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MPFL Reconstruction - Pediatric and Adolescent

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • symptoms
  • physical exam
  • recognizes factors that could predict complications or poor outcome

2

Orders and interprets required diagnostic studies

  • radiographs

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Postop: 3-4 Week Postoperative Visit

  • wound check
  • start full range of motion at 4 with progressive quadriceps strengthening, edema control, pain control and gait training
  • continue to use the brace in community setting until adequate quadriceps strength has returned at about 6 weeks
  • diagnose and management of early complications
B

Advanced Evaluation and Management

1

Post operative instructions

  • Hinged knee brace locked in extension during ambulation for 4 weeks postoperatively, followed by slow weaning
  • May unlock brace during sitting
  • Gradual increase from touch down weight bearing to full weight bearing over 4 weeks postoperatively

2

Physical Therapy guidelines

  • Begin PT within one week following surgery
  • Limit knee flexion to 90 degrees for first 6 weeks post operatively
  • Closed chain strengthening per weight bearing restrictions, core, hip abductor strengthening
  • If meeting PT criteria, jogging by 3-4 months postoperatively can be allowed
  • Return to sports activity by 5-6 month postoperatively if meeting PT criteria

Operative Techniques

E

Preoperative Plan

1

Preoperative clinical assessment

  • Evaluate gait, lower extremity angular and rotational profile, Q angle, tibial torsion, patella tilt, femoral version, ligamentous laxity (Beighton score), and range of motion
  • Clinical questioning to assess Tanner stage

2

Preoperative radiographic assessment

  • Radiographs - AP, lateral, and sunrise of the injured knee
  • Assess physeal development, osteochondral injury, trochlear dysplasia, patella alta
  • MRI as indicated
  • More fully characterize osteochondral injuries, trochlear dysplasia, bone edema, location of MPFL injury, associated intraarticular pathologies, and tibial tubercle to trochlear groove distance
  • Angular profile as indicated
  • Full length standing hips to ankles AP radiograph if concern for angular (varus/valgus) malalignment on clinical exam
  • Bone age Xray as indicated
  • PA hand and wrist radiograph if skeletal age unclear on lower extremity radiographs

3

Examine the knee under anesthesia

  • Range of motion, Ligamentous stability, medial and lateral patellar translation in 25-30 degrees of knee flexion. Compare all exam findings to contralateral side
F

Room Preparation

1

Surgical instrumentation

  • Basic arthroscopy set
  • Basic orthopaedic set
  • K-wires
  • Bioabsorbable suture anchor with braided non-absorbable sutures

2

Room setup and equipment

  • Radiolucent OR table
  • Arthroscopy equipment - smaller patients will benefit from a small arthroscope to minimize iatrogenic cartilage damage
  • C-arm positioned on the opposite side of the injured extremity

3

Patient positioning

  • Supine
  • Lateral post for valgus stress for arthroscopic procedure
  • Radiolucent triangle under knee
G

Graft Exposure

1

Expose the graft

  • Graft exposure and preparation is performed after knee arthroscopy
  • A lateral release in carefully selected patients can be performed if tightness of the lateral retinaculum prevents normal medial patella translation or in cases of abnormal patella tilting
  • Longitudinal incision from superior pole of the medial aspect of patella, extending 5 to 6-cm proximally
  • Full-thickness flaps developed and dissected down to the quadriceps tendon and its insertion on patella

2

Femoral sided exposure

  • 2-cm longitudinal incision centered over medial epicondyle based on fluoroscopy and palpation
  • Dissection performed distal to physis to level of bone
H

Graft Preparation

1

Harvest graft

  • Identify VMO insertion on quadriceps tendon, harvest just lateral to VMO leaving 1-2-mm sleeve of remaining quadriceps tendon medially
  • Harvest an 8-mm by 70-mm full-thickness graft leaving the patella insertion intact
  • If tendon very thick can harvest partial-thickness graft

2

Place suture in graft

  • Suture the proximal free end of the graft with a whip stitch using a non-absorbable suture to prepare for passage of the graft
J

Graft Passage

1

Graft passage

  • Create tunnel for passing graft with large hemostat between the medial retinaculum and the synovium
K

Graft Tensioning

1

Identification of femoral insertion of MPFL

  • Use radiolucent triangle to flex knee to around 40 degrees to facilitate lateral radiograph
  • Find the "Schottle point": Identify MPFL insertion on lateral fluoroscopic radiograph 2-mm anterior to posterior cortex of the femur, and 2-mm distal to the posterior origin of the medial femoral condyle, and just proximal to Blumensaat line
  • Anatomic site for the femoral attachment of the MPFL lies a few millimeters distal to the medial aspect of the distal femoral physis
  • Place bioabsorbable suture anchor at this femoral insertion point

2

Tension the graft

  • Place knee in 30 to 45 degrees of flexion
  • Patella should translate about 10-mm laterally before end point to prevent overtensioning
  • Goal is to maintain the patella tracking centrally in the trochlea without any sign of medial subluxation
  • Provisional placement of pilot stitch
  • Place pilot suture through graft and periosteum of epiphyseal region of distal femur after setting tension of graft
  • Gently range knee through flexion and extension to assess graft tension and patellar position with motion
  • Make adjustments to this pilot stitch as indicated based on improper tensioning
  • Use sutures from previously placed suture anchor to secure graft on the femoral side in the position determined by pilot suture
  • Reinforcement of fixation on femoral side with additional non-absorbable sutures to medial intermuscular septum
  • Place non-absorbable sutures from periosteum of patella into graft
  • Assess patellar tracking through range of knee motion
N

Wound Closure

1

Deep closure

  • Quadriceps tendon graft site closed with absorbable vicryl suture

2

Superficial wound closure

  • Subcutaneous tissues closed with absorbable interrupted suture
  • Skin closed with running subcuticular suture

3

Dressings and immobilization

  • Place in a locked hinged knee brace in full extension

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control
  • physical therapy
  • start active and passive range of motion in a few days to prevent any arthrofibrosis
  • use protected weightbearing with crutches until the patient is comfortable enough to walk in a locked knee brace in full extension
  • restrict range of motion to 0 to 90 degrees for the first 3 to 4 weeks

2

Discharges patient appropriately

  • pain control
  • schedule follow up in 3-4 weeks
  • wound care
R

Complex Patient Care

1

Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings

 

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