Comparation and evaluation of the accuracy of the sulcus localization method to establish the medial patellofemoral ligament femoral tunnel: A cadaveric and clinical study

Abstract

Background: In anatomic medial patellofemoral ligament (MPFL) reconstruction, malpositioning of the MPFL femoral tunnel is common. A palpable sulcus reportedly exists at the anatomic femoral attachment of the MPFL. The present study aimed to investigate the accuracy of the sulcus localization method to establish the MPFL femoral tunnel. Methods: A cadaveric study was first done on 12 knees to evaluate the accuracy of the sulcus localization method to establish the entry points of the MPFL femoral tunnel in comparison with the midpoint and fluoroscopic localization methods. The center of the native MPFL femoral attachment was served as the reference in the cadaveric study. A clinical study was then performed to further evaluate the accuracy of the sulcus localization method in 53 patients (60 knees). Schöttle's point was served as the reference in the clinical study. Femoral tunnel placement was defined as accurate when it was less than 5 mm from Schöttle's point. In both the cadaveric and clinical studies, MPFL femoral tunnel placement was assessed on postoperative reconstructed three-dimensional computed tomography images. In the cadaveric study, the accuracy of different localization methods was compared using analysis of variance. Results: In the cadaveric study, the mean distances from the native MPFL attachment to the femoral tunnel entry point were 4.2 ± 1.0 mm (range 2.4-5.6 mm), 4.4 ± 1.4 mm (range 1.8-6.6 mm) and 2.9 ± 0.8 mm (range 1.9-4.4 mm) using the midpoint, fluoroscopic, and sulcus localization methods, respectively; this distance significantly differed between the midpoint and sulcus localization methods, and between the fluoroscopic and sulcus localization methods (p ≤.05). While there were no significant differences between the midpoint and fluoroscopic localization methods (n.s.). In the clinical study, the mean distance between the femoral tunnel and Schöttle's point was 3.5 ± 1.5 mm (range 0.4-6.1 mm), with accurate tunnel placement achieved in 49 of 60 cases (82%). Conclusion: The sulcus localization method can accurately guide MPFL femoral tunnel placement. This method might be useful for orthopedic surgeons. Level of evidence: IV.