Skip to main content
Log in

Functional testing and return to sport following stabilization surgery for recurrent lateral patellar instability in competitive athletes

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy are commonly used to treat recurrent lateral patellar instability, yet there are limited available data on return to sport (RTS) following these procedures. The purpose of this study is to evaluate patient factors associated with excellent functional outcomes, including successful RTS, following surgical stabilization including MPFL reconstruction in competitive athletes with recurrent lateral patellar instability.

Methods

Athletes undergoing primary MPFL reconstruction for recurrent lateral instability from 2005 to 2013 were identified at a single institution. Concomitant procedures, such as tibial tubercle osteotomy (TTO), were included. Patient demographic information, including BMI, gender, age, and pre-injury Tegner score, was recorded. In addition, radiographs were reviewed for pre-operative patellar height (Caton–Deschamps index) and trochlear dysplasia (Dejour classification). All patients underwent a standardized rehabilitation/post-operative protocol, with isokinetic strength and functional testing being performed at 6 months post-operatively. Final Tegner scores, RTS status, subjective instability ratings, and Kujala scores were collected at a minimum of 2 years. Chi-squared analysis for categorical variables and Wilcoxon rank-sum analysis for continuous variables were used to determine the relationship between the previously mentioned patient and knee characteristics with isokinetic data, RTS status, or Kujala scores.

Results

Thirty-nine athletes (23 male, 16 female) at a mean age of 17.5 ± 2.9 years (range, 13–26) underwent primary MPFL reconstruction (32 autografts, seven allografts) for recurrent patellar instability with a mean follow-up of 47.0 ± 16.4 months. Sixteen patients (41%) underwent concomitant tibial tubercle osteotomies. Isokinetic data collected at 6 months post-operatively demonstrated mean knee flexion and extension strength deficits of 15.8 ± 10.1% and 21.4 ± 14.3%, respectively, compared to the contralateral leg (p < 0.001 for both). Patients who underwent concomitant tibial tubercle osteotomy (p = 0.04), males (p = 0.01) and those with patella alta (p = 0.04) had weaker 6-month isokinetic testing. Thirty-three of the thirty-nine (85%) athletes were able to RTS at a mean of 8.1 ± 3.9 months. Patients undergoing MPFL with concomitant TTO (p = 0.02) returned to sport at a slower rate. One patient (3%) reported an episode of recurrent dislocation requiring revision surgery. Kujala and Tegner scores at final follow-up were 91.1 ± 6.3 and 6 (range, 4–9), respectively.

Conclusion

Surgical stabilization including MFPL reconstruction for recurrent lateral patellar instability is an effective procedure for returning athletes to competitive sports. However, strength deficits persist at 6 months after surgery, especially in those undergoing concomitant TTO, which may delay return to sport. Physicians can use these results to counsel patients that return to competitive sports is safe with good clinical outcomes and low rate of recurrence at 4-year follow-up; however, predisposing factors, like a lateralized tibial tubercle, should be addressed if necessary, but athletes should be counselled that a slower recovery and longer return to sport time may be expected.

Level of evidence

IV.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Ahmad CS, Stein BE, Matuz D, Henry JH (2000) Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation. A review of eight cases. Am J Sports Med 28:804–810

    Article  CAS  PubMed  Google Scholar 

  2. Ambrozic B, Novak S (2016) The influence of medial patellofemoral ligament reconstruction on clinical results and sports activity level. Phys Sports Med 44:133–140

    Article  Google Scholar 

  3. Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220

    Article  CAS  PubMed  Google Scholar 

  4. Ardern CL, Taylor NF, Feller JA, Webster KE (2012) Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med 40:41–48

    Article  PubMed  Google Scholar 

  5. Banke IJ, Kohn LM, Meidinger G, Otto A, Hensler D, Beitzel K, Imhoff AB, Schottle PB (2014) Combined trochleoplasty and MPFL reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study. Knee Surg Sports Traumatol Arthrosc 22:2591–2598

    Article  PubMed  Google Scholar 

  6. Buckens CF, Saris DB (2010) Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. Am J Sports Med 38:181–188

    Article  PubMed  Google Scholar 

  7. Conlan T, Garth WP Jr, Lemons JE (1993) Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 75:682–693

    Article  CAS  PubMed  Google Scholar 

  8. Costain R, Williams AK (1984) lsokinetic quadriceps and hamstring torque levels of adolescent, female soccer players. J Orthop Sports Phys Ther 5:196–200

    Article  CAS  PubMed  Google Scholar 

  9. Desio SM, Burks RT, Bachus KN (1998) Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 26:59–65

    Article  CAS  PubMed  Google Scholar 

  10. Drez D, Edwards TB, Williams CS (2001) Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation. Arthroscopy 17:298–306

    Article  PubMed  Google Scholar 

  11. Enderlein D, Nielsen T, Christiansen SE, Fauno P, Lind M (2014) Clinical outcome after reconstruction of the medial patellofemoral ligament in patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 22:2458–2464

    Article  PubMed  Google Scholar 

  12. Feller JA, Richmond AK, Wasiak J (2014) Medial patellofemoral ligament reconstruction as an isolated or combined procedure for recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc 22:2470–2476

    Article  PubMed  Google Scholar 

  13. Fisher B, Nyland J, Brand E, Curtin B (2010) Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy. Arthroscopy 26:1384–1394

    Article  PubMed  Google Scholar 

  14. Fisher TF, Waterman BR, Orr JD, Holland CA, Bader J, Belmont PJ Jr (2016) Tibial tubercle osteotomy for patellar chondral pathology in an active United States military population. Arthroscopy. doi:10.1016/j.arthro.2016.03.027

    PubMed  Google Scholar 

  15. Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, White LM (2004) Epidemiology and natural history of acute patellar dislocation. Am J Sports Med 32:1114–1121

    Article  PubMed  Google Scholar 

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

    Article  Google Scholar 

  17. Hewett TE, Myer GD, Zazulak BT (2008) Hamstrings to quadriceps peak torque ratios diverge between sexes with increasing isokinetic angular velocity. J Sci Med Sport 11:452–459

    Article  PubMed  Google Scholar 

  18. Kamath GV, Murphy T, Creighton RA, Viradia N, Taft TN, Spang JT (2014) Anterior cruciate ligament injury, return to play, and reinjury in the elite collegiate athlete: analysis of an ncaa division I cohort. Am J Sports Med 42:1638–1643

    Article  PubMed  Google Scholar 

  19. Krych AJ, Woodcock JA, Morgan JA, Levy BA, Stuart MJ, Dahm DL (2015) Factors associated with excellent 6-month functional and isokinetic test results following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 23:1053–1059

    Article  PubMed  Google Scholar 

  20. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9:159–163

    Article  CAS  PubMed  Google Scholar 

  21. Lewallen LW, McIntosh AL, Dahm DL (2013) Predictors of recurrent instability after acute patellofemoral dislocation in pediatric and adolescent patients. Am J Sports Med 41:575–581

    Article  PubMed  Google Scholar 

  22. Lind M, Enderlein D, Nielsen T, Christiansen SE, Fauno P (2016) Clinical outcome after reconstruction of the medial patellofemoral ligament in paediatric patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc 24:666–671

    Article  PubMed  Google Scholar 

  23. Maenpaa H, Huhtala H, Lehto MU (1997) Recurrence after patellar dislocation. Redislocation in 37/75 patients followed for 6-24 years. Acta Orthop Scand 68:424–426

    Article  CAS  PubMed  Google Scholar 

  24. Mikashima Y, Kimura M, Kobayashi Y, Miyawaki M, Tomatsu T (2006) Clinical results of isolated reconstruction of the medial patellofemoral ligament for recurrent dislocation and subluxation of the patella. Acta Orthop Belg 72:65–71

    PubMed  Google Scholar 

  25. Myklebust G, Bahr R (2005) Return to play guidelines after anterior cruciate ligament surgery. Br J Sports Med 39:127–131

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Nelitz M, Williams SR (2015) Combined trochleoplasty and medial patellofemoral ligament reconstruction for patellofemoral instability. Oper Orthop Traumatol 27:495–504

    Article  CAS  PubMed  Google Scholar 

  27. Nomura E, Inoue M, Kobayashi S (2007) Long-term follow-up and knee osteoarthritis change after medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 35:1851–1858

    Article  PubMed  Google Scholar 

  28. Oliva F, Ronga M, Longo UG, Testa V, Capasso G, Maffulli N (2009) The 3-in-1 procedure for recurrent dislocation of the patella in skeletally immature children and adolescents. Am J Sports Med 37:1814–1820

    Article  PubMed  Google Scholar 

  29. Paxton EW, Fithian DC, Stone ML, Silva P (2003) The reliability and validity of knee-specific and general health instruments in assessing acute patellar dislocation outcomes. Am J Sports Med 31:487–492

    Article  PubMed  Google Scholar 

  30. Ronga M, Oliva F, Longo UG, Testa V, Capasso G, Maffulli N (2009) Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 37:1735–1742

    Article  PubMed  Google Scholar 

  31. Schiphouwer L, Rood A, Tigchelaar S, Koeter S (2016) Complications of medial patellofemoral ligament reconstruction using two transverse patellar tunnels. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4245-4

    PubMed  Google Scholar 

  32. Schottle PB, Fucentese SF, Romero J (2005) Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 13:516–521

    Article  CAS  PubMed  Google Scholar 

  33. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C (2012) A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 40:1916–1923

    Article  PubMed  PubMed Central  Google Scholar 

  34. Sillanpaa PJ, Salonen E, Pihlajamaki H, Maenpaa HM (2014) Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome. Knee Surg Sports Traumatol Arthrosc 22:2414–2418

    Article  PubMed  Google Scholar 

  35. Smith TO, Walker J, Russell N (2007) Outcomes of medial patellofemoral ligament reconstruction for patellar instability: a systematic review. Knee Surg Sports Traumatol Arthrosc 15:1301–1314

    Article  PubMed  Google Scholar 

  36. Sousa PL, Krych AJ, Cates RA, Levy BA, Stuart MJ, Dahm DL (2015) Return to sport: does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes? Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3697-2

    Google Scholar 

  37. Stephen JM, Dodds AL, Lumpaopong P, Kader D, Williams A, Amis AA (2015) The ability of medial patellofemoral ligament reconstruction to correct patellar kinematics and contact mechanics in the presence of a lateralized tibial tubercle. Am J Sports Med 43:2198–2207

    Article  PubMed  Google Scholar 

  38. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

    Google Scholar 

  39. Thevenin-Lemoine C, Ferrand M, Courvoisier A, Damsin JP, Ducou le Pointe H, Vialle R (2011) Is the Caton-Deschamps index a valuable ratio to investigate patellar height in children? J Bone Joint Surg Am 93:e35

    Article  PubMed  Google Scholar 

  40. Tischer T, Geier A, Lenz R, Woernle C, Bader R (2016) Impact of the patella height on the strain pattern of the medial patellofemoral ligament after reconstruction: a computer model-based study. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4190-2

    Google Scholar 

  41. Valkering KP, Rajeev A, Caplan N, Tuinebreijer WE, Kader DF (2016) An evaluation of the effectiveness of medial patellofemoral ligament reconstruction using an anatomical tunnel site. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4292-x

    PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Aaron J. Krych.

Ethics declarations

Conflict of interest

All the authors declare that they have no relevant conflict of interest.

Funding

No external source of funding was used.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

All patients did provide informed consent before being included in this study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Krych, A.J., O’Malley, M.P., Johnson, N.R. et al. Functional testing and return to sport following stabilization surgery for recurrent lateral patellar instability in competitive athletes. Knee Surg Sports Traumatol Arthrosc 26, 711–718 (2018). https://doi.org/10.1007/s00167-016-4409-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-016-4409-2

Keywords

Navigation