Medial Quadriceps Tendon Femoral Ligament Reconstruction Technique and Surgical Anatomy

Abstract

Medial patellofemoral ligament reconstruction risks patellar fracture with the osseous violation necessary for patellar attachment. Anatomic studies identify an entire medial patellofemoral complex of structures responsible for medial restraint to patellar lateral instability. One specific component of this complex is the medial quadriceps tendon femoral ligament (MQTFL). This note presents the technique, pearls and pitfalls, and critical surgical anatomy necessary for successful MQTFL reconstruction-a treatment strategy for patellar instability with no increased risk for patellar fracture. An autograft hamstring tendon or allograft tendon is fixed to the anatomically identified femoral origin and passed deep to the vastus medialis obliquus to then weave around the distal medial quadriceps tendon. This simulates the native anatomic interdigitation of the MQTFL with the quadriceps tendon and provides a stable restraint to prevent lateral patellar subluxation or dislocation.

Fig 1

Left knee with proposed medial quadriceps tendon femoral ligament reconstruction skin incisions drawn and surface landmarks demarcated (AT, adductor tubercle; MFE, medial femoral epicondyle; PT, patellar tendon; QT, quadriceps tendon; TT, tibial tubercle; VMO, vastus medialis obliquus.)

Fig 2

Cadaveric dissection of a left knee highlighting anatomic landmarks surrounding the medial quadriceps tendon femoral ligament (MQTFL) origin and insertion. (A) Spinal needle exiting at superior pole of patella. (B) Forceps elevating the VMO border revealing MQTFL's deeper continued trajectory. (C, D) Closer views highlighting MQTFL's decussation with undersurface of VMO and QT. (AMT, adductor magnus tendon; AT, adductor tubercle; MFE, medial femoral epicondyle; MQTFL, medial quadriceps tendon femoral ligament; VMO, vastus medialis obliquus.)

Fig 3

Cadaveric dissection of a left knee showing VMO incision with scalpel positioned in desired trajectory along with a hemostat pointing out the superomedial pole of the patella (A). The hemostat is then passed into the incision and deep to the VMO (B). (QT, quadriceps tendon; VMO, vastus medialis obliquus.)

Fig 4

Cadaveric dissection of a left knee showing quadriceps incision. The scalpel blade is positioned at the location of desired incision, and the hemostat marks the superior pole of the patella. (QT, quadriceps tendon; VMO, vastus medialis obliquus.) Note that the graft has already been passed through the VMO incision in this image.

Fig 5

Cadaveric dissections of a left knee showing passage of the graft. (A) Hemostat placed into the VMO incision and deep to VMO to exit at the most medial border over the anatomic medial quadriceps tendon femoral ligament (highlighted in purple marker) to retrieve the graft after it has been fixed at the femoral insertion point in the saddle region just proximal to the medial femoral epicondyle (red pin head). (B, C) Direct medial view and an oblique view demonstrate the graft passed deep to VMO and exits more anteriorly from the VMO incision. (D) Hemostat placed into the VMO incision and out the quadriceps tendon incision via a partial-thickness connection between the 2 incisions. (E) The graft is placed in the hemostat, and by way of retrieving the hemostat, the graft is delivered into the quadriceps incision and back out the VMO incision. This image shows the ending position with the hemostat still holding the graft after delivery. (QT, quadriceps tendon; VMO, vastus medialis obliquus.)

Fig 6

Cadaveric specimen of a left knee with graft passed in final position and securing stitches holding graft at desired length and tension. (QT, quadriceps tendon; VMO, vastus medialis obliquus.)

Fig 7

Schematic drawing of final medial quadriceps tendon femoral ligament reconstruction construct in a left knee. (AMT, adductor magnus tendon; PT, patellar tendon; QT, quadriceps tendon; VMO, vastus medialis obliquus.) Note that the securing stitches are not drawn.