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Femoral fixation of medial patellofemoral ligament reconstruction grafts varies, presents challenge
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Editor’s note: Members of the Patellofemoral Foundation review and add clinical perspective to recently published studies on the causes, prevention and treatment of patellofemoral disorders. The twice monthly blogs are edited by John P. Fulkerson, MD, and can be found on Healio.com/Orthopaedics. To read all the Patellofemoral Update blogs, click here.
Elvire Servien, MD, PhD, and her team in Lyon, France, have studied the femoral fixation of medial patellofemoral ligament reconstruction grafts. They have emphasized the variability and complexity of this challenging, yet important, part of medial patellofemoral ligament (MPFL) restoration.
Useful techniques
I present the following techniques which have been useful in the restoration of medial patellofemoral support.
I palpate the medial structures and mark them, including the adductor magnus tendon, adductor tubercle, medial joint line and medial epicondyle, with methylene blue until I can visualize the anatomy percutaneously as accurately as possible. It is tough or impossible on some large knees in which case I make an even larger incision as needed.
Image: Ladenhauf HN
Then I make a fairly generous incision, about 3 cm to 6 cm long, extending from the adductor magnus tendon to the medial epicondyle, dissecting until I can put a hemostat under the adductor tendon, and define it clearly so I can see its glistening beauty as it inserts into the adductor tubercle – then pick my femoral site for graft attachment visually depending on whether I am reconstructing the MPFL or medial quadriceps tendon-femoral ligament (MQTFL), which is slightly more proximal, coming off of the adductor tubercle. Radiographic views may be helpful in larger knees when landmarks are less distinct, and should be available for confirmation as needed, but have become less necessary as we have become more comfortable with the anatomy.
Graft placements
We have done almost 90 MPFL and MQTFL reconstructions to date during the last 6 years to 7 years, and dissected more than 20 cadaver knees to understand this anatomy. We are happy with our graft placements, “setting out to length’” (which is a great term from Jack Farr, MD) on the patella/quadriceps tendon side.
The best steps were making the incision longer, taking more time for the dissection, and clearly defining the adductor magnus tendon and its insertion at the adductor tubercle, which then defines the origins of the MPFL and MQTFL.
Reference:
- Servien E. Am J Sports Med. 2011; doi:10.1177/0363546510381362.
- John P. Fulkerson, MD, is a clinical professor of orthopedic surgery at the University of Connecticut School of Medicine and practices at Orthopedic Associates of Hartford in Farmington, Conn., USA. He is also president of The Patellofemoral Foundation.
Disclosure:
- Disclosure: Fulkerson receives royalties from DJO Global and is a patent holder for DJO Global.
Perspective
Back to TopHannah N. Ladenhauf, MD
Daniel W. Green, MD, MS, FACS, at Hospital for Special Surgery, in New York, and colleagues typically utilize an anatomic reconstruction of the medial patellofemoral ligament (MPFL) using a free hamstring autograft technique in skeletally immature patients. This modified technique avoids the distal femoral growth plate, minimizing the risk of injury, and allowing a safe, effective and anatomic treatment option.
Daniel W. Green
Hannah N. Ladenhauf
We recognize there are many surgical options in regards to MPFL graft choice and fixation techniques. We believe that while techniques may vary, the literature supports the statement that MPFL reconstructions are clinically superior to surgical repair or imbrication of the MPFL.
We perform a small skin incision (1 cm to 2 cm) in the area of the medial epicondyle and the adductor tubercle. Using fluoroscopic imaging, the socket for the femoral graft insertion is placed just a few millimeters distal to the distal femoral growth plate on the AP view. On the lateral view, the socket is located at the radiographic landmark of Schoettle, parallel to the posterior cortex of the diaphysis of the femur. Because the distal femoral growth plate is not flat, surgeons should be cautioned that on a true lateral radiograph, the femoral insertion point may falsely appear to be proximal of the distal femoral growth physis. The previously harvested double bundled autograft is then secured with a tenodesis screw into a 15-mm socket. The two free ends are passed subcutaneously beneath the fascia to the superior half of the patella.
At the patella, we create a 2-cm skin incision and expose the bone of the patella. Small socket tunnels are drilled in the patella once the graft length and isometry are adjusted by assessing patellar tracking and range of motion. The graft is then placed into the short sockets and secured with two tenodesis screws. In younger children, less than 10 years of age, one fixation point and a single bundle reconstruction at the patella are often used. We typically harvest the graft from a small cosmetic posterior incision. The use of intraoperative radiographs allows for smaller incisions to be used.
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