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“The Superficial Quad Technique” for Medial Patellofemoral Ligament Reconstruction: The Surgical Video Technique

Open AccessPublished:October 19, 2015DOI:https://doi.org/10.1016/j.eats.2015.06.003

      Abstract

      With the introduction of the superficial quad technique, there has been a recent revival of interest in the quadriceps tendon as a graft choice for medial patellofemoral ligament (MPFL) reconstruction. The superficial quad technique has many anatomic advantages because the length, breadth, and thickness of the graft are similar to those of the native MPFL; moreover, the graft provides a continuous patellar attachment at the superior half of the medial border of the patella. The technique requires neither a patellar bony procedure nor patellar hardware. Biomechanically, the mean strength and stiffness of the graft are very similar to those of the native MPFL. The anatomic and biomechanical advantages depend on correct identification of the anatomic superficial lamina of the quadriceps tendon; hence the correct harvesting technique for the superficial lamina is crucial. Various sub-techniques for harvesting the quadriceps graft have emerged recently, such as superficial strip, pedicled, or partial graft harvesting; these can create confusion for surgeons. Additional confusion related to the preparation and fixation of the graft should also be addressed to avoid any potential complications. A step-by-step video of the superficial quad technique is presented, covering the exact dissection of the graft material and its preparation, delivery, and fixation.

      Technique Video

      See video under supplementary data.

      Use of partial-thickness quadriceps tendon for medial patellofemoral ligament (MPFL) reconstruction was described earlier in the literature in 2 independent studies by Steensen et al.
      • Steensen R.N.
      • Dopirak R.M.
      • Maurus P.B.
      A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft.
      and Noyes and Albright
      • Noyes F.R.
      • Albright J.C.
      Reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon.
      ; however, both received little attention in the literature. Goyal revived interest in the use of the quadriceps tendon for MPFL reconstruction after presentation of the superficial quad technique during the 7th Indian Arthroscopy Society Meeting (Goa, India, 2008) and then during the 14th meeting of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (Oslo, Norway, June 9-12, 2010), and later publication of its midterm results.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The technique has the distinct anatomic advantage of providing a thin, broad strip of tissue similar to the native MPFL.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The technique does not require any patellar bony procedure or patellar hardware but still provides a continuous anatomic attachment along the superior half of the medial border of the patella.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      In addition, biomechanically, the graft has proved to be of nearly similar mean strength and stiffness to those of the native MPFL.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      • Herbort M.
      • Hoser C.
      • Domnick C.
      • et al.
      MPFL reconstruction using a quadriceps tendon graft.
      Some sub-techniques such as partial-thickness graft and pedicled graft techniques have also been published, but the distinct anatomic and biomechanical advantages of the superficial quad technique lie in the careful dissection of the superficial lamina, which is an anatomically distinct and dissectible tissue in the conjoined quadriceps tendon aponeurosis. The original study did not show any major complications
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      ; however, the technique has the potential to cause some major complications, such as missing the exact plane of separation, pre-amputating the graft, performing incorrect delivery, or over-tensioning the graft.
      • Vaishya R.
      • Goyal D.
      The superficial quad technique: Letter to the editor.
      The purpose of this report is to provide the detailed step-by-step method of the superficial quad technique, covering anatomic graft harvesting and graft preparation, delivery, and fixation for a sound MPFL reconstruction (Video 1).

      Surgical Technique

      The 10-step surgical technique was briefly discussed earlier.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      A detailed point to point dissection steps are described along with the video of the superficial quad technique (Video 1).

      Step 1: Arthroscopic Surgery

      Arthroscopic assessment is important to document the patellofemoral relation, including mal-tracking, subluxation, or obvious dislocation; the presence of chondral damage on the patellar or condylar surface; the presence of trochlear pathology such as dysplasia and its grade; and the presence of any loose bodies such as a osteochondral fracture fragment due to patellar dislocation. Sometimes, it may be important just to document the intra-articular findings, whereas at other times, one may choose to address the intra-articular pathologic conditions during the same stage (e.g., fixing a loose osteochondral fracture fragment).

      Step 2: Graft Harvesting From Superficial Slip of Quadriceps Tendon

      Because the superficial quad technique relies on anatomically separable tissue planes for graft harvesting, no special instruments are required. An incision measuring around 7 to 8 cm is made on the anterior aspect of the knee, starting at the midpoint of the patella and progressing proximally. The superficial fascia and deep fascia are incised along the incision lines until a fatty tissue layer is encountered just below the deep fascia. With the help of blunt dissection with dry gauze, these fatty tissues are dissected out of the surgical field. This step exposes the quadriceps tendon. There is, again, a thin fascial layer of tissue over the quadriceps tendon that needs to be incised. The skin and fascia are lifted in the surgical field using T retractors, and with the use of sharp scissors, the subfascial dissection is extended more proximally toward the mid thigh and more distally toward the lower pole of the patella. This step ensures that while there is a smaller incision on the skin, the subfascial area of the surgical field is much larger.
      The quadriceps tendon near its patellar insertion is a trilaminar structure.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The superficial lamina comprises the rectus femoris, the middle lamina comprises the vastus medialis and vastus lateralis, and the deeper lamina comprises the vastus intermedius. The most critical part of the technique is identifying a naturally occurring surgical plane of separation between the superficial and middle laminas that is present around 2 to 3 cm proximal to the proximal pole of the patella.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      On fine inspection, one can observe the laminated tendons 2 to 3 cm proximal to the patella. Because the deep layer is much deeper, only 2 laminas (superficial and middle) can be identified. The surgeon should gradually lift the superficial lamina using fine Adson forceps and, with the help of sharp scissors, separate the 2 laminas. Occasionally, the laminated structure is not naturally visible. In this case a small vertical nick is made at the lateral-most part of the tendinous structure, around 2 cm proximal to the upper pole of the patella. The fine scissors now can easily be placed between the superficial and middle laminas, and the surgeon can easily push them toward the medial side of the tendinous superficial lamina. Usually, the breadth of the superficial lamina at this point is around 10 to 13 mm. The 2 blades of the scissors are then separated to perform blunt dissection at the plane of separation. A small T retractor is inserted between the laminas, and the superficial lamina is lifted (Fig 1). Now, it is very easy to dissect the superficial lamina proximally and distally because the plane of separation has been identified. Proximally, there are no adherent tissues, and blunt dissection with dry gauze can easily separate the superficial lamina from the deeper structures. Some of the muscle fibers might be found to be adherent to the superficial lamina; these can be erased using either blunt dissection or sharp scissors. The proximal dissection is made easy as the assistant is holding the 2 retractors in his or her hands and continuously lifting the skin and fascia in the surgical field. This increases the viewing area through the smaller incision and allows cutting of the graft at the required length.
      Fig 1
      Fig 1Graft harvesting in a right knee in the supine position, viewed from the medial aspect. An anterior midline incision of around 7 to 8 cm is centered over the upper pole of the patella. A small vertical nick is made at the lateral-most part of the quadriceps tendinous structure, around 2 cm proximal to the upper pole of the patella. Fine scissors are used to gain access between the superficial and middle laminas. It should be noted that the usual breadth of the superficial lamina at this point is around 10 to 13 mm. A small T retractor is inserted between the 2 surgically separable laminas, and the superficial lamina is lifted.
      Now, the dissection is directly distally. The superficial and middle laminas merge and adhere to each other near the last 2 cm and at the attachment at the proximal pole of the patella. Two sharp vertical incisions are made on the distal tendon (starting at around 2 cm proximal to the patella) in continuity with the separated graft borders until the proximal pole of the patella is reached. Now, the surgeon lifts the earlier dissected superficial laminar graft and dissects the undersurface of the superficial lamina from the middle lamina using sharp scissors until the proximal pole of the patella is reached (Fig 2).
      Fig 2
      Fig 2Graft harvesting in a right knee in the supine position, viewed from the medial aspect. The dissected superficial laminar graft is lifted with the T retractor, and sharp distal dissection is carried out to separate the superficial lamina from the middle lamina using sharp scissors until the proximal pole of the patella is reached.
      The approximate native MPFL length is measured from the medial border of the patella to the medial epicondyle with the knee in 30° of flexion and the patella reduced in the trochlea. Another 3 cm is added to this length because some length will be lost when rotating the graft, and an extra length of 2 to 2.5 cm is required for intraosseous fixation of the graft at the femur. The graft is cut proximally at the required length (Fig 3), the proximal edge of the graft is grasped with Ellis forceps (Fig 4), and No. 2 Ethibond (Ethicon, Johnson & Johnson, Aurangabad, India) is used to suture the graft in a whipstitch fashion. A nicely harvested superficial lamina should leave the intact quadriceps tendon behind, and there should not be a joint violation at this stage. In general, the graft breadth is kept between 10 and 12 mm, which may become slightly broader near the patellar attachment.
      Fig 3
      Fig 3Graft harvesting in a right knee, viewed from the medial aspect. The dissected graft is pulled inferiorly with the help of a finger; the graft is then further sharply dissected proximally until the required length is achieved and is cut with sharp scissors.
      Fig 4
      Fig 4Graft harvesting in a right knee, viewed from the anteromedial aspect. The proximally cut end of the graft is grasped with Ellis forceps, and the scissors show the completely dissected graft until the upper pole of the patella is reached.

      Step 3: Preparation of Graft for Repositioning

      The points of attachment of the most superior and most inferior fibers of the native MPFL to the patella are approximately at the superomedial corner of the patella (Fig 5) and at the midpoint of the medial margin of the patella, respectively.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      Hence, to re-create these anatomic points of fixation for MPFL reconstruction on the patella, surgeon should further dissect the graft obliquely in the subperiosteal plane on the patella. The medial point of dissection should be at the level of the superomedial corner of the patella, and the lateral point of dissection should be at the level of the midpoint of the medial border of the patella (Fig 6). The surgeon should perform this dissection using a sharp knife and should be careful not to amputate the graft at this level.
      • Vaishya R.
      • Goyal D.
      The superficial quad technique: Letter to the editor.
      The graft is then rotated medially such that the deeper layer of the graft becomes superficial. This step also converts the medial border of the graft to its superior border and converts the lateral border to its inferior border. The superior and inferior edges of the rotated graft thus match the anatomic points of the native MPFL
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      (Fig 7).
      Fig 5
      Fig 5Preparing the graft for repositioning in a right knee. The graft is dissected on the patella until the level of the superomedial corner of the patella is reached. This point is the anatomic point that matches the superior point of the attachment of the native medial patellofemoral ligament on the medial border of the patella.
      Fig 6
      Fig 6Preparing the graft for repositioning in a right knee. The graft is further dissected on the lateral side of the patella obliquely until the midpoint of the lateral border of the patella is reached. This point is in line with the midpoint of the medial border of the patella that matches the inferior point of the attachment of the native medial patellofemoral ligament on the medial border of the patella.
      Fig 7
      Fig 7Preparing the graft for repositioning in a right knee. The graft is rotated medially such that the deeper layer of the graft becomes superficial. This step converts the medial border of the graft to its superior border and converts the lateral border to its inferior border. The superior and inferior edges of the rotated graft thus match the anatomic points of the native medial patellofemoral ligament.

      Step 4: Creation of Subvastus Space

      The surgeon should follow the insertions of the vastus medialis on the upper part of the medial border of the patella. The whole insertion is then lifted using a toothed forceps, and with the help of sharp scissors, the subvastus space is created (Fig 8). With gradual blind dissection, the surgeon proceeds from the medial border of the patella toward the medial epicondyle in the subvastus plane. It is important to avoid violating the capsule during this step. The best way is to carefully dissect the medial retinaculum off the capsule and create a wide space toward the medial epicondyle.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      Fig 8
      Fig 8Creation of the subvastus space in a left knee, viewed from the lateral aspect (different case than that shown in Fig 1, Fig 2, Fig 3, Fig 4, Fig 5, Fig 6, Fig 7). The insertion of the vastus medialis near the superomedial border of the patella is lifted using a toothed forceps, and with the help of sharp scissors, the subvastus space is created.

      Step 5: Graft Delivery

      A 2-cm incision is centered at the medial epicondyle of the femur, and dissection is carried out to locate the adductor tubercle and medial epicondyle (Fig 9). An artery forceps is passed from the patellar side through the subvastus space created in the previous step and penetrated out of the medial incision. Another artery forceps is clamped on the tip of the previous forceps, and these artery forceps are then railroaded out of the anterior incision through the subvastus space. Alternatively, a loop of Ethibond suture is clamped with the tip of the first artery forceps at the medial incision and is pulled out of the anterior incision. Either with the tip of the second artery forceps or with the loop of the Ethibond, the sutures placed on the graft ends are pulled out of the medial incision (Fig 10). The surgeon must take care to avoid re-rotating the graft during this maneuver.
      Fig 9
      Fig 9Graft delivery in a right knee, viewed from the medial aspect. A 2-cm incision is made over the medial epicondyle, and dissection is carried out to locate the adductor tubercle and the medial epicondyle.
      Fig 10
      Fig 10Graft delivery in a left knee (different case than that shown in Fig 1, Fig 2, Fig 3, Fig 4, Fig 5, Fig 6, Fig 7, Fig 9), viewed from the anterior aspect. The rotated graft is pulled out through the medial incision through the subvastus space.

      Step 6: Placement of Stay Sutures at Patellar Anatomic Attachment

      So far, the patellar end of the graft has remained attached to the anterior surface of the patella and not on the medial border of the patella. The procedure takes advantage of the strong natural anatomic insertion of the graft on the anterior surface of the patella because it is not disturbed. However, it should also act biomechanically at the correct anatomic point on the medial border.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      To achieve this, a few stay sutures using No. 2 Ethibond are placed on the medial border of the patella near the native MPFL attachments.

      Step 7: Identification of Point of Isometry at Femur

      Unlike the patellar attachment, which is wide, the femoral attachment is a single point of fixation. An isometric point of fixation is identified medially between the adductor tubercle and medial epicondyle. The surgeon can use either the method of Farr and Schepsis or the method of Schottle to identify the point of isometry
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      (Fig 11). At the isometric point, a Beath pin is passed from the medial side so that its tip emerges on the lateral side. The pin is over-drilled with a 4-mm EndoButton drill until the lateral cortex is reached so that the sutures do not become caught against the wall of the lateral cortex when the sutures are pulled out from the lateral side. Then, a 6-mm reamer is used to over-drill for 3.5 cm (Fig 12). The length of the 6-mm drill reaming depends on an approximate size of the graft that should go intraosseous. Sutures on the graft are passed through the eye of the Beath pin, and the pin is pulled out laterally.
      Fig 11
      Fig 11Identifying the point of isometry in a left knee (different case than that shown in Fig 1, Fig 2, Fig 3, Fig 4, Fig 5, Fig 6, Fig 7, Fig 9), viewed from the medial aspect. The graft is rolled on the Beath pin, and the knee is then subjected to a complete range of motion. An unchanging graft length signifies that the Beath pin is at the isometric point.
      Fig 12
      Fig 12Femoral fixation in a left knee (different case than that shown in Fig 1, Fig 2, Fig 3, Fig 4, Fig 5, Fig 6, Fig 7, Fig 9), viewed standing near the opposite hip. A 6-mm reamer is used to over-drill the Beath pin for 3 to 4 cm. This allows around 2.5 to 3 cm of graft to be pulled in for intraosseous fixation.

      Step 8: Optimization of Correct Length of MPFL Graft

      The superficial quad technique emphasizes that the graft should not be tensioned; rather, the graft length should be optimized. Ligament surgeons per se have a habit of placing extra pull on the graft while fixing it. This can cause over-tensioning of the graft. A controlled pull from the lateral side is applied in 30° of flexion. Then, keeping the same controlled pull, the surgeon performs an optimized length check in full extension. The surgeon should be able to move the patella in either direction and should be able to push the patella laterally until half the width of the patella is reached. Keeping the same length of the graft, the surgeon again brings the knee into 30° of flexion and fixes it.

      Step 9: Femoral Fixation

      After maintaining the optimum length as described in step 8, the graft is fixed with an absorbable interference screw (Bio-RCI; Smith & Nephew, Andover, MA). Alternatively, in patients who opt for a nonabsorbable screw, a titanium screw (Hib Surgicals, Mumbai, India) can be used. The most common size required for this fixation is 7 × 25 mm (Fig 13).
      Fig 13
      Fig 13Femoral fixation in a left knee, viewed from the medial side. Interference screw fixation is performed over the Beath pin; generally, a 7 × 25–mm screw is sufficient.

      Step 10: Repair of Medial Retinaculum and Second-Look Arthroscopy

      The final step consists of repair of the medial retinaculum if there is any damage. Second-look arthroscopy is strongly recommended to recheck the proper realignment of patellar excursion.

      Postoperative Rehabilitation

      The patient is allowed full weight bearing from day 0 using a brace. A long knee brace is applied until the patient regains good quadriceps control. Quadriceps-strengthening exercises are encouraged starting in the evening on the same day of surgery, and use of the brace is usually discontinued after 1 week. Active range-of-motion exercises are started on day 0 within the limits of the patient's tolerance. However, the patient is encouraged to quickly regain his or her movements as early as possible. Pre-existing quadriceps wasting can aggravate the postoperative course as is the case with any knee operation. Because the described surgical procedure does not disturb the quadriceps mechanism much, an aggressive quadriceps-strengthening regimen restores pre-existing as well as postsurgical quadriceps wasting soon.

      Discussion

      The superficial quad technique has distinct anatomic and biomechanical advantages as previously described by Goyal
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      (Table 1). The harvested graft is a thin, broad, sheet-like structure, very similar to the native MPFL. The graft has a strong natural attachment at the anterior surface of the patella and substituted attachment at the superior half of the medial border of the patella.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      Because of this double fixation, graft attachment remains strong at the patella without the use of any patellar bony procedure or use of any patellar hardware. At the same time, stay sutures cause the graft to act on the superior half of the medial border of the patella, which is the natural attachment site of the native MPFL. This patellar attachment also acts as a continuous attachment at the patella instead of the 1- or 2-point fixation provided by hamstring tendons.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      Moreover, biomechanically, it has been proved that the superficial quadriceps lamina has nearly the same mean strength and stiffness as the native MPFL.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      • Herbort M.
      • Hoser C.
      • Domnick C.
      • et al.
      MPFL reconstruction using a quadriceps tendon graft.
      Table 1Advantages of Superficial Quad Technique for MPFL Reconstruction
      The graft is a broad, thin, sheet-like structure similar to the native MPFL.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The technique provides a continuous attachment on the superior half of the medial border of the patella similar to the native MPFL.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The technique does not require any patellar bony procedure or any patellar hardware.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The mean strength and stiffness of the superficial quadriceps graft are biomechanically similar to those of the native MPFL.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      • Herbort M.
      • Hoser C.
      • Domnick C.
      • et al.
      MPFL reconstruction using a quadriceps tendon graft.
      The main quadriceps tendon remains undamaged and hence can be used in the future.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The technique spares the hamstring tendons, which are potentially important future graft sources, mainly in places where allografts are not available.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      The technique encourages optimizing the length of the graft rather than tensioning the graft.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      MPFL, medial patellofemoral ligament.
      A few cautions are important for beginners to note (Table 2). The most important term in the phrase “the superficial quad technique” is “superficial,” not “quad.” A surgeon who is accustomed to harvesting quadriceps tendon graft is highly likely to go deeper than required. Careful identification of the superficial lamina is the most important step in the technique. The dissection for the harvesting of the graft starts 2 cm proximal to the patella and not at the superficial pole of the patella. This is the key difference between partial-thickness grafts and the superficial quadriceps graft. Given that the anatomic and surgical plane of separation lies 2 cm above the patella and all the layers of the quadriceps tendon are fused at the superior pole of the patella, any dissection that starts at the superior pole is likely to miss the surgical plane when the dissection is advanced proximally. However, if the dissection starts at the anatomically identifiable plane of separation, then it will follow the same plane within the fused aponeurotic trilaminar quadriceps attachment at the patella. Harvesting the correct length of graft is equally important because some length is lost in turning the graft and some extra length is required for intraosseous fixation of the graft. A careful dissection of the graft on the anterior surface of the patella is crucial because graft amputation can take place if the subperiosteal plane is missed. A careful dissection at the medial border of the patella is required to gain access to the subvastus space. While the surgeon is passing the graft through the subvastus space, the graft should not be re-rotated. Over-tensioning of the graft must be avoided, and only the optimized graft length should be selected before performing femoral fixation.
      Table 2Anticipated Problems During MPFL Reconstruction Using Superficial Quad Technique and Their Reasons and Solutions
      Anticipated ProblemReasonSolution
      Partial-thickness graft instead of superficial quadriceps graftAll 3 laminas of the quadriceps tendon are fused near its patellar attachment. Hence any graft harvested from the superficial pole of the patella will result in a partial-thickness graft rather than a superficial laminar graft.The surgeon should look for the surgical plane of separation 2-3 cm above the proximal pole of the patella and not at the proximal pole of the patella. At this point, there is a naturally present plane of separation between the superficial and middle laminas of the quadriceps aponeurosis.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      Insufficient length of graftSome amount of graft length is lost when turning the graft at the patella, and 2.5 cm of extra length is required for intraosseous fixation of the graft with an interference screw.The surgeon should measure the required length from the midpoint of the patella to the medial epicondyle and add 2.5-3 cm to the measured length. The surgeon should pull the graft distally so that a more proximal cut at the required length can be made.
      Graft amputationThe superficial lamina is a thin structure and is adherent to the periosteum on the anterior surface of the patella. It is difficult to dissect between the lamina and the periosteum.A very sharp dissection is required on the bone. The surgeon should virtually peel the graft off the bone. The dissection should be a subperiosteal dissection.
      Access to subvastus spaceThe medial retinaculum or, occasionally, the fibers of a well-developed vastus medialis are attached to the superior half of the medial border of the patella. In either case, there is no identifiable entry to the subvastus space.A sharp incision on the medial retinaculum or on both the medial retinaculum and overlying vastus medialis fibers is required over the superior half of the medial border of the patella. This allows entry into the subvastus space.
      Graft rotationWhile the graft is being pulled out of the medial incision, the graft is re-rotated, leading to bumpy tissue near the medial patellar border.Passage of the graft through the subvastus space should be guided properly so that the superficial surface of the harvested graft becomes the deeper surface of the reconstructed graft and vice versa.
      Graft over-tensioningLigament surgeons have a habit of over-tightening the grafts. Over-tensioning can place abnormal loads on the patellofemoral joint.The surgeon should optimize the length of the graft in such a way that the patella remains movable in either direction, with 50% of patellar width movement on either side; testing should be performed in full extension.
      MPFL, medial patellofemoral ligament.
      Although the superficial quad technique is a simple and easily reproducible technique with distinct anatomic and biomechanical advantages, the anterior incision is a noteworthy limitation. The anterior incision over the patella can be a cause of concern for many surgeons. In addition, our previously published midterm results showed a few incidences of scar hypertrophy.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.
      Methods should be developed to minimize the size of the anterior incision.
      • Goyal D.
      Medial patellofemoral ligament reconstruction: The superficial quad technique.

      Supplementary Data

      References

        • Steensen R.N.
        • Dopirak R.M.
        • Maurus P.B.
        A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft.
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        • Noyes F.R.
        • Albright J.C.
        Reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon.
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        Medial patellofemoral ligament reconstruction: The superficial quad technique.
        Am J Sports Med. 2013; 41: 1022-1029
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        • Domnick C.
        • et al.
        MPFL reconstruction using a quadriceps tendon graft.
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        • Goyal D.
        The superficial quad technique: Letter to the editor.
        Am J Sports Med. 2013; 41 (NP47 (letter))