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Technical Note| Volume 12, ISSUE 3, e329-e335, March 2023

Combined Medial Patellofemoral Ligament, Medial Quadriceps Tendon-Femoral Ligament, and Medial Patellotibial Ligament Reconstruction for Patellar Instability: A Technical Note

Open AccessPublished:February 08, 2023DOI:https://doi.org/10.1016/j.eats.2022.11.011

      Abstract

      Lateral patellar dislocations often occur in a young, athletic population of recurrent dislocators with generalized laxity and an interest in returning to an active lifestyle. A recent appreciation for the distal patellotibial complex has directed surgeons toward attempting to re-create the native anatomy and knee biomechanics during medial patellar reconstructive procedures. By reconstructing the medial patellotibial ligament (MPTL) in addition to the medial patella-femoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL), the current article describes a potentially more stable construct that can be utilized in patients with subluxation with the knee in full extension, patellar instability with the knee in deep flexion, genu recurvatum, and generalized hyperlaxity. Additionally, the current technique utilizes a tibialis anterior allograft. The purpose of this Technical Note is to describe, in detail, the current authors' technique for a combined MPFL, MQTFL, and MPTL reconstruction.

      Technique Video

      (mp4, (70.69 MB)

      This technique video describes our combined reconstruction of the medial patellofemoral ligament (MPFL), medial quadriceps tendon-femoral ligament (MQTFL), and medial patellotibial ligament (MPTL) for patellar instability. It describes the indications, physical examination findings, and necessary setup and equipment utilized for the reconstruction. The patient is placed supine with leg holders to allow for 30° and 90° of knee flexion. The video then describes graft preparation using a split tibialis anterior tendon allograft. A careful dissection ensues just medial to the patella. The MQTFL tunnel is the first to be established at the medial inferior aspect of the quadriceps tendon. Next, the MPTL is established by making a bone tunnel at the proximal one-third point and the middle of the medial aspect of the patella. Finally, the medial patellotibial patellar attachment is established approximately 5 mm proximal to the distal-most aspect of the medial patella, just medial to the patellar tendon insertion. The femoral attachment of the MPFL and MQTFL is identified using intraoperative fluoroscopy and careful dissection. Next, fluoroscopy is used to help establish the tibial attachment of the MPTL, which is found at a 28° angle from the medial aspect of the patellar tendon. Then, 2.8-mm suture anchors are placed at this anatomic footprint. The MPTL graft is passed through the established soft tissue tunnel and fixed to the inferomedial portion of the patella using a 1.8-mm suture anchor. Fluoroscopy is then used to help ensure proper passage and stable fixation of the combined MPFL/MQTFL graft. The MPFL is first passed through its respective bone tunnel and ultimately tied back upon itself. The MQTFL is then passed through the soft tissue tunnel at the distal quadriceps tendon before being tied back upon itself. The excess graft is removed, and final product is visualized.

      Technique Video

      See video under supplementary data.

      Lateral patellar dislocations have a reported incidence of 23.2 injuries per 100,000 adolescents each year and have been estimated to make up approximately 2% to 3% of all knee injuries.
      • Sanders T.L.
      • Pareek A.
      • Hewett T.E.
      • Stuart M.J.
      • Dahm D.L.
      • Krych A.J.
      Incidence of first-time lateral patellar dislocation: A 21-year population-based study.
      ,
      • Arendt E.A.
      • Fithian D.C.
      • Cohen E.
      Current concepts of lateral patella dislocation.
      There are 3 primary ligaments that have a significant role in maintaining the stability of the medial patellofemoral joint: the medial patellofemoral ligament (MPFL), the medial patellotibial ligament (MPTL), and the medial patellomeniscal ligament (MPML).
      • Hinckel B.B.
      • Gobbi R.G.
      • Demange M.K.
      • et al.
      Medial patellofemoral ligament, medial patellotibial ligament, and medial patellomeniscal ligament: Anatomic, histologic, radiographic, and biomechanical study.
      Cadaveric studies have provided detailed anatomic descriptions of the medial patellar stabilizing ligaments. The MPTL originates at the medial aspect of the distal pole of the patella and courses at a 28° angle relative to the medial aspect of the patellar tendon. It attaches at the medial tibia approximately 9.4 mm distal to the joint line, in line with the medial tibial spine; the average length is 3.6 cm and average width is 7.1 mm.
      • Hinckel B.B.
      • Gobbi R.G.
      • Demange M.K.
      • et al.
      Medial patellofemoral ligament, medial patellotibial ligament, and medial patellomeniscal ligament: Anatomic, histologic, radiographic, and biomechanical study.
      The MPFL originates in between the adductor tubercle and medial epicondyle and attaches between the middle and proximal one-third of the medial aspect of the patella.
      • Aframian A.
      • Smith T.O.
      • Tennent T.D.
      • Cobb J.P.
      • Hing C.B.
      Origin and insertion of the medial patellofemoral ligament: A systematic review of anatomy.
      More recently, expansions of the patellar attachment of the MPFL have been recognized as an important stabilizing structure named the medial quadriceps tendon-femoral ligament (MQTFL).
      • Tanaka M.J.
      • Chahla J.
      • Farr II, J.
      • et al.
      Recognition of evolving medial patellofemoral anatomy provides insight for reconstruction.
      ,
      • Fulkerson J.P.
      • Edgar C.
      Medial quadriceps tendon-femoral ligament: Surgical anatomy and reconstruction technique to prevent patella instability.
      This structure provides static connection between the medial femur and the extensor mechanism throughout knee flexion and extension. Biomechanical studies have reported that the MPFL accounts for 50% to 60% of restraint against lateral patellar displacement, while the MPTL and MPML combined provide 20% to 40% of restraint with the knee at full extension.
      • Panagiotopoulos E.
      • Strzelczyk P.
      • Herrmann M.
      • Scuderi G.
      Cadaveric study on static medial patellar stabilizers: The dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament.
      • Hautamaa P.V.
      • Fithian D.C.
      • Kaufman K.R.
      • Daniel D.M.
      • Pohlmeyer A.M.
      Medial soft tissue restraints in lateral patellar instability and repair.
      • Desio S.M.
      • Burks R.T.
      • Bachus K.N.
      Soft tissue restraints to lateral patellar translation in the human knee.
      In addition, the MPTL and MPML are responsible for 72% of patellar tilt and 92% of patellar rotation.
      • Philippot R.
      • Boyer B.
      • Testa R.
      • Farizon F.
      • Moyen B.
      The role of the medial ligamentous structures on patellar tracking during knee flexion.
      While the majority of techniques for lateral patellar instability involve reconstructing the MPFL in isolation, several recent techniques have incorporated both anatomic and nonanatomic reconstructions of the MPTL or MPML/MPTL complex in addition to MPFL reconstruction.
      • Hinckel B.B.
      • Gobbi R.G.
      • Demange M.K.
      • Bonadio M.B.
      • Pécora J.R.
      • Camanho G.L.
      Combined reconstruction of the medial patellofemoral ligament with quadricipital tendon and the medial patellotibial ligament with patellar tendon.
      Conversely, other techniques have described MQTFL reconstructions in isolation.
      • Fulkerson J.P.
      • Edgar C.
      Medial quadriceps tendon-femoral ligament: Surgical anatomy and reconstruction technique to prevent patella instability.
      ,
      • Joseph S.M.
      • Fulkerson J.P.
      Medial quadriceps tendon femoral ligament reconstruction technique and surgical anatomy.
      Thus, this technique describes a combined MPFL, MQTFL, and MPTL reconstruction using a tibialis anterior allograft.

      Indications and Contraindications

      The indications for this technique are lateral patellar subluxation with quadriceps contraction with the knee in extension, flexion instability (obligate dislocation in flexion), knee hyperextension associated with generalized laxity, increased quadriceps vector due to rotational deformities, and children with significant risk factors for recurrence of dislocation when bony surgery is limited due to open physes.
      • Hinckel B.B.
      • Lipinski L.
      • Arendt E.A.
      Concepts of the distal medial patellar restraints: Medial patellotibial ligament and medial patellomeniscal ligament.
      Additionally, indications for the correction of trochlear dysplasia, increased quadriceps vector, patella alta, and significant coronal malalignment with associated procedures remain the same. However, in patients with borderline risk factors, reconstruction of the medial patellar stabilizers described in the current report may offer adequate stability and can be indicated to limit the need for bony procedures such as tibial tuberosity osteotomy and/or trochleoplasty. Video 1 presents the senior authors' technique for combined reconstruction of the MPFL, MQTFL, and MPTL. Table 1 contains the pearls and pitfalls for successfully performing the surgery. Table 2 contains the advantages and disadvantages of the described technique.
      Table 1Pearls and Pitfalls
      PearlsPitfalls
      Use of fluoroscopy facilitates the identification of the “anatomic cloud” of the MPFL. However, testing the metrics behavior and “setting the graft to length” is essential to guarantee proper function.Inadequate anchor and tunnel placement can increase risk for patella fracture.
      Fix the MPTL graft first to help centralize the patella.Failure to thoroughly prepare/clean the patellar tunnels can cause grafts to get caught or damaged.
      A detailed understanding of the anatomy and layers of the medial retinaculum allows for proper graft passage.Fixing grafts at incorrect angles may cause grafts to become loose and can cause instability or too much tightness and can cause pain or decreased range of motion.
      MPFL, medial patellofemoral ligament; MPTL, medial patellotibial ligament.
      Table 2Advantages and Disadvantages
      AdvantagesDisadvantages
      Additional stability for patients with risk factors for persistent patellar instabilityTechnically demanding anchor and tunnel placement
      Allograft decreases donor site morbidityComplex anatomy
      Can be performed in patients with connective tissue disorders or others for whom autograft is not availablePotentially longer operation

      Patient Positioning and Anesthesia

      The patient is placed in the supine position on the operating table. After the induction of anesthesia, a bilateral clinical knee examination is performed to assess the degree of pathologic laxity of the patella as well as to evaluate for any concurrent ligamentous. The procedure indications for the patient in the corresponding technique were recurrent patellar instability with knee hyperextension associated with generalized laxity (Beighton score = 7 and Ehlers-Danlos hypermobility type). A tourniquet was applied to the operative thigh and posts were fixed to the bed. One lateral post and 2 foot-posts positioned the knee in 30 and 90° of flexion (Fig 1). After securing the contralateral limb to the table, the operative extremity was prepped and draped in a standard sterile fashion.
      Figure thumbnail gr1
      Fig 1With the patient supine, right lower extremity (A) Leg holders are placed to allow the patient's leg to be placed at 30 (black arrow) and 90 of knee flexion (white arrow). (B) Setup after draping. Both images demonstrate the setup for a right knee procedure.

      Surgical Technique

      Standard anterolateral and anteromedial portals were established. A diagnostic arthroscopy ensued, which demonstrated no concerning concomitant pathology, including ligamentous, meniscal, or cartilaginous pathologies. A primary goal of the diagnostic evaluation is to assess the cartilage status and determine if there is significant cartilage damage that requires cartilage restoration and/or concern for progression that may warrant future surgical intervention. Chondroplasty should also be performed when indicated.

      Graft Preparation

      A tibialis anterior allograft tendon measuring 28 cm in length is thawed and rinsed. The graft is split longitudinally to create 2 distinct grafts: a slightly thicker portion is used to reconstruct the MPFL/MQTFL while a slightly thinner portion is used to reconstruct the MPTL. The MPFL/MQTFL graft is fashioned so that one end fits in a 4.5-mm sizer (in order to pass in a 4.5-mm bone tunnel in the patella), and the folded graft portion should fit a 7- to 8-mm sizer (in order to fit in the femoral tunnel). The MPTL graft should be 6 to 7 mm, but because it will not go through any bone tunnel, its width does not need to be measured. The ends of both grafts are whipstitched and a button is placed in the looped end of the MPFL/MQTFL graft. A mark is placed 15 mm from the button to help with future graft insertion in the femoral tunnel. Both the MPFL/MQTFL and the MPTL grafts are placed in a vancomycin solution and allowed to soak for 10 minutes while attention is turned to the operative extremity.

      Establishing Patellar and Quadriceps Fixation

      A skin incision is made from the inferomedial aspect of the quadriceps tendon to the inferior pole of the medial patella. A careful dissection is performed to the level of the medial retinaculum. The 3 layers of the medial retinaculum are identified and carefully dissected. Layers 1 and 2 are elevated as a unit from the quadriceps tendon insertion to the distal medial patella. A soft tissue tunnel is created between layers 2 and 3, from the medial epicondyle to the patella and distal quadriceps tendon and from the patella to the anteromedial tibia. A No. 15 blade is used to create an anterior to posterior incision in the quadriceps tendon, 1 cm lateral to the medial-most insertion of the quadriceps tendon into the patella (Fig 2). A passing suture is placed to aid in future passage of the MQTFL.
      Figure thumbnail gr2
      Fig 2The medial quadriceps tendon-femoral ligament (MQTFL) soft tissue tunnel is established (right knee, view from the medial side of the knee).
      Next, attention is turned to the MPFL patellar attachment. Two 4.5-mm tunnels are utilized for this portion of the procedure. The first tunnel is drilled between the proximal one-third point and the middle of the medial aspect of the patella. This is drilled to a depth of 1 cm. A second tunnel is drilled from anterior to posterior about 1 cm lateral to the previous tunnel, such that these 2 tunnels would meet (Fig 3). A curved curette is then used to round the sharp angle of the tunnel. A suture passer is then used to pass suture through the tunnel.
      Figure thumbnail gr3
      Fig 3Two perpendicular tunnels are made in the proximal one-third and the middle of the patella for passage of the medial patella-femoral ligament (MPFL). (A) Medial to lateral tunnel. (B) Anterior to posterior tunnel (right knee, view from the medial side of the knee).
      Finally, we establish the patellar fixation for the MPTL reconstruction. Once again, the 3 layers of the medial capsule are identified and dissected. A 1.8-mm Q-FIX all-suture anchor (Smith and Nephew) is placed approximately 5 mm proximal to the distal-most aspect of the medial patella, just medial to the patellar tendon insertion (Fig 4).
      Figure thumbnail gr4
      Fig 4Patellar attachments of the medial patella-femoral ligament (MPFL) and the medial patellotibial ligament (MPTL), as well as the medial attachment of the medial quadriceps tendon-femoral ligament (MQTFL; right knee, view from the medial side of the knee).

      MPTL Reconstruction

      Anatomic and imaging references are used to define the MPTL tibial insertion point. The MPTL insertion is identified on fluoroscopy 10 mm distal to the joint line, just medial to the medial border of the medial tibial spine.
      • Hinckel B.B.
      • Gobbi R.G.
      • Demange M.K.
      • et al.
      Medial patellofemoral ligament, medial patellotibial ligament, and medial patellomeniscal ligament: Anatomic, histologic, radiographic, and biomechanical study.
      This insertion is angled at approximately a 20° to 30° angle in relation to the patellar tendon (Fig 5). At this anatomic insertion, a 2.8-mm all-suture (Smith and Nephew) anchor is placed. The anchor should be aimed slightly distal to avoid violating the subchondral region of the tibial plateau. At this point, the graft is shuttled between layers 2 and 3 from the tibial to the patellar insertion. Fixation is initiated at the tibial anchor site. The knee should be flexed to 90° for re-creation of maximal tension and the patellar insertion is fixed. We add a No. 1 Vicryl suture to the tendon and adjacent soft tissue structures for added fixation. The graft is observed through flexion and extension without getting caught on the soft tissue tunnel.
      Figure thumbnail gr5
      Fig 5The medial patellotibial ligament (MPTL) is passed at a 28° angle relative to the medial aspect of the patellar tendon. This is passed underneath a soft tissue tunnel (right knee, view from the medial side of the knee).

      MPFL/MQTFL Reconstruction

      With the knee in a true lateral position, a fluoroscopic “cloud” is identified using the assistance of fluoroscopy. The femoral tunnel should be slightly anterior to the posterior femoral cortical line and in between 2 perpendicular lines, tangent to the posterior point of the Blumensaat and the origin of the medial femoral condyle (Fig 6). Staying more distal and posterior in this cloud will increase the chances of having anatomic-metric graft behaviors.
      • Matsushita T.
      • Araki D.
      • Hoshino Y.
      • et al.
      Analysis of graft length change patterns in medial patellofemoral ligament reconstruction via a fluoroscopic guidance method.
      ,
      • Kernkamp W.A.
      • Wang C.
      • Li C.
      • et al.
      The medial patellofemoral ligament is a dynamic and anisometric structure: An in vivo study on length changes and isometry.
      The skin is then incised at the identified location. The adductor tendon and adductor tubercle (lighthouse of the medial knee) and the medial epicondyle are identified. A Beath guide pin is placed just proximal and posterior to the medial epicondyle and in the fluoroscopic “cloud.” A suture is placed around the pin and pulled through the tunnel between layers 2 and 3 and through the patellar tunnel. The suture is clamped with a hemostat in the anterior tunnel of the patella with the knee flexed to 30° to 45° to allow engagement of the patella in the trochlea, where it should be centralized. The patella and sutures are then observed through full range of motion to ensure proper tracking and anatomic-metric behavior. The hemostat should get slightly further from the patella, up to 3 to 4 mm, in deep flexion, meaning the ligament will be more laxed in flexion of that same amount. That more closely resembles normal MPFL behavior, which loosens in the first 40° of flexion and is mostly isometric with further flexion.
      • Kernkamp W.A.
      • Wang C.
      • Li C.
      • et al.
      The medial patellofemoral ligament is a dynamic and anisometric structure: An in vivo study on length changes and isometry.
      ,
      • Victor J.
      • Wong P.
      • Witvrouw E.
      • Sloten J.V.
      • Bellemans J.
      How isometric are the medial patellofemoral, superficial medial collateral, and lateral collateral ligaments of the knee?.
      Once the surgeon is satisfied with the patellar tracking and metrics of the temporarily attached sutures, we drill the pin across the knee, allowing it to exit laterally at the level of the distal lateral femur. If the metrics are inadequate, the pin needs to be repositioned, usually to be more distal and posterior.
      • Matsushita T.
      • Araki D.
      • Hoshino Y.
      • et al.
      Analysis of graft length change patterns in medial patellofemoral ligament reconstruction via a fluoroscopic guidance method.
      The 7- to 8-mm tunnel is then reamed to a depth of 20 to 25 mm, followed by a 4.5-mm reamer, until the lateral cortex is breached. The button sutures are shuttled to the lateral aspect of the femur using the Beath needle, and the ULTRABUTTON adjustable fixation device (Smith and Nephew) is pulled into the femoral tunnel and flipped just outside the medial femoral cortex. Fluoroscopy is then used to confirm a satisfactory position for the button on the lateral femoral cortex (Fig 7). The graft is then pulled into the femoral tunnel to the 15-mm mark with the MQTFL positioned proximally and the MPFL distally. The 2 arms of the graft are pulled between layers 2 and 3 to the level of the patella and quadriceps tendon slings. One should make sure the grafts do not get tangled in the soft tissue tunnel. The MPFL is then pulled through the established bone tunnels and the MQTFL is pulled through the soft tissue sling. The knee is flexed to 30° to 45° to allow for proper engagement of the patella in the trochlea. The grafts are folded back on themselves for final fixation. The MQTFL is secured first, followed by the MPFL. A combination of No. 1 Vicryl (more superficial) and No. 0 Fiber-wire (deeper) is utilized to perform 4 sutures in each graft. After the suture is placed, the patella should be observed through a full range of motion to ensure proper tracking, and the patella is stressed medially and laterally to ensure sufficient stability, without constraining of the patellofemoral joint (Fig 8). Adjustments can be made as needed, and the remaining sutures are secured.
      Figure thumbnail gr6
      Fig 6Intraoperative fluoroscopy demonstrating the femoral attachment point. The femoral tunnel should be slightly anterior to the posterior femoral cortical line and in between 2 perpendicular lines, tangent to the posterior point of the Blumensaat and the origin of the medial femoral condyle.
      Figure thumbnail gr7
      Fig 7Fluoroscopy was perfomed to ensure that the button used for the medial patellofemoral ligament (MPFL) flipped and is well seated on the lateral cortex.
      Figure thumbnail gr8
      Fig 8The final construct prior to trimming the residual sutures and graft ends and retinaculum closure. The medial quadriceps tendon-femoral ligament (MQTFL), the medial patellofemoral ligament (MPFL), and the medial patellotibial ligament (MPTL; right knee, view from the medial side of the knee).
      Layers 1 and 2 are sutured back to the soft tissue over the anteromedial patella. The subcutaneous layer and superficial skin are closed as desired.

      Postoperative Rehabilitation

      Assuming no additional concomitant procedures are performed, patients are allowed to weightbear as tolerated in a hinged knee brace locked in extension.
      • Grantham W.J.
      • Aman Z.S.
      • Brady A.W.
      • et al.
      Medial patellotibial ligament reconstruction improves patella tracking when combined with medial patellofemoral reconstruction: An in vitro kinematic study.
      ,
      • Abdelrahman T.
      • Moatshe G.
      • Arendt E.
      • Feller J.
      • Getgood A.
      Combined medial patellofemoral ligament and medial patellotibial ligament reconstruction for recurrent lateral patellar dislocation in flexion.
      There is an early focus on motion, both active and passive range of motion, as tolerated. These should be achieved with continuous passive motion or heel slides, extension exercises, and patellar mobilization. Additionally, patients should perform isometric quadriceps sets and straight-leg raises, which are important not only for quadriceps strength but also for obtaining full extension. Patients who do not progress well with respect to knee extension and quadriceps activation should perform passive extension exercises with an IdealKnee stretcher and the “Lyon” extension deficit protocol.
      • Delaloye J.R.
      • Murar J.
      • Sanchez M.G.
      • et al.
      How to rapidly abolish knee extension deficit after injury or surgery: A practice-changing video pearl from the Scientific anterior Cruciate ligament Network International (SANTI) study Group.
      After 2 weeks, they can begin kinetic closed-chain strengthening. At 4 to 6 weeks, patients are allowed to start progressive strengthening with gradual return to athletic exercises. Patients are typically allowed to proceed with no restrictions to daily activities between 8 and 12 weeks postoperatively. Full return to sports can be achieved between 4 and 6 months, and a return to sports test is recommended.

      Discussion

      This Technical Note describes our preferred surgical technique for performing a combined MPFL, MQTFL, and MPTL reconstruction in patients with lateral patellar instability, providing a robust stabilization without significant disruption to the patella integrity.
      One systematic review suggests that double-bundle MPFL may provide more stability than single-bundle MPFL reconstruction.
      • Migliorini F.
      • Trivellas A.
      • Colarossi G.
      • Eschweiler J.
      • Tingart M.
      • Rath B.
      Single- versus double-bundle patellar graft insertion for isolated MPFL reconstruction in patients with patellofemoral instability: A systematic review of the literature.
      By fixing 1 limb of the proximal reconstruction in the patella and 1 in the quadriceps tendon, a double-bundle proximal reconstruction can be performed without 2 major bone tunnels in the proximal patella. This technique provides a similar biomechanically supportive effect to double-bundle MPFL.
      • Cregar W.M.
      • Huddleston H.P.
      • Shewman E.F.
      • Cole B.J.
      • Yanke A.B.
      Lateral translation of the patella in MPFC reconstruction: A biomechanical study of three approaches.
      In addition, the reduced number of tunnels in the proximal patella allows for safer placement of the MPTL anchor regarding tunnel convergence and weakening of the patellar bony strength.
      The addition of the MPTL reconstruction to one of the previously described MPFL/MQTFL reconstruction techniques offers added stability, specifically in flexion, which may be beneficial for selected patients as mentioned in the indications section. Work from Grantham et al.
      • Grantham W.J.
      • Aman Z.S.
      • Brady A.W.
      • et al.
      Medial patellotibial ligament reconstruction improves patella tracking when combined with medial patellofemoral reconstruction: An in vitro kinematic study.
      report that the MPFL is the primary restraint to lateral translation, but in the MPFL-deficient patient, MPTL deficiency leads to significantly greater instability than MPFL deficiency alone. Moreover, combined MPFL/MPTL reconstruction provides improved patellar stability. A systematic review by Baumann et al.
      • Baumann C.A.
      • Pratte E.L.
      • Sherman S.L.
      • Arendt E.A.
      • Hinckel B.B.
      Reconstruction of the medial patellotibial ligament results in favorable clinical outcomes: A systematic review.
      indicated that good to excellent outcomes were reported in >75% of isolated or combined MPTL reconstructions with <10% of patients having redislocation events.
      In the current technique, the MPTL graft is fixed into the patella by a 1.8-mm suture anchor at its native insertion. This relatively small anchor avoids significant disruption to the patellar bony strength, allows the surgeon to avoid tunnel convergence with the MPFL, avoids violating the patellar tendon attachment, and also minimizes the risk of violating the cartilaginous surface.
      • Shah A.
      • Kay J.
      • Memon M.
      • et al.
      What makes suture anchor use safe in hip arthroscopy? A systematic review of techniques and safety profile.
      Moreover, it is important to note that this small anchor has previously demonstrated excellent pullout strength and reliability in biomechanical studies.
      • Byrd J.W.T.
      Arthroscopic acetabular labral repair using the Q-FIX suture anchor.
      • Barber F.A.
      • Herbert M.A.
      All-suture anchors: Biomechanical analysis of pullout strength, displacement, and failure mode.
      • Nolte P.C.
      • Midtgaard K.S.
      • Ciccotti M.
      • et al.
      Biomechanical comparison of knotless all-suture anchors and knotted all-suture anchors in type II SLAP lesions: A cadaveric study.
      The use of allograft in the current technique provides similar outcomes regarding stability
      • Migliorini F.
      • Trivellas A.
      • Eschweiler J.
      • Knobe M.
      • Tingart M.
      • Maffulli N.
      Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: Systematic review and meta-analysis.
      and has the advantages of decreased donor site morbidity, decreased surgical times, faster recovery, and likely increased strength in patients with connective tissue disorders. Moreover, the use of allograft guarantees the graft length is adequate for this particular surgical technique (>27-28 cm).

      Conclusions

      This Technical Note describes an approach for an MPFL, MPTL, and MQTFL reconstruction for patients with risk factors for persistent patellar instability, including, subluxation in extension, instability in deep flexion, and genu recurvatum, among other factors. A comprehensive diagnostic workup and detailed understanding of the medial knee anatomy and biomechanics are integral to performing this procedure safely and effectively. Further clinical studies are needed to assess the long-term outcomes of MPFL, MPTL, and MQTFL reconstruction.

      Supplementary Data

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