MPFL Reconstruction

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Introduction

The MPFL (Medial Patello-Femoral Ligement) is the main ligament stabilising the kneecap. It helps to prevent dislocation of the kneecup. Whenever the patella experiences lateral movement, the MPFL is at risk of injury or tearing.

After the patella has dislocated once, it is common for the MPFL to become ruptured or stretched, resulting in reduced reliability to prevent further dislocations. In such cases, surgical reconstruction of this ligament becomes necessary to stabilise the patella and reduce the likelihood of future dislocations.

Patients with patella instability should consult their doctor for a comprehensive evaluation of their condition and a detailed discussion of the most suitable treatment options. It is essential to address any concerns or enquiries with the healthcare provider to gain a better understanding of the condition and receive the best possible care.

Indications and Contraindications

Indications

A MPFL Reconstruction is recommended for those who have had one or more patellar dislocations and have ongoing knee instability.

Contraindications

If there are coexisting bony deformities, the MPFL reconstruction is usually not a sufficient option, and additional procedures might be necessary.

Benefits and Risks

Like any surgery, MPFL Reconstruction comes with both potential benefits and risks. The decision to undergo the procedure should be made in consultation with a skilled orthopaedic surgeon, and the patient’s specific circumstances will influence the potential outcomes. Here are some of the benefits and risks associated with MPFL reconstruction:

Benefits

Restoration of Patellar Stability: The primary goal of MPFL reconstruction is to restore stability to the patella and improve knee function.
Pain Relief: Many individuals with patellar instability experience pain, MPFL reconstruction can alleviate this pain.
Improved Quality of Life: Patients often report an improved quality of life following successful MPFL reconstruction. They can return to sports, physical activities, and daily tasks with greater confidence.
Reduced Risk of Recurrent Dislocations: MPFL reconstruction is effective at reducing the risk of recurrent patellar dislocations. This can help prevent further damage to the knee joint.
Arthroscopic Approach: In many cases, MPFL reconstruction can be performed using minimally invasive arthroscopic techniques, which result in smaller incisions, less scarring, and potentially faster recovery compared to open surgery.

Risks

Infection: As with any surgical procedure, there is a risk of infection. Surgeons take precautions to minimise this risk, but it can still occur.
Graft Failure: The graft used to reconstruct the MPFL may not heal properly or may stretch or tear, leading to a recurrence of patellar instability.
Stiffness and Reduced Range of Motion: Following surgery, patients may experience stiffness in the knee joint, leading to a reduced range of motion. This can be mitigated with proper rehabilitation.
Nerve or Blood Vessel Injury: There is a small risk of damaging nearby nerves or blood vessels during the surgery, which can result in numbness or other complications.
Persistent Pain: While the goal of MPFL reconstruction is to relieve pain, some patients may continue to experience discomfort after the surgery.
Blood Clots (Deep Vein Thrombosis): There is a small risk of developing blood clots in the legs (deep vein thrombosis) after surgery, which can be a serious complication.
Anaesthesia Complications: As with any surgery, there are risks associated with anaesthesia, including allergic reactions or adverse effects.
Scar Tissue Formation: Some individuals may develop excessive scar tissue in the knee joint, potentially causing problems with joint movement.

Surgical Approach

Medial Patellofemoral Ligament (MPFL) reconstruction can be performed using different surgical approaches depending on the patient’s specific condition and the extent of the procedure. Here are some common surgical approaches for MPFL reconstruction:

Arthroscopic Approach: Arthroscopy is a minimally invasive surgical technique that involves using small incisions and a tiny camera (arthroscope) to visualise and perform the procedure. In the context of MPFL reconstruction, the arthroscopic approach allows the surgeon to work inside the joint with minimal disruption to the surrounding tissues.
Open Surgical Approach: In some cases, open surgery may be necessary, especially when there are additional structural issues or complex anatomical abnormalities that need to be addressed alongside MPFL reconstruction. Open surgery involves making a larger incision, providing more direct access to the knee joint. It may be employed when arthroscopic techniques are insufficient to address the patient’s condition adequately.
Combined Approaches: Some surgeons may use a combination of arthroscopic and open techniques, depending on the specific requirements of the surgery. For instance, arthroscopy may be used to assess the joint and perform initial steps, while open surgery may be employed for more extensive reconstruction or adjustments to the bony structures.

The choice of surgical approach will depend on factors such as the patient’s unique condition and the extent of the damage or deformity.

For MPFL reconstruction a tendon graft is used. It can be taken from own patient’s tissues (autograft), from a tissue bank (allograft), or a synthetic ligament can be used.

Pre-Surgery Information

Before MPFL Reconstruction surgery, the following procedures and preparations will take place:

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

Professor Al Muderis has revolutionized MPFL Reconstruction by introducing a minimally invasive technique using LARS ligaments (Ligament Augmentation and Reconstruction System). that mimic natural knee ligament fibres. It can significantly reduce surgery time since there’s no need for additional graft harvesting. As a result, patients can expect a faster return to full function

MPFL Reconstruction Surgical Procedure:

The procedure starts with a knee arthroscopy to remove any loose bodies and address any other intra-articular issues associated with the injury.
Next, a minimally invasive open approach is made to the patella. A release of tight structures around the patella is performed.
A hole is drilled through patella to allow passage of a new ligament.
The ligament is then secured to the end of the thigh bone, to pull the patella into its right position.
For skeletally immature patients, this must be done with superior care, to avoid injury to the growth plate.
Proper tension of the ligament is ensured and the patella is checked for stability.
The wound is then closed in layers, and a bandage dressing is then applied. If no other procedures have been performed, a knee brace is not needed.

Post-Surgery Information

Immediate Post-Surgery:

Following the surgery, patients will be taken to the recovery room for monitoring. Once their condition stabilises, they will be transferred to the ward. Pain management will be administered.

Patients will be encouraged to start moving their knee and walking within a day or two of the surgery. The surgical wound dressing will usually be reduced on the second day post-op to make movement easier. A physiotherapist will be available to guide them through exercises and assist with rehabilitation and mobility.

The expected hospital stay after the surgery is approximately one to three days.

The Recovery Process:

During the first week after surgery, the leg may be swollen, and the knee may feel stiff. It is normal to require regular pain medication during this period. Patients are advised to diligently perform the prescribed exercises at home to optimise recovery following surgery. The most important part of rehabilitation is maintaining strength and motion. Weight-bearing as tolerated, with crutches will be advised for an initial period after surgery.

Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:

1 week postop: for wound check,
2 weeks postop: for sutures removal.
6 weeks postop: for x-ray assessment of healing progressing,
Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.

Consistent commitment to the prescribed physiotherapy exercises significantly influences recovery after MPFL reconstruction.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000