Nepal Orthopaedic Association Journal (NOAJ)
Vol. 6 No. 2, Jul-Dec. 2020 17
INTRODUCTION
First-time patellar dislocation is treated
conservatively in various stages.1 However,
redislocation has been reported in 44% of
patients undergoing conservative management.2
Further, chronic instability and pain occur when
recurrence is neglected. Studies suggest that when
the second dislocation occurs or conservative
treatment fails, surgical management should
be performed. These include proximal or
distal realignment procedures or combination
of both.3 Among proximal procedures, Medial
patellofemoral ligament(MPFL) reconstruction
has gained popularity. Non-reconstruction
ABSTRACT
INTRODUCTION: This study aims to assess the functional outcomes of patients undergoing
medial patellofemoral ligament reconstruction using supercial quadriceps tendon and also assess
the postoperative complication and patient’s satisfaction level.
METHODS: We retrospectively reviewed 33 patients (15 males, 18 females) with an average age of
19 years with recurrent patellar dislocation, operated from August 2015 to January 2018. Inclusion
criteria of the study was patients with a recurrent patellar dislocation undergoing medial patellofemoral
ligament reconstruction with a minimum follow-up of 1 year. Exclusion criteria of the study were: (1)
associated ligamentous injuries of the knee joint, and (2) previous history of bony correction along
with medial patellofemoral ligament reconstruction. The clinical evaluation was performed using
Kujala knee score and visual analogue scale scores. Postoperative satisfaction level was performed
using a self-constructed questionnaire.
RESULTS: At the nal follow-up, the mean Kujala score was signicantly improved from 72
points (range 53-94) to 95 points (range 87-100) (p<0.001). Similarly, the VAS score is signicantly
reduced from 3.5 points (range, 0-6) preoperatively to 1 point (range, 0-3) postoperatively (p<0.001).
Postoperatively, 25 patients (76%) were very satised with the surgery, 7 patients (21%) were satised
and 1 patient (3%) was neutral with the surgery. One patient reported frequencies of subluxation of
the patella with a positive apprehension, others did not report any cases of dislocation. Supercial
infection was evident in 2 patients with a complete resolution with oral antibiotics and regular dressing
change.
CONCLUSION: medial patellofemoral ligament reconstruction using supercial quadriceps
tendon for the recurrent patella dislocation provides satisfactory functional outcomes with minimal
complications and is a cost-eective method for the countries like Nepal.
KEYWORDS: Recurrent patellar dislocation, Medial patellofemoral ligament, Quadriceps tendon,
Hamstring tendon
Original Article
Medial Patellofemoral Ligament Reconstruction Using
in Recurrent Patellar Dislocation.
Binoid Sherchan1, Vaskar Humagain1, Rai Saroj1
1Department of Orthopedics and Trauma Surgery, National Trauma Center, National Academy of
Medical Sciences, Mahankal 44600, Kathmandu, Nepal.
Vol. 6 No. 2, Jul-Dec. 2020
Nepal Orthopaedic Association Journal (NOAJ)
18
techniques like plication and realignment
disturb the native patellofemoral biomechanics
and repair involves already compromised tissue.
Many MPFL reconstruction techniques have
been described, but there is no consensus about
the choice of graft, graft positioning, type of
xation, correct tension and outcome. Commonly
used grafts are gracillis, semitendinosus and
quadriceps tendon.4–6
The use of autologous partial-thickness
quadriceps tendon was rst described by
Steensen et al. in 2005.6 They used central one-
third of the rst layer of the quadriceps tendon,
leaving the patellar attachment intact. After
harvesting, it was rotated 900 medially and
xed with trans-osseous sutures on the femoral
side. One year later, Noyes et al.7 presented a
similar technique with the same graft but xed
to the medial intermuscular septum. However, it
gained little attention at that time. The technique
was revived and popularized by Goyal8 as
“supercial quad technique”. There are several
advantages of this graft over others. Hamstring
and other tendon grafts are thicker and stronger
than the native MPFL.9 Further, they require
osseous tunnels and some form of xation at the
patellar side. This may emanate complications
like patellar fracture, hardware irritation,
violation of chondral surface of the anterior
cortex of patella, and increase stress risers.10
Additionally, the structural and biochemical
properties of the quadriceps tendon graft are
similar to that of native MPFL.11
This study aims to assess the functional outcomes
of patients undergoing MPFL reconstruction
using supercial quadriceps tendon and also
assess the postoperative complication and
patient’s satisfaction level.
METHODS
We retrospectively reviewed 33 patients (15
males, 18 females) with recurrent patellar
dislocation, operated from August 2015
to January 2018. Inclusion criteria of the
study was patients with a recurrent patellar
dislocation undergoing MPFL reconstruction
with a minimum follow-up of 1 year. Exclusion
criteria of the study were: (1) associated
ligamentous injuries of the knee joint, and (2)
previous history of bony correction along with
MPFL reconstruction. Detailed demographic
characteristics of the participants are well
depicted in Table 1. Intervention was carried
out on 23 right and 10 left knees. Mean age of
the patient was 19 years (range, 12-35 years).
The mean follow- up was 27 months from index
surgery (range, 12-44 months). All patients
suered at least 3 unilateral dislocations (mean
5, maximum of 11 episodes).
Table 1: Demographic Parameters of the patients
Parameters Mean±SD
or n Range
Age (years) 19.48±6.02 12-35
Male/Female 15/18
Right/Left 23/10
Follow-up (months) 26.88±9.85 12-44
n=number of patients,
SD=standard deviation
Detailed clinical examination to rule out any
patellofemoral pathology was done. Plain
radiographs (anteroposterior, lateral and bilateral
skyline views at 300 exion) were studied in
each patient. Geometric parameters of the
patellofemoral joint like trochlear dysplasia,
patella alta, abnormal tibial tuberosity-trochlear
groove (TT-TG) distance were documented using
computed tomography (CT) scans. Magnetic
resonance imaging (MRI) was also done in each
subject. Other regional and generalized causes of
patellofemoral instability were also examined.
All procedures were carried out under spinal
anesthesia in the supine position. Patient
positioning was done to allow free knee motion
from 0 to 1200. Access to uoroscope was
checked before draping. We used the technique
as Goyal8 and Fink et al.12 described. Initially,
diagnostic arthroscopy was performed detailed
assessment and management of intra-articular
pathologies and chondral injuries. After
arthroscopy, a longitudinal incision measuring
7-8 cm was made on the anterior aspect of the
knee, starting at the midpoint of the patella and
progressing proximally.
Nepal Orthopaedic Association Journal (NOAJ)
Vol. 6 No. 2, Jul-Dec. 2020 19
The supercial and deep fascia were incised along
the line of skin incision until a fatty tissue layer
was encountered. This tissue was removed from
the surgical eld using blunt dissection with dry
gauze, exposing quadriceps tendon. Another thin
fascial layer of tissue over the quadriceps was
incised and extended proximally to mid-thigh
and distally to the lower pole of the patella. The
next and the most crucial step was to identify a
naturally occurring plane of separation between
the supercial and middle lamina about 2-3 cm
proximal to the patella. The supercial lamina
was lifted, and the two laminae were separated
by blunt dissection. Then, approximately 10
mm wide mid-portion of the supercial slip was
dissected proximally for the required length (10
cm). The graft was further dissected distally
and obliquely on the subperiosteal plane of
the patella. Medial point of this dissection was
aimed till the superomedial corner of the patella,
and lateral point of dissection was made till the
level of the midpoint of the medial border of the
patella. Care was taken not to amputate the graft
at this level. The proximal portion of the graft
was sutured with No. 2 Ethibond.
The prepared graft was then rotated medially
such that the superior and inferior edges of the
rotated graft matched the anatomic attachments
of native MPFL. Next step was to lift the insertion
of vastus medialis and creation of subvastus
space. The graft was then routed through this
space. A 2 cm incision was centered over the
medial epicondyle, and adductor tubercle and
medial epicondyle were located. By using artery
forceps, the graft was pulled out of the medial
incision, avoiding re-rotation. An isometric
point on femur was identied by Schottle’s
method.5
A Beath pin was passed from medial Schottle’s
point to the lateral side. Drilling was done with
6.5 mm reamer through this pin till the desired
intraosseous diameter of the graft. The graft
was then passed through this point by pulling
the Beath pin laterally. Optimum length without
over tensioning the graft was checked in 300
exion and full extension, and then the graft was
xed in 300 exion with an appropriately sized
absorbable interference screw. At the end of
the procedure, medial retinaculum was repaired
for any damage, and diagnostic arthroscopy
performed to recheck patellar tracking.
Postoperatively, patients were allowed to fully
weight-bear since day 1. Long knee immobilizer
was applied until the patients gained good
quadriceps control. Quadriceps strengthening
physiotherapy was administered.
The clinical evaluation was performed using
Kujala knee score13 and visual analogue
scale (VAS) scores. Preoperative data were
obtained from the hospital database, whereas
postoperative data were collected during the
last follow-up visit. Postoperative satisfaction
level was performed using a self-constructed
questionnaire consisting of very satised,
satised, neutral, dissatised and very
dissatised.
We used SPSS Statistics version 25 for statistical
analysis. Continuous variables were analyzed
using the paired t-test and categorical variables
were analyzed using the chi-square test. Results
of continuous data were presented as the mean
± standard deviation (SD) and range, whereas
the results of categorical data were presented as
frequencies and percentages. A p-value of <0.05
is regarded as statistically signicant.
RESULTS
Functional outcome of the patients is well
depicted in Table 2. At the nal follow-up, the
mean Kujala score was signicantly improved
from 72 points (range 53-94) to 95 points
(range 87-100) (p<0.001). Similarly, the VAS
score is signicantly reduced from 3.5 points
(range, 0-6) preoperatively to 1 point (range,
0-3) postoperatively (p<0.001). Postoperatively,
25 patients (76%) were very satised with the
surgery, 7 patients (21%) were satised and
1 patient (3%) was neutral with the surgery.
None of the patients was dissatised or very
dissatised.
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Nepal Orthopaedic Association Journal (NOAJ)
20
Table 2: Preoperative and postoperative functional outcomes of the patients.
Parameters Preoperative
Mean±SD (Range)
Postoperative
Mean±SD (Range) p-value
Kujala score 72.09±12.69(53-94) 94.94±4.25 (87-100) <0.001*
VAS Score 3.58±1.39 (0-6) 1.03±0.98(0-3) <0.001*
SD=Standard deviation, * Statistically signicant dierence exists
Post-operative complication occurred in 3
patients (9%) (Table 3). One patient reported
frequencies of subluxation of the patella with a
positive apprehension, others did not report any
cases of dislocation. Supercial infection was
evident in 2 patients with a complete resolution
with oral antibiotics and regular dressing change.
Table 3: Complications following MPFL
reconstruction.
Complications n (%)
Supercial Infection 2 (6)
Patella fracture 0
Knee stiness 0
Redislocation/subluxation 1 (3)
Overall 3 (9)
n=Number of patients
DISCUSSION
Most important nding of this study was
that MPFL reconstruction using a strip
of supercial quadriceps tendon provides
satisfactory functional outcomes with minimum
complications. Ninety-seven per cent of the
patients were very satised or satised with the
surgery.
Of numerous proximal patellar realignment
procedures, MPFL reconstruction has become
one of the most frequently used methods for
addressing recurrent patellar dislocation. For
many years, this ligament has been thought of
only an inconstant anatomic structure.14 However,
today lesion of the MPFL is considered to be an
‘essential lesion’, comparable to Bankart lesion
in anterior shoulder instability, without which
the patella cannot laterally dislocate.15
Multiple procedures have been described for
the reconstruction of this structure, depending
upon the type of graft and the xation technique
used in patella and femur. However, there is no
consensus to which one is better and clinically
superior over another.
Hamstrings tendon was utilized as the most
frequent source of autologous graft. The
procedure resulted in high success; however,
it has complications rate of up to 26%.16 The
complications were mainly patellar fractures and
impairment of knee exion.17 Intra-operative
iatrogenic patellar fractures have also been
described.18 Being stronger and stier, this graft
tends to overload the graft-patellar junction,
weakening the medial patellar ridge, causing
stress risers as well as late patellar fractures
after many years.10 Further, Mountney et al.19
showed that the strength of various xation
methods of grafted tendons was remarkably
lesser than the native MPFL. Hence, they would
fail at patellar xation site amongst others.
Similarly, using more substantial and stier
graft than the original ligament will increase
the stress in the patella, aggravating any pre-
existent anatomic abnormality and potentiating
early patellofemoral osteoarthritis. Hence,
to maintain the exact native dimensions and
strength, graft used for reconstruction must have
similar properties to that of the latter.
MPFL is a thin ligament with a length ranging
from 4.5 to 6.5 cm.20 The width of MPFL at
patellar insertion is almost double than the
femoral side, making it broad and sheet-like.21
On the other hand, the average lengths of
gracillis and semitendinosus tendons were 20-
25cm and 23.5 to 28 cm, respectively.22,23 Hence,
their widths are larger, making them thick
and cord-like. Andrikoula et al.24 reported the
length of the supercial slip of the quadriceps
tendon ranged from 5.0 – 8.5cm, width at the
superior aspect of patella being 4.1cm and at
the middle of the tendon to be 2.2cm. Further,
Nepal Orthopaedic Association Journal (NOAJ)
Vol. 6 No. 2, Jul-Dec. 2020 21
the attachment of this supercial slip is as broad
as the native MPFL.25 Biomechanically, the
strength, stiness, yield load and maximum
load to failure of this slip match those of original
MPFL while tested as reconstruction.11
Another advantage of this technique is the
cheaper procedural cost because this technique
requires only a single bioabsorbable screw for
the xation at the femoral insertion site and few
Ethibond stitches at the patellar side. Whereas
in the hamstring and other xation techniques
may require xation at both in the patellar and
femoral side, it demands the further economic
burden to the patients of countries like Nepal
where most of the payment has to be made by
patients themselves.26
Supercial quadriceps technique is free from
complications as mentioned above of hamstring
tendon, including patellar fracture. Similarly, it
is also possible to use in revision MPFL surgery,
that have previously used tunnels or hardware
in the patella. Use of supercial quadriceps
tendon also reserves the source of autologous
graft from hamstrings to be used in any other
reconstruction, if required. A careful dissection
of the supercial lamina is the most pivotal step
in this technique. Harvesting the desired length
is another critical aspect. A hasteful dissection
on the anterior surface of the patella may lead
to graft amputation. Another point of attention
should be while gaining access to the subvastus
space by carefully dissecting the medial border
of the patella.27
Patients satisfaction following surgical
stabilization of the patella depends on the
postoperative functions and redislocation. Most
of our patients were satised with the surgery.
The average Kujala score in our cohort was
improved from 72 points preoperatively to 95
points postoperatively at the nal follow-up.
Similar improvement was noted in the studies
of Goyal et al.27 (from 49 to 91 points), Nelitz et
al.28 (from 63 to 89 points), Bouras et al.29 (from
60 to 92 points), Vavalle et al.3 (from 36 to 89
points). Similarly, Fink et al.30 used Lysolm
score for the clinical assessment and reported
to improve from 69 points preoperatively to 88
points postoperatively at the nal follow-up.
As of postoperative satisfaction level, 97% of
patients in our cohort were very satised or
satised with the surgery, and the results were
similar to that of previous studies by Fink,30
Vavalle,3 Hinckel31 and Leal-Blanquet et al.32
However, many previous studies did not report
any complications except by Hinkel et al.31
They reported 1 postoperative wound infection
requiring regular washout and debridement.
We also had supercial wound infection in 2
patients who required regular dressing changes
and oral antibiotics. One of our patients reported
episodes of patellar subluxation and a positive
apprehension. However, he did not undergo any
further surgical stabilization procedure.
Although this is the rst study from Nepal,
it has all the limitations that a retrospective
with a limited number of the sample and non-
randomized study would have. Prospective
randomized control trials assessing the
outcomes, complications with a cost-eective
analysis would provide a robust result in the
future.
CONCLUSION
MPFL reconstruction using supercial
quadriceps tendon for the recurrent patella
dislocation provides satisfactory functional
outcomes with minimal complications and is
a cost-eective method for the countries like
Nepal.
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Address for correspondence:
DR. BINOD SHERCHAN
Department of Orthopedics and Trauma Surgery, National Trauma Center,
National Academy of Medical Sciences, Mahankal 44600, Kathmandu, Nepal
Phone: +9779851048455
Email: drbsherchan@gmail.com
