Medial patellofemoral ligament (MPFL) reconstruction has become a popular surgical option in the management of patellofemoral instability in select patients. Recently, Fulkerson and Edgar have suggested that the MPFL reconstruction may be anatomically incorrect [6]. Through detailed anatomic dissections of the deep medial knee retinaculum, Fulkerson and Edgar have demonstrated a consistent prominent structure extending from the distal deep quadriceps tendon to the adductor tubercle region, forming a distinct medial quadriceps tendon-femoral ligament (MQTFL). In their published series, reconstruction of this anatomic structure yielded consistent medial stabilization of the patellofemoral joint without drilling into the patella in 17 patients with recurrent patella instability with greater than 12 months follow-up [6]. Further research is required to investigate the anatomic and functional importance of the MQTFL.

Although posterolateral corner (PLC) injuries may occur in conjunction with up to 7.5 % of ACL injuries [7], this combined injury pattern is still often missed. Failure of recognition and appropriate treatment of PLC injury places increased stress on ACL reconstructions and may predispose patients to early graft failure. Anatomic extra-articular restoration of injured PLC structures will likely protect anatomic ACL reconstruction and optimize functional outcome in patients presenting with this combined injury. Kim et al. recently demonstrated that within a population of 425 patients, 32 patients who presented with combined PLC and ACL injury and were managed with anatomic PLC and ACL reconstruction had significantly less anterior tibial translation and comparable functional outcome scores at 2 years postoperatively when compared to 393 patients with isolated ACL injury who were managed with ACL reconstruction alone [7]. Interestingly, in a recent cohort study, Yoon et al. found no objective or functional benefit to the addition of a popliteal tendon reconstruction in addition to an anatomic PLC reconstruction [8]. This illustrates the importance that knee surgeons remain focused on restoration of anatomy in order to achieve the best possible patient outcomes.

Early medial collateral ligament (MCL) reconstruction involved nonanatomic sling-type procedures that frequently resulted in residual laxity, loss of knee motion, and disappointing patient outcomes. Over the past 10 years, a number of more anatomic procedures for MCL reconstruction have been developed, typically involving hamstring tendon graft with modern fixation devices to reconstruct the superficial MCL. These procedures have demonstrated improved results compared to early techniques; however, they fail to address the injured posteromedial structures in addition to the superficial MCL. Recently, LaPrade and Wijdicks, in conjunction with the University of Oslo, Norway, have undertaken detailed quantitative anatomic studies in addition to static and dynamic biomechanical studies in order to develop an anatomic medial knee reconstruction. LaPrade and Wijdicks’ [9] technique consists of a reconstruction of the proximal and distal divisions of the superficial medial collateral ligament in addition to the posterior oblique ligament (POL) using two separate grafts. In a group of 28 patients with MCL insufficiency followed prospectively for an average of 18 months, LaPrade and Wijdicks found this anatomic technique to restore valgus, external rotation, and internal rotation stability and improve patient function [9]. Future medial knee reconstructions may benefit from the addition of POL reconstruction in order to truly restore patient anatomy and optimize postoperative function.