Medial Quadriceps Tendon-Femoral Ligament Reconstruction

John P. Fulkerson

Sheeba Joseph

INTRODUCTION

Pathogenesis

Reconstruction of the medial patellofemoral retinaculum is often necessary in the surgical treatment of recurrent patellar instability.
Recently, attention has been focused on the medial patellofemoral ligament (MPFL) and its reconstruction, yet this structure is only one component of a complex medial retinaculum. Most or even all of this complex retinaculum can be seriously disrupted following a lateral patellar dislocation. Multiple authors have focused attention on the exquisite complexity of this medial retinaculum.¹,²,³,⁴ Tanaka et al have appropriately called this the medial patellofemoral complex (MPFC) in order to more fully appreciate the multiple medial patellofemoral supports.²
Patellar fracture has been a particularly serious complication of MPFL reconstruction because of the need for drill holes in the patella to secure the graft into the patella osseous structure.⁵,⁶
As a result, a technique has been developed by the authors for reconstructing the medial quadriceps tendon-femoral ligament (MQTFL), which is the most proximal component of the MPFC7 (Figure 10.1).
The femoral attachment of MQTFL is crucial. The knowledge of the relationship between MQTFL femoral attachment and adductor magnus tendon, adductor tubercle, medial epicondyle, and vastus medialis obliquus is important to perform an anatomic reconstruction (Figures 10.2 and 10.3).
Table 10.1 lists indications and contraindications for MQTFL reconstruction.

Figure 10.1 Schematic drawing of left knee viewed from anteromedial aspect of final medial quadriceps tendon-femoral ligament graft positioning and weaving through vastus medialis obliquus and medial quadriceps tendon.

SURGICAL MANAGEMENT

Preoperative Planning

Before reconstructing the MQTFL, the patella must be optimally aligned with the trochlea. In some cases, a tibial tubercle transfer is necessary to establish balanced tracking as a prerequisite to medial patellofemoral stabilization.

Figure 10.2 Right knee, medial aspect: the red ball is at the distal most extent of the adductor tubercle. Note proximal medial quadriceps tendon-femoral ligament (MQTFL) fibers (trajectory paralleled by needle) emanate from this location, which is where femoral fixation must be placed to reproduce the proximal MQTFL component of the medial patellofemoral complex. Blue ball is at the medial femoral epicondyle.

If the patient has lateral tracking of the patella with distal and/or lateral articular surface breakdown, then anteromedialization of the tibial tubercle is advisable to minimize contact on damaged or painful patellar articular cartilage while aligning the patellofemoral articulation.⁸,⁹

Figure 10.3 Right knee, medial aspect: the adductor tubercle (a), the distal most extent of the adductor tubercle (asterisk) and the medial femoral epicondyle (hash) are marked. Note proximal medial quadriceps tendon-femoral ligament (MQTFL) fibers (outlined in dotted red lines) emanate from this location, which is where femoral fixation must be placed to reproduce the MQTFL component of the medial patellofemoral complex. Blue dashed line outlines the medial edge of the vastus medialis obliquus, and green dashed line outlines the posterior edge of the adductor magnus tendon.

In some patients with patella alta, slight distalization may be accomplished at the time of tibial tubercle transfer. This is not usually necessary, and recent evidence suggests that distalization carries some risk of increased patellar articular loads in early flexion.¹⁰

TABLE 10.1 Indications and Contraindications for Medial Quadriceps Tendon-Femoral Ligament Reconstruction

Indications	Contraindications
Any patient needing restoration of MPFC (commonly, MPFL reconstruction) to control lateral patellar instability Revision of failed MPFL reconstruction Preferred to any procedure involving patellar drilling or cortical bone disruption in contact athletes to minimize fracture risk Preferred to patellar drilling procedures in skeletally immature patients Preferred in any patient who has had a previous procedure involving cortical disruption of the patella (bone tendon bone anterior cruciate ligament reconstruction) Quadriceps tendon autograft reconstruction (Fink method, see Chapter 8)	Patients in whom satisfactory patellar stability may be restored by MPFC imbrication or repair Patients in whom tibial tubercle transfer (medialization, anteromedialization, distalization) alone restores satisfactory stability
Abbreviations: MPFC, medial patellofemoral complex; MPFL, medial patellofemoral ligament.