Original Article

Management of Injuries to the Medial

Patellofemoral Ligament: A Review
Jaydev B. Mistry, MD1 Kevin F. Bonner, MD2 Chukwuweike U. Gwam, MD1 Melbin Thomas, MD1
Jennifer I. Etcheson, MD, MS1 Ronald E. Delanois, MD1

1 Center for Joint Preservation and Replacement, Rubin Institute for
Advanced Orthopedics, Baltimore, Maryland
2 Department of Orthopedic Surgery and Sports Medicine, Jordan-
Young Institute, Virginia Beach, Virginia
J Knee Surg
Address for correspondence Ronald E. Delanois, MD, Center for Joint
Preservation and Replacement, Rubin Institute for Advanced
Orthopedics, 2401 W. Belvedere Ave Sinai Hospital of Baltimore,
Baltimore, MD 21215
(e-mail: delanois@me.com; rdelanoi@lifebridgehealth.org).

Abstract The medial patellofemoral ligament (MPFL) is thought to be the most important medial
structure providing restraint to lateral subluxation of the patella. After an initial patellar
dislocation, the MPFL is frequently injured and can usually be treated with conservative
measures. However, these patients often suffer from recurrent dislocations, which
Keywords thereby necessitate operative intervention. In the setting of normal anatomy and

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► medial kinematics, isolated reconstruction of the MPFL is an effective treatment for preventing
patellofemoral recurrent dislocations. Various surgical techniques have been described, with differ-
ligament ences in fixation and graft selection. The treatment of MPFL injuries should aim to
► reconstruction provide patellar stabilization and restore normal kinematics throughout the joint. This
► management review will discuss the following: (1) anatomy of the MPFL, (2) presentation and
► MPFL assessment of MPFL injuries, (3) management of patients with MPFL injuries, and (4)
► patellar dislocation complications following MPFL reconstruction.

Primary dislocation of the patella accounts for 2 to 3% of knee
injuries and is estimated to occur at rates of 5.8 per 100,000
in the general population.1,2 This condition primarily affects
young athletes of both sexes between the ages of 10 and
17 years, but has a slightly greater incidence in females.1
Abnormalities such as vastus medialis oblique (VMO) atro-
phy, patellar dysplasia, trochlear dysplasia, patella alta,
femoral anteversion, valgus deformity of the knee, and
ligamentous laxity may increase predisposition to patello-
femoral instability.3,4 Initial patellar dislocations are
typically managed conservatively; however, up to 40% of
patients may experience a recurrent dislocation.1,5 This rate
increases to 50% for patients who have had two prior
dislocations.6 Yet, even in the absence of recurrence, pain
and instability continue to persist in many patients.7
The medial patellofemoral ligament (MPFL) is thought to
be the predominant soft tissue stabilizer of the patellofe-
moral joint by providing 50 to 60% of soft tissue restraint to
lateral translation of the patella.8 Injury to the MPFL almost
always occurs during the initial dislocation and typically
exhibits poor healing potential, effectively increasing the risk
of patellofemoral instability and recurrent dislocation.9,10 In
the setting of recurrent dislocation, patients often present
with accompanying bony and soft tissue damage, typically
involving the articular cartilage of the trochlea, patella, and
lateral femoral condyle.11,12 Furthermore, it is estimated that
traumatic chondral injury after patellar dislocation may be
identified by magnetic resonance imaging (MRI) in 40 to 95%
of knees.13,14 Consequently, patients may become function-
ally restricted in their daily activities and limited in athletic
involvement, thereby necessitating operative intervention.
Modalities for MPFL reconstruction have evolved in recent
years, with advancements in surgical technique, graft selec-
tion, and fixation methods that have been shown to improve
functional outcomes.15–17 However, given the increased
prevalence of associated injuries to surrounding structures,

received Copyright © by Thieme Medical DOI https://doi.org/

November 18, 2016 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0037-1604142.
accepted after revision New York, NY 10001, USA. ISSN 1538-8506.
May 31, 2017 Tel: +1(212) 584-4662.
Management of MPFL Injuries Mistry et al.
additional procedures may be required to appropriately
restore joint alignment and stability.18,19
The treatment of MPFL injuries should aim to provide
patellar stabilization and restore normal kinematics
throughout the joint. This review will discuss the following:
(1) anatomy of the MPFL, (2) presentation and assessment of
MPFL injuries, (3) management of patients with MPFL in-
juries, and (4) complications following MPFL reconstruction.
Anatomy and Biomechanics
The MPFL is a bandlike structure that originates near the
medial femoral epicondyle and courses toward the medial
border of the patella while demonstrating variations in
thickness, quality, and length. Previously, it was widely
accepted that the lateral portion of the MPFL had a broad
attachment onto the proximal medial portion of the patella
over a 20- to 30-mm–wide area.20 However, a recent cada-
veric study of 28 knees by Tanaka21 found that MPFL inser-
tion onto the patellar demonstrated considerable variability.
In the 28 knees that were analyzed, the mean percentage of
MPFL fibers that inserted onto the patella was 57.3
19.5%
(range: 0–100%; 95% confidence interval [CI]: 50.1–64.5).
Reports have described the femoral attachment to be at the
medial epicondyle,4,22–24 at the anterior25 or posterior26
aspects of the medial epicondyle, at or just distal8,27 to the
adductor tubercle,28 or at the MCL.29,30 These variations in
description of the femoral attachment of the MPFL highlight
the difficulty in distinguishing its origin. This may be partly
due to the broad attachment points, making the exact origin
of the MPFL unclear.
The patella is a triangular-shaped sesamoid bone with its
apex at the inferior pole, where it gives rise to the patellar
tendon that attaches onto the tibial tubercle. The superior
pole of the patella forms the base and provides the attach-
ment area for the quadriceps tendon. The patella serves to
increase the leverage that the quadriceps tendon exerts on
the femur by increasing the angle upon which it acts.31 The
posterior surface of the patella articulates with the anterior
aspect of the distal femur within the trochlear groove and is
separated into the medial and lateral facets, which articulate
with the medial and lateral femoral condyles, respectively.32
During the first 20 to 30 degrees of knee flexion, the
quadriceps muscle tightens and pulls the patella laterally.
This lateral translation is counteracted by the MPFL, which
helps guide the patella into the trochlear groove.24,33 This
was demonstrated in a report by Nomura et al,34 which
showed increased lateral subluxation of the patella between
20 and 90 degrees of flexion with progressive sectioning of
the MPFL, even the presence of other intact medial stabili-
zers. Beyond 30 degrees of knee flexion, the patellar tendon
and quadriceps tendon engage the patella into the trochlear
groove where further stability is provided by the bony
constraint medial and lateral femoral condyles.33 It is im-
portant to note that patients with conditions such as tro-
chlear dysplasia or hyperplasia are at increased risk for
patellofemoral instability, independent of the condition of
the soft tissue stabilizers.35
The Journal of Knee Surgery
History and Assessment
Injuries to the MPFL are reported following movements that
involve an axial load to the knee joint in conjunction with
twisting or pivoting with the knee extended and foot externally
rotated. As the patient may report details that can mirror that of
an anterior cruciate ligament tear, orthopaedists must be able
to distinguish between the two. Physical examination should
focus on the involved limb, assessing for pain, swelling, defor-
mity, and signs of diffuse ligamentous laxity.36 Provocative
maneuvers, such as the patellar apprehension test or Bassett’s
Sign, may help confirm diagnosis. For the patellar apprehension
test, the patient lies supine on the examination table laterally
directed pressure is applied to the patella. Involuntary contrac-
tion of the quadriceps or expression of guarding/apprehension
by the patient indicates a positive test.37 Bassett’s sign is
positive when tenderness upon palpation of the adductor
tubercle and medial epicondyle is observed, which may in-
dicate rupture or disruption of the MPFL.37
Loss of the normal anterior anatomical landmarks of the
knee may be observed as a result of a joint effusion due to
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hemarthrosis or shifting of the patella. Patellar laxity can be
determined by measuring the extent of passive translation of
the patella (►Fig. 1). The test is considered positive if the
patella is displaced by more than two quadrants, or 50%, of its
width.38 In addition, the quadriceps angle, or Q-angle, may
be assessed to determine the biomechanical function and
alignment of the lower extremity (►Fig. 2). The Q-angle is
defined as the angle formed by a line connecting the center of
the patella and the anterior superior iliac spines, and a line
connecting the center of the patella to the anterior tibial
tubercle.39 A normal Q-angle is 13.5
4.5 degrees.40 Clini-
cally, high Q-angles are associated with increased lateral
forces on the patella that may contribute to subluxation.40 In
patients with patella alta, the assessment and measurement
of the Q-angle may be less accurate if measured in full
extension due to the additional superior translation pro-
vided by contraction of the quadriceps muscle.41
Fig. 1 Patellar laxity is defined as translation of at least two quad-
rants, or 50%, of the width of the patella.

Fig. 2 Determination of quadriceps angle to assess biomechanical
function and alignment of the lower extremity.
Radiographic evaluation can identify other contributory
factors that may need to be addressed in addition to MPFL
reconstruction. These include excessive femoral anteversion,
external tibial torsion, or dysplasia of the patellofemoral
joint.36 Weight-bearing anteroposterior, lateral, and poster-
oanterior flexion knee radiographs should be obtained to
assess lower extremity alignment and bony morphology. In
addition, sunrise or Merchant views may help to determine
the degree of patellar tilt or the extent of arthritis in the
patellofemoral joint. These X-rays can identify the osteo-
chondral injury or the medial ossicle, which is often seen
following chronic patella dislocations. Imaging modalities
such as MRI or computed tomography (CT) are increasingly
being used because of their ability to better visualize patellar
tracking, MPFL lesions, bony deformities, and chondral
lesions as compared with standard radiographs.42–44
Aside from the Q-angle, which has grown out of favor due
to high variability, more objective measurements such as the
tibial tubercle–trochlear groove (TTTG) or the tibial tuber-
cle–posterior cruciate ligament (TT-PCL) distance are more
widely used.45 The TTTG can be measured by from CT or MRI
by superimposing the axial section that best displays the
Management of MPFL Injuries Mistry et al.
bottom of the trochlear groove and the patellar tendon
attachment to the tibial tuberosity. Two lines, one from
deepest point of the trochlear groove and the other at the
center of the tibial tubercle, should be extended posteriorly
to a perpendicular line that is tangential with the posterior
femoral condyles. A distance of less than 15 mm between the
two lines is considered normal, 15 to 20 mm is borderline,
and greater than 20 mm of translation is abnormal.46 The
TT-PCL line is obtained similarly, with the exception that a
line is drawn adjacent to the medial aspect of the PCL as
opposed to the trochlear groove, and distances greater than
24 mm are considered abnormal.47
Treatment
Nonoperative Management
First-time patellar dislocations with MPFL injury can be
treated nonoperatively in the absence of concomitant chon-
dral and osteochondral damage. Goals of early treatment are
reduction of pain and swelling, as well as strengthening and
reconditioning of the dynamic stabilizers. This may include
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modalities such as stretching, bracing, soft-tissue massage,
muscle stimulation, and functional exercises.48 Patients may
also be immobilized through casting, bracing, or splinting.
Maenpaa and Lehto49 demonstrated that patients treated
with a posterior splint had the lowest risk of recurrent
dislocation as compared with those treated with braces or
casts at 13-year follow-up.
Some reports have also compared nonoperative treatment
with early operative intervention for first-time patellar dis-
locators who had MPFL injuries. In a prospective randomized
trial of 62 patients, Palmu et al50 found no significant differ-
ence in recurrent dislocation, subjective outcome, activity, or
function scores between the two cohorts at 14-year follow-up.
Similarly, Buchner et al51 were unable to identify a significant
difference in redislocation rates, subjective outcomes, activity,
or functional scores at 8-year follow-up for patients treated
conservatively (N ¼ 63) or surgically (N ¼ 63).
Physical therapy for MPFL injuries should be focused on
strengthening of the quadriceps and gluteal muscles, proprio-
ceptive training, and patellar taping. In particular, strengthen-
ing of the VMO can help affect the vector of forces on the patella
and help medialize the patella into the trochlear groove.52
Strengthening of the gluteal muscles may help increase
the external rotation of the femur and, as a result, reduce
the Q-angle during the gait phase.52 Patellar taping may help
mitigate excessive patellar motion during rehabilitation and
can also provide the patient with a sense of stability.53 This was
seen in a report by Cowan et al,53 where patients who received
patellar taping demonstrated earlier activation of the VMO and
vastus lateralis muscles during a stair climbing exercise as
detected by electromyography when compared with patients
who received either placebo taping or no taping.
Operative Management
In the setting of normal anatomy and kinematics, isolated
reconstruction of the MPFL is the accepted method to restore
medial stabilization in the setting of recurrent patellar
The Journal of Knee Surgery
Management of MPFL Injuries Mistry et al.
Table 1 Summary of techniques
Technique Femoral attachment
Quadriceps Just distal to the adductor tubercle
tendon grafting and superoposterior to medial
femoral epicondyle (anatomical
MPFL insertion site)
Gracilis Anatomical MPFL insertion site
tendon grafting
Patellar Area between the medial
tendon grafting epicondyle and adductor tubercle
Semitendinosus Anatomical MPFL site; tenodesis
tendon grafting on the adductor magnus tendon
Fulkerson MQTFL Adductor tubercle
reconstruction
Abbreviations: MPFL, medial patellofemoral ligament; MQTFL, medial quadriceps tendon–femoral ligament.
dislocations.54 Various surgical techniques have been de-
scribed, with differences in their patellar, femoral, or soft
tissue fixation, as well as in the type of graft used.
See ►Table 1 for a summary.
Quadriceps Tendon Grafting
Fink et al55 described this technique, where the quadriceps
tendon is harvested through a small suprapatellar transverse
incision no more than 2 to 3 cm long. The graft should be at
least 1 cm wide, 8 cm long, and 2 to 3 mm thick. The superior
portion of the graft should be peeled distally to the patella and
passed medially under the patellar periosteum at the site of the
MPFL insertion on the proximal patella, where it should be
secured with sutures. The site of femoral fixation can be
determined using techniques described by Schöttle et al.56
Using a lateral radiograph, the femoral tunnel is to be posi-
tioned 1.3 mm in front of a tangential line to the posterior
cortex and 2.5 mm below the perpendicular line to this
tangent at the junction between the posterior cortex and
lateral condyle. The graft can be fixed into the femoral bone
tunnel with the knee in 20 degrees of flexion to avoid excessive
tension, although several studies have reported successful
graft tensioning with knee flexion as high as 60 to
90 degrees.57–60 Using this technique, Goyal61 described
excellent results in 32 patients at mean follow-up of
38 months. No subsequent dislocations were reported, and
mean Kujala scores improved from 49 preoperatively to 91 at
final follow-up (p < 0.05). A report by Vavalle and Capozzi62
found no recurrent dislocations in 16 patients who received
isolated reconstruction of the MPFL with autologous quad-
riceps tendon at mean follow-up of 38 months (range: 28–48
months). Furthermore, the improvements were seen in mean
Kujala and Lysholm scores from preoperatively to final follow-
up (36–89 and 43–89 points, respectively; p < 0.001 for both).
Gracilis Tendon Grafting
Femoral fixation can be achieved using the methods pre-
viously described,56 whereas patellar fixation is performed
using two limbs of the graft that are passed through a bone
tunnel and buried or impacted using anchors. Over the
The Journal of Knee Surgery
Patellar attachment Considerations/ complications
Superomedial border, proximal Graft length; quadriceps muscle
one-third of the patella shortening
Superomedial border, proximal Graft size; susceptible to
one-third of the patella rupture
Periosteum between the proximal Extensor mechanism weakness;
and middle-third of the patella anterior knee pain; patella baja
Superomedial border, proximal Patella fracture
one-third of the patella
Vastus medialis and intermedius Insufficient fixation in quadriceps
tendons just above the patella tendons (rare) will result in failure
medial surface of the proximal patella, two convergent drill
holes of 4.5 mm in size and 10 mm in depth should be
created, with separation by a bone bridge of approximately
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10 mm, forming a V-shape.63 The graft should be tensioned
such that it allows for one to two quadrants of patellar
displacement, while preventing any further excursion.64
Wagner et al65 presented a series of 50 patients with MPFL
reconstruction using an autologous gracilis tendon with a
minimum follow-up of 12 months. Eighty percent of patients
were able to return to the same or higher level of physical
activity, and the mean Kujala score increased from 70 to 87
points postoperatively (p < 0.001). One (2%) patient experi-
enced a recurrent dislocation, and two (4%) patient required
reoperation due to issues with wound healing. A study by
Enderlein et al66 demonstrated significant improvements in
pre- and postoperative Kujala scores at 1-year follow-up in
224 patients (240 knees) who received a gracilis tendon
autograft for reconstruction of the MPFL (63–80 points;
p < 0.001). In addition, the authors noted that 23% of cases
required a tibial tubercle osteotomy to supplement the
reconstruction, and that seven patients (4.6%) overall
suffered from a redislocation. Patients also reported a sig-
nificant improvement in numeric rank scale (NRS) scores for
pain during activity (3.2 to 1.3; p < 0.001).
Patellar Tendon Grafting
Camanho et al67 initially described this technique; however, it
is not commonly used. Subperiosteal patellar dissection is
performed at the upper one-third of the patella. The proximal
portion of the graft consists of the intact patellar periosteum,
whereas the distal portion consists of a medial strip of the
patellar tendon and its corresponding tibial bone block that are
passed through medial soft tissue structures and fixated into a
premade femoral bone tunnel. The graft should also be sutured
to the VMO for added fixation. Witoński et al68 used this
technique to perform an isolated MPFL reconstruction in 10
patients. At a mean follow-up of 42 months, all patients
demonstrated a significant improvement in Kujala scores
from 60 points preoperatively to 84 points (p < 0.05), and
no recurrent dislocations were reported.

Semitendinosus Tendon Grafting
The semitendinosus can be harvested through a small incision
over its insertion at the pes anserinus and should be at least 20
cm long.69 The two tails of the graft should be tied together,
where they will be subsequently fixed into the patella. Femoral
fixation can be achieved through tenodesis on the adductor
magnus tendon.69 In an analysis of 19 patients who underwent
MPFL reconstruction using a semitendinosus autograft,
Calanna et al15 reported no patellar dislocations or complica-
tions and achievement of full knee range of motion (ROM)
in all patients at median follow-up of 22 months (range:
6–39 months). Positive apprehension sign and patellar glide
test also markedly decreased from the preoperative period to
final follow-up (from 89 to 11% of cases and from 100% to 0% of
cases, respectively). Furthermore, significant improvements
were observed between preoperative and postoperative
median visual analog scale pain scores (8–2; p < 0.05), mean
Kujala scores (65–95 points; p < 0.05), and mean Lysholm
scores (64–94 points; p < 0.05). In their study of 42 patients
(44 knees) who underwent isolated, anatomical MPFL recon-
struction using a semitendinosus autograft, Kita et al70 found
that two (4.5%) knees had redislocated and eight (18.2%) knees
demonstrated positive apprehension sign at a mean follow-up
of 3.2 years (range: 2–9 years). Following postoperative radio-
graphic analysis, the authors determined that the sulcus angle
(odds ratio [OR]: 1.11; 95% CI: 1.01–1.22; p ¼ 0.04) and
trochlear dysplasia (OR: 3.04; 95% CI: 1.39–6.63; p ¼ 0.01)
were associated with postoperative patellofemoral instability.
At final follow-up, all patients demonstrated an improvement
in Kujala scores. However, final Kujala scores were significantly
higher in those who did not suffer from postoperative patello-
femoral instability as compared with those who did (94 vs. 89
points; p < 0.01).
Other Considerations
While a variety of modalities for MPFL reconstruction have been
described, there is no established consensus as to which
technique, surgical construct, or graft source maximizes clinical
outcomes, partly due to the paucity of prospective comparative
studies.36,71,72 There is a general lack of literature directly
comparing single- versus double-limb constructs or allograft
versus autograft sources.73,74 However, Weinberger et al75
recently performed a meta-analysis of 31 studies examining
these factors in 1,065 MPFL reconstructions. The authors found
greater postoperative improvement in Kujala scores associated
with autograft when compared with allograft reconstructions
(32.2 vs. 22.5 points; p < 0.001), but were unable to identify a
significant difference in recurrent instability (5.7 vs. 6.7%;
p ¼ 0.74). Furthermore, double-limbed constructs demon-
strated both a lower rate of failure (5.5 vs. 10.6%; p ¼ 0.030)
and a significantly greater improvement in postoperative Kujala
scores (37.8 vs. 31.6 points; p < 0.001). While autograft ten-
dons may be linked to superior patient reported outcomes,
allograft configurations may be preferred for patients with
connective tissue diseases or ligamentous laxity.76 In addition,
the use of allograft constructs may help limit donor-site
morbidity by mitigating the loss of strength and reducing
surgical time.76 In general, patient factors and graft processing
Management of MPFL Injuries Mistry et al.
techniques should be carefully considered during preoperative
planning.
Furthermore, several studies have highlighted the impor-
tance of using anatomical and radiographic methods for secur-
ing proper tunnel placement.56,77,78 Accurate placement of the
femoral and patellar tunnels is necessary to reestablish the
normal MPFL anatomy and soft tissue tension. If tunnels are
placed inappropriately, the resultant abnormal tension may
generate elevated patellofemoral contact pressures, acceler-
ated arthrosis, pain with ROM, stretching or loosening of the
graft, and instability.79,80 Moreover, it should be noted that
solely using radiographic methods for determining tunnel
placement is not recommended, given the increased risk of
choosing an incorrect fixation site due to variations in patient
anatomy. Sanchis-Alfonso et al81 studied the three-dimen-
sional CT images from 30 knees suffering from chronic lateral
patellar instability to understand the femoral fixation of the
MPFL. The authors examined radiographic reference techni-
ques described by Schöttle et al56 and Stephen et al82 compared
with an anatomical reference point (the adductor tubercle) as
described by Fujino et al.83 Using radiographic references, they
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noted that the percentage of overlap with the anatomical
femoral tunnel was 36.7
25.2% with Schöttle’s method and
25.5
21.5% with Stephen’s method. As a result of these
potential inaccuracies, radiographic identification of the
femoral graft fixation site is only an approximation and should
not be the sole method for determining femoral graft fixation.
Fulkerson and Edgar84 describe a technique involving
reconstruction of the medial quadriceps tendon–femoral liga-
ment (MQTFL) using either the posterior tibial tendon allograft
or semitendinosus autograft to help provide medial stabiliza-
tion as an alternate to traditional MPFL reconstruction meth-
ods. With this technique, the graft is fixated at the anatomical
femoral origin of the MQTFL, which is just off of the adductor
tubercle. The length of the graft should be adjusted to repro-
duce anatomical tracking of the patella centrally in the trochlea.
Care should be taken to avoid injury to the medial infrapatellar
branch of the saphenous nerve. Next, the graft is pulled up
under the VMO and passed directly into the distal quadriceps
tendon. Here, it is sutured securely to the vastus medialis and
intermedius tendons just above the patella. By cycling the knee
through flexion and extension several times and using an
arthroscope in the joint, the proper location and tension for
graft fixation can be determined. In the case of over-tension, the
fixation sutures may be released and replaced appropriately
after retensioning. In contrast to traditional MPFL reconstruc-
tion methods, the advantage of MQTFL reconstruction is that it
avoids patella bone tunnels or patella intraosseous fixation,
thereby minimizing the risk of patellar fracture. The authors84
reported successful early results (minimum 1-year follow-up)
and no recurrent patellar dislocations in 17 patients who
received MQTFL reconstruction.
Complications
Patella Fracture
Patellar fractures can occur intraoperatively when drilling the
tunnels or when screws or anchors are being implanted. Small,
The Journal of Knee Surgery
Management of MPFL Injuries Mistry et al.
dysplastic patellas are predisposed to fracture following screw
or anchor implantation.85 Tunnels that are drilled within
15 mm of each other86 or positioned too anteriorly in the
patella may lead to stress fractures.87 In a systematic review of
25 articles examining complications of MPFL reconstructions,
Shah et al88 determined that patellar stress fractures occurred
most frequently following complete drilling of the tunnels
through the patella. In an analysis of 68 patients who under-
went MPFL reconstruction, Hopper et al89 noted that post-
operative anterior patellar stress fractures occurred in 5.6% of
cases at a mean follow-up of 31.3 months (range: 13–72
months). Techniques using soft tissue fixation minimize risk
of patellar fractures.84 Great care should be taken during
transpatellar drilling to avoid this intraoperative complication.
Postoperative Stiffness and Medial Knee Pain
The most common complication following MPFL reconstruc-
tion is reduced ROM, which is hypothesized to be the result of
improper tensioning of the MPFL graft.85 This may also accom-
pany pain over the medial retinaculum or in the patellofemoral
joint in up to 30% of cases.66 Overtensioning of the graft may
occur during initial graft fixation or if the femoral tunnel is
placed too proximally.90 Larson et al91 demonstrated that
deviations as little as 10.5 mm from the correct femoral
fixation point can increase the risk of medial knee pain and
result in a decrease of KOOS (Knee injury and Osteoarthritis
Outcome Score) and WOMAC (Western Ontario and McMaster
Universities Osteoarthrtis Index) scores. To avoid this, posi-
tioning of the femoral tunnel should be confirmed using an
image intensifier during fluoroscopic imaging,45 and graft
tension should be checked with a tension gauge not to exceed
20 N in 30 degrees of flexion.92
Failed Medial Patellofemoral Ligament
Reconstruction
A reconstructed MPFL is considered to have failed in the setting
of persistent postoperative instability with positive apprehen-
sion sign or a recurrent dislocation.87 Despite low rates of
postoperative recurrence up to 4%, nearly 8.5% of patients
continue to experience feelings of instability or demonstrate
patellar hypermobility after one year.88,93 While the results of
isolated MPFL reconstructions have been largely successful, a
higher incidence of failures has been demonstrated in patients
with additional bony or soft tissue deformities.89,94 Therefore,
orthopaedists must ensure that all potentially contributing
factors (trochlear dysplasia, femoral anteversion, ligamentous
laxity, etc.) are addressed during MPFL reconstruction to max-
imize outcomes.
Conclusion
Patellar dislocation may result in persistent pain and func-
tional limitations. Patients who are experiencing a first-time
dislocation can often be successfully managed with rehabi-
litation and other nonoperative modalities. However, in the
face of recurrent dislocation, surgical intervention is
indicated. Operative management can help increase stability,
but should also address concomitant injuries and other
The Journal of Knee Surgery
anatomical risk factors that may predispose the patient to
recurrent dislocation. In the absence of anatomical deformi-
ties or associated injuries, isolated MPFL reconstruction may
be sufficient for restoring patellofemoral stability. While a
variety of modalities for MPFL reconstruction have been
described, there is no consensus as to which technique,
construct, or graft type offers the best outcomes. Patients
who receive appropriate treatment should achieve normal
kinematics and balanced load transmission in the joint, and
be able to return to normal, if not higher, levels of activity
and sport.
Key Points
• Tension is not present in the MPFL unless there is a
lateral displacement force, which can be simulated by
applying 0.5 N of lateral force.
• MPFL grafts reach maximal length between 20 and
30 degrees.
• Due to varying patient anatomy and radiographic land-
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marks, length change of the MPFL graft through the ROM
is the most important consideration.
• A properly positioned MPFL reconstruction can be placed
through immediate full ROM to avoid knee stiffness.
• While there are a variety of fixation methods about the
patella, only techniques that do not incorporate bone
drilling can avoid fractures.
• Most currently available reports predate the information
provided by Tanaka et al21 and may need modification in
the future.
• Overtensioning of the MPFL graft must be avoided.
• Thorough assessment of patient comorbidities is essen-
tial in order to maximize outcomes.
Conflict of Interest
Dr. Delanois is a paid consultant/presenter/speaker for Corin
USA. He is also a board/committee member for the Mary-
land Orthopaedic Association. Dr. Bonner receives research
support from or is a paid consultant/speaker/presenter for
DePuy, LifeNet, Mitek, and Zimmer. He receives IP royalties
from Zimmer. He is also a board/committee member for the
Arthroscopy Association of North America. The remaining
authors have no disclosures to report.
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