From the Guidelines
Management of a large tear of the medial patellofemoral ligament (MPFL) should prioritize a comprehensive approach including knee-targeted exercise therapy, education, and supportive interventions as required, rather than immediate surgical reconstruction, to address the underlying causes of patellofemoral pain and improve quality of life. This approach is supported by recent studies, such as 1 and 1, which emphasize the importance of delivering knee-targeted exercise therapy and education to patients with patellofemoral pain.
The initial management should include:
- Delivering knee-targeted exercise therapy to improve muscle strength, particularly in the quadriceps and hip muscles, as suggested by experts in 1 and patients in 1
- Education to challenge inaccurate beliefs, build confidence, and promote autonomy, as highlighted in 1 and 1
- Supporting approaches, such as prefabricated foot orthoses, movement/running retraining, and taping, may be considered based on individual patient needs and response to treatment, as discussed in 1
It is essential to objectively evaluate physical impairments, including muscle strength, movement patterns, and tissue tolerance to load, to inform treatment selection, as recommended in 1. By prioritizing a comprehensive and patient-centered approach, clinicians can improve outcomes and quality of life for patients with large tears of the MPFL, as supported by the expert opinions and patient voices in 1, 1, and 1.
From the Research
Management of Large Tear of Medial Patellofemoral Ligament
- The medial patellofemoral ligament (MPFL) is the primary static restraint to lateral patellar translation, and its injury is common in patellar dislocations, affecting approximately 6 to 29 of 100,000 patients 2.
- Risk factors for patellar dislocation include patella alta, trochlear dysplasia, genu valgus, increased Q angle, and hyperlaxity 2.
- The treatment for patellar instability depends on the clinical and radiographic findings and can be nonoperative for first-time dislocations or operative for recurrent dislocations 2, 3.
- Medial patellofemoral ligament reconstruction is an effective treatment for preventing recurrent dislocations, with various surgical techniques described, including differences in fixation and graft selection 3, 4.
- The goal of MPFL reconstruction is to reproduce the anatomy and isometry of the native ligament, with graft choice and methods of fixation being less critical to achieve successful outcomes 2.
- Studies have reported successful outcomes and improved Kujala scores, with recurrent instability ranging from 1% to 5% 2, 5.
- A network meta-analysis found that MPFL reconstruction appears to be a better treatment than repair, proximal realignment, or conservative management for primary patellar dislocation, with a lower probability of re-dislocation 5.
Surgical Techniques and Considerations
- Careful surgical technique is critical to avoid complications, including fracture, graft failure, loss of range of motion, persistent anterior knee pain, medial instability, and recurrent instability 2.
- The treatment of MPFL injuries should aim to provide patellar stabilization and restore normal kinematics throughout the joint 3.
- Patient selection and individualized treatment are important considerations, including the patient's unique anatomy, such as the tibial tuberosity-trochlear groove (TT-TG) distance, trochlear dysplasia, and patella alta 6.
- The role of the medial quadriceps tendon femoral ligament should also be considered in future research 2.