Hello, this is John Pulaski and I'm going to be talking about the superficial quad technique for MPFL reconstruction. I want to thank Dr. Deepak Goyal who originally described this procedure. This is one of among several procedures described utilizing the quadriceps tendon, but this is his technique specifically and has been used quite successfully. Dr. Goyal is from India and he is an arthroscopy and sports medicine knee surgeon. Below is the reference for his article including the surgical technique which was published both in AJSM but there's a surgical technique video at the reference below which I think can be helpful in learning how to do this technique. So thanks to Dr. Goyal and we'll talk about his technique now. So you want to start with an incision about 7 to 8 centimeters long, starting at the midpoint of the patella and moving proximally. That's what this picture is showing. There's your quadriceps tendon. Patella is to the left and proximal thigh is to the right. Proceed with blunt dissection down through the subcutaneous tissue to make a mobile window so that you can move back and forth proximally and distantly and get the appropriate graft length and also dissect down onto the patella which we're going to show in a minute in order to flip the graft and pass it through the tunnel. You want to incise the superficial fascia over the tendon to expose the native tendon. So you can separate the lamina. Then you want to identify the superficial lamina of the quadriceps tendon and this is best seen about 2 to 3 centimeters proximal to the patella where the layers of the superficial lamina, the superficial lamina, middle lamina, and deep lamina are relatively distinct. They get very confluent as you get more distal towards the patella. So you want to find this at the muscular border and separate this bluntly with scissors and then you'll take the entire width of that superficial lamina between the vastus muscles and dissect those layers off. You want to dissect proximally and distally in that plane and this shows it being separated out. That's the superficial lamina and that's the entire width of it which is about that 10 to 13 millimeters wide. So it's important to recognize that as you get more distal in your dissection you need to convert to sharp dissection within about 2 centimeters proximal to the patella where those layers again become confluent. You sort of have to stay in that layer and continue down to the patella. Prior to amputating your graft proximally you need to measure the graft length that you feel like you need. To do this you want to flex the knee to about 30 degrees and measure from the medial border of the patella to the medial epicondyle just on the skin and then add about another three centimeters to allow for the turn across the patella as well as the tunnel that you dock the graft into on the femur which is going to be about 30 or so millimeters in length. So this shows our tendon out and separated that superficial lamina the deep quad tendon remains. So cut the graft proximally to your desired length and then leave it attached distally but you're going to sharply dissect in that subperiosteal plane onto the patella keeping the graft attached and you're going to do this in sort of a triangular pattern where the medial dissection stops at the superior medial border of the patella but you're going to continue the lateral dissection down to about the mid patella so you almost have this triangular peel off of the quad tendon off of the patella although it's remaining attached. So at this point the graft is then rotated 90 degrees medially and this is sort of like folding a flag you're going to get this again triangular fold in the graft where the deep becomes superficial and the medial becomes the superior border of your new MPFL and at this point you're going to suture this with number two sutures over the patella and again this shows that graft and then this shows the graft turned and you can see that triangular pattern where the graft is flipped and the deep layer is now superficial and the border is flipped up and it's 90 degrees rotated over to go medially for the MPFL graft. So now you're going to do pretty much your standard MPFL technique where you're going to tunnel to the medial epicondyle so you lift up the VMO bluntly dissect deep to the VMO between the retinaculum and the capsule make another two centimeter incision over the medial epicondyle and you want to find the isometric point there's several different ways to do that one is the radiographic way described by Schottel the other one is to find the midpoint between the medial epicondyle and the hadrocteric tubercle whichever way you'd like to do it or whichever way you do in your standard MPFL technique is fine and then to confirm that you're at this isometric point you want to roll you want to roll the graft around the beef pin then flex and extend the knee and if the graft isn't changing in length you know you found the isometric point if you don't at that have the isometric point at that time then you can reshoot the pin and change the position a little bit and find it then in the standard way we have a six millimeter tunnel to about 35 millimeters in depth suture the graft so you can pass the sutures through that tunnel and then pass the beef pin from medial to lateral pulling the graft through and this is where you optimize the graft length instead of tension obviously the MPFL can be made too tight which makes a very miserable patient a very stiff knee so the way it's described to do this is to optimize the graft length and you basically pull the graft into the tunnel about 30 degrees of flexion then extend the knee and check for about 50 lateral excursion of the patella so it still kind of floats on top and can move about 50 of the width of the patella and then move back to 30 degrees and you can fix with a seven millimeter interference screw keeping that same tension and length on your graft and then it can be helpful to do a second look arthroscopy to dynamically look at how the patella engages and how it moves into the trochlea with flexion extension to be sure that it's stable but not overly constrained for rehab we do weight bearing is tolerated in a long knee brace immediate quad strengthening you really haven't detached anything and tends to be very stable you do active range of motion is tolerated and discontinue the brace after one week or so and proceed with a normal MPFL type rehab thank you very much

superficial quad technique

MPFL reconstruction

Dr. Deepak Goyal

graft length and tension

quad strengthening and rehab exercises