Arthroscopic extraarticular reconstruction of the medial patellofemoral ligament with gracilis tendon autograft - surgical technique

Abstract

The standard approach to reconstruct the medial patellofemoral ligament (MPFL) is by mini-open incision at its patellar insertion and femoral origin. At the medial patella rim, the MPFL insertion may be visualized in most cases by dissection during surgery. On the femur, it is more difficult to localize the MPFL remnants by a mini-open incision due to soft tissue covering the anatomical origin. Therefore, the femoral MPFL origin is usually identified by intraoperative lateral fluoroscopy. However, the insertion and origin of the MPFL at the patella and femur might be directly visualized using an arthroscopic extraarticular approach from the knee joint through a window of the synovial layer. This is especially helpful on the femoral side but also at the patella to find the individual anatomical MPFL footprints. Arthroscopic extraarticular reconstruction may then be performed using one additional medial mid-parapatellar portal. The major advantages of this technique are an individualized anatomical procedure, which is minimal invasive and cosmetically appealing. The aim of this study was to describe the arthroscopic extraarticular approach to the MPFL insertion at the patella and origin at the femur through synovial windows and to explain the procedure of arthroscopic MPFL reconstruction with a gracilis tendon autograft. Level of evidence Expert opinion, surgical technique, Level V.

Widespread Implementation of Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Maintains Functional Outcomes at Midterm to Long-Term Follow-up While Decreasing Complication Rates: A Systematic Review

“…Many techniques are used to accomplish this, and various graft options have been described, including semitendinosus, 18-29 patellar tendon, 30,31 partial quadriceps tendon, 30,32 adductor magnus, 6,30,33 gracilis, 9,15,[34][35][36][37] and iliotibial band grafts 38 ; allografts 12,30,39 ; and synthetic grafts. 17,40,41 Methods for patellar fixation vary as well and include tunnels with interference screws 12,22,39 ; single 40,42,43 and double 34,44 through-and-through tunnels with looped, knotted, 17 or soft-tissue suture fixation 6,20,21 ; V-shaped converging tunnels 35,45 ; double diverging tunnels 24 ; anchor fixation 23 ; and soft-tissue sutures.…”

Medial Patellofemoral Ligament Reconstruction Using Dual Patella Docking Technique

“…4,6 The importance of this ligament in chronic lateral patellar instability in a patient with normal osseous anatomy and limb alignment has led to the development of various surgical techniques to reconstruct the MPFL with variations in graft choice, anatomic versus nonanatomic reconstruction, and fixation methods. [7][8][9][10][11][12][13][14][15][16][17][18][19][20] Several studies have shown the importance of an anatomic reconstruction of the femoral attachment. 34,35,38 A femoral tunnel that is too proximal may lead to graft laxity in extension and over-tensioning in flexion, a femoral tunnel that is too distal may lead to graft over-tensioning in extension and laxity in flexion, and tunnel placement too anterior can cause overloading of the medial patellofemoral cartilage.…”

“…[1][2][3][4][5][6] Because of its importance, various techniques have been described to reconstruct the MPFL in chronic lateral patellar instability. [7][8][9][10][11][12][13][14][15][16][17][18][19][20] The purpose of this Technical Note and accompanying video (Video 1) is to describe an MPFL reconstruction technique that uses a patella dual docking tunnel technique to create an anatomic reconstruction.…”

Anatomic Reconstruction of the Medial Patellofemoral Ligament Using the Fascia Lata as an Autograft

“…Another advantage of the fascia lata in contrast to the most frequently used grafts for MPFL reconstruction, that is, the gracilis, quadriceps, or semitendinosus tendon, lies in the comparable shape and biomechanical similarity to the native MPFL. 32 , 33 , 34 The gracilis or semitendinosus tendon's shape can be considered tubular and longer than needed, whereas the fascia lata presents the shape of an aponeurosis. 35 , 36 A biomechanical study has recently shown that cordlike grafts cannot completely replace the MPFL's natural functional behavior.…”