Knee Bracing after Medial Patellofemoral Ligament Reconstruction: A Systematic Review of Protocols and Postoperative Outcomes

Medial Quadriceps Tendon-Femoral Ligament Reconstruction Offers Favorable Clinical Outcomes and Low Complication Rates for Recurrent Patellar Instability: A Systematic Review.

PURPOSE To evaluate the surgical methods, clinical outcomes, and complication profile of patients undergoing medial quadriceps tendon-femoral ligament reconstruction (MQTFLR), either isolated or as medial patellofemoral complex reconstruction (MPFCR), for recurrent patellar instability. METHODS Three databases (PubMed, EMBASE, and MEDLINE) were searched on July 28, 2025, for clinical studies assessing patient outcomes following MQTFLR with or without concurrent medial patellofemoral ligament reconstruction (MPFLR). Data on functional outcomes including Kujala scores, International Knee Documentation Committee (IKDC) scores, Lysholm scores, Tegner score, and visual analog scale scores were collected, along with return to sport, redislocation rates, revisions, and other complications. The Methodological Index for Non-Randomized Studies criteria were used to assess study quality. RESULTS Nine studies comprising 347 patients (68.3% female, mean age 18.6 years (range: 12.2-29.0)) were included. Combined MQTFLR + MPFLR (MPFCR) showed favorable Kujala scores (range 85.9-93.6), IKDC scores (range 81.5-91.2), Lysholm scores (range 84.3-93.3), and moderate Tegner scores (4.6-6.0). Among MPFCR patients with available minimum clinically important difference data, the minimum clinically important difference was achieved in 61/61 knees (100%) for Kujala, 97/103 knees (94.1%) for IKDC, 60/61 knees (98.1%) for Lysholm, and 44/61 knees (72.1%) for Tegner. The IKDC patient acceptable symptom state score was surpassed by 28/42 knees (66.7%). Patients undergoing MPFCR were found to have a high return to sport rate (88.5%-100%) and a low redislocation rate (1.6%). The single major complication was arthrofibrosis in 2 patients. Isolated MQTFLR and isolated MPFLR both showed comparable functional outcomes, but a higher rate of complications such as arthrofibrosis, flexion limitation, and patellar fracture compared with patients who underwent MPFCR. CONCLUSIONS MQTFLR in combination with MPFLR (MPFCR) is a viable option for surgical management of patellofemoral instability, with favorable clinical outcomes supporting its use. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.

Lateral Extra-articular Procedures Decrease Rates of Graft Failure and Positive Pivot Shift in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

PURPOSE To synthesize the existing literature on clinical outcomes and patient-reported outcome measures following primary anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular procedures (LEAP) in randomized controlled trials, whereas also determining ceiling effects for the patient-reported outcome measures utilized. METHODS A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. PubMed, MEDLINE, and Embase databases were used for an electronic search of Level I-II randomized controlled trials. Publications which followed skeletally mature patients randomized to undergo primary ACLR with or without the addition of LEAP were considered. Studies with <9-month follow-up were excluded to ensure clinical relevance. RESULTS Twelve publications met eligibility criteria for this review, including a total of 1327 patients with outcomes available for data extraction. Anterolateral ligament reconstruction was performed in 7 studies, and lateral extra-articular tenodesis was performed in 5 studies. A significant reduction in graft failure was found in patients who underwent ACLR plus LEAP ([0.235, 0.580], P < .001). A significantly lower rate of positive postoperative pivot shift was also found in this group ([0.324, 0.703], P < .001). Regarding patient-reported outcome measures, Lysholm scores favored the addition of LEAP to ACLR ([0.779, 3.093], P = .001), whereas International Knee Documentation Committee scores ([-0.521, 3.757], P = .138) and Tegner scores ([-0.304, 0.222], P = .760) showed no significant difference between groups. Using a 15% threshold of study subjects, significant ceiling effects were found in 3 of 4 studies reporting International Knee Documentation Committee scores and all studies reporting Lysholm scores. CONCLUSIONS Clinical outcomes, including graft failure and persistent positive pivot shift following ACLR with hamstring autograft, are improved by the addition of LEAP. Lysholm scores also improved, favoring the addition of LEAP to ACLR. The nonsignificant finding for International Knee Documentation Committee scores should be interpreted with caution, as there is a ceiling effect observed in a majority of included trials. LEVEL OF EVIDENCE Level II, meta-analysis of Level I and II studies.

Paper 35. Failure Following Medial Patellofemoral Ligament Reconstruction: A Propensity-Matched Comparative Analysis

Objectives: Medial patellofemoral ligament reconstruction (MPFLR) has emerged as a foundation of patellofemoral instability (PFI) treatment, with numerous studies demonstrating its efficacy in preventing recurrent instability. While generalized ligament laxity and bony risk factors have been shown to increase risk of reconstruction failure, optimal graft selection, fixation technique, and concomitant procedures in MPFLR remain an area of uncertainty. There is a paucity of research on differences in demographic, radiographic, and operative variables between matched failed and non-failed MPFLR cohorts. The aims of this study were to evaluate such differences between failed and non-failed reconstructions in order to identify potential risk factors for MPFLR failure and to inform surgical decision making to prevent recurrence of PFI or the need for revision. Methods: To identify the failed MPFLR cohort, we retrospectively identified patients who underwent primary MPFLR between 2004 and 2022 and underwent subsequent revision MPFLR for recurrent instability at a single institution. Patients presenting with repeat revision or graft over-tensioning were excluded. A control group of patients diagnosed with PFI who underwent MPFLR without documentation of graft failure or recurrent patellar dislocation was propensity matched 2:1 for age and gender. Demographic measures, graft characteristics, fixation techniques, and concomitant procedures were recorded. Preoperative radiographic measures including patellar tendon to lateral trochlear ridge (PT-LTR), tibial tubercle to trochlear groove (TT-TG), tibial tubercle to posterior cruciate ligament (TT-PCL), and Caton-Deschamps Index (CDI) were collected. Statistical analysis was conducted utilizing RStudio (Rv4.4.1) to compare failed and non-failed reconstructions. Results: A total of 102 patients were included (34 failed MPFLR, 68 non-failed MPFLR). The mean age at surgery was similar between groups (19.9 ± 6.9 vs 19.3 ± 6.3 years, p > 0.9). Patients in the failed cohort had a significantly higher BMI compared to controls (28.4 ± 7.6 vs 25.4 ± 7.6, p = 0.022). Hypermobility was more frequent among the failed cohort, though not statistically significant (41% vs 24%, p = 0.065), and mean time from surgery to revision for the failed cohort was similar to follow-up time for non-failed reconstructions (2.4 vs 2.8 years, p = 0.33) (Table 1). Radiographic parameters were comparable between groups. Mean PT-LTR was 9.8 ± 4.5 mm in the failure cohort and 11.7 ± 9.2 mm in controls (p = 0.4). TT-TG distance was similar (15.8 ± 4.5 mm vs 15.1 ± 5.3 mm, p = 0.7), as was TT-PCL (21.4 ± 5.3 mm vs 22.5 ± 5.5 mm, p = 0.3). CDI did not differ between groups (1.2 ± 0.2 for both, p = 0.5). Dejour classification distribution showed no significant differences (p = 0.3), with most failed reconstructions classified as type A (67% vs 41% in controls) (Table 2). Concomitant procedures performed with MPFLR did not differ significantly between groups (p = 0.502). Isolated MPFLR was the most common in both cohorts (61.8% failed vs 57.4% control) (Figure 1). Graft tendon type (semitendinosus vs gracilis) was similar between groups (p = 0.7). However, use of autograft versus allograft differed significantly with 100% of control patients receiving allograft compared to 61% among the failed reconstructions (p < 0.001). Graft diameter trended larger in the failure group, though not statistically significant (p = 0.088). Patellar fixation technique differed significantly with failed reconstructions more likely to use inlay fixation compared to controls (48% vs 18%, p = 0.003). Femoral fixation method also differed significantly with failed reconstructions less likely to use inlay fixation compared to controls (76% vs 94%, p < 0.007) (Table 3). Conclusions: In this propensity-matched cohort, failed MPFL reconstructions were characterized by significantly higher BMI and greater utilization of autograft tissue. While demographic, radiographic, and concomitant procedures were otherwise comparable, fixation technique differed where failed cases more frequently used patellar inlay fixation and femoral onlay or loop constructs, whereas controls more commonly underwent patellar onlay and femoral inlay fixation. Collectively, our results demonstrate the potential importance of graft selection and fixation approach in reducing the risk of MPFLR failure and may help guide surgical decision making to optimize the success of this procedure in treating PFI.

The incidence and epidemiology of patellar fractures following medial patellofemoral ligament reconstruction: a systematic review and meta-analysis

Patellar instability can arise from a traumatic event with anatomical predisposing factors increasing the risk of dislocation. Medial patellofemoral ligament reconstruction (MPFLR) is commonly performed to treat patellar instability. The aim of this systematic review was to determine the incidence of and risk factors for patellar fractures after MPFLR. The protocol for this review was registered on PROSPERO with registration number CRD420251066107. The PRISMA 2020 checklist was followed. Electronic databases and conference proceedings were searched to the 15th of May 2025. Studies were eligible if they reported incidence of patellar fractures after MPFLR. A random-effects meta-analysis was performed. Included studies were appraised using tools respective of study design. A total of 4,972 records were screened in the initial search. A total of 110 studies satisfied the inclusion criteria, evaluating 115,496 patients. The evidence was moderate to low in quality. The incidence of patellar fracture ranged from 0 to 9.50%, with a pooled incidence of 1.17% (95% confidence interval [CI] 0.76- 1.68%). There was no difference in incidence of patellar fractures between patients who did and did not undergo bone tunnel fixation (0.94%, 95% CI 0.69–1.24 vs. 1.00%, 95% CI 0.15–2.44%, respectively). There was no difference in fracture incidence between patients who underwent concomitant procedures (1.26%, 95% CI 0.51–2.32) and those who underwent MPFLR alone (0.53%, 95% CI 0.13–1.16%). Patellar fractures are a known complication of MPFLR, with a higher incidence observed in patients undergoing this procedure compared to the baseline population risk. Current evidence suggests its incidence is not affected by tunnel location or the performance of concomitant procedures, though further prospective studies are required to corroborate this. Appropriate post-operative follow-up is required to monitor the occurrence of patellar fractures during the post-operative period.

MEDIAL PATELLOFEMORAL LIGAMENT SURGERY IN THE PEDIATRIC POPULATION: A LITERATURE REVIEW ON THE CURRENT STATE OF THE ART

Complications Related to Arthroscopic Isolated Posterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of 4162 Patients

Background: Posterior cruciate ligament (PCL) reconstruction (PCLR) is increasingly performed for mid-substance tears, but complications after isolated PCLR remain poorly characterized. Purpose: To identify the complication profile of isolated arthroscopic PCLR. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, databases were searched. Adult studies of isolated mid-substance PCLR reporting at least 1 postoperative complication were included. Pooled proportions and 95% CIs were calculated using random-effects models. A quantitative synthesis of data was conducted to compare complication rates between single- and double-bundle reconstructions and between autograft and allograft types. Results: A total of 65 studies comprising 4162 patients met the inclusion criteria. The overall complication rate was 14.8% (n = 616). The most frequent postoperative complications were persistent postoperative pain (4.2% [95% CI, 2.3%-6.6%]), residual posterior laxity (4.1% [95% CI, 2.4%-6.2%]), and arthrofibrosis (3.1% [95% CI, 1.8%-4.8%]). Structural complications occurred at lower rates, including tunnel enlargement (2.5% [95% CI, 0.5%-5.8%]), graft failure or rupture (1.7% [95% CI, 0.8%-2.8%]), and postoperative osteoarthritis (2.2% [95% CI, 1.2%-3.6%]). Reoperations remained infrequent, with nonrevision reoperations at 3.4% (95% CI, 1.8%-5.4%) and revision PCLR at 1.1% (95% CI, 0.7%-1.6%). All other complications, including infection, venous thromboembolism, vascular injury, neurologic symptoms, hardware failure, and conversion to arthroplasty, were reported with weighted proportions <1%. Subgroup analyses showed no statistically significant differences by bundle type (single vs double) or graft selection (autograft vs allograft). However, these pooled results should be interpreted with caution, given the heterogeneity across studies. Conclusion: Isolated arthroscopic PCLR demonstrates a pooled complication rate of 14.8%, with persistent pain, residual posterior laxity, and arthrofibrosis being the most frequently reported complications. Major complications were uncommon in the available literature. Subgroup analysis showed no statistically significant differences by the number of bundles reconstructed or by the use of an autograft or an allograft.