Description of the process, patient selection, rehab

1. ARTHROSCOPY ASSISTED MPFL
RECONSTRUCTION
DR.SABYASACHI BARDHAN
DR.S KUMAR
DR.A.K.GARG
DR.K.K.MUKHOPADHYAY

2. MPFL
•Most important
static restraint
•Extrasynovial
ligament
•Medial femoral
epicondyle to
medial patellar
edge ; 6-7cm,deep
to the distal part of
vastas medialis
obliqus.

3. MPFL RECONSTRUCTION
•
Proximal realignment for patellar instability
•
Classical indication of isolated MPFL
reconstruction is post traumatic lateral
patellar dislocation having no anterior knee
pain.
•
Anatomical repair ; Open or arthroscopic

4. CLINICAL PROFILE
• H/O dislocation of patella…single or multiple
episodes
• Patellar translation
• Patellar tilt test
• Apprehension test
• Retropatellar tenderness
• Knee ROM & patellar tracking
• Q angle

5. IMAGING
• Standard X ray of knee
-AP, Lateral & skyline
view
• MRI

6. CHOICE OF PATIENTS
INDICATIONS
• Young
• Recurrent dislocation
• Painless
CONTRAINDICATIONS
• Tight lateral structures
• Medial instability
• Q angle>20 degs/ genu
valgum are relative
contraindications for
isolated MPFL
reconstruction

7. OVERVIEW OF STEPS
•
•
•
•
•
•
•
Examination under anaesthesia
Diagnostic scopy
Graft harvest
Patellar preparation
Femoral condyle preparation
Graft passage and graft isometry check
Fixation under arthroscopic supervision.

8. EXAMINATION UNDER ANAESTHESIA
• Patellar stability, translation, and tilt are
usually easier to characterize when the
patient is anesthetized
• If the patient's symptoms and exam are
consistent with excessive lateral retinacular
tightness, then consideration should be given
to performing a concomitant arthroscopic
lateral retinacular release.

9. PATELLAR TRANSLATION

10. PATELLAR TILT

11. DIAGNOSTIC ARTHROSCOPY
• Careful assesment of
loose bodies
• Articular surfaces
, patella and trochlear
surface are carefully
examined
• Patellar tracking

12. SURFACE LANDMARKS

13. GRAFT HARVEST
• Semitendinous graft
• Standard harvesting
technique

14. PATELLAR
TUNNEL
•Make two tunnels of
10mm each the first
one just where the
obliquity of medial
border turns to be
straight.
•The other one 10mm
below that
•Each tunnel is about
4mm in diameter
•Tunnels are made in
divergent fashion

15. PATELLAR
TUNNEL
•Vertical drill holes of
the same diameter are
made 1 cm from the
medial patellar margin
in a antero post
fashion to connect
with the horizontal
tunnels.
•Once tunnel is made
Each end of the graft
is passed through .

16. PASSING THE GRAFT

17. FEMORAL
PREPARATION
•Femoral attachment site
of the MPFL is in between
medial epicondyle and
adductor tubercle
•Malposition of the
femoral tunnel even 5 mm
results in increased graft
force .
•3cms incision over the
medial epicondyl.
Adductor tubercle
identified. A beath pin is
drilled across to the
opposite cortex

18. Between the patellar and
femoral incision a dialator is
passed to make room for
the passage of the graft
between the layer 2 and 3.

19. GRAFT ISOMETRY
• To check the behavior of the graft through a
range of motion.
• Done by passing a beath pin through the
femoral attachment site and wrapping the
graft around it observing the length change
behavior of the graft between 30-90 range
• Fixed to femur with Intf screw

20. FINAL TENSIONING OF GRAFT AND
FIXATION
• Most important step dictating the surgical
outcome
• Prime importance to avoid graft over
tightening.
• Arthroscopic visualisation of patellar tracking
confirms that patella is fitting properly in the
grove without excessive medial pull.

21. PATELLAR TRACKING

22. POST OP PROTOCOL
• Static quadriceps after 24 hrs
• Dressing change with lighter dressing after
48hrs.
• Knee bending, Heel slides to start after 48 hrs;
knee brace at all other times, to attain 90 degs
flexion by 2 wks
• Partial weight bearing after 48hrs….full weight
bearing by 6 weeks

23. RESULTS
• No of patients : 6 (4 females, 2 males)
• 16y-37y
• One of them is professional dancer and one elite
athlete.
• The cause of dislocation was post trauma in all
cases.
• None of them had preceding anterior knee pain.
• Average follow up period was 11 months

24. RESULTS
ROM:
• All patients had 90 deg flexion by 3 weeks.
and no extension lag by 6weeks.
• All patients had no pain and full range of
movement by 6 weeks.

25. RESULTS
• All of them achieved their pre injury activity
level and did not have any apprehension or
episode of dislocation during the follow up
period.
• One patient had a minor skin infection
immediate post op which resolved with
antibiotics.

26. CLINICAL PHOTOGRAPHS

27. CONCLUSION
MPFL reconstruction is a relatively safe
technique with very predictable outcome in
carefully selected subset of patients with
recurrent patellar lateral instability.

28. THANK
YOU