Elvire Servien, MD, PhD, and her team in Lyon, France have studied the femoral fixation of medial patellofemoral ligament reconstruction grafts. They have emphasized the variability and complexity of this challenging, yet important, part of medial patellofemoral ligament (MPFL) restoration.
I present the following techniques which have been useful in the restoration of medial patellofemoral support.
I palpate the medial structures and mark them, including the adductor magnus tendon, adductor tubercle, medial joint line and medial epicondyle, with methylene blue until I can visualize the anatomy percutaneously as accurately as possible. It is tough or impossible on some large knees in which case I make an even larger incision as needed.
Then I make a fairly generous incision, about 3 cm to 6 cm long, extending from the adductor magnus tendon to the medial epicondyle, dissecting until I can put a hemostat under the adductor tendon, and define it clearly so I can see its glistening beauty as it inserts into the adductor tubercle – then pick my femoral site for graft attachment visually depending on whether I am reconstructing the MPFL or medial quadriceps tendon-femoral ligament (MQTFL), which is slightly more proximal, coming off of the adductor tubercle. Radiographic views may be helpful in larger knees when landmarks are less distinct, and should be available for confirmation as needed, but have become less necessary as we have become more comfortable with the anatomy.
John P. Fulkerson
We have done almost 90 MPFL and MQTFL reconstructions to date during the last 6 years to 7 years, and dissected more than 20 cadaver knees to understand this anatomy. We are happy with our graft placements, “setting out to length’" (which is a great term from Jack Farr, MD) on the patella/quadriceps tendon side.
The best steps were making the incision longer, taking more time for the dissection, and clearly defining the adductor magnus tendon and its insertion at the adductor tubercle, which then defines the origins of the MPFL and MQTFL.
Servien E. Am J Sports Med. 2011; doi:10.1177/0363546510381362.
John P. Fulkerson, MD, is a clinical professor of orthopedic surgery at the University of Connecticut School of Medicine and practices at Orthopedic Associates of Hartford in Farmington, Conn. He is also president of The Patellofemoral Foundation.
- Disclosure: Fulkerson receives royalties from DJO Global and is a patent holder for DJO Global.