Anisometry of Medial Patellofemoral Ligament Reconstruction in the Setting of Increased Tibial Tubercle–Trochlear Groove Distance and Patella Alta

Purpose: To assess the impact elevated tibial tubercle–trochlear groove (TT-TG) distance and patella height, as measured by the Caton-Deschamps Index (CDI), have on the isometry of a reconstructed medial patellofemoral ligament (MPFL). Methods: Nine fresh-frozen cadaveric knees were placed on a custom testing fixture, with a fixed femur and a mobile tibia. A suture fixed to the MPFL origin on the patella and free to move at the Schöttle point on the femur represented a reconstructed MPFL. A local coordinate system was established, and retroreflective markers attached to the suture quantified MPFL length changes by use of a 3-dimensional motion capture system. The tubercle was transferred to create TT-TG distances of 20 mm and 25 mm and CDIs of 1.2 and 1.4 (patella alta). Recordings of the MPFL suture length change as the knee was brought through a range of motion were made using all combinations of tubercle anatomy in a randomized order for each specimen. A generalized estimating equation modeling technique was used to analyze and control for the clustered nature of the data. Results: Knees with native tibial tubercle anatomy showed MPFL isometry through 20° to 70° range of motion. Tibial tubercle lateralization (increased TT-TG distance) significantly altered MPFL isometry with a TT-TG distance of 20 mm (P <.0001). Patella alta significantly altered MPFL isometry with a CDI of 1.2 (P =.0182). The interaction of tibial tubercle lateralization combined with patella alta significantly increased the amount of anisometry seen in the reconstructed MPFL (P <.001). Conclusions: Increased tibial tubercle lateralization and patella alta produce anisometry in an MPFL reconstruction using currently recommended landmarks, leading to potentially increased graft tension and potential failure. Clinical Relevance: Tibial tubercle transfer should be considered when performing an MPFL reconstruction for recurrent patellofemoral instability in the setting of significant patella alta and an elevated TT-TG distance—especially when both are present—because an isolated MPFL reconstruction will be prone to failure given the anisometry shown in this study.