Quadriceps Tendon Autograft Medial Patellofemoral Ligament Reconstruction

Abstract

Purpose: Critically evaluate the published literature related to quadriceps tendon (QT) medial patellofemoral ligament (MPFL) reconstruction.

Recent findings: Hamstring tendon (HT) MPFL reconstruction techniques have been shown to successfully restore patella stability, but complications including patella fracture are reported. Quadriceps tendon (QT) reconstruction techniques with an intact graft pedicle on the patella side have the advantage that patella bone tunnel drilling and fixation are no longer needed, reducing risk of patella fracture. Several QT MPFL reconstruction techniques, including minimally invasive surgical (MIS) approaches, have been published with promising clinical results and fewer complications than with HT techniques. Parallel laboratory studies have shown macroscopic anatomy and biomechanical properties of QT are more similar to native MPFL than hamstring (HS) HT, suggesting QT may more accurately restore native joint kinematics. Quadriceps tendon MPFL reconstruction, via both open and MIS techniques, have promising clinical results and offer valuable alternatives to HS grafts for primary and revision MPFL reconstruction in both children and adults.

Keywords: MPFL; Medial patellofemoral ligament; Patella dislocation; Patella instability; Quadriceps tendon.

Fig. 1

Schematic representation of quadriceps tendon anatomy showing the three anatomical layers and the relative size of graft harvested in relation to the total tendon volume

Fig. 2

Harvesting the superficial layer of the quadriceps femoris tendon composed of rectus femoris and continuing sub-periosteal dissection over the anterior aspect of patella more distal laterally than medially to create a diagonal hinge point

Fig. 3

Distance of anterior sub-periosteal dissection determines the location of the hinge point and thus the point of femoral attachment of the reflected graft in a proximal to distal axis

Fig. 4

Stay sutures to stabilise the patella anatomic attachment as described by various authors (see text for details)

Fig. 5

Minimally invasive quadriceps tendon graft harvesting via a 3-cm transverse incision at the superior margin of the patella. A double-bladed knife (a) and a tendon separator (b) (KARL STORZ, Germany) are sequentially inserted to determine the graft width and depth, typically 12 mm width and 3 mm depth

Fig. 6

The tendon strip is cut at a desired length (8–10 cm) using a tendon cutter (Karl STORZ, Tuttlingen, Germany)

Fig. 7

Combined QT MPFL and PT MPTL reconstruction. The partial thickness QT MPFL graft is reflected into position as per Steenson et al. The full-thickness patella tendon MPTL graft is rotated into position

Fig. 8

The MIS technique results in smaller surgical scars, than open techniques for QT harvest. The incision follows Langer’s lines, improving the cosmetic results

Fig. 9

AP and axial schematic diagrams of QT graft medial rerouting. If the graft is taken centrally in the tendon, then there is sufficient medial pre-patellar tissue that it is possible to pass the graft under both the anterior pre-patellar tissue and periosteum as described by Fink et al., adding to stability and positioning the neo-attachment of the MPFL in a deeper, more anatomical plane. When the graft is taken more medially, there is insufficient pre-patellar tissue medial to the graft to anchor the graft in this way. This may result in a more superficial positioning of the neo-ligament attachment, which risks altering the patella axis and causing patella tilt