ࡱ> 24/01y ]4bjbj  s{{+b<<8f,*t"cccl*n*n*n*n*n*n*$a,/*cA"ccc**cl*cl*>'(8{v'X**0*'/sT/ ((&/(pccccccc**Hccc*cccc/ccccccccc< \: Patient Information Orthopaedics Medial Patellofemoral Ligament (MPFL) Reconstruction You are reading this leaflet because you and your orthopaedic surgeon have decided together that this procedure may be of some benefit to you. It is intended to help you understand the operation and what to expect if you decide to go ahead with the procedure. We hope that it will assist in reducing any anxiety you may have, answer some of your questions and offer some practical advice. It is not intended to be a comprehensive guide, and it is essential that you discuss any further queries that you may have with your consultant surgeon. What is the medial patellofemoral ligament (MPFL)? The knee cap (patella) is designed to help the muscles on the front of your thigh to straighten your leg. As you bend and straighten your leg, the patella glides in a groove at the end of your thigh bone (femur) known as the trochlear groove of the femur. Sometimes the patella can come out of the groove, with or without an injury to the knee. This can lead to ongoing recurrent patella instability, with a feeling that the patella may slide out of the groove when the knee moves (subluxations) or complete dislocations. This may be painful as it causes scuffing (wear) to the under-surface of the patella and may lead to the development of osteoarthritis. To aid stability of the patella there are a number of soft-tissues that attach to it. The medial patellofemoral ligament (MPFL) is by far the most important structure and accounts for the majority of the stabilising strength. The MPFL is a thin strip of tissue that attaches from the inside edge of your patella to the inner side of the lower end of your femur. It acts as an anchor and helps prevent the patella from sliding out of its groove.  If your patella feels unstable or is regularly dislocating this can sometimes be improved by strengthening the muscles around the knee using physiotherapy. If this does not provide much improvement for you, reconstruction of the MPFL may help improve the stability of your patella. What is MPFL reconstruction? Surgical reconstruction of the MPFL is carried out under a general anaesthetic. It is a minimally invasive procedure and will require only a few small incisions on the front and side of your knee. A small camera will be used to look inside your knee and to repair any other damage that may be found in the joint. One of your hamstring tendons (from the muscles on the back of the thigh) will be used to reconstruct the new ligament and will be harvested through one of the small incisions that have been made. It will cause a small reduction in the strength of the hamstring muscle (less than 10% loss of power). This generally goes unnoticed and will not stop you from carrying on with your day to day and sporting activities. The new ligament is secured by passing it through a small tunnel made on the inner edge of the patella and then fixing it to a short tunnel in the inner side of the femur. We take x-rays during the operation to confirm correct placement of the tunnel in the femur. Great care is taken not to under or over tighten the ligament so that it can effectively carry out its new job. The soft tissues that attach to the outside edge of the patella are sometimes also divided to prevent the outwards pull on the patella. This is known as a lateral release. Once the new ligament is in place the knee will be washed out thoroughly and the small cuts will be closed. Lots of local anaesthetic is injected into the knee and around the incisions so your knee should be comfortable when you wake up. The knee will then be bandaged and you will be sent to the recovery room to wake up from the anaesthetic. What are the benefits and outcomes of the surgery? The aim of the procedure is to prevent the feeling of instability (giving way) and the recurrent dislocations that occur when the MPFL is disrupted. This is usually an extremely successful operation with high levels of satisfaction for those who undergo this surgery. Around 90-95% of people who undergo MPFL reconstruction are happy with the outcome. What are the risks of surgery? As with any operation, there are potential risks involved but the chances of complications occurring is very low. You will also be required to sign a consent form by your surgeon during which time any surgical risks will be explained to you in full. These include common risks of any surgical procedure around the knee such as: Wound problems such as slow healing + oozing <2% Infection sometimes requiring antibiotics < 2% Stiffness requiring extensive physiotherapy <5% Blood clots (DVT/PE) requiring 6 months treatment with blood thinning tablets and sometimes causing long-term leg swelling or severe breathing problems < 1% A very small risk associated with general anaesthetic this can be discussed with your anaesthetists Specific risks of this operation include: It is normal to have some numbness around the scars and potentially an area of numbness over the outer aspect of their knee. This isnt often troublesome and usually reduces with time. It can occasionally be permanent. It is normal to have some swelling and stiffness of your knee after the operation A small proportion of patients are left with persistent pain at the front of their knee after any knee operation There is a very small chance of fracture to the patella by the process of drilling a tunnel through the bone to secure the graft Sometimes the metalwork used to secure the graft is prominent and needs to be removed some months post-operatively Recurrent instability occurs in <1% of patients undergoing this procedure. If this is the case then further procedures may be required at a later stage Reconstructing the MPFL and preventing further instability of the patella does not necessarily protect you from developing osteoarthritis in the future. This is due mainly to any damage that has already been done What are the alternatives to an MPFL reconstruction? The first alternative is to continue non-operative treatments, with the physiotherapy and exercises that you may be already doing to strengthen the muscles that support the patella. You may be happy just to accept the problem and not go through with any surgery. Surgical alternatives do exist and have shown varying levels of success. The first of these is the lateral release of the tissues that attach to the outside of your patella (see above). On its own this operation is rarely successful and you are unlikely to notice much improvement. However this is usually carried out in addition to MPFL reconstruction and can improve the success of the operation. Another alternative is to move the attachment of your patella tendon where it inserts into the top of the shin bone (tibia). This is called a tibial tubercle osteotomy. This changes the angle at which your patella is being pulled and can therefore make it more likely to stable. This is a larger operation than an MPFL reconstruction and has a longer period of rehabilitation. This operation is only an option when the angle of pull of the muscles is the cause of your problem. You will need to discuss with your surgeon as to whether this would be a suitable alternative for you. If it is found that you have a shallow trochlear groove in which the patella glides, an operation that may help you is a Trochleoplasty. This is much bigger operation that involves lifting the articular surface of the groove and then hollowing out the groove to make it deeper. The articular surface is then replaced and patella stability is improved as the groove is deeper. This procedure is only required if your trochlear groove is completely absent. It should be noted that MPFL reconstruction has been shown to be an extremely successful alternative to the above operations. It has fewer complications associated with it and has a shorter recovery time. What happens before surgery? Once surgery has been agreed, you will be asked to attend a pre-assessment clinic. Here a nurse will ask you about previous medical problems, your social circumstances, as well as checking your blood pressure, pulse and temperature. You may also require a few further tests such as blood tests and a heart trace (ECG). Very occasionally a chest X-ray is required. If there are any concerns about your health you may be asked to see an anaesthetist. You will then be expected to attend the ward on the day of the surgery and will need to be nil by mouth for 6 hours. Details of this will be provided in your confirmation letter if you do decide to go ahead with the surgery. It is then important that an anaesthetist checks to make sure that you are fit to undergo the surgery and answers any queries that you may have regarding the general anaesthetic. What happens after surgery? After the operation, you will wake in the recovery room and a nurse will be there to assist you. An anaesthetist will be there to help manage any discomfort you may experience after the procedure. When you are fully awake, you will be moved back onto the ward. You will be allowed to fully weight bear on the operated leg straight away, but often additional support is necessary in the form of crutches. Physiotherapy commences immediately after the operation, working on regaining range of movement and muscle strength. While the rehabilitation program may differ depending on the individual, the general goal is to gradually increase your level of activity under the guidance of your physiotherapist. It is recommended that you take around 2-4 weeks off work. You can commence driving when you are safe to mobilise without crutches at around 4-6 weeks. It is expected that you can return to sporting activities from 3-4 months. Will I have to stay in hospital? Patients normally stay in hospital for one night after the operation. This is to help manage postoperative pain and allow you to start your physiotherapy. On rare occasions, a person may need to be kept in hospital longer. What is the follow-up care? As well as regular physiotherapy you will also have follow-up appointments with your surgeon. Two weeks after the operation you will be seen on the ward. You will usually be seen in Outpatients Clinic at: 6-8 weeks (x-rays taken) 3 months 6 months 12 months If you have any further queries or concerns after your operation then please contact the appropriate orthopaedic secretary to raise the issue. Tel. 024 7696 4000 If you are concerned about post-operative complications please contact your consultants secretary on the numbers below or see your GP: Mr Shahs/Thompsons secretary: 02476 965096 Mr Ahearns/Spaldings secretary: 02476 965098 Mr Metcalfes secretary: 02476 964965 The Trust has access to interpreting and translation services. If you need this information in another language or format please contact your consultants secretary and we will do our best to meet your needs. The Trust operates a smoke free policy. 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