Combined Reconstruction of the Medial Patellofemoral Ligament With Quadricipital Tendon and the Medial Patellotibial Ligament With Patellar Tendon Betina Bremer Hinckel, M.D., Riccardo Gomes Gobbi, Ph.D., Marco Kawamura Demange, Ph.D., Marcelo Batista Bonadio, M.D., José Ricardo Pécora, Ph.D., and Gilberto Luis Camanho, Ph.D.
Abstract: Although the medial patellotibial ligament (MPTL) has been neglected regarding its function in patellar stability, recently, its importance in terminal extension and during flexion has been recognized. Indications for reconstruction of the medial patellofemoral ligament combined with the MPTL are extension subluxation, flexion instability, children with anatomic risk factors for patellar instability, and knee hyperextension associated with generalized laxity. We describe a combined reconstruction of the medial patellofemoral ligament with quadricipital tendon and reconstruction of the MPTL with patellar tendon autografts.
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ateral patellar dislocation is responsible for 2% to 3% of all knee injuries and is the second leading cause of hemarthrosis.1,2 The medial ligaments responsible for maintaining the stability of the patellofemoral joint are the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), and medial patellomeniscal ligament (MPML). There are several studies on the MPFL and its anatomic and biomechanical characteristics2-6; however, little is known about the MPTL and MPML.2,3,5,6 The first biomechanical studies showed that the MPFL contributes 50% to 60% to medial restriction during initial flexion (between 0 and 30 of flexion).4-6 The contribution of the secondary restrictors varies among those studies, ranging from 0% to 24% for the MPTL From the Institute of Orthopedics and Traumatology, Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil. The authors report the following potential conflict of interest or source of funding: M.K.D. receives support from Arthrex, DePuy Synthes, Fundação de Amparo à Pesquisa do Estado de São Paulo, Mundipharma, and Baxter. Received March 17, 2015; accepted October 15, 2015. Address correspondence to Betina Bremer Hinckel, M.D., Institute of Orthopedics and Traumatology, Clinical Hospital, Medical School, University of São Paulo, Ovídio Pires de Campos St, 333, Cerqueira Cesar, São Paulo, SP 5403-010, Brazil. E-mail: [email protected] Ó 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved. 2212-6287/15256/$36.00 http://dx.doi.org/10.1016/j.eats.2015.10.004
and from 8% to 38% for the MPML.3,5,6 However, in a more recent study, Philippot et al.2 evaluated the medial ligaments in higher degrees of flexion (from 0 to 90 of flexion), showing that the contributions of the MPTL and MPML to lateral translation restriction increase from 26% in extension to 46% at 90 of flexion. In addition, the influences of the MPTL and MPML at 90 of flexion were 72% in patellar tilt and 92% in patellar rotation.2 In the study by Philippot et al., the combined importance of the MPTL and MPML was evaluated rather than the isolated actions of each of these ligaments. In a clinical study, Garth et al.7 observed the presence of clinical and arthroscopic subluxation in patients with isolated MPML lesions with the knee in extension. Thus the MPTL and MPML are important in maintaining normal kinematics of the patellofemoral joint in all ranges of motion, especially at extension and higher degrees of flexion. Usually, surgical treatment involves a combination of reconstruction of the injured MPFL and adjuvant procedures for better alignment and congruence of the patellofemoral joint. Several types of grafts have been described for the reconstruction of the MPFL, and they have shown good results.8-10 In a systematic review of the complications associated with exclusive reconstruction of the MPFL, the observed complication rate was 26.1% of cases. Clinical failure presenting with persistence of
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semitendinosus or gracilis tendons with preservation of their tibial insertions, which does not coincide with the anatomic insertion of the MPTL. Reconstruction of the MPTL with the patellar tendon associated with procedures other than MPFL reconstruction (lateral retinacular lengthening, vastus medialis obliquus advancement, medial retinaculum closure, and tibial tuberosity osteotomy) has also been described with good outcomes.18-20 This study aimed to describe a surgical technique for anatomic reconstruction of the MPFL with quadricipital tendon combined with reconstruction of the MPTL with patellar tendon. Fig 1. Patient with knee hyperextension positioned in operating room. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
objective or subjective instability totaled 12%.11 We hypothesize that recurrence of instability may be caused by progressive loosening due to increased stress on the reconstructed MPFL. The reconstruction of one of the secondary restrictor ligaments (the MPTL or the MPML) could decrease the stress on the MPFL and thus could improve functional outcomes. The MPTL can decrease the Q angle, improving patellar excursion without causing many changes in the kinematics of the tibiofemoral joint relative to medialization osteotomy of the tibial tuberosity.12 In children, when it is not possible to perform osteotomies for correction of risk factors, the reconstruction of these secondary ligaments becomes even more important. Some reports in the literature have described case series of combined MPFL and MPTL reconstructions, mostly in children, with good results.13-17 These reconstructions use the
Surgical Technique Indications The indications for MPFL reconstruction combined with MPTL reconstruction are extension subluxation (proximal and lateral patellar translation with quadriceps contraction in full extension), flexion instability (habitual dislocation in flexion or lateral glide in flexion), children with other anatomic risk factors, and knee hyperextension associated with generalized laxity (Fig 1). Additional procedures (trochleoplasty, osteotomy of the tibial tuberosity, and lateral retinacular lengthening) are performed concomitantly following the classical indications according to the predisposing factors. The reconstruction of the MPFL is performed with the quadricipital tendon in association with the reconstruction of the MPTL with patellar tendon, according to the step-by-step described in this report. Positioning The patient is placed in the supine position on the operating table with spinal or general anesthesia (Video 1).
Fig 2. (A) Separation of superficial layer from quadriceps (quad) tendon. (B) Harvested quadriceps tendon (minimally invasive technique). (MPFL, medial patellofemoral ligament.) Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
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from the remaining portion of the tendon. The patellar tendon graft is slightly proximally and superiorly detached, keeping it in the distal third of the patella. Figure 4 shows both grafts harvested with an opentechnique incision. Ligament Reconstruction
Fig 3. Graft harvest from medial portion of patellar tendon using minimally invasive technique. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
An examination under anesthesia is performed, assessing range of motion and testing instability as exemplified in a right knee in Video 1. A tourniquet is used. Arthroscopy is not routinely performed, unless a previously detected intra-articular condition demanding surgical treatment is present. Skin Incisions Two small anterior incisions (2 to 3 cm each) are made to harvest the quadricipital and patellar grafts (minimally invasive technique), and an incision (approximately 1 to 2 cm) is made on the medial epicondyle for the insertion of the MPFL into the femur. An anterior 8-cm incision can be performed when additional procedures are required (open technique).
MPFL Insertion. The free proximal edge is passed under the medial retinaculum and incised medially to the patella near the harvested graft (Figs 5 and 6). A tunnel between layers 2 and 3 is created through blunt dissection, reaching the area around the medial epicondyle. This tunnel should be wide enough to allow free graft excursion through knee range of motion. The femoral insertion is located with radioscopic assistance21 between the medial epicondyle and the adductor tubercle, where a 5-mm anchor (Fastin RC [DePuy Mitek, Raynham, MA], loaded with two Orthocord sutures; Johnson & Johnson, New Brunswick, NJ) is inserted. In patients with open physes, a 3.5-mm anchor is used and inserted at the same point, distal to the femoral physeal growth plate. MPTL Insertion. A 5-mm titanium anchor (Fastin RC, loaded with two Orthocord sutures) is inserted with radioscopic assistance in the tibia, 2 cm below the joint
Quadriceps Graft Harvest A 2- to 3-cm skin incision is made proximally to the patella (Fig 2). With a surgical scalpel, an 8-mm-wide strip of the medial portion of the quadricipital tendon containing the superficial portion of the quadriceps (related to the rectus femoris) is incised, with maintenance of its patellar insertion. The distal edge of the graft is carefully partially detached from the patella up to the transition of the upper and middle thirds of the patella height. The free proximal end is rotated 90 , and two long-lasting absorbable sutures (PDS II, No. 0 or 1; Ethicon, Somerville, NJ) are placed in the periosteum and adjacent tendon for positioning it and reinforcing the insertion. Patellar Tendon Graft Harvest An anterior incision just medial to the patellar tendon is made with the knee flexed, initiated just below the lower pole of the patella to the tibial tuberosity (Fig 3). Dissection is performed until the peritendon is reached; the peritendon must be incised vertically in its medial third. With a surgical scalpel, a 6-mm strip of the medial third of the patellar tendon is separated and detached
Fig 4. Grafts harvested from quadricipital tendon and patellar tendon using open technique. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
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Fig 5. Insertion and reconstruction of medial patellofemoral ligament with quadricipital tendon and of medial patellotibial ligament with patellar tendon: (A) anteroposterior view and (B) lateral view. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
line and 2 cm medial to the patellar tendon, forming a 20 angle with the patellar tendon (Figs 5 and 6).3,5 In children, a 3.5-mm anchor is used, with preservation
Fig 6. Final aspect of reconstruction of medial patellofemoral ligament with quadricipital tendon and of medial patellotibial ligament with patellar tendon using open technique. (MPFL, medial patellofemoral ligament; MPTL, medial patellotibial ligament.) Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
of a 20 angle with the patellar tendon, positioned just above the physeal growth plate, on the proximal epiphysis of the tibia, so tension can be maintained during growth. Because the tibial insertion site usually coincides with the physeal scar in adults, graft fixation in this position satisfactorily reconstructs the anatomy of the MPTL. Tensioning and Fixation of Grafts. First, the patellar tendon graft is fixed (Fig 6). The knee is placed at 90 of flexion in the position of highest tension and contribution to lateral restraint.2 In this position, the patella is reduced in the intercondyle, and the MPTL is tensioned so that the graft has similar tension to the patellar tendon. Excessive tension is avoided because it causes increased pressure on the patellofemoral compartment. The graft is then sutured to the previously secured anchor. The knee is then placed at 30 to 45 of flexion, with the patella in the trochlea. The quadricipital graft is tensioned only to maintain patella position and prevent excessive lateral translation. The patella should have a medial-lateral excursion of one to two quadrants. With adequate tension and positioning, the reconstructed MPFL should be looser in flexion than in extension. Finally, two or three sutures (PDS II) are placed between the quadricipital graft of the MPFL and the vastus medialis for a dynamic active component. Table 1 shows tips and pitfalls for this technique. Closure The tourniquet is released and hemostasis performed. The subcutaneous tissue is then closed in layers, and the
MEDIAL PATELLOTIBIAL LIGAMENT RECONSTRUCTION Table 1. Tips and Pitfalls to Consider During MPFL and MPTL Reconstruction Tips MPTL reconstruction should be considered in the following patients: Knee hyperextension associated with generalized laxity Patients with flexion instability (habitual dislocation in flexion and lateral glide in flexion) Patients with extension subluxation (proximal and lateral patellar translation with quadriceps contraction in full extension) Children with other anatomic risk factors and knee hyperextension associated with generalized laxity The quadriceps graft harvest should be started proximally where the superficial layer is easily separated from the deep layer. PDS II suture (Ethicon) provides longer suture stability than Vicryl (Ethicon). If the physeal growth plate is still present, the anchors should be inserted distally in the femur and proximally in the tibia. Tensioning of the MPTL graft is performed first with 90 of flexion, aiming to reproduce the same resistance, by touch, as the remaining patellar tendon. Pitfalls The surgeon must avoid over-tightening, which can result in medial subluxation, patella baja, or over-constraining of the patellofemoral joint. MPFL, medial patellofemoral ligament; MPTL, medial patellotibial ligament.
skin is closed with a running subcuticular No. 4-0 Monocryl stitch (Ethicon). Steri-Strips (3M, St. Paul, MN) are loosely applied, followed by application of a sterile dressing and a knee immobilizer in full extension (Fig 7).
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tibial insertion of the flexor tendons is 41 6.6 mm from the tibial plateau and 6.88 1 mm medial to the patellar tendon, whereas the MPTL is 15 to 20 mm distal from the tibial plateau and 15 to 20 mm medial to the patellar tendon in adults.22 With the distal edge free, graft placement can be performed in the anatomic position. The independent distal edges of the quadricipital and patellar grafts allow the tensioning of the reconstructions of the MPFL and MPTL at different flexion angles, but maintaining the insertion of the flexor tendons results in technical difficulties. Hence, only one of the previous reports describes tensioning of the MPFL and MPTL at different flexion angles.23 Furthermore, fixing the MPTL on the proximal epiphysis of the tibia rather than on the proximal tibial metaphysis reduces the risk of distal migration of the insertion of the graft with growth, which could change its tensioning and function. The principle of the insertion in the epiphysis is analogous to that used in the reconstruction of the MPFL. Reconstruction of the MPFL along with the MPTL with flexor tendon grafts has shown good results in five case series totaling 74 patients.13-17 The only difference in our proposed procedure involves the grafts used. The use of the quadricipital and patellar grafts for the reconstruction of the MPFL is already well-known and widespread, and the use of the patellar tendon for
Postoperative Rehabilitation The patient is admitted to the hospital overnight for pain control. Touch-down weight bearing is allowed for the first 6 weeks in a knee immobilizer. Patients can remove the knee immobilizer for range-of-motion exercises, with active flexion and passive extension of 0 to 90 initiated on postoperative day 1. Physical therapy is very important for quadriceps activation, edema control, and range of motion. After 6 weeks, use of the immobilizer can be discontinued and patients can be weaned off crutches once able to ambulate without a limp.
Discussion The advantages of the described technique are as follows: anatomic reconstruction of the MPFL and MPTL; maintenance of the patellar insertion of the quadricipital and patellar tendons, avoiding the need for hardware or perforation of the patella, which can lead to fracture of the patella11; and the possibility of graft tensioning at different degrees of flexion, thus preserving the function of each ligament. With the use of previous reconstructions, the distal insertion of the flexor tendons is maintained, which does not coincide with the insertion of either the MPTL or the MPML. The
Fig 7. Sutured minimally invasive incisions. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
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isolated reconstruction of the MPTL has also been described.8,9,16,18-20 The risks involved are similar to those described for any MPFL reconstruction: overtightening of the graft leading to pain, restricted range of motion, medial subluxation, and patella baja. Surgeons should be careful when suturing the grafts to avoid these complications. This technique is contraindicated in patients who have undergone a previous surgical intervention involving the quadricipital and patellar tendons, including autografts for anterior cruciate ligament reconstruction, as well as quadricipital or patellar tendon repair. Previous manipulation of the patellar or quadricipital tendon and tibial tubercle osteotomy should be considered relative contraindications because the condition of the quadricipital and patellar tendons can be suboptimal. We believe that our proposed procedure of combined reconstruction of the MPFL with quadricipital tendon and reconstruction of the MPTL with patellar tendon is technically safe because it involves procedures and concepts that are commonplace for the knee surgeon.
References 1. Arendt EA, Fithian DC, Cohen E. Current concepts of lateral patella dislocation. Clin Sports Med 2002;21:499-519. 2. Philippot R, Boyer B, Testa R, Farizon F, Moyen B. The role of the medial ligamentous structures on patellar tracking during knee flexion. Knee Surg Sports Traumatol Arthrosc 2012;20:331-336. 3. 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. Knee Surg Sports Traumatol Arthrosc 2006;14:7-12. 4. Nomura E, Horiuchi Y, Kihara M. Medial patellofemoral ligament restraint in lateral patellar translation and reconstruction. Knee 2000;7:121-127. 5. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59-65. 6. Conlan T, Garth WP Jr, Lemons JE. Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 1993;75:682-693. 7. Garth WP Jr, Connor GS, Futch L, Belarmino H. Patellar subluxation at terminal knee extension: Isolated deficiency of the medial patellomeniscal ligament. J Bone Joint Surg Am 2011;93:954-962. 8. Dopirak R, Adamany D, Bickel B, Steensen R. Reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft: A case series. Orthopedics 2008;31:217. 9. Camanho GL, Bitar AC, Hernandez AJ, Olivi R. Medial patellofemoral ligament reconstruction: A novel technique using the patellar ligament. Arthroscopy 2007;23: 108.e1-108.e4.
10. Farr J, Schepsis AA. Reconstruction of the medial patellofemoral ligament for recurrent patellar instability. J Knee Surg 2006;19:307-316. 11. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2012;40:1916-1923. 12. Mani S, Kirkpatrick MS, Saranathan A, Smith LG, Cosgarea AJ, Elias JJ. Tibial tuberosity osteotomy for patellofemoral realignment alters tibiofemoral kinematics. Am J Sports Med 2011;39:1024-1031. 13. Giordano M, Falciglia F, Aulisa AG, Guzzanti V. Patellar dislocation in skeletally immature patients: Semitendinosous and gracilis augmentation for combined medial patellofemoral and medial patellotibial ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2012;20: 1594-1598. 14. Ebied AM, El-Kholy W. Reconstruction of the medial patello-femoral and patello-tibial ligaments for treatment of patellar instability. Knee Surg Sports Traumatol Arthrosc 2012;20:926-932. 15. Brown GD, Ahmad CS. Combined medial patellofemoral ligament and medial patellotibial ligament reconstruction in skeletally immature patients. J Knee Surg 2008;21:328-332. 16. Sobhy MH, Mahran MA, Kamel EM. Midterm results of combined patellofemoral and patellotibial ligaments reconstruction in recurrent patellar dislocation. Eur J Orthop Surg Traumatol 2013;23:465-470. 17. Drez D Jr, Edwards TB, Williams CS. Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation. Arthroscopy 2001;17:298-306. 18. Zaffagnini S, Grassi A, Marcheggiani Muccioli GM, et al. Medial patellotibial ligament (MPTL) reconstruction for patellar instability. Knee Surg Sports Traumatol Arthrosc 2014;22:2491-2498. 19. Oliva F, Ronga M, Longo UG, Testa V, Capasso G, Maffulli N. The 3-in-1 procedure for recurrent dislocation of the patella in skeletally immature children and adolescents. Am J Sports Med 2009;37:1814-1820. 20. Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Results, and its place in the management of patellofemoral instability. Am J Sports Med 1999;27: 575-579. 21. Schottle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 2007;35:801-804. 22. Grassi CA, Fruheling VM, Abdo JC, et al. Estudo anatômico da inserção dos tendões flexores do joelho. Rev Bras Ortop 2013;48:417-420. 23. Sobhy MH, Mahran MA, Kamel EM. Midterm results of combined patellofemoral and patellotibial ligaments reconstruction in recurrent patellar dislocation. Eur J Orthop Surg Traumatol 2013;23:465-470.
Abstract: Although the medial patellotibial ligament (MPTL) has been neglected regarding its function in patellar stability, recently, its importance in terminal extension and during flexion has been recognized. Indications for reconstruction of the medial patellofemoral ligament combined with the MPTL are extension subluxation, flexion instability, children with anatomic risk factors for patellar instability, and knee hyperextension associated with generalized laxity. We describe a combined reconstruction of the medial patellofemoral ligament with quadricipital tendon and reconstruction of the MPTL with patellar tendon autografts.
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ateral patellar dislocation is responsible for 2% to 3% of all knee injuries and is the second leading cause of hemarthrosis.1,2 The medial ligaments responsible for maintaining the stability of the patellofemoral joint are the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), and medial patellomeniscal ligament (MPML). There are several studies on the MPFL and its anatomic and biomechanical characteristics2-6; however, little is known about the MPTL and MPML.2,3,5,6 The first biomechanical studies showed that the MPFL contributes 50% to 60% to medial restriction during initial flexion (between 0 and 30 of flexion).4-6 The contribution of the secondary restrictors varies among those studies, ranging from 0% to 24% for the MPTL From the Institute of Orthopedics and Traumatology, Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil. The authors report the following potential conflict of interest or source of funding: M.K.D. receives support from Arthrex, DePuy Synthes, Fundação de Amparo à Pesquisa do Estado de São Paulo, Mundipharma, and Baxter. Received March 17, 2015; accepted October 15, 2015. Address correspondence to Betina Bremer Hinckel, M.D., Institute of Orthopedics and Traumatology, Clinical Hospital, Medical School, University of São Paulo, Ovídio Pires de Campos St, 333, Cerqueira Cesar, São Paulo, SP 5403-010, Brazil. E-mail: [email protected] Ó 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved. 2212-6287/15256/$36.00 http://dx.doi.org/10.1016/j.eats.2015.10.004
and from 8% to 38% for the MPML.3,5,6 However, in a more recent study, Philippot et al.2 evaluated the medial ligaments in higher degrees of flexion (from 0 to 90 of flexion), showing that the contributions of the MPTL and MPML to lateral translation restriction increase from 26% in extension to 46% at 90 of flexion. In addition, the influences of the MPTL and MPML at 90 of flexion were 72% in patellar tilt and 92% in patellar rotation.2 In the study by Philippot et al., the combined importance of the MPTL and MPML was evaluated rather than the isolated actions of each of these ligaments. In a clinical study, Garth et al.7 observed the presence of clinical and arthroscopic subluxation in patients with isolated MPML lesions with the knee in extension. Thus the MPTL and MPML are important in maintaining normal kinematics of the patellofemoral joint in all ranges of motion, especially at extension and higher degrees of flexion. Usually, surgical treatment involves a combination of reconstruction of the injured MPFL and adjuvant procedures for better alignment and congruence of the patellofemoral joint. Several types of grafts have been described for the reconstruction of the MPFL, and they have shown good results.8-10 In a systematic review of the complications associated with exclusive reconstruction of the MPFL, the observed complication rate was 26.1% of cases. Clinical failure presenting with persistence of
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semitendinosus or gracilis tendons with preservation of their tibial insertions, which does not coincide with the anatomic insertion of the MPTL. Reconstruction of the MPTL with the patellar tendon associated with procedures other than MPFL reconstruction (lateral retinacular lengthening, vastus medialis obliquus advancement, medial retinaculum closure, and tibial tuberosity osteotomy) has also been described with good outcomes.18-20 This study aimed to describe a surgical technique for anatomic reconstruction of the MPFL with quadricipital tendon combined with reconstruction of the MPTL with patellar tendon. Fig 1. Patient with knee hyperextension positioned in operating room. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
objective or subjective instability totaled 12%.11 We hypothesize that recurrence of instability may be caused by progressive loosening due to increased stress on the reconstructed MPFL. The reconstruction of one of the secondary restrictor ligaments (the MPTL or the MPML) could decrease the stress on the MPFL and thus could improve functional outcomes. The MPTL can decrease the Q angle, improving patellar excursion without causing many changes in the kinematics of the tibiofemoral joint relative to medialization osteotomy of the tibial tuberosity.12 In children, when it is not possible to perform osteotomies for correction of risk factors, the reconstruction of these secondary ligaments becomes even more important. Some reports in the literature have described case series of combined MPFL and MPTL reconstructions, mostly in children, with good results.13-17 These reconstructions use the
Surgical Technique Indications The indications for MPFL reconstruction combined with MPTL reconstruction are extension subluxation (proximal and lateral patellar translation with quadriceps contraction in full extension), flexion instability (habitual dislocation in flexion or lateral glide in flexion), children with other anatomic risk factors, and knee hyperextension associated with generalized laxity (Fig 1). Additional procedures (trochleoplasty, osteotomy of the tibial tuberosity, and lateral retinacular lengthening) are performed concomitantly following the classical indications according to the predisposing factors. The reconstruction of the MPFL is performed with the quadricipital tendon in association with the reconstruction of the MPTL with patellar tendon, according to the step-by-step described in this report. Positioning The patient is placed in the supine position on the operating table with spinal or general anesthesia (Video 1).
Fig 2. (A) Separation of superficial layer from quadriceps (quad) tendon. (B) Harvested quadriceps tendon (minimally invasive technique). (MPFL, medial patellofemoral ligament.) Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
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from the remaining portion of the tendon. The patellar tendon graft is slightly proximally and superiorly detached, keeping it in the distal third of the patella. Figure 4 shows both grafts harvested with an opentechnique incision. Ligament Reconstruction
Fig 3. Graft harvest from medial portion of patellar tendon using minimally invasive technique. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
An examination under anesthesia is performed, assessing range of motion and testing instability as exemplified in a right knee in Video 1. A tourniquet is used. Arthroscopy is not routinely performed, unless a previously detected intra-articular condition demanding surgical treatment is present. Skin Incisions Two small anterior incisions (2 to 3 cm each) are made to harvest the quadricipital and patellar grafts (minimally invasive technique), and an incision (approximately 1 to 2 cm) is made on the medial epicondyle for the insertion of the MPFL into the femur. An anterior 8-cm incision can be performed when additional procedures are required (open technique).
MPFL Insertion. The free proximal edge is passed under the medial retinaculum and incised medially to the patella near the harvested graft (Figs 5 and 6). A tunnel between layers 2 and 3 is created through blunt dissection, reaching the area around the medial epicondyle. This tunnel should be wide enough to allow free graft excursion through knee range of motion. The femoral insertion is located with radioscopic assistance21 between the medial epicondyle and the adductor tubercle, where a 5-mm anchor (Fastin RC [DePuy Mitek, Raynham, MA], loaded with two Orthocord sutures; Johnson & Johnson, New Brunswick, NJ) is inserted. In patients with open physes, a 3.5-mm anchor is used and inserted at the same point, distal to the femoral physeal growth plate. MPTL Insertion. A 5-mm titanium anchor (Fastin RC, loaded with two Orthocord sutures) is inserted with radioscopic assistance in the tibia, 2 cm below the joint
Quadriceps Graft Harvest A 2- to 3-cm skin incision is made proximally to the patella (Fig 2). With a surgical scalpel, an 8-mm-wide strip of the medial portion of the quadricipital tendon containing the superficial portion of the quadriceps (related to the rectus femoris) is incised, with maintenance of its patellar insertion. The distal edge of the graft is carefully partially detached from the patella up to the transition of the upper and middle thirds of the patella height. The free proximal end is rotated 90 , and two long-lasting absorbable sutures (PDS II, No. 0 or 1; Ethicon, Somerville, NJ) are placed in the periosteum and adjacent tendon for positioning it and reinforcing the insertion. Patellar Tendon Graft Harvest An anterior incision just medial to the patellar tendon is made with the knee flexed, initiated just below the lower pole of the patella to the tibial tuberosity (Fig 3). Dissection is performed until the peritendon is reached; the peritendon must be incised vertically in its medial third. With a surgical scalpel, a 6-mm strip of the medial third of the patellar tendon is separated and detached
Fig 4. Grafts harvested from quadricipital tendon and patellar tendon using open technique. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
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Fig 5. Insertion and reconstruction of medial patellofemoral ligament with quadricipital tendon and of medial patellotibial ligament with patellar tendon: (A) anteroposterior view and (B) lateral view. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
line and 2 cm medial to the patellar tendon, forming a 20 angle with the patellar tendon (Figs 5 and 6).3,5 In children, a 3.5-mm anchor is used, with preservation
Fig 6. Final aspect of reconstruction of medial patellofemoral ligament with quadricipital tendon and of medial patellotibial ligament with patellar tendon using open technique. (MPFL, medial patellofemoral ligament; MPTL, medial patellotibial ligament.) Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
of a 20 angle with the patellar tendon, positioned just above the physeal growth plate, on the proximal epiphysis of the tibia, so tension can be maintained during growth. Because the tibial insertion site usually coincides with the physeal scar in adults, graft fixation in this position satisfactorily reconstructs the anatomy of the MPTL. Tensioning and Fixation of Grafts. First, the patellar tendon graft is fixed (Fig 6). The knee is placed at 90 of flexion in the position of highest tension and contribution to lateral restraint.2 In this position, the patella is reduced in the intercondyle, and the MPTL is tensioned so that the graft has similar tension to the patellar tendon. Excessive tension is avoided because it causes increased pressure on the patellofemoral compartment. The graft is then sutured to the previously secured anchor. The knee is then placed at 30 to 45 of flexion, with the patella in the trochlea. The quadricipital graft is tensioned only to maintain patella position and prevent excessive lateral translation. The patella should have a medial-lateral excursion of one to two quadrants. With adequate tension and positioning, the reconstructed MPFL should be looser in flexion than in extension. Finally, two or three sutures (PDS II) are placed between the quadricipital graft of the MPFL and the vastus medialis for a dynamic active component. Table 1 shows tips and pitfalls for this technique. Closure The tourniquet is released and hemostasis performed. The subcutaneous tissue is then closed in layers, and the
MEDIAL PATELLOTIBIAL LIGAMENT RECONSTRUCTION Table 1. Tips and Pitfalls to Consider During MPFL and MPTL Reconstruction Tips MPTL reconstruction should be considered in the following patients: Knee hyperextension associated with generalized laxity Patients with flexion instability (habitual dislocation in flexion and lateral glide in flexion) Patients with extension subluxation (proximal and lateral patellar translation with quadriceps contraction in full extension) Children with other anatomic risk factors and knee hyperextension associated with generalized laxity The quadriceps graft harvest should be started proximally where the superficial layer is easily separated from the deep layer. PDS II suture (Ethicon) provides longer suture stability than Vicryl (Ethicon). If the physeal growth plate is still present, the anchors should be inserted distally in the femur and proximally in the tibia. Tensioning of the MPTL graft is performed first with 90 of flexion, aiming to reproduce the same resistance, by touch, as the remaining patellar tendon. Pitfalls The surgeon must avoid over-tightening, which can result in medial subluxation, patella baja, or over-constraining of the patellofemoral joint. MPFL, medial patellofemoral ligament; MPTL, medial patellotibial ligament.
skin is closed with a running subcuticular No. 4-0 Monocryl stitch (Ethicon). Steri-Strips (3M, St. Paul, MN) are loosely applied, followed by application of a sterile dressing and a knee immobilizer in full extension (Fig 7).
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tibial insertion of the flexor tendons is 41 6.6 mm from the tibial plateau and 6.88 1 mm medial to the patellar tendon, whereas the MPTL is 15 to 20 mm distal from the tibial plateau and 15 to 20 mm medial to the patellar tendon in adults.22 With the distal edge free, graft placement can be performed in the anatomic position. The independent distal edges of the quadricipital and patellar grafts allow the tensioning of the reconstructions of the MPFL and MPTL at different flexion angles, but maintaining the insertion of the flexor tendons results in technical difficulties. Hence, only one of the previous reports describes tensioning of the MPFL and MPTL at different flexion angles.23 Furthermore, fixing the MPTL on the proximal epiphysis of the tibia rather than on the proximal tibial metaphysis reduces the risk of distal migration of the insertion of the graft with growth, which could change its tensioning and function. The principle of the insertion in the epiphysis is analogous to that used in the reconstruction of the MPFL. Reconstruction of the MPFL along with the MPTL with flexor tendon grafts has shown good results in five case series totaling 74 patients.13-17 The only difference in our proposed procedure involves the grafts used. The use of the quadricipital and patellar grafts for the reconstruction of the MPFL is already well-known and widespread, and the use of the patellar tendon for
Postoperative Rehabilitation The patient is admitted to the hospital overnight for pain control. Touch-down weight bearing is allowed for the first 6 weeks in a knee immobilizer. Patients can remove the knee immobilizer for range-of-motion exercises, with active flexion and passive extension of 0 to 90 initiated on postoperative day 1. Physical therapy is very important for quadriceps activation, edema control, and range of motion. After 6 weeks, use of the immobilizer can be discontinued and patients can be weaned off crutches once able to ambulate without a limp.
Discussion The advantages of the described technique are as follows: anatomic reconstruction of the MPFL and MPTL; maintenance of the patellar insertion of the quadricipital and patellar tendons, avoiding the need for hardware or perforation of the patella, which can lead to fracture of the patella11; and the possibility of graft tensioning at different degrees of flexion, thus preserving the function of each ligament. With the use of previous reconstructions, the distal insertion of the flexor tendons is maintained, which does not coincide with the insertion of either the MPTL or the MPML. The
Fig 7. Sutured minimally invasive incisions. Ó 2016 Betina Bremer Hinckel. All Rights Reserved.
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isolated reconstruction of the MPTL has also been described.8,9,16,18-20 The risks involved are similar to those described for any MPFL reconstruction: overtightening of the graft leading to pain, restricted range of motion, medial subluxation, and patella baja. Surgeons should be careful when suturing the grafts to avoid these complications. This technique is contraindicated in patients who have undergone a previous surgical intervention involving the quadricipital and patellar tendons, including autografts for anterior cruciate ligament reconstruction, as well as quadricipital or patellar tendon repair. Previous manipulation of the patellar or quadricipital tendon and tibial tubercle osteotomy should be considered relative contraindications because the condition of the quadricipital and patellar tendons can be suboptimal. We believe that our proposed procedure of combined reconstruction of the MPFL with quadricipital tendon and reconstruction of the MPTL with patellar tendon is technically safe because it involves procedures and concepts that are commonplace for the knee surgeon.
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