Plantaris Tendon Autograft Can Restore Patellar Stability in Adolescent Medial Patellofemoral Ligament Reconstruction: A Technical Note

Document Type : TECHNICAL NOTE

Authors

1 1 Division of Paediatric Orthopaedic Surgery, Children’s Hospital Zagreb, Zagreb, Croatia 2 School of Medicine, University of Zagreb, Zagreb, Croatia

2 2 School of Medicine, University of Zagreb, Zagreb, Croatia 3 Department of Orthopaedic Surgery, University Hospital Centre Zagreb, Zagreb, Croatia

3 Department of Radiology and Ultrasound Diagnostics, Special Hospital for Pulmonary Diseases, Zagreb, Croatia

4 Department of Radiology, University Hospital Centre Zagreb, Zagreb, Croatia

5 Department of Materials, Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia

10.22038/abjs.2024.75154.3476

Abstract

Medial patellofemoral ligament reconstruction is a standard treatment option for patients with patellar 
instability. The main purpose of this study was to determine whether isolated anatomic medial 
patellofemoral ligament reconstruction using double folded, four-strand plantaris tendon autograft restores 
patellar stability in adolescent patients. Plantaris tendon autografts were harvested through proximal 
approach and used in four adolescent patients. A four-strand autograft was prepared in a double-limbed 
configuration and fixed on the patella and the femur with suture anchors and interference screws, 
respectively. The mean Kujala score improved significantly from 44 ± 24 SD (range, 19 to 69) points 
preoperatively to 94 ± 10 SD (range, 78 to 100) points postoperatively (P< 0.001). All patients reported 
excellent subjective outcomes and returned to their pre-injury level of sporting activities. The use of a 
four-strand plantaris tendon autograft in isolated anatomic medial patellofemoral ligament reconstructi on 
can restore patellar stability in adolescents. 
Level of evidence: IV

Keywords

Main Subjects


  1. Mountney J, Senavongse W, Amis AA, Thomas NP. Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction. J Bone Joint Surg Br.2005; 87:36-40.
  2. Yeung M, Leblanc MC, Ayeni OR, et al. Indications for Medial Patellofemoral Ligament Reconstruction: A Systematic Review. J Knee Surg. 2016; 29:543-554. doi: 10.1055/s-0035-1564730.
  3. McNeilan RJ, Everhart JS, Mescher PK, Abouljoud M, Magnussen RA, Flanigan DC. Graft choice in isolated medial patellofemoral ligament reconstruction: a systematic review with meta-analysis of rates of recurrent instability and patient-reported outcomes for autograft, allograft, and synthetic options. Arthroscopy. 2018; 34:1340-1354. doi: 10.1016/j.arthro.2017.11.027.
  4. Sidharthan S, Wang G, Schlichte LM, Fulkerson JP, Green DW. Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients. JBJS Essent Surg Tech. 2020; 10:1-3. doi: 10.2106/JBJS.ST.18.00110.
  5. VandenBerg CD, Sarkisova N, Pace JL, et al. Current practice trends in the surgical management of patellofemoral instability: a survey of the Paediatric Research in Sports Medicine (PRiSM) Society. J Child Orthop. 2021; 15:571-576. doi: 10.1302/1863-2548.15.210084.
  6. Migliorini F, Maffulli N, Bell A, Betsch M Outcomes, return to sport, and failures of MPFL reconstruction using autografts in children and adolescents with recurrent patellofemoral instability: A systematic review. Children (Basel). 2022; 9:1892. doi: 10.3390/children9121892.
  7. Schepsis AA, Rogers AJ. Medial patellofemoral ligament reconstruction: indications and technique. Sports Med Arthrosc Rev. 2012; 20:162-170. doi: 10.1097/JSA.0b013e318264188b.
  8. Gfoller P, Hoser C, Runer A, Abermann E, Wierer G, Fink C. Medial patellofemoral ligament (MPFL) reconstruction using quadriceps tendon autograft provides good clinical, functional and patient-reported outcome measurements (PROM): a 2-year prospective study. Knee Surg Sports Traumatol Arthrosc. 2019; 27:2426-2432. doi: 10.1007/s00167-018-5226-6.
  9. Sanchis-Alfonso V, Montesinos-Berry E, Ramirez-Fuentes C, Leal-Blanquet J, Gelber PE, Monllau JC. Failed medial patellofemoral ligament reconstruction: Causes and surgical strategies. World J Orthop 2017; 8:115-129. doi:10.5312/wjo.v8.i2.115
  10. Silver RL, de la Garza J, Rang M. The myth of muscle balance. A study of relative strengths and excursions of normal muscles about the foot and ankle. J Bone Joint Surg Br. 1985; 67:432-437. doi: 10.1302/0301-620X.67B3.3997956.
  11. Spina AA. The plantaris muscle: anatomy, injury, imaging, and treatment. J Can Chiropr Assoc. 2007; 51:158-165.
  12. Vlaic J, Josipovic M, Bohacek I, Jelic M. The plantaris muscle: too important to be forgotten. A review of evolution, anatomy, clinical implications and biomechanical properties. 2019; 59:839-845. doi: 10.23736/S0022-4707.18.08816-3.
  13. Pagenstert GI, Hintermann B. Proximal mini-invasive grafting of plantaris tendon. In: Easley ME, Wiesel SW, editors. Operative Techniques in Foot and Ankle Surgery, Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011.
  14. Miller TT, Staron RB, Feldman F. Patellar height on sagittal MR imaging of the knee. AJR Am J Roentgenol. 1996; 167:339-341. doi: 10.2214/ajr.167.2.8686598.
  15. Dejour DH. The patellofemoral joint and its historical roots: the Lyon School of Knee Surgery. Knee Surg Sports Traumatol Arthrosc. 2013; 21:1482-1494. doi: 10.1007/s00167-012-2331-9.
  16. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993; 9:159-163. doi: 10.1016/s0749-8063(05)80366-4.
  17. O'Connor CM, Ring D. Correlation of single assessment numeric evaluation (SANE) with other patient reported outcome measures (PROMs). Arch Bone Jt Surg. 2019; 7:303-306.
  18. Zarzycki W, Mazurkiewicz S, Wisniewski P. Research on strength of the grafts that are used in anterior cruciate ligament reconstruction. Pol Orthop Traumatol. 1999; 64:293-302.
  19. Bohnsack M, Surie B, Kirsch IL, Wulker N. Biomechanical properties of commonly used autogenous transplants in the surgical treatment of chronic lateral ankle instability. Foot Ankle Int. 2002; 23:661-664. doi: 10.1177/107110070202300714.
  20. Vlaic J, Josipovic M, Bohacek I, et al. Plantaris tendon is valuable graft for the medial patellofemoral ligament reconstruction: A biomechanical study. Knee. 2022; 38:212-219. doi: 10.1016/j.knee.2022.08.016.

 

 

  1. Schottle P, Schmeling A, Romero J, Weiler A. Anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft. Arch Orthop Trauma Surg. 2009; 129:305-309. doi: 10.1007/s00402-008-0712-9.
  2. Schöttle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med. 2007; 35:801-804. doi: 10.1177/0363546506296415.
  3. Josipović M, Vlaić J, Serdar J, et al. Plantaris tendon: a novel graft for anterolateral ligament reconstruction and additional reinforcement for anterior cruciate ligament autografts in combined reconstructive procedures Knee Surg Sports Traumatol Arthrosc. 2020; 28:2604-2608. doi: 10.1007/s00167-020-05885-x.
  4. Placella G, Tei M, Sebastiani E, et al. Anatomy of the medial patello-femoral ligament: a systematic review of the last 20 years literature. Musculoskelet Surg. 2015; 99:93-103. doi: 10.1007/s12306-014-0335-y.
  5. Weinberger JM, Fabricant PD, Taylor SA, Mei JY, Jones KJ. Influence of graft source and configuration on revision rate and patient-reported outcomes after MPFL reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2017; 25:2511-2519. doi: 10.1007/s00167-016-4006-4.
  6. Arendt EA. Anatomy and biomechanics of the patellar ligaments. Tecniche Chirurgiche in Ortopedia E Traumatologia .2007; 5:13-18.
  7. Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, Bonanzinga T, Marcacci M. Minimally invasive medial patellofemoral ligament reconstruction with fascia lata allograft: surgical technique. Knee Surg Sports Traumatol Arthrosc. 2014; 22:2426-2430. doi: 10.1007/s00167-014-2940-6.
  8. Nordin JS, Olsson O, Lunsjo K. The gracilis tendon autograft is a safe choice for orthopedic reconstructive procedures: a consecutive case series studying the effects of tendon harvesting. BMC Musculoskelet Disord. 2019; 20:138. doi: 10.1186/s12891-019-2520-5.
  9. Adams DJ, Mazzocca AD, Fulkerson JP. Residual strength of the quadriceps versus patellar tendon after harvesting a central free tendon graft. Arthroscopy. 2006; 22:76-79. doi: 10.1016/j.arthro.2005.10.015.