This article by Hangzhou Zhang, MD, and colleagues nicely demonstrates that there are many techniques with which to achieve success in medial patellofemoral ligament reconstruction. The authors have studied a technique of patellar fixation using small bore medial to lateral tunnels through the patella in which sutures are passed and then used to secure the medial patellofemoral ligament graft to the medial patella. With minimum 2-year follow-up in 29 patients, there was no recurrence of instability and all other outcomes were shown to improve from preoperative evaluation. In particular, I am struck by the fact that this technique represents a nice way to avoid placement of any implants in the patella, which avoids larger drill holes and added cost.

There are a number of things to note, however, about this study and the approach. There is no description of the mechanism of injury or of nonoperative management prior to surgery. The authors screened patients for any bony abnormality, so it is important for readers to understand these are isolated medial patellofemoral ligaments in patients with recurrence, but no bony abnormality. In other words, this is a population that is most likely to do well, and we do not know how this would perform in more complex patients.

From a technique standpoint, the wide spread of drill tunnels means a roughly 2 cm attachment on the patella and therefore a connection to the proximal two-thirds of the patella, which is non-anatomic. In addition, while the drill holes are small bore, they still completely traverse the patella. If the drilling is too anterior, there is a risk of stress riser and potential for iatrogenic fracture; if the drilling is too posterior, it risks the lateral facet osteochondral surface.

In summary, this technique seems a viable approach for medial patellofemoral ligament reconstruction, but it must be understood that this study was in low-risk patients and that there are some pitfalls to this technique.