Medial Patellofemoral Ligament Reconstruction Utilizing Autograft Quadriceps Tendon.

Abstract

Background: Medial patellofemoral ligament reconstruction (MPFLR) is a common surgical procedure for the treatment of recurrent patellar instability. Techniques vary by graft type, fixation method, number of graft limbs, graft placement, and tensioning. Hamstring tendons are most commonly used, but autograft causes donor-site morbidity, while allograft increases cost and requires availability. Recent anatomic studies have described a medial patellofemoral complex (MPFC) with a broad attachment to both the superomedial patella and the distal medial quadriceps tendon, suggesting the need to restore a broad footprint across both sites.

Indications: MPFLR may be performed in isolation or in combination with bony procedures that address structural malalignment. Recent evidence suggests a role for isolated MPFLR regardless of coronal alignment and patellar height, in the absence of severe dysplasia or jumping J sign. We present a modification of the MPFLR technique described by Fink et al, utilizing quadriceps tendon autograft to restore a broad footprint of the MPFC.

Technique description: A 6 to 7 mm-diameter partial-thickness strip of tendon is harvested from the medial quadriceps tendon, leaving a thin cuff of tendon intact medially for side-to-side repair. The graft is left intact at the patellar insertion and redirected 90°, beneath the intact medial tendon insertion. The graft base is attached to exposed bone on the medial aspect of the superomedial corner of the patella using an all-suture anchor. The free end is passed between layers 2 and 3 and fixed within a socket at the Schottle point on the medial femoral condyle using a resorbable interference screw.

Results: The described technique utilizes the quadriceps tendon autograft for MPFLR. The graft is easily obtained through a slight proximal extension of the incision required for patellar graft fixation. Harvest is reliable and reproducible, with extremely low donor site morbidity.

Discussion/conclusion: Maintenance of graft origin at the proximal patella with secondary fixation at the superomedial patella combines the traditional construct for MPFLR (bone fixation at superomedial patella) with that described by Tanaka as medial quadriceps tendon femoral ligament reconstruction (attachment at medial quadriceps tendon insertion). Thus, the technique described here restores a larger footprint of the entire MPFC, more closely approximating normal anatomy.

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