Palpation and Fluoroscopy are Valid but Unreliable for the Assessment of Femoral Tunnel Position after Medial Patellofemoral Ligament Reconstruction

Objectives The purpose of this study was to evaluate the validity and reliability of two techniques, palpation and fluoroscopy, for assessing medial patellofemoral ligament (MPFL) reconstruction femoral tunnel position accuracy. Methods Twenty-one fresh frozen cadaveric knees had an MPFL femoral tunnel drilled and filled with a metal screw. Tunnels were created in a non-standard fashion to ensure the sample included a range of tunnel positions from poor to ideal. Six experienced sport medicine and arthroscopy surgeons evaluated the placement of the femoral tunnel by palpating the screw in relation to anatomic landmarks and by fluoroscopy related to Schöttle’s Point. They evaluated 1) the accuracy of femoral tunnel placement, 2) the direction of tunnel error, and 3) the clinical acceptability of the tunnel position. Validity measures included sensitivity, specificity, and correlation to clinical acceptability, which were calculated for the palpation and fluoroscopic assessments. Reliability measures included Inter-rater reliability (ICC 2,k) for femoral tunnel accuracy and percent agreement of the raters’ tunnel direction assessment. Results The palpation method demonstrated a sensitivity of 0.79 and specificity of 0.84 for assessing the accuracy of femoral tunnel placement, while the fluoroscopic method showed a sensitivity of 0.83 and specificity of 0.92. Pearson correlation coefficients for clinical acceptability of tunnel position were high, with both techniques ranging from .589 to .854. Inter-rater reliability for the palpation and fluoroscopic techniques for assessment of tunnel accuracy were 0.31 and 0.55 (ICC 2,k), respectively. Assessment of the direction of tunnel error was good with the fluoroscopic technique slightly more accurate than palpation. Conclusion This study demonstrated that both palpation and fluoroscopy are valid techniques for assessing femoral tunnel position after MPFL reconstruction. Despite demonstrating good validity, the accuracy of assessing tunnel position was unreliable in a group of six experienced knee surgeons. Further research into MPFL reconstruction femoral tunnel assessment techniques, including patient-specific reference standards, is warranted. Level of Evidence Level 2