BLOG: MPFL reconstruction with the adductor magnus tendon can be a useful alternative
Medial patellofemoral ligament reconstruction is done in most cases with a medial hamstring autograft, that is either gracilis or semitendinosus. However, medial patellofemoral ligament reconstruction can also be performed with the adductor magnus tendon. This surgical technique can be attractive particularly in revision cases or in patients with open physes, because it permits a femoral bone tunnel to be avoided.
Evidence-based outcome of MPFL reconstruction with the adductor magnus tendon
Studies of medial patellofemoral ligament (MPFL) reconstruction with adductor magnus tendon are rare. A PubMed search using the search terms “medial and patellofemoral and ligament and reconstruction and adductor” produced 22 hits, but provided only five relevant articles — one “technical note,” two case series, one retrospective comparative study and one cadaver study.
Michael C. Liebensteiner
One case series reported 14 cases with an average follow-up of 6.9 years, and the other case series reported and 39 cases with an average follow-up of 2.6 years. The authors found good clinical success with regard to knee scores (using Lysholm and Kujala scores) and the rate of recurrent dislocations. Fixation of the graft on the patella was done either in the soft tissues or with trans-osseous sutures.
The only available comparative study in the field of adductor magnus tendon MPFL reconstruction, written by Sillanpaa and colleagues and published in 2008, is worth mentioning. The authors compared 18 MPFL reconstructions with adductor magnus tendon to 29 Roux-Goldwait procedures (partial transposition of the insertion of the patella tendon) with regard to the Kujala score, range of motion and re-dislocation after 10 years. No significant differences were identified between the two groups. However, the authors reported a tendency for more degenerative changes in the Roux-Goldwait group.
Special appropriateness for skeletally immature patients
It is the advantage of the MPFL reconstruction with the adductor magnus tendon that the risks of a femoral fixation in the proximity of the distal femoral physis can be avoided. With a medial subvastus approach, the adductor magnus tendon is found running from the adductor tubercle toward proximal. Care must be taken not to harm the superficial femoral artery. Harvesting of the tendon should therefore be performed under full vision in an open manner.
The tendon is left attached at its insertion on the adductor tubercle and shuttled (under the vastus medialis obliquus) toward the superomedial aspect of the patella. For fixation at the patella, one should choose a technique that accounts for the respective size and thickness of the patella. Either suture anchors or an interference screw technique (e.g., 4.5 mm) can be used. Another option for fixation is to weave it through the most distal and medial aspect of the quadriceps tendon and fix it back on itself with sutures (the medial quadriceps tendon-femoral ligament).
It is concluded that MPFL reconstruction with the adductor magnus tendon can be a useful alternative when a femoral bone tunnel is critical (immature patients and some revision cases) and the specific risks of the technique (artery) are respected.
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Sillanpaa PJ, et al. Clin Orthop Relat Res. 2008 Jun;466(6):1475-84. doi: 10.1007/s11999-008-0207-6.
Sillanpaa PJ, et al. Knee Surg Sports Traumatol Arthrosc. 2009;doi:10.1007/s00167-008-0713-9.
Michael C. Liebensteiner, MD, PhD, is from the Medical University Innsbruck in Innsbruck, Austria.
Disclosure: Liebensteiner reports no relevant financial disclosures.