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Patients with bidirectional patellar instability who are unresponsive to conservative management may benefit from a medial patellofemoral ligament (MPFL) reconstruction and lateral patellofemoral ligament (LPFL) reconstruction. If an isolated MPFL reconstruction does not provide adequate stabilization intraoperatively, combined MPFL and LPFL reconstruction allows independent reconstruction, which can be performed with a facile, reproducible technique. The purpose of this report was to describe our technique for performing an MPFL reconstruction with a concurrent soft-tissue LPFL reconstruction combined with a distalizing tibial tubercle osteotomy to correct patella alta., Technique Video Video 1 This video is a narrated step-by-step approach to performing a concomitant MPFL and LPFL reconstruction. The MPFL reconstruction is performed first via an osseous based approach with graft fixation with 2 PEEK SutureTak anchors along the medial aspect of the patella and an interference screw in the femur. After this, a soft tissue–based LPFL is performed by making incisions in the iliotibial band, quadriceps tendon, and patellar tendon, looping the graft through these and suturing it down. (LPFL, lateral patellofemoral ligament; MPFL, medial patellofemoral ligament.)

Recurrent patellar dislocations have been correlated with an elevated risk of further patellar dislocations, often requiring surgical treatment. Risk factors include medial patellofemoral ligament (MPFL) tears, patella alta, trochlear dysplasia, and an increased tibial tubercle–trochlear groove distance. Surgical management must be based on a patient’s unique joint pathoanatomy and may require MPFL reconstruction with tibial tubercle osteotomy or trochleoplasty either alone or in combination. This article discusses our preferred technique for surgical treatment of recurrent patellar instability with MPFL reconstruction using a quadriceps tendon autograft, an open trochleoplasty, and a tibial tubercle osteotomy for patients with patella alta, trochlear dysplasia, and an increased tibial tubercle–trochlear groove distance., Technique Video Video 1 The patient is examined under anesthesia and found to have a positive J-sign, dislocating laterally and remaining so until 60° of flexion, consistent with severe trochlear dysplasia. An anterior arthrotomy is made, and partial-thickness quadriceps tendon graft is harvested. Q-Fix anchors are placed at the adductor tubercle. A tibial tubercle osteotomy is performed with a drill, osteotomes, and a small anterior cruciate ligament saw, and the tibia, 12 mm distally, is prepared for reattachment. A medial parapatellar arthrotomy is next incised, and the trochlear groove is outlined. The periosteum is elevated with a scalpel, and a burr and osteotomes are used to create the new trochlear shape, with an arthroscope passed beneath the osteochondral flap to help clear the undersurface. Four guide pins are placed and screws are used to keep the cartilage flap reduced. The tibial tubercle osteotomy is completed by reattaching the tubercle to its new distal position with cannulated screws and washers. The arthrotomy is closed, and medial patellofemoral ligament reconstruction is completed by passing the folded quadriceps graft, attached at the superior pole of the patella with a Q-Fix anchor, through the retinacular channel and affixing it to the adductor tubercle with 2 Q-Fix anchors. Once patellar stability is ensured through range of motion, the incision is closed.

Purpose To investigate the isolated and combined effects of medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) deficiency and reconstruction on patellofemoral kinematics. Methods Sixteen matched-paired female cadaveric knee specimens with a mean age of 53.5 years (range, 26-65) were tested in 5 conditions: (1) intact, (2) MPFL or MPTL cut, (3) MPFL and MPTL combined cut, (4) MPFL or MPTL reconstruction, and (5) MPFL and MPTL combined reconstruction. Dynamic testing allowed continuous analysis of kinematics from 0° to 90° of knee flexion. Knees were also tested statically using a lateral load of 45 N at 0°, 30°, 60°, and 90° of flexion. In both dynamic and static loading tests, a motion capture system detected patellar position for each testing state to distinguish changes in patellar kinematics. Random-intercepts linear mixed-effects models were used to compare patellar kinematics. Results The MPFL is the primary restraint to lateral translation of the patella at all knee flexion angles. MPTL deficiency alone did not create significant patella instability, but further increased instability when the MPFL was deficient. Isolated MPFL and combined reconstruction provided improved stability. Through full range of motion native patella tracking was best recreated with combined ligament reconstruction. Conclusions The MPFL plays the greatest role in medial patellar stability, but the MPTL appears to have an influence on patella tracking. This study provides further understanding to the impact of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking. Clinical Relevance This study provides further understanding of the role of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking.

Although several surgical treatments for patellar instability with patella alta have been reported, the clinical outcomes and optimal surgical procedures for patellar instability with patella alta in middle-aged patients are still controversial. We hypothesized that optimal surgical procedures for patellar instability with patella alta in middle-aged patients may induce good clinical outcomes with better patellofemoral geometry.Twelve middle-aged patients with a mean age of 44 years (range: 40-55 years), who presented with patellar instability and patella alta, were treated with a combination of several surgeries, such as medial patellofemoral ligament (MPFL) reconstruction, trochleoplasty, lateral release, and three-dimensional transfer of the tibial tuberosity, based on a surgical algorithm. Patellar position and clinical outcomes were evaluated postoperatively. The mean follow-up time was 41.5 months (range: 24-72 months).Patellar position altered from 1.31 (1.21-1.53) preoperatively to 0.88 (0.69-1.06) postoperatively on the Caton-Deschamps Index (p0.01). The tibial tuberosity-trochlear groove (TT-TG) distance altered from 21.8mm (20.1-25.8mm) to 10.3mm (5.1-14.7mm), and patellar tilt ranged from 28.1° (21-40°) to 14.6° (5-28°), respectively (p0.01). Clinical outcomes on the Lysholm and Kujala scales improved from 43.1 and 38.4 to 86.7 and 78.3, respectively, at final follow-up (p0.01). Surgical treatment that included trochleoplasty resulted in better outcomes than other surgical combinations without trochleoplasty (p0.05). Sulcus angle and postoperative patellar tilt improved more in those who underwent trochleoplasty than in those who did not (p0.05).Surgical treatment for patellar instability with patella alta in middle-aged patients resulted in improved clinical outcomes. In particular, a combination surgery including trochleoplasty resulted in the greatest improvement in case of severe trochlear dysplasia.IV. Retrospective case series study.

Given different functions of the medial quadriceps tendon–femoral ligament and medial patellofemoral ligament components of the proximal medial patellar restraints, reconstructions to the midpoint of the medial patellofemoral ligament and medial quadriceps tendon–femoral ligament are probably optimal, combining the benefits of both in surgical treatment of recurrent patella instability.

This article was updated on November 17, 2015. The title, which had previously read “Medial Patellofemoral Reconstruction in Children and Adolescents” now reads “Medial Patellofemoral Ligament Reconstruction in Children and Adolescents.” An erratum has been published: JBJS Reviews. 2015 Dec 15;3(12):e4. Patellar dislocations are a common disabling knee injury in children and adolescents. Approximately 90% of primary patellar dislocations result in injury to the medial patellofemoral ligament (MPFL)1,2. MPFL injuries in children and adolescents, and the management of those injuries, differ from those in adults in numerous ways. In the past decade, studies have demonstrated better results with MPFL reconstruction than with medial repair and/or lateral release3-5. The purpose of this article is to review recent literature on the natural history of pediatric patellar dislocations, review advances in imaging following acute patellar dislocation in pediatric patients, discuss the biomechanical properties of the MPFL, and evaluate the surgical options as well as the outcomes of MPFL reconstruction. This article will cover

Recurrent patellar instability can be very debilitating and may require surgical intervention. A thorough workup must be completed in this subset of patients. Risk factors for recurrent instability include patella alta, trochlear dysplasia, an increased tibial tubercle–trochlear groove distance, and insufficiencies in the medial retinacular structures. Necessary treatment of these risk factors, once identified, should be addressed surgically. Patellofemoral reconstruction must be individually tailored to each patient's anatomy and may necessitate medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, or trochleoplasty in any combination or as a standalone procedure. This article details our technique for surgical treatment of recurrent patellar instability with a medial patellofemoral ligament reconstruction, an open trochleoplasty, and a tibial tubercle osteotomy for patients with severe trochlear dysplasia, an increased tibial tubercle–trochlear groove distance, or patella alta.