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Article ; Online: Editorial Commentary: Diverse Factors Affect Measurement of Patella Alta: Trochlear Morphology and Sagittal Knee Balance Represent Defining Factors of Patellofemoral Stability.

Tanaka, Miho J

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2024

Abstract: Patella alta is a known risk factor for patellar instability, contributing to increased length changes of the medial patellofemoral complex, and associated with high rates of failure after medial patellofemoral complex reconstruction. Distalization ... ...

Abstract	Patella alta is a known risk factor for patellar instability, contributing to increased length changes of the medial patellofemoral complex, and associated with high rates of failure after medial patellofemoral complex reconstruction. Distalization through tibial tuberosity osteotomy (TTO) is a surgical option to address patella alta during patellar stabilization surgery. However, distalization has been shown to have greater complication rates than other types of TTO, and therefore precise indications through proper assessments of patellar height are needed. The Caton-Deschamps index is a commonly used measurement and is independent of patellar tendon length, allowing for assessment of patellar height before and after distalizing TTO. Additional options that may offer this ability are femoral-based measurements such as the patellotrochlear index and sagittal patellar engagement, which also do not rely on the position of the tubercle and may better represent the functional engagement of the patellofemoral joint. However, femoral-based measurements depend on trochlear morphology; theoretically, an advantage of femoral-based measurements is that they may reflect the functional engagement of the patella within the trochlea. However, in knowing the common relation between patella alta and trochlear dysplasia, the question becomes whether an overlap between the patella and a dysplastic proximal trochlea on a sagittal measurement truly represents functional engagement and stability of the patellofemoral joint. Measurement of patella alta and determining indications for distalization can be influenced by measurement techniques including magnetic resonance imaging versus radiography, tibial- versus femoral-based measurements, and positional and morphologic considerations. Increased understanding of trochlear morphology and sagittal knee balance as they relate to patella alta will be important for defining the factors that affect patellofemoral stability.
Language	English
Publishing date	2024-03-12
Publishing country	United States
Document type	Editorial
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2024.03.008
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Article ; Online: Editorial Commentary: Handling the (Contact) Pressure in Patellofemoral Surgery: The Role of Lateral Retinacular Release.

Tanaka, Miho J

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2022 Volume 38, Issue 3, Page(s) 965–966

Abstract: The role of lateral retinacular release for the treatment of patellofemoral pathology has evolved over the years. Although once popularized in the treatment of patellofemoral pain and instability, complications such as iatrogenic medial patellar ... ...

Abstract	The role of lateral retinacular release for the treatment of patellofemoral pathology has evolved over the years. Although once popularized in the treatment of patellofemoral pain and instability, complications such as iatrogenic medial patellar instability and decreases in lateral patellar stability have limited the indications for performing isolated lateral release. However, there exists a need for more clearly defined parameters and understanding of when and how lateral release should be incorporated with other procedures during patellar stabilization and joint-preservation surgery. Advances in finite element analysis, as well as refining our surgical indications and techniques for concurrent lateral release, will allow us to optimize both joint pressures and stability during the surgical management of patellar instability.
MeSH term(s)	Humans ; Joint Instability/surgery ; Patella ; Patellofemoral Joint/surgery ; Pressure
Language	English
Publishing date	2022-03-05
Publishing country	United States
Document type	Editorial ; Comment
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2021.10.010
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Article ; Online: Editorial Commentary: The Medial Patellofemoral Complex Is Composed of the Medial Patellofemoral Ligament and the Medial Quadriceps Tendon-Femoral Ligament: Do We Need to Reconstruct Both?

Tanaka, Miho J

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2022 Volume 39, Issue 1, Page(s) 112–113

Abstract: The medial patellofemoral ligament (MPFL) has been known as the primary soft-tissue restraint to lateral patellar translation. More recent anatomic studies have identified additional fibers that extend to the quadriceps tendon (medial quadriceps tendon- ... ...

Abstract	The medial patellofemoral ligament (MPFL) has been known as the primary soft-tissue restraint to lateral patellar translation. More recent anatomic studies have identified additional fibers that extend to the quadriceps tendon (medial quadriceps tendon-femoral ligament [MQTFL]), leading to the use of the term "medial patellofemoral complex" (MPFC) to describe the broad and variable attachment of this complex on the patella and quadriceps tendon. Whereas many techniques and outcomes of traditional MPFL reconstruction have been described, fewer reports exist on anatomic MPFC reconstruction to recreate both bundles of this complex. To date, the specific biomechanical roles of, and indications for, reconstruction of the MPFL versus MQTFL fibers have not been defined. One primary benefit of MQTFL reconstruction has been to avoid the risk of patella fracture, which is not obviated in the setting of concurrent patellar fixation when reconstructing both components of the MPFC. The risks and benefits comparing fixation on the patella, quadriceps tendon, or both with anatomic double-bundle reconstruction remain to be determined. Additional studies are needed to understand the differences between reconstructing the proximal and distal fibers of the MPFC with regard to graft length changes and femoral attachment sites, in order to optimally recreate the function of each graft bundle in the surgical treatment of patellar instability.
MeSH term(s)	Humans ; Joint Instability/surgery ; Patellofemoral Joint/surgery ; Ligaments, Articular/surgery ; Knee Joint ; Tendons/transplantation ; Patella
Language	English
Publishing date	2022-12-20
Publishing country	United States
Document type	Editorial ; Comment
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2022.08.027
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Article ; Online: Editorial Commentary: Trochlear Dysplasia Is Difficult to Measure, No Matter How You Slice It.

Tanaka, Miho J

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2021 Volume 37, Issue 4, Page(s) 1212–1213

Abstract: Trochlear dysplasia is one of the primary morphologic abnormalities associated with patellar instability. Although qualitative classifications based on trochlear shape such as the Dejour classification exist, radiographic measurements to quantify the ... ...

Abstract	Trochlear dysplasia is one of the primary morphologic abnormalities associated with patellar instability. Although qualitative classifications based on trochlear shape such as the Dejour classification exist, radiographic measurements to quantify the severity of trochlear dysplasia are numerous and varied. Each measurement addresses a different element of the complex and wide-ranging presentations that exist along a spectrum of abnormalities in trochlear morphology, and the reported reliability of such measurements are mixed. Overall, our understanding of trochlear dysplasia continues to evolve, and the ability to quantify the morphology of the trochlea, as well as its influence on patellar stability, remains a work in progress. Future directions include developing improved 3-dimensional descriptions of trochlear anatomy, as well as standardizing measurement methods and image slice selection, to better evaluate trochlear morphology in the assessment of patellar instability.
MeSH term(s)	Femur/diagnostic imaging ; Humans ; Joint Instability/diagnostic imaging ; Knee Joint/diagnostic imaging ; Patella/diagnostic imaging ; Reproducibility of Results
Language	English
Publishing date	2021-04-03
Publishing country	United States
Document type	Editorial ; Comment
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2020.12.220
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Article: Telemedicine After COVID-19: Incorporating Virtual Visits Into Your Practice.

Tanaka, Miho J / Gallo, Robert A

Instructional course lectures

2023 Volume 73, Page(s) 67–75

Abstract: The use of telemedicine services within orthopaedics increased rapidly as a result of the COVID-19 pandemic. Telemedicine may improve access to care and save time and money for patients and clinicians; however, limitations such as technical issues and ... ...

Abstract	The use of telemedicine services within orthopaedics increased rapidly as a result of the COVID-19 pandemic. Telemedicine may improve access to care and save time and money for patients and clinicians; however, limitations such as technical issues and limited physical examination may reduce its widespread adoption. Virtual visits generally produce equivalent satisfaction and clinical outcomes compared with those performed in person. Although telemedicine has served many different roles within orthopaedic practices, its main utility is for patients who have to travel significant distances and for visits that do not require physical examination to determine a treatment plan. Several regulations govern the use of telemedicine. Most notably, clinicians must be licensed to practice medicine in the state in which the patient is located during the appointment. Although compliance issues remain a potential source of legal issues, experts cite misdiagnosis from limited physical examination as the most likely reason for medical liability. Clinicians should be familiar with techniques for virtual physical examination and should provide instruction to patients before the visit to optimize data obtained.
MeSH term(s)	Humans ; COVID-19/epidemiology ; Pandemics ; Telemedicine/methods ; Physical Examination ; Orthopedics/methods
Language	English
Publishing date	2023-12-13
Publishing country	United States
Document type	Journal Article
ZDB-ID	802490-x
ISSN	0065-6895
ISSN	0065-6895
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Article ; Online: Editorial Commentary: Repair or Reconstruct? Addressing Medial Patellofemoral Ligament Insufficiency in the Absence of Morphologic Abnormalities.

Tanaka, Miho J

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2020 Volume 36, Issue 6, Page(s) 1735–1737

Abstract: The role of medial patellofemoral ligament (MPFL) repair versus reconstruction in the treatment of patellar instability continues to undergo debate. Repair of the ligament can be technically less demanding with fewer risks of morbidity, whereas ... ...

Abstract	The role of medial patellofemoral ligament (MPFL) repair versus reconstruction in the treatment of patellar instability continues to undergo debate. Repair of the ligament can be technically less demanding with fewer risks of morbidity, whereas reconstruction carries concerns of graft malpositioning or over-tensioning as well as the risk of patellar fracture. Studies directly comparing the 2 procedures in the setting of recurrent patellar instability have consisted of small series or low levels of evidence that inevitably include patients with concurrent morphologic risk factors such as tuberosity malalignment or patella alta, which are known factors that can influence the biomechanical behavior of the MPFL. Heterogeneity in patient-related risk factors and surgical techniques continues to pose limitations in allowing for direct comparisons between procedures. For the treatment of recurrent patellar instability in the setting of no (or concurrently addressed) morphologic abnormalities, MPFL reconstruction has become a common procedure and generally preferred approach. The superior outcomes associated with reconstruction over repair, however, should be qualified with the fact that attention to the critical details of the technique, including graft position and tension, is paramount to success when performing this procedure.
MeSH term(s)	Humans ; Joint Instability ; Knee Joint ; Ligaments, Articular ; Patella ; Patellar Dislocation ; Patellofemoral Joint
Language	English
Publishing date	2020-05-04
Publishing country	United States
Document type	Editorial ; Comment
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2020.02.040
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Article ; Online: Femoral Origin Anatomy of the Medial Patellofemoral Complex: Implications for Reconstruction.

Tanaka, Miho J

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2020 Volume 36, Issue 12, Page(s) 3010–3015

Abstract: Purpose: To report the shape and orientation of the medial patellofemoral complex (MPFC) footprint on the medial femur and describe the difference between the proximal (medial quadriceps tendon femoral ligament, MQTFL) and distal (medial patellofemoral ... ...

Abstract	Purpose: To report the shape and orientation of the medial patellofemoral complex (MPFC) footprint on the medial femur and describe the difference between the proximal (medial quadriceps tendon femoral ligament, MQTFL) and distal (medial patellofemoral ligament, MPFL) fibers. Methods: In 20 cadaveric knees, the MPFC footprint on the medial femur was exposed. Images of the medial femur were analyzed using ImageJ software. The length and width of the MPFC footprint were described to the nearest 0.1 mm; the angle of its long axis was described relative to the axis of the femoral shaft (0.1°). The footprint's most proximal and distal margins were described in relation to the adductor tubercle and medial epicondyle. The differences between each were compared using paired t tests. Results: 17 knees from 10 cadavers were included in this study. The MPFC footprint had a length of 11.7 ± 1.8 mm and a width of 1.7 ± 0.4 mm. The long axis of the footprint was at an angle 14.6° ± 16.6° anterior to the axis of the femoral shaft. The most proximal (MQTFL) fibers originated 7.4 ± 3.8 mm anterior and 1.8 ± 4.7 mm distal to the adductor tubercle and 4.1 ± 2.9 mm posterior and 8.4 ± 5.6 mm proximal to the medial epicondyle. The most distal (MPFL) fibers originated 4.9 ± 4.2 mm anterior and 12.7 ± 4.3 mm distal to the adductor tubercle, as well as 7.1 ± 2.4 mm posterior and 0.5 ± 5.6 mm distal to the medial epicondyle. The distal margin of the femoral MPFC footprint was 10.9 ± 1.7 mm distal (p < .001) and 2.6 ± 3.2 mm more posterior (p = .005) than the proximal margin. Conclusions: The femoral footprint of the MPFC has a length almost 7 times greater than its width, with the distal margin being 10.9 mm distal and 2.6 mm posterior to the proximal margin. Clinical relevance: This differential anatomy within the femoral origin suggests that MPFL and MQTFL reconstruction may require separate positions of femoral fixation to recreate the anatomy of these fibers.
MeSH term(s)	Adult ; Cadaver ; Epiphyses/anatomy & histology ; Female ; Femur/anatomy & histology ; Humans ; Male ; Patellar Ligament/anatomy & histology ; Patellofemoral Joint/anatomy & histology ; Patellofemoral Joint/surgery ; Quadriceps Muscle/anatomy & histology ; Reconstructive Surgical Procedures ; Software ; Tendons/anatomy & histology ; Thigh/anatomy & histology
Language	English
Publishing date	2020-06-20
Publishing country	United States
Document type	Journal Article
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2020.06.015
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Article: Return to Play Considerations After Patellar Instability.

Lampros, Rachel E / Tanaka, Miho J

Current reviews in musculoskeletal medicine

2022 Volume 15, Issue 6, Page(s) 597–605

Abstract: Purpose of review: To discuss the treatment options and rehabilitation protocols after non-operative and operative treatment of patellar instability, and to discuss expected return to play outcomes and functional performance with non-operative and ... ...

Abstract	Purpose of review: To discuss the treatment options and rehabilitation protocols after non-operative and operative treatment of patellar instability, and to discuss expected return to play outcomes and functional performance with non-operative and operative treatment of patellar instability. Recent findings: A criterion-based program assessing range of motion, joint effusion, strength, neuromuscular control, proprioception, agility, and power are critical measures to assess when rehabilitating this population. A series of functional tests including quadriceps strength testing, single-limb hop testing, lateral step-down test, the side hop test, the lateral leap and catch test, the Y-balance test, and the depth jump should be considered when determining an athlete's return to sport clearance. These objective measures combined with psychological readiness and a comprehensive understanding of the sports-specific tasks required for participation should be considered when evaluating an athlete's ability to safely and successfully return to sport. We discuss rehabilitation management when working with non-operative and operative management of patellar instability and provide considerations for clinicians working with these athletes to facilitate safe return to sport.
Language	English
Publishing date	2022-11-11
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	2407827-X
ISSN	1935-9748 ; 1935-973X
ISSN (online)	1935-9748
ISSN	1935-973X
DOI	10.1007/s12178-022-09792-1
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Article ; Online: Adding Tibial Tuberosity Medialization to Medial Patellofemoral Ligament Reconstruction Reduces Lateral Patellar Maltracking During Multidirectional Motion in a Computational Simulation Model.

Elias, John J / Cosgarea, Andrew J / Tanaka, Miho J

Arthroscopy, sports medicine, and rehabilitation

2023 Volume 5, Issue 4, Page(s) 100753

Abstract: Purpose: To determine whether adding tibial tuberosity medialization to medial patellofemoral ligament (MPFL) reconstruction reduces lateral patellar maltracking during a dynamic multidirectional activity and to investigate when medial patellofemoral ... ...

Abstract	Purpose: To determine whether adding tibial tuberosity medialization to medial patellofemoral ligament (MPFL) reconstruction reduces lateral patellar maltracking during a dynamic multidirectional activity and to investigate when medial patellofemoral contact pressures are elevated during daily activities, such as squatting. Methods: Seven computational models representing knees with patellar instability, including lateral patellar maltracking, were evaluated following simulated MPFL reconstruction (bisect offset index > .75). Tibial tuberosity medialization was added to MPFL reconstruction for each model. Patellar tracking during multidirectional motion was evaluated by simulating pivot landing. Analysis of pivoting focused on early flexion (5° to 40°). Patellofemoral contact pressures during daily function were evaluated by simulating knee squatting. Data were analyzed with paired comparisons between MPFL reconstruction with and without tuberosity medialization. Results: The patella dislocated during pivoting for 2 models with an isolated MPFL reconstruction and for 1 model including tibial tuberosity medialization. Adding tibial tuberosity medialization to MPFL reconstruction significantly decreased bisect offset index by ∼0.1 from 5° to 40° ( Conclusions: In this study of simulated multidirectional motion, MPFL reconstruction did not sufficiently constrain the patella for some knees. Adding tibial tuberosity medialization to MPFL reconstruction in these models reduced lateral patellar maltracking during multidirectional motion but increased pressure applied to medial cartilage during squatting. Clinical relevance: After establishing the influence of tibial tuberosity medialization on patellar maltracking for an idealized population, as was done in the current study, future simulation studies can be performed to better determine the anatomical characteristics of patients for whom tibial tuberosity medialization is needed to reduce the risk of postoperative patellar maltracking.
Language	English
Publishing date	2023-07-10
Publishing country	United States
Document type	Journal Article
ISSN	2666-061X
ISSN (online)	2666-061X
DOI	10.1016/j.asmr.2023.100753
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Article ; Online: Medial Patellofemoral Reconstruction Techniques for Patellar Instability.

Velasquez Hammerle, Maria V / Tanaka, Miho J

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2023 Volume 39, Issue 6, Page(s) 1373–1375

Abstract: The medial patellofemoral complex (MPFC) is the term used to describe the primary soft tissue stabilizer of the patella, which consists of fibers that attach to the patella (medial patellofemoral ligament, or MPFL), and the quadriceps tendon (medial ... ...

Abstract	The medial patellofemoral complex (MPFC) is the term used to describe the primary soft tissue stabilizer of the patella, which consists of fibers that attach to the patella (medial patellofemoral ligament, or MPFL), and the quadriceps tendon (medial quadriceps tendon femoral ligament, or MQTFL). Despite the variability of its attachment on the extensor mechanism, the midpoint of this complex is consistently at the junction of the medial quadriceps tendon with the articular surface of the patella, indicating that either patellar or quadriceps tendon fixation can be used for anatomic reconstruction. Multiple techniques exist to reconstruct the MPFC, including graft fixation on the patella, quadriceps tendon, or both structures. Various techniques using several graft types and fixation devices have all reported good outcomes. Regardless of the location of fixation on the extensor mechanism, elements critical to the success of the procedure include anatomic femoral tunnel placement, avoiding placing undue tension on the graft, and addressing concurrent morphological risk factors when present. This infographic reviews the anatomy and techniques for the reconstruction of the MPFC, including graft configuration, type, and fixation, while addressing common pearls and pitfalls in the surgical treatment of patellar instability.
MeSH term(s)	Humans ; Patellofemoral Joint/surgery ; Patellofemoral Joint/anatomy & histology ; Joint Instability/surgery ; Ligaments, Articular/surgery ; Ligaments, Articular/anatomy & histology ; Patella/surgery ; Patella/anatomy & histology ; Tendons/transplantation
Language	English
Publishing date	2023-05-03
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2023.01.006
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