TT-TG) distance and tibial tubercle-posterior cruciate ligament (TT-PCL) distance were measured. According to the LTI patients were divided into groups, group 1 with an LTI less than 11° and group 2 above 10°.
Results: The mean LTI of group 1 was 6,1 and 14,4 in group 2. The mean IKDC subjective score was 82 in group 1 and 81.6 in group 2. The mean Lysholm score was 84 in group 1 and 86 in group 2. Comparing the level of activity before and after the operation with the Tegner score showed that it was the same or even higher in 89% of all patients in group 1 and 92% in group 2. 
The mean VAS score was 2 (range 0-7) in group 1 and 1.6 (range 0-5) in group 2.77.8 % in group 1 were satisfied or very satisfied, whereas 92% in group 2 were satisfied or very satisfied. One patient in group 1 had a recurrent dislocation and one patient in group 2 had a subluxation postoperatively.
Conclusion: Patients with patellofemoral instability and a trochlea dysplasia achieved excellent results after an isolated MPFL reconstruction comparable to those without trochlea dysplasia. Thus, it seems that the MPFL can partially compensate the dysplasia. Therefore, the indication for a trochleoplasty should not just be according to radiological measures.

Keywords

Medial patellofemoral ligament , Patella , Dislocation , Patellofemoral instability , Trochlear dysplasia , Knee

ABBREVIATIONS

MPFL: Medial Patellofemoral Ligament; LTI: Lateral Trochlea Inclination; ROM: Range of motion; IKDC: International Knee Documentation Committee Subjective Knee Evaluation Score; VAS: Visual Analogue Scale; TT-TG distance: Tibial-Tuberosity to Trochlear Groove distance; TT-PCL distance: tibial TuberclePosterior Cruciate Ligament distance; MRI: Magnetic Resonance Image

Citation

Schäferhoff T, Sowada M, Schäferhoff P, Klein P, Dewitz H, Banerjee M (2021) Excellent Results of Isolated MPFL Reconstruction in Patients with and without High Grade Trochlea Dysplasia. Ann Sports Med Res 8(2): 1181.

INTRODUCTION

Patella dislocation is a common pathology and tends to affect especially young, active adolescent females [1,2]. Mostly the first patellar dislocation occurs before the second decade of life prevalently under the age of 16 [3].

There are passive, static and dynamic stabilizers of the patella. The main stabilizer (up to 90%) in early extension between 0° to 20° flexion of the patella, is the medial patellofemoral ligament (MPFL), which is a passive stabilizer [4,5]. At a flexion between 20° to 60°, the lateral trochlear facet provides stability of the patella as a static stabilizer. The more the knee is flexed the steeper becomes the trochlea groove [5]

Acute patellar dislocation is usually associated with a significant trauma such as a fall or an impact injury, which leads to a lateral displacement of the patella [6]. However, atraumatic dislocations are often due to predisposing factors including functional and morphological patellofemoral disorders such as patella alta, trochlea dysplasia, increased patella tilt, increased distance between the trochlear groove and the tibial tuberosity, genu valgum and ligament laxity [7-11].

The recurrence rate following a first-time dislocation is 44% [12]. This is due to the fact that 90% of all first-time patella dislocations have an insufficient or torn MPFL [13,14]. Previous studies have shown that torn or insufficient MPFL results in a lateral riding patella. Even a few millimetres more lateral riding of the patella than normal can cause a significant difference [15].

Several surgical techniques for treating patella tracking disorders including the loosening or tightening of stabilizing ligaments as well as the reconstruction of the medial patellofemoral ligament (MPFL) have been described [5]. Medial patellofemoral ligament (MPFL) reconstruction has become a widely used technique to treat patellofemoral instability. Several studies have shown excellent results of this technique [16,17]. However, in patients with severe dysplasia of the trochlea the results were less favourable and the failure rate was higher [18].

96% of all patients with instability of the patellofemoral joint have a flattened or deformed trochlea, known as a trochlear dysplasia, as an underlying cause [19]. In these patients deepening of the trochlea groove known as trochleoplasty has been advised as an additional procedure to MPFL reconstruction. The lateral trochlea inclination (LTI) angle (Figure 1) seems to be an objective parameter for the evaluation and quantification of trochlea dysplasia [20,14]. Furthermore, the LTI besides the Insall-Salvati ratio has been shown as the best predictor of lateral patella displacement and lateral tilt [21].

Accordingly, the aim of this study was to evaluate the clinical outcomes after an isolated MPFL reconstruction in patients with or without high-grade trochlear dysplasia.

MATERIALS AND METHODS

This study was approved by the medical review board of the University of Witten/ Herdecke (trial number 129/2017) and informed consent was obtained from all subjects.

The present study included 43 patients with objective patellofemoral instability. 25 of these patients had more than two patella re-dislocations and 13 had even more than four patella re-dislocations. 22 patients were female and 21 males, with a median age of 25.6 years. They were all operated by the same surgeon in the same surgical technique.

Surgical technique

MPFL reconstruction included a knee arthroscopy and minimal invasive open approach to the patella. First, a diagnostic arthroscopy was performed to evaluate the patellofemoral joint

Figure 1 Lateral trochlea inclination (LTI) angle

Figure 1: Lateral trochlea inclination (LTI) angle

.Figure 2 MRI scan showing lateralisation of the patella after patella dislocation.

Figure 2: MRI scan showing lateralisation of the patella after patella dislocation.

Figure 3 MRI scan showing subluxation of the patella with a trochlea dysplasia.

Figure 3: MRI scan showing subluxation of the patella with a trochlea dysplasia.

articulation with respect to a lateralisation or subluxation of the patella (Figures 2,3) or any other joint pathology such as chondral lesions. Patients with a trochlea dysplasia at 30° knee flexion during arthroscopy were regarded as an indication for a trochleoplasty and were not subject of the present study.

Then the MPFL was reconstructed in an anatomic doublebundle technique to replicate the native shape of the ligament and to provide sufficient stability. The gracilis tendon of the ipsilateral side was harvested and sutured at both ends. Both ends of the graft were then fixated with two 4.75mm BioComposite SwiveLock screws (Arthrex) in the proximal third of the medial side of the patella. The graft was then fixed with a 6mm BioComposite interference screw at the anatomic femoral origin of the MPFL, known as the Schöttle point [28]. The Schöttle point provides a static fixation point that equalizes the tension across the graft in flexion and extension. During the femoral fixation the knee was flexed at 30 degrees and the patella joint articulation was checked arthroscopically (Figures 4-6).

Rehabilitation following MPFL reconstruction

Post-operative care involved partial weight-bearing for 2 weeks and then gradually increasing the weight-load on the operated leg until full weight bearing was reached. The most important criteria were being pain free during weight bearing.

Additionally, all patients wore a posterior extension splint for 1 week, followed by wearing a knee brace with a flexion limitation to 90 degrees for 6 weeks. At the same time, this was supported by a physiotherapy/rehabilitation program to increase strength, improve coordination of the operated leg and achieve a good range of motion. From the 7th postoperative week onwards, free ROM was allowed and cycling on a stationary bike followed by outdoor cycling and slow running.

All patients were followed-up after an average of 37.1 month postoperatively. They completed post-operative outcome scores, including International Knee Documentation Committee Subjective Knee Evaluation Score (IKDC) [22], Tegner activity

Figure 4 Patella lateralisation from an arthroscopic view.

Figure 4: Patella lateralisation from an arthroscopic view.

Figure 5 Arthroscopic view after femoral fixation of the MPFL.

Figure 5: Arthroscopic view after femoral fixation of the MPFL.

Figure 6 Double bundle technique from an arthroscopic view.

Figure 6: Double bundle technique from an arthroscopic view.

and Lysholm scores [23,24] as well as visual analogue scale (VAS) [25].

Additionally, the Caton-Deschamps Index [26], tibialtuberosity to trochlear groove distance (TT-TG distance) [27], tibial tubercle-posterior cruciate ligament distance (TT-PCL distance) [28], and LTI [29], were measured on preoperative MRI scans.

The LTI was measured on the most proximal axial magnetic resonance image (MRI) of the trochlear chondral surface with respect to the angle of the posterior condyles (Figure 1) [16].

According to the LTI patients were divided into two groups, group 1 with an LTI below or equal 10° (≤ 10°) and group 2 greater than 10° (>10°).

Statistical analysis

The two groups were compared semi-quantitatively and statistically. Interval scaled variables were measured on a normal scale and independent random samples were compared using t-test for normally distributed data. The Mann-Whitney-U-Test was used was used for non-normally distributed data. The groups were compared of the ordinal variables such as the lickert-scale with a Mann-Whitney-U-Test.

The statistical tests to compare both groups used are the chisquare test, at a fourfold schematic stem with the exact Fisher´s test. All tests were evaluated at the significance level of 5%.

The Tegner activity score showed normally distributed data and was seen as an interval scaled variable, all three different time points were compared between the two study groups using twoway analysis of variance (ANOVA) with repeat measurements. To account alpha mistakes the Bonferroni-correction was used at the Post-Hoc-Test.

RESULTS

The median follow-up was 3.2 years in group 1 (LTI ≤ 10°) and 2.8 years in group 2 (LTI >10°). In group 1 there were 11 females and 7 males with a median age of 25.3 years. In group 2 were 11 females and 14 males with a median age of 27.7, years. The mean BMI was 23.7 in group 1 and 24.0 in group 2 (p= 0.82). The median LTI in group 1 was 6.1° (range 0.1-9.9) and 14,4° in group 2 (range 10.7-23.0).

One patient in group 1 had a recurrent patellar dislocation and one patient of group 2 had a patellar subluxation after the MPFL reconstruction. This represents a success rate of 95%.

The mean IKDC subjective score was 82 in group 1 (minimum score 49 and maximum score 99) and 81.6 in group 2 (minimum score 46 and maximal score 100) (p= 0.73). The mean Lysholm score was 84 in group 1 and 86 in group 2. The difference for both scores was statistically not significant between the two groups (p= 0.51) (Figure 7).

In group 1 the mean VAS score was 2, with a range of VASmin 0 to VASmax of 7. In group 2 the mean VAS score was 1.6, with a range of VASmin 0 and VASmax 5 (Figure 8).

Thus, the three most important results of both groups were comparable.

The analysis of the Lysholm score showed that group 2 had more excellent (24%) results than group 1 (5.5%). In group 1, 55.5% had good, 33% fair and 5.5% poor results. Similarly, in group 2 44% had good, 24% fair and 8% poor results.

The Tegner activity score showed a significant difference at the different time periods: preinjury the mean was 6.39±0.28 points; preoperatively the mean was 3.25±0.43 points whereas at the time of examination it was 5.43±0.30 points (p<0.001). However, there was no significant difference between both groups (Figure 9). Overall group 1 showed a slightly higher score compared to group 2 at all time periods. In group 1 the Tegner score was 6.8 preoperatively and 5.6 at the time of examination,

Figure 7 IKDC and Lysholm scores after MPFL reconstruction.

Figure 7: IKDC and Lysholm scores after MPFL reconstruction.

Figure 8 VAS Score after MPFL reconstruction.

Figure 8: VAS Score after MPFL reconstruction.

Figure 9 Tegner activity score.

Figure 9: Tegner activity score.

Figure 10 Tegner activity score comparing pre- & postoperative results.

Figure 10: Tegner activity score comparing pre- & postoperative results.

whereas in group 2 preoperatively 5.8 and 5.2 at the time of examination (Figure 9).

89% of patients in group 1 and 92% of patients in group 2 had an equal or even better level of activity when comparing the Tegner activity score before and after surgery (Figure 10).

77.8 % in group 1 and 92% in group 2 were satisfied or very satisfied with the operation (p= 0.3).

In group 1 there were two patients and in group 2 three patients with a mean TT-TG distance of more than 15mm. Two patients of group 1 had a mean TT-PCL distance higher than 24 mm, whereas only one patient in group 2 exceeded a TTPCL distance of 24mm (P 0.03). Likewise, the mean CartonDeschamps-Index was significantly higher in group one. In seven MRI scans it was greater than 1.2 in group 1 and in only five MRI scans in group 2 it was greater than 1.2 (P 0.45).

DISCUSSION

The most important finding of the current study was that isolated MPFL reconstruction for patello-femoral instability was successful not only in patients without trochlea dysplasia but also in those with significant trochlea dysplasia defined as a lateral trochlea inclination (LTI) of 10° or less. This is in contrast to the current literature.

Isolated MPFL reconstruction has shown excellent results for patients with recurrent patella dislocation [17]. However, in case of trochlea dysplasia the failure rate is increasing. Kita et al., found that trochlea dysplasia was the most important predictor of residual instability following isolated MPFL reconstruction [30]. Wagner et al., showed that patients with grade III trochlea dysplasia according to Dejour had a worse outcome than patients with type I and II [31]. Feucht et al., analysed 26 patients who failed after isolated MPFL reconstruction. They found a trochlea dysplasia as the most common anatomical risk factor for failure in 50% of patients [32]. Nelitz et al., found in their study of failed MPFL reconstructions that 5 out of 6 patients with recurrent instability had a trochlea dysplasia [33].

One problem in the indication for surgery is the quantification of trochlea dysplasia and the question which parameter is most appropriate to indicate trochleoplasty. Most of the aforementioned studies used the Dejour classification for the assessment of trochlea dysplasia. Some authors define type B, C and D as severe trochleas dysplasia [34], while in other studies only type C and D are regarded as high grade dysplasia [35,36]. Lippacher et al. found that the Dejour classification has shown a low inter- and intra-observer agreement for the discrimination of the four types [34]. They concluded that it was only useful for the separation of low-grade and high-grade dysplasia. Stefanik et al., examined several parameters to describe the morphology of the trochlea and found that the LTI besides the Insall-Salvati ratio was the best predictor lateral patella displacement and lateral tilt [21]. Nelitz et al., analysed 80 knees and correlated the Dejour classification with objective parameters of trochlea dysplasia (lateral trochlea inclination and others). They found a moderate inter- and intraobserver agreement especially in high grade dysplasia. Patients with dysplasia type A according to Dejour showed an LTI of 15°, type B of 11°, type C of 7° and type D of-1°. 75% of the patients with high grade dysplasia showed an LTI of less than 11°, whereas 84% of patients with a low-grade dysplasia had an LTI of 11° or more [21]. Thus, the cut-off of 11° stated by Carrillon et al., who first described the LTI was confirmed [4].

Due to these results the current study used the LTI with a cutoff value of 11° to objectively quantify trochlea dysplasia. Patients with and without high grade trochlea dysplasia had no difference in the IKDC and Lysholm score and in the pain level (VAS). The Tegner score was even slightly better in patients with trochlea dysplasia (5.6 vs 5.2 in patients without dysplasia). The redislocation rate as the most important parameter of success was similar in both groups with one re-dislocation in patients with and one subluxation in the group without trochlea dysplasia. In the study of Hiemsta et al., 61.5% of failed MPFL reconstructions had a high-grade trochlea dysplasia. However also 52.7% of the 243 intact reconstruction had a high-grade dysplasia defined as a type B, C or D dysplasia according to Dejour [12]. Thus, trochlea dysplasia is a common accompanying pathology in patients with patella-femoral instability. We suppose that the MPFL reconstruction can partially compensate a trochlea dysplasia.

In the subgroup analysis of the Lysholm score patients with and without trochlea dysplasia both showed comparable numbers of excellent and good results (61% vs. 68%). However, patients with trochlea dysplasia had less excellent results (5.5%) than those without dysplasia (24%). Although the difference was not statistically significant the number of satisfied or very satisfied patients with trochlea dysplasia was 15% less than in patients without dysplasia (77.5% vs. 92%).

The current study has some limitations. First it is a retrospective case series with no prospective randomisation of the two groups. Second patellofemoral instability is a common pathology, but the sample size is relatively small. Third patellofemoral instability is a multifactorial pathology, but the results were only interpreted in terms of trochlea dysplasia.

CONCLUSION

In summary an isolated MPFL reconstruction can restore stability of the patellofemoral joint and lead to excellent clinical results despite an underlying high grade trochear dysplasia (LTI ≤ 10°). In patients with trochlea dysplasia the rate of satisfied or very satisfied patients as well as the rate of patients with an excellent result in the Lysholm score may be slightly lower than in the group without dysplasia with otherwise comparable results between the two groups. Radiological measures like the lateral trochlea inclination are helpful to evaluate trochlea dysplasia but should not be used as the main criterion to indicate trochleoplasty.

REFERENCES

1. Graf R, Löhr J, Wirth CJ. Die Patellaluxation. Orthopäde. 1998; 27: 197–205.

2. Scharf HP. Orthopädie und Unfallchirurgie: Facharztwissen nach der neuen Weiterbildungsordnung . München: Urban & Fischer in Elsevier. 2008.

3. Y Nietosvaara, K Aalto, PE Kallio. Acute patellar dislocation in children: incidence and associated osteochondral fractures. J Pediatr Orthop. 1994; 14: 513-515.

4. Janice K. Loudon. Biomechanics and pathomechanics of the patellofemoral joint. Int J Sports Phys Ther. 2016; 11: 820–830.

5. Schöttle P. MPFL and Trochleoplasty Presentation Arthrex, Naples. 2014.

6. Jagodzinski M, Niemeyer P, Zeichen J, Balcarek P. S1-Leitlinie 012/024: Patellaluxation Leitlinien Unfallchirurgie - Überarbeitete Leitlinie Patellaluxation. 2014.

7. Beeton KS. The knee. Manual therapy masterclass: the peripheral joints. Churchill Livingstone. Elsevier. 2003; 54–55.

8. Frobell R, Cooper R, Morris H, Arendt H. Acute knee injuries. In: Brukner P, Bahr R, Blair S, Cook J, Crossley K, McConnell J, McCrory P, Noakes T, Khan K. Clinical Sports Medicine: 4th edition. Sydney: McGraw-Hill. 2012; 626-683.

9. Feucht MJ, Mehl J, Forkel P, Achtnich A, Schmitt A, Izadpanah K, et al. Failure analysis in patients with patellar redislocation after primary isolated medial patellofemoral ligament reconstruction. Orthop J Sports Med. 2020; 8: 2325967120926178.

10. Meeusen R. Praktijkgids knieletsels. Cursus. Vrije Universiteit Brussel. 2011.

11. Skinner HB, Barrack RL, Bedmar MS, Clarson GD. Sports medicine. In: Reinhardt S, Nogueira I, Boyle PJ. Current diagnosis en treatment in orthopedics. 2nd edition. McGraw-Hill: United States of America. 2020; 125–175.

12. Colvin AC, West RV. Patellar instability. J Bone Joint Surg Am. 2008; 90: 2751–2762.

13. M Petri, C von Falck, M Broese, E Liodakis, P Balcarek, P Niemeyer, et al. Influence of rupture patterns of the medial patellofemoral ligament (MPFL) on the outcome after operative treatment of traumatic patellar dislocation. Knee Surg Sports Traumatol Arthrosc. 2013; 21: 683–689.

14. Schöttle PFD. Die Therapie der instabilen Patella, MPFL - Funktion, Sinn und Unsinn, AGA-Komitee-Knie-Patellofemoral. 2016; 33-40

15. PV Hautamaa, DC Fithian, KR Kaufman, DM Daniel, AM Pohlmeyer. Medial soft tissue restraints in lateral patellar instability and repair. Clin Orthop Relat Res. 1998; 349: 174–182.

16. Joseph SM, Cheng C, Solomito MJ, Pace JL. Lateral trochlear inclination in children and adolescents: modified measurement technique to characterize patellar instability. Orthop J Sports Med. 2019; 7: 2325967119S00146.

17. Schneider DK, Grawe B, Magnussen RA, Ceasar A, Parikh SN, Wall EJ, et al. Outcomes after isolated medial patellofemoral ligament reconstruction for the treatment of recurrent lateral patellar dislocations. A systematic review and Meta-analysis. Am J Sports Med. 2016; 44: 2993-3005.

18. Balcarek P, Radebold T, Schulz X, Vogel D. Geometry of torsional malalignment syndrome: Trochlear dysplasia but not torsion predicts lateral patellar instability. Orthop J Sports Med. 2019; 7: 2325967119829790.

19. Berruto M, Ferrua P, Carimati G, Uboldi F, Gala L. Patellofemoral instability: classification and imaging. Joints. 2013; 1: 7–14.

20. Anderson AF, Irrgan JJ, Kocher MS, Mann BJ, Harrast JJ. The international knee documentation committee subjective knee evaluation form: normative data. Am J Sports Med. 2006; 34:128-135

21. Schöttle P, Schmeling A, Rosenstiel N, Weiler A. Rediographic landmarks for femoral tunnel placing in medial patellofemoral ligmanet reconstruction. Am J Sports Med. 2007; 35: 801-4.

22. Stefanik JJ, Zumwalt AC, Segal NA, Lynch JA, Powers CM. Association between measures patella height, morphologic features of the trochlea, and patellofemoral joint alignement: The MOST study. Clin Orthop Rel Res. 2013; 471: 2641-2648.

23. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clinical orthopaedics and related research. 1985; 198: 43–49.

24. Wülker N, Kohn D, Siebert WE, Wirth CJ. Die Bedeutung des Aktivitäts-Scores bei der Bewertung von Kniebandrekonstruktionen. Sportverletzung Sportschaden: Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin. 1991; 5: 130–134.

25. Flandry F, Hunt JP, Terry GC, Hughston JC. Analysis of subjective knee complaints using visual analog scales. Am J Sports Med. 1991; 19: 112- 8.

26. Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Patella infera. apropos of 128 cases. Revue de Chirurgie Orthopedique et reparatrice de l’appareil moteur. 1982; 68: 317–325

27. Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF,Romero J. The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee. 2006; 13: 26–31.

28. Seitlinger G, Scheurecker G, Högler R, Labey L, Innocenti B, Hofman S. Tibial tubercle-posterior cruciate ligament distance: a new measurement to define the position of the tibial tubercle in patients with patellar dislocation. Am J Sports Med. 2012; 40: 1119-25.

29. Carrillon Y, Abidi H, Dejour D, Fantino O, Moyen B, Tran-Minh Van A. Patellar instability: assessment on MR images by measuring the lateral trochlea inclination-initial experience. Radiology. 2000; 216: 582-585.

30. Kita K, Tanaka Y, Toritsuka Y, Amano H, Ushida R, Takao R, Horibe S. Factors affecting the outcomes of double-bundle medial patellofemoral ligament reconstruction for recurrent patellar dislocations evaluated by multivariate analysis. Am J Sports Med. 2015; 43: 2988-96.

31. Wagner D, Pfalzer F, Hingelbaum S, Huth J, Mauch F, Bauer G. The influence of risk factors on clinical outcomes following anatomical patellofemoral ligament (MPFL) reconstruction using the gracilis tendon. Knee Surg Sports Traumatol Arthroscop. 2013; 21: 318-324.

32. Feucht MJ, Mehl J, Forkel P, Achtnich A, Schmitt A, Izadpanah K, Imhoff AB, Berthold DP. Failure analysis in patients with patellar redislocation after primary isolated medial patellofemoral ligament reconstruction. Orthop J Sports Med. 2020; 8: 2325967120926178.

33. Nelitz M, Williams RS, Lippacher S, Reichel H, Dornacher D. Analysis of failure and clinical outcome after unsuccessful medial patellofemoral ligament reconstruction in young patients. Int Orthop. 2014; 38: 2265-2272.

34. Lippacher S, Dejour D, Elsharkawi M, Dornacher D, Ring C, Dreyhaupt J, et al. Observer agreement on the Dejour Trochlea dysplasia classification: a comparison of true lateral radiographs and axial magnetic resonance images. Am J Sports Med. 2012; 40: 837-843.

35. Hopper GP, Leach WJ, Rooney BP, Walker CR, Blyth MJ. Does degree of trochlea dysplasia and position of femoral tunnel influence outcome after medial patellofemoral reconstruction? Am J Sports Med. 2014; 42: 716-722.

36. Nelitz M, Lippacher S, Reichel H, Dornacher D. Evaluation of trochlea dysplasia using MRI: correlation between the classification of Dejour and objective parameters of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 2012; 22: 120-127

Received : 28 Jun 2021
Accepted : 21 Aug 2021
Published : 22 Aug 2021
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X