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Anterior and distal tunnel orientation for anatomic reconstruction of the medial patellofemoral ligament is safer in patients with open growth plates

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

In patients with open growth plates, the direction of tunneling that avoids distal femoral physis (DFP) damage in anatomic reconstructions of the medial patellofemoral ligament (MPFL) has been a topic of discussion. The objective of this study was to determine the ideal orientation for anatomic reconstructions of MPFL tunneling that minimized DFP damage while avoiding breaching the intercondylar notch.

Methods

Eighty magnetic resonance images of patients aged 10 through 17 were obtained, randomly sampled from the institutional database. A de novo software was developed to obtain 3D models of the distal femur and DFP. In each model, the anatomical insertion point of the MPFL was determined as defined by Stephen. A 20-mm-depth drilling was simulated, starting from the insertion point at every possible angle within a 90° cone using 5-, 6- and 7-mm drills. Physeal damage for each pair of angles and each drill size was determined. Damage was expressed as a percentage of total physis volume. Statistical analysis was conducted using Student’s t test and one-way ANOVA.

Results

Maximum physeal damage (5.35% [4.47–6.24]) was obtained with the 7-mm drill when drilling 3° cephalic and 15° posterior from insertion without differences between sexes (n.s.). Minimal physeal damage (0.22% [0.07–0.37]) was obtained using the 5-mm drill aimed 45° distal and 0° anteroposterior, not affected by sex (n.s.). Considering intra-articular drilling avoidance, the safest zone was obtained when aiming 30°–40° distal and 5°–35° anterior, regardless of sex.

Conclusion

Ideal femoral tunnel orientation, avoiding physeal damage and breaching of the intercondylar notch, was obtained when aiming 30°–40° distal and 5°–35° anterior, regardless of sex. This area is a safe zone that allows anatomic MPFL reconstruction of patients with an open physis.

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Acknowledgements

We would like to thank Fernando Marin, Anselmo Alegría, Matías Rojas, Jorge López, and José Tomás Ossa for their contribution in data recollection. We also thank Catalina Vidal for her contribution in statistical analysis and manuscript overview. Finally, we would like to thank Rafael Vega, Luis Irribarra, Julio Espinosa, and Raimundo Vial for their cooperation in our research team.

Funding

This study did not require funding.

Author information

Authors and Affiliations

  1. Orthopedic Surgery Department, Pontificia Universidad Católica de Chile, Diagonal Paraguay Nº 362, 3rd floor, Santiago, Chile

    Sebastián Irarrázaval, Pablo Besa, Maria J. Lira & Mario Orrego

  2. School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile

    Francisco Fernández & Tomás Fernández

  3. Clínica Alemana, Universidad del Desarrollo, Santiago, Chile

    Maria Tuca

  4. Hospital Mutual de Seguridad, Santiago, Chile

    Maria Tuca

Authors
  1. Sebastián Irarrázaval
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  2. Pablo Besa
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  3. Francisco Fernández
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  4. Tomás Fernández
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  5. Maria Tuca
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  6. Maria J. Lira
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  7. Mario Orrego
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Contributions

SI: conception and design, analysis and interpretation of data; drafting the manuscript and revising it critically for important intellectual content; final approval of the version to be published; agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; PB: conception and design, analysis and interpretation of data; drafting the manuscript and revising it critically for important intellectual content; final approval of the version to be published; agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; FF: acquisition of data, analysis and interpretation of data; revising the manuscript critically for important intellectual content; final approval of the version to be published; agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; TF: acquisition of data, analysis and interpretation of data; revising the manuscript critically for important intellectual content; final approval of the version to be published; agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; MJT: conception and design, analysis and interpretation of data; revising the manuscript critically for important intellectual content; final approval of the version to be published; agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; MJL: acquisition of data, analysis and interpretation of data; revising the manuscript critically for important intellectual content; final approval of the version to be published; agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; MO: conception and design, analysis and interpretation of data; revising the manuscript critically for important intellectual content; final approval of the version to be published; agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to Pablo Besa.

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Irarrázaval, S., Besa, P., Fernández, F. et al. Anterior and distal tunnel orientation for anatomic reconstruction of the medial patellofemoral ligament is safer in patients with open growth plates. Knee Surg Sports Traumatol Arthrosc 29, 1822–1829 (2021). https://doi.org/10.1007/s00167-020-06229-5

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