Reconstrucción del ligamento patelofemoral medial (LPFM) con autoinjerto cuadricipital y uso de TAC 3D preoperatorio para establecer punto anatómico femoral
DOI:
https://doi.org/10.1016/j.rccot.2019.12.005Palabras clave:
ligamento patelofemoral medial, tendón cuadricipital, TAC 3DResumen
Introducción: En los últimos años ha cobrado importancia la reconstrucción del LPFM. La técnica más utilizada es con autoinjerto de tendones isquiotibiales. En algunas series los reportes de complicaciones son mayores al 26%. Este trabajo pretende demostrar la utilidad del autoinjerto del cuádriceps para la reconstrucción del LPFM, sin túneles rotulianos y sin el uso de fluoroscopia intraoperatoria.
Materiales y métodos: Se incluyeron pacientes con historia clínica de al menos dos episodios de luxación. Se tomaron en todas los pacientes serie radiográfica, TAC axial rótulas, TAC 3D y RNM. Se obtuvo registro de manera retrospectiva de puntuaciones en las escalas de Lysholm, Tegner y Kujala en el posoperatorio con controles a los 6,12 y 18 meses.
Resultados: Cumplieron con los criterios de selección 24 pacientes, 16 mujeres y 8 hombres, edad promedio de 23 años. En nuestro estudio se observó la mejoría de puntuaciones en las escalas de Lysholm, Tegner y Kujala en el posoperatorio con controles a los 6,12 y 18 meses. Sin presentarse nuevos episodios de luxación rotuliana u otras complicaciones relevantes. Hubo un retorno en todos los casos a la actividad deportiva.
Discusión: Este estudio reafirma que el tendón cuadricipital es un injerto que reproduciendo mejor la anatomía del LPFM, presenta cifras comparables o mejores funcionalmente con los otros injertos utilizados en la actualidad. Con el protocolo preoperatorio de TAC3D se ha conseguido identificar en forma individual y con la especificidad anatómica de cada paciente, al tubérculo aductor y epicóndilo medial, dando mayor certeza en la ubicación anatómica de la inserción femoral LPFM. Con las ventajas adicionales de disminuir el tiempo quirúrgico, y evitar radiación innecesaria en el equipo quirúrgico.
Nivel de Evidencia: IV
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Referencias bibliográficas
Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elías DA, White LM. Epidemiology and Natural History of Acute Patellar Dislocation. The American Journal of Sports Medicine. 2004;32:1114-21. https://doi.org/10.1177/0363546503260788
Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP. Anatomy and biomechanics of the medial patellofemoral ligament. The Knee. 2003;10:215-20. https://doi.org/10.1016/S0968-0160(03)00006-1
Baldwin JL. The Anatomy of the Medial Patellofemoral Ligament. The American Journal of Sport Medicine. 2009;37:2355-61, https://doi.org/10.1177/0363546509339909
Bicos J, Fulkerson JP, Amis AA. Current concepts review: the medial patellofemoral ligament. The American Journal of Sports Medicine. 2007;35:484-92. https://doi.org/10.1177/0363546507299237
Camp CL, Krych AJ, Dahm DL, Levy BA, Stuart MJ. Medial Patellofemoral Ligament Repair for Recurrent Patellar Dislocation. The American Journal of Sports Medicine. 2010;38:2248-54. https://doi.org/10.1177/0363546510376230
Christiansen SE, Jacobsen BW, Lund B, Lind M. Reconstruction of the Medial Patellofemoral Ligament With Gracilis Tendon Autograft in Transverse Patellar Drill Holes. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008;24:82-7. https://doi.org/10.1016/j.arthro.2007.08.005
Drez D Jr, Edwards TB, Williams CS. Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2001;17:298-306. https://doi.org/10.1053/jars.2001.21490
Elias JJ, Cosgarea AJ. Technical Errors During Medial Patellofemoral Ligament Reconstruction Could Overload Medial Patellofemoral Cartilage. The American Journal of Sports Medicine. 2006;34:1478-85. https://doi.org/10.1177/0363546506287486
Ellera Gomes J. Medial patellofemoral ligament reconstruction for recurrent dislocation of the patella: a preliminary report. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1992;8:335-40. https://doi.org/10.1016/0749-8063(92)90064-I
Ellera Gomes JL, Stigler Marczyk LR, César de César P, Jungblut CF. Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2004;20:147-51. https://doi.org/10.1016/j.arthro.2003.11.006
Farahmand F, Senavongse W, Amis AA. Quantitative study of the quadriceps muscles and trochlear groove geometry related to instability of the patellofemoral joint. Journal of Orthopaedic Research. 1998;16:136-43. https://doi.org/10.1002/jor.1100160123
Fink C, Veselko M, Herbort M, Hoser C. MPFL reconstruction using a quadriceps tendon graft: part 2: operative technique and short term clinical results. Knee. 2014;21:1175-9. https://doi.org/10.1016/j.knee.2014.05.006
Fink C, Veselko M, Herbort M, Hoser C. Minimally Invasive Reconstruction of the Medial Patellofemoral Ligament Using Quadriceps Tendon. Arthroscopy Techniques. 2014;3:e325-9, https://doi.org/10.1016/j.eats.2014.01.012
Goyal D. Medial Patellofemoral Ligament Reconstruction: The Superficial Quad Technique. The American Journal of Sports Medicine. 2013;41:1022-9. https://doi.org/10.1177/0363546513477828
Grelsamer RP, Meadows S. The modified Insall-Salvati ratio for assessment of patellar height. Clinical Orthopaedics and Related Research. 1992;282:170-6. https://doi.org/10.1097/00003086-199209000-00022
Guerrero P. Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology. 2009;1:1. https://doi.org/10.1186/1758-2555-1-17
Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: An anatomic radiographic study. Knee Surgery, Sports Traumatology, Arthroscopy. 1994;2: 19-26. https://doi.org/10.1007/BF01552649
Schöttle P. Anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft. Archives of Orthopaedic and Trauma Surgery. 2009;129:305. https://doi.org/10.1007/s00402-008-0712-9
Schöttle PB, Fucentese SF, Romero J. Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2005;13: 516-21. https://doi.org/10.1007/s00167-005-0659-0
Harris NL, Smith DAB, Lamoreaux L, Purnell M. Central Quadriceps Tendon for Anterior Cruciate Ligament Reconstruction: Part I: Morphometric and Biomechanical Evaluation. The American Journal of Sports Medicine. 1997;25:23-8. https://doi.org/10.1177/036354659702500105
Herbort M, Hoser C, Domnick C, Raschke MJ, Lenschow S, Weimann A, Kösters C, Fink C. MPFL reconstruction using a quadriceps tendon graft: part 1: biomechanical properties of quadriceps tendon MPFL reconstruction in comparison to the Intact MPFL. A human cadaveric study. Knee. 2014;21:1169-74, https://doi.org/10.1016/j.knee.2014.07.026
Steensen RN, Dopirak RM, Maurus PB. A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2005;21:365-70. https://doi.org/10.1016/j.arthro.2004.10.007
Mountney J, Senavongse W, Amis AA, Thomas NP. Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction Journal of Bone and Joint Surgery. British volume. 2005;87-B:36-40. https://doi.org/10.1302/0301-620X.87B1.14924
Stephen JM, Kaider D, Lumpaopong P, Deehan DJ, Amis AA. The Effect of Femoral Tunnel Position and Graft Tension on Patellar Contact Mechanics and Kinematics After Medial Patellofemoral Ligament Reconstruction. The American Journal of Sports Medicine. 2014;42:364-72. https://doi.org/10.1177/0363546513509230
Stephen JM, Lumpaopong P, Kader DF, Deehan D, Amis AA. The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and non-anatomic attachments. The American Journal of Sports Medicine. 2012;40:1871-9. https://doi.org/10.1177/0363546512449998
Stupay KL, Swart E, Shubin Stein BE. Widespread Implementation of Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Maintains Functional Outcomes at Midterm to Long-Term Follow-up While Decreasing Complication Rates: A Systematic Review. Arthroscopy. 2015;31:1372-80, https://doi.org/10.1016/j.arthro.2014.12.029
Wang C-h, Ma L-f, Zhou J-w, Ji G, Wang H-y, Wang F, Wang J. Double-bundle anatomical versus single-bundle isometric medial patellofemoral ligament reconstruction for patellar dislocation. International Orthopaedics. 2013;37:617-24. https://doi.org/10.1007/s00264-013-1788-6
Ramírez Fuentes, Sanchis Alfonso. Tesis Doctoral Análisis en vivo mediante TAC 3D de Isometría LPFM. Universidad de Valencia, octubre. 2015.
