Medial Quadriceps Tendon Femoral Ligament Reconstruction for Anatomic Reconstruction of the Medial Patellofemoral Complex

Abstract

The medial patellofemoral complex (MPFC) refers to the primary static restraint to lateral patellar translation. Originally thought of as the medial patellofemoral ligament, anatomic studies over the past 10 years have identified the additional fibers that attach to the quadriceps tendon, which some have termed the medial quadriceps tendon femoral ligament. Anatomic studies have demonstrated that the MPFC midpoint is at the junction of the medial border of the quadriceps tendon and the articular surface of the patella, indicating that fixation can be on either structure. This technique describes a single-bundle reconstruction technique with anatomic fixation on the quadriceps tendon at the MPFC midpoint that involves fixation on the extensor mechanism first.

Fig 1

Illustration of a right knee demonstrates the medial patellofemoral complex fibers originating from the femur and attaching to the patella and quadriceps tendon. The yellow star indicates the midpoint of the anterior attachment, while the blue star indicates the midpoint of the femoral attachment. (MPFC, medial patellofemoral complex.)

Fig 2

(A) In this illustration of a left knee, the graft is passed through a 1-cm incision at the midpoint of the medial patellofemoral complex (MPFC), exiting through a 1-cm incision at the junction of the medial and central thirds of the distal quadriceps tendon. (B) After the graft is passed through the midpoint of the MPFC and the quadriceps tendon, it is secured to itself using a looped suture, after which 1 limb of the suture is passed through the patellar periosteum at the junction of the medial border of the quadriceps tendon. (C) After passing 1 limb of the suture through the patellar periosteum at the MPFC midpoint, the 2 ends of the looped suture are tied to secure the graft to the superomedial corner of the patella. The proximal aspect of the incision in the quadriceps tendon is closed using interrupted sutures. (VMO, vastus medialis obliquus.)

Fig 3

Intraoperative view of a left knee demonstrates the medial patellofemoral complex graft that has been looped through the quadriceps tendon and secured to itself.

Fig 4

Intraoperative fluoroscopy is critical to determining appropriate femoral tunnel position. A lateral fluoroscopic image demonstrates pin position distal to the posterior condyles, proximal to the Blumensaat line, and slightly posterior to the point described by Schottle to allow for the anterior margin of the subsequently reamed tunnel to approximate the radiographic medial patellofemoral complex midpoint.

Fig 5

In this procedure on a left knee, after the medial patellofemoral complex graft is secured on the extensor mechanism, the graft is passed between layer 2 and layer 3 of the medial knee and retrieved through the femoral incision.

Fig 6

In this procedure on a left knee, for fixation within the femoral tunnel, the graft is (A, B) secured to the fixation device and (C) placed within the tunnel, aligning the marked portion of the graft with the aperture of the tunnel to ensure appropriate graft length.