Comparison of 2 different techniques for anatomic reconstruction of the medial patellofemoral ligament: A prospective randomized study.
Kang H, Cao J, Yu D, Zheng Z, and Wang F. Am J Sports Med. 2013; [Epub Ahead of print].
Take Home Message: While both the Y-graft and C-graft effectively stabilized the patellofemoral joint, the patients who received the Y-graft had significantly better subjective outcome scores than the patients who received the C-graft.
Patients who endure a patellofemoral dislocation are often plagued with patellofemoral instability and frequent re-injury. While multiple methods of patellar fixation exist, a gold-standard does not. Therefore, Kang and colleagues performed a randomized trial to compare the double-bundle anatomic medial patellofemoral ligament reconstruction with one of two fixation methods – Y-graft or C-graft. The authors randomized 82 patients (40 in Y-graft group, 42 in C-graft group) with chronic patellar dislocations or instability and none of the exclusion criteria: (1) pervious surgery on the injured knee, (2) Q-angle greater than 20° in female patients and 17° in male patients, (3) trochlear angle greater than 145°, (4) tibial tuberosity-trochlear groove distance of ≥20 mm, (5) patella alta, (6) patellar dysplasia (grades IV or V), or (7) full-thickness articular cartilage damage. All patients were examined under anesthesia to confirm the diagnosis of a lateral patellar dislocation. To create the graft, surgeons harvested the tendon of the semitendinosus. The C-graft technique consisted of the folded end of the tendon being fixed to the medial patella and the 2 free ends being anchored into the medial femoral condyle. The Y-graft technique consisted of the 2 forked ends of the graft being fixated on the medial patella and the common end being anchored into the medial femoral condyle. Following the reconstruction all patients, regardless of group, followed the same rehabilitation protocol. At follow-up (~24 to 32 months post-operative) all patients underwent a patellar stability evaluation (apprehension test used), an axial CT scan at 30° of knee flexion, and completed both the Lysholm and Kujala scores (subjective knee function). Overall, the study demonstrated that at follow-up, both grafts were equally as effective at improving knee stability; however, patients with the Y-graft reported better subjective knee function scores compared with the C-graft group at a minimum of 2-year follow-up.
Overall, the authors found that both techniques were beneficial and that patients may report slightly greater function with the Y-graft. Clinicians in the sports medicine team should be aware of best practices with regards to objective measures, patient-reported outcomes, and adverse events (complications). This allows clinicians to communicate all options to the patient to help them make the best, informed decision. In this study, the authors reported no adverse events related to either procedure, similar objective measures, and a slight advantage to the Y-graft in patient-reported outcomes. However, we cannot ignore other important factors such as the patient’s goals and surgeon’s preference/experience. Further, it is important to note that future research should continue to follow these patients to gauge any potentially detrimental effects of the different graft types in the long-term (5, 10, 20, 30 years). Unfortunately, this can add another level of complications since clinical practice often changes faster than long-term data can be acquired. In the end, we must rely on evidence-based medicine but not forget patient preference, clinical experience, and best judgement.
Questions for Discussion: Do you and your sports medicine team keep abreast on the gold-standard of treatments, even those treatments that you do not apply?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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