Abstract
Technique Video
A right knee is shown, with the joint kept in full extension throughout the procedure. The surgeon uses 4 arthroscopic portals: a standard lateral portal for visualization, standard medial and superior-medial portals for suture management, and a central-medial portal for anchor placement and knot tying. The surgeon marks the anatomy of the MPFL on the skin and places spinal needles on the proximal and distal borders of the MPFL. The first step is to debride the capsuloligamentous tear and its bony insertion on the patella. A central-medial portal for anchor placement is then made under arthroscopic visualization. A first all-suture double-loaded anchor is implanted on the medial-proximal aspect of the patella, and its sutures are retrieved through the superior-medial portal. A second all-suture double-loaded suture anchor is implanted in the medial-distal part of the patella, and its sutures are retrieved through the medial portal. A spinal needle single loaded with a No. 1 polydioxanone (PDS) suture, thus creating a loop, is inserted deep into the upper half of the medial patellofemoral ligament (MPFL) tissue and brought into the joint under arthroscopic visualization. The green suture of the proximal anchor is retrieved through the PDS loop, and the spinal needle with the loop is retracted, shuttling the green suture through the MPFL tissue. The needle with the PDS loop is brought through the upper half of the MPFL tissue, and the tiger suture of the proximal anchor is retrieved through the loop and shuttled through the MPFL tissue. Next, the needle with the PDS loop is brought through the upper half of the MPFL tissue, and both the green and tiger sutures of the proximal anchor are retrieved through the loop and shuttled through the MPFL tissue. The next step is to retrieve the distal anchor sutures from the superior-medial portal. As before, the spinal needle with the PDS loop is used to shuttle the distal anchor sutures sequentially through the distal half of the MPFL. Subsequently, the subcutaneous plane is bluntly divided with a Pean forceps inserted through the central-medial portal in the direction of the medial femoral condyle. The anchor sutures are retrieved from the subcutaneous space, and the sutures of the proximal and distal anchors are separated. The sutures are sequentially tied through the central-medial portal, starting with the proximal anchor sutures, by use of standard arthroscopic sliding knots. The arthroscopic portals are closed using absorbable sutures.
Indications
Surgical Technique

Diagnostic Arthroscopy: Identification of MPFL and Debridement of MPFL Tear


Anchor Placement

Suture Passage



Suture Retrieval and Knot Tying




Postoperative Care
Advantages |
Quick procedure |
Surgical procedure performed through 4 arthroscopic portals with reduced morbidity compared with open procedures |
Anatomic repair of MPFL |
Allows for adequate control of tension of repair |
No special equipment needed |
Disadvantages |
Cost of implants (suture anchors) |
Advanced arthroscopic skills required (especially regarding suture management) |
Pearls |
Meticulous outlining of anatomic structures (patella and MPFL) with a skin marker is essential for adequate placement of spinal needles to help distinguish the proximal and distal MPFL borders while viewing intra-articularly. |
To distinguish the sutures of the proximal and distal anchors before knot tying, it is helpful to color the extremities of the sutures of one anchor with a skin marker before suture passage. |
To correctly place the arthroscopic knots, the surgeon should always direct the tip of the knot pusher toward the medial femoral condyle. |
Pitfalls |
Clear exposure of bone prior to anchor hole drilling and anchor insertion on the patella is crucial to avoid incomplete insertion of the all-suture anchor resulting in potential anchor pullout. |
The surgeon should avoid forceful tapping during all-suture anchor implantation as the drill guide may penetrate and weaken the patellar cortex and thus compromise the pullout strength of the anchor. |
Failure to perform the sequence of suture passages through the MPFL tissue systematically, starting from proximal to distal, may lead to suture entanglement and, consequently, limit correct sliding of the knots. |
Discussion
Supplementary Data
- ICMJE author disclosure forms
- Video 1
A right knee is shown, with the joint kept in full extension throughout the procedure. The surgeon uses 4 arthroscopic portals: a standard lateral portal for visualization, standard medial and superior-medial portals for suture management, and a central-medial portal for anchor placement and knot tying. The surgeon marks the anatomy of the MPFL on the skin and places spinal needles on the proximal and distal borders of the MPFL. The first step is to debride the capsuloligamentous tear and its bony insertion on the patella. A central-medial portal for anchor placement is then made under arthroscopic visualization. A first all-suture double-loaded anchor is implanted on the medial-proximal aspect of the patella, and its sutures are retrieved through the superior-medial portal. A second all-suture double-loaded suture anchor is implanted in the medial-distal part of the patella, and its sutures are retrieved through the medial portal. A spinal needle single loaded with a No. 1 polydioxanone (PDS) suture, thus creating a loop, is inserted deep into the upper half of the medial patellofemoral ligament (MPFL) tissue and brought into the joint under arthroscopic visualization. The green suture of the proximal anchor is retrieved through the PDS loop, and the spinal needle with the loop is retracted, shuttling the green suture through the MPFL tissue. The needle with the PDS loop is brought through the upper half of the MPFL tissue, and the tiger suture of the proximal anchor is retrieved through the loop and shuttled through the MPFL tissue. Next, the needle with the PDS loop is brought through the upper half of the MPFL tissue, and both the green and tiger sutures of the proximal anchor are retrieved through the loop and shuttled through the MPFL tissue. The next step is to retrieve the distal anchor sutures from the superior-medial portal. As before, the spinal needle with the PDS loop is used to shuttle the distal anchor sutures sequentially through the distal half of the MPFL. Subsequently, the subcutaneous plane is bluntly divided with a Pean forceps inserted through the central-medial portal in the direction of the medial femoral condyle. The anchor sutures are retrieved from the subcutaneous space, and the sutures of the proximal and distal anchors are separated. The sutures are sequentially tied through the central-medial portal, starting with the proximal anchor sutures, by use of standard arthroscopic sliding knots. The arthroscopic portals are closed using absorbable sutures.
References
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The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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