Reconstruction. Shital, can you hear us? Yeah, I can hear you. Can you hear me? And we can hear you. Can you hear me? Yep, we can hear you. OK, so we are going to demonstrate our MPFL reconstruction using an allograft, a free allograft technique. This is a left knee. Can we show them the left knee? We have the medial side here, the lateral side here. And what I've done is made an incision here. So my typical incision would be a little bit shorter than this, so it's about 3 to 4 centimeters long right now. But my typical incision would be around 2 and 1 half to 3 centimeters. And then we go down and create sub-Q layers, sub-Q flaps on both medial and the lateral sides. And then I palpate the patella. And the incision is just over the medial border of the patella. You can also use a midline incision if you think that you have to do a lateral release or lateral lengthening. And I would rather make a midline incision so I can go lateral as well. But for most of the cases, for isolated MPFL, I would make a medial incision, which is typically just a touch smaller than what it is now. And then I would just make the sub-Q flaps, medial and lateral. So we'll have a little bit of retraction here so we can see it. And then I would take a bovie, and I would go down the medial border of the patella here. So I can feel the medial border here. I don't have a bovie, so I've just taken a knife and I've gone through it here. But I'll show you a little bit in detail this small incision. You don't have to make it too big. And where you have to make it is just, if you palpate the patella, the maximum width of the patella, just above it is where your tunnels are going to be in the patella. Now, studies have shown no significant difference whether you fix with an anchor, whether you fix it in tunnels, whether you fix it with a docking technique or just suture it to the soft tissues, like the weave technique we saw in the front before this demonstration. But my preference is to use a patella tunnel. I would take the tissues off the first and the second layer. I always want to see the first layer, the VMO, right in here, the VMO. And then I go in and dissect the second and the third layers. And my dissection is between layer two and three. So once you take the retinacular layer off from the patella, and I don't know how well you can see it, but you can see the fibers of the capsular tissue. It's yellow in color. It has a little bit of fatty tissue there. So you know you're in the right plane. And then you just want to dissect and go where your femoral insertion point is. Right now, I would not pierce the retinaculum and come out here, because I don't know where my femoral attachment point is. But I'll make this interval right at this moment. And then I would do my patella tunnels. So for the patella tunnels, I typically use the 3.5 drill bit. It doesn't matter what size graft I have. I make sure the graft fits the tunnel rather than making a tunnel fit the graft. So I use a 3.5 millimeter tunnel. I palpate the patella, and I just go above the midpoint of the patella. So if this is the patella just above the equator of the patella, I would go in for about a centimeter in the tunnel. Once I am about a centimeter in the tunnel, then I take it out and I put an instrument. I usually put the outflow cannula, but here I'm just going to put this guide pin. And that is going to tell me the depth of it. I can make sure that it's about one centimeter deep here. And then I'm going to come a little bit further on the lateral side here. And I'm going to create a one centimeter bone bridge about one centimeter right in this area here. I'm going to drill my second tunnel coming from the front to the anterior to posterior. So I'll make that tunnel, direct it a little bit towards my previous tunnel, and I make sure that I'm touching my wire here. And I can feel it right now. So I do this tunnel. Then I take a curette, because now we have two right angled tunnels like this. And I want to make sure I chamfer the sharp edge of it. So I take a curette, and I put it in the tunnel. And I make sure that I chamfer the curved part of the right angle part of the tunnel from both sides. So that would make a circular tunnel. Now once I've done this, then I would take, see this, I'll take this Y-crill here. It's an OS6 needle, which is typically about a centimeter and a half is the radius of curvature, which fits very well into the tunnel. So I use this, just a Y-crill suture, and I put it in this tunnel here so that it comes out from the other part. So it's not too difficult to pass my suture. You can see that it fits in really well. And then I put a loop at the end of this suture, which I have it here. And now I pass my graft. So I pass the narrower end of the graft. I just kind of taper it so that it's easy to pass. And then I would just pass the graft without suturing it. I pass the graft, and I pull it out. I may have to use some mineral oil if I'm using an allograft, but typically it would go. OK? All right, so I've passed the graft here. Then what I would do is grasp this end of it and pull it out, and then I would suture it. So if I do the suturing like this, it keeps my tunnel size smaller, especially if I'm doing an epiphyseal. It does decrease the tunnel size when I have both ends sutured together. So I'll do this, and Carl, my friend here, colleague, is going to help me suture this together. I use a number two fiber wire suture. In the meantime, we'll go ahead and do the femoral tunnel. So we're just going to use our regular suture technique to suture the graft. And what I'll do next is put my femoral guide pin. I use fluoro. So you can see the lateral and the AP shots here on the fluoro. We have already put our guide pin in. So you know the shuttle's point, just anterior to the posterior femoral cortical line. We'll put the guide pin. And on the AP, you can see it's just distal to the adductor tubercle. So I've placed my guide pin in this area. Now, what I would like to show here is that if, for some reason, you are not happy with the placement of the guide pin, or if you have a revision case and you want to check whether it's an isometric position, then what you can do is you can open up, like I've opened up here, and I hope that you can see it here. You can see this well, the opening here. I've just extended it approximately to show the insertion point of the MPFL on the femur if you're doing an open technique without the fluoro. So what you want to do is you palpate the adductor tubercle, which I can palpate it right now. And to confirm it, you can just dissect the adductor tendon. This is the adductor tendon. And you can see the adductor tendon. If you trace the insertion of the adductor tendon, it is inserting at the adductor tubercle and just distal to it in the saddle where the MCL is going to be right here. Just distal to the adductor tubercle is your guide pin. It's more reliable than using fluoro. If you just put the guide pin just distal to the adductor tendon insertion, it is exactly in that position when you do the shuttle point. But sometimes if you have dysplasia of the distal femur or if you're questioning your insertion, then it's better to confirm it with a little bit of opening here. So now that we have the guide pin positioned here, I'm going to push the guide pin all the way through on the other side. And then we have the graft is already sewn together. So we have the graft here. Now we typically size it. And we have this is a 7 millimeter sizer here. So it's going very easily through it. We'll have a 6 millimeter sizer here. So it goes through a 6. And then we have a 5. And it's not going through 5. So it's typically between a 5 and a 6 here. So the next thing what I'll do is I'll put my graft between the two layers. But now I would use this, my hemostat. And I will pierce through the retinaculum to come out of the medial portal. Because now I know where my graft is going to be on the femur side. So it is easy for me to go in this direction. You can see. And then I curve it so it follows the curve of the condyle. And then I want to come out exactly where the pin is coming, the pin is being positioned. So if I do it beforehand, then it's possible that I'm putting it here. And then it gets curved into the tunnel or comes from proximal to distal. This way I know that I'm exactly in the position where the pin is. So now I'll take that vicryl suture loop that I had that I used to pass the, or I can take any suture loop. That's OK. And then I'll pass the graft through the interval between layers 2 and 3. And you can now check your isometricity. You can put it around the pin. And you can check your flexion extension. You can check your tension here. You can see the graft, how it looks here. And then once I'm happy with it, then I would just put my graft in the islet. And let me just turn it a little bit to point. Or I can see it. That's fine. Perfect. OK, so we'll have both ends. So we have put it through the islet. And now we'll pull the guide pin out of this incision. But I like to hold this here in position. We can pull it out. And then the reason I want it not to go all in one pass is because I usually do the medial side percutaneously. So I don't want it to bunch up against my tunnel. Did we drill all the way through? We did not do the 8. We have not drilled. So let me have the guide pin again. So we need to drill our tunnel. So I'm just going to put this back into our position here. Sorry about that. OK, let's get the drill. So we measured that it was about 5 and 1 half. But this is a little bit bigger drill bit so that we don't have any issues passing the graft. I will drill it up to the other cortex, typically. But you can just drill up to the side based on the size of your graft here. And then before we put the graft in, I'll put the 19-hole wire so that I can put an interference screw when I get the graft in the tunnel. So here is my sutures. I need to put the other suture in. One minute. OK, all right. So we can pull the suture. We can pull the gut. OK, so now I'll pull the graft in the tunnel. And I want to make sure that I feel it going in, which I did. And you can see it on the medial side how it's going in the tunnel. Now, what I do at this time is I put my knee in flexion. And I put a hemostat against the skin here. And then I check it. Before I put my interference screw, I check it clinically, make sure that it's not too tight inflection or extension. I need about one to two quadrants medial and lateral positioning or displacement. And I check it with my scope as well. I want to make sure that I can see my graft. Because sometimes it can happen that you have made your tunnel between layer two and three, but you may have pierced the capsule at some point and the graft is intra-articular. I hope it's not in this position that we'll check it. We have the trocar for the scope? Otherwise, we can make it happen. I don't see it up here, Jim. OK. Let's give it an extension a little bit. OK. There we go. All right, we have our scope in. So we'll check how it looks. Without fixation, we just have our graft in. And one thing you can notice, see, I have the fluid running. And if the fluid is not coming out here, that means that I have not gone through the capsule. Because if I had gone through the capsule, I would see fluid coming out of my incision. So that kind of helps me to know that my graft is not, at least not violated the capsule. It's in, but it's getting stuck somewhere. OK, all right. OK, so let's see the graft now. How does it look on the fluoro? I don't need the teller. The knee has been operated on a few times, so it's a little bit difficult for me to see here, but okay, now you can see it. So you see this shadow here, and that's the shadow I'm pushing on it. You'll see it a little bit better if you don't have it here. There's a lot of, you know, leaking of the fluid here, and I'm not able to, you know, distend the knee very well. But if the knee is distended, you'll see the graft sticking very well right in this area here. And you can even check the functioning of the graft. Like when you're moving the knee from flexion to extension, you can look at the functioning, but you need an intact knee for that. But anyways, I'm happy with the positioning of the graft here. So the last thing I would do is, once I'm happy with it, is I would put the interference screw in. And this is the same size as the tunnel. It is 30 millimeters long. And when I'm putting it, I'll flex the knee, make sure the patella is engaged in the trochlea, and then I'll go ahead and fix it with the interference screw. And then we can check the entire construct once the screw is positioned on the medial side here. And so that's your MPFL. Now, if you look at the x-rays one more time, you can see the position of the patella tunnel, that it is positioned just a little bit above the maximum width of the patella. That is where I would like it to have. And then clinically, you can check the positioning of the graft, the MPFL graft here, well-tensioned here. And the last thing I would do is imbrication of the medial structures. So I'll take a suture, and I'll imbricate this structure on the MPFL. And I'll just show one stitch, and then we can take any questions if they have. So I'll just show the closure part of this MPFL here. I'll take a suture here, and we'll do a pants-over-vest repair. So we'll take a little bit of tissue from the medial side and then put it over the lateral side. Thank you. And that way, we can imbricate the medial tissues. It's a pants-over-vest repair. You can see the overlap between the tissues. It takes a slack from the medial side and covers the MPFL graft. So those were the main points about surgery. We'd be happy to take questions. And we have Karl, who has helped me with surgery, so I'll really acknowledge his help. Any questions? Shatol, what is the youngest kid that you will do an MPFL reconstruction, and what modifications do you do for the younger kid? OK, so the question is about younger kid. I think I've done about a 7-year-old is my youngest, because the ones that are prior to that age, like I've done a 3- and 4-year-old, but they are all quadricepsplasty for other types of instability. But I would say youngest that I've done an MPFL has been 7 years. And the modification is to move your point distal, do the drilling under fluoro. I still use the pull-through technique. I don't use a socket on the, I mean, I don't use a full tunnel, but I still use a pull-through technique on the epiphysis of the femur. So I'll just make sure that I drill under fluoro, and I keep it below the level of, I mean, distal to the physis. And the position in which you secure the MPFL, does that change based on the height of the patella? No, not based on the height of the patella. So it's typically, I just want to make sure, I always do it in a little bit deep flexion, 45 to 60. And even if you have patella alta, it is going to engage. You know, if it doesn't engage by that much of motion, I mean, that much of flexion, probably that needs distalization. So, you know, I would usually do it between 45 and 60 degrees, is when I fix the graft in. That's great. Thank you very much. I appreciate it. Any... Smooth and easy. I just stood here. So we're going to just transfer a specimen and begin.

MPFL reconstruction surgery

allograft technique

patella tunnels

graft placement

femoral guide pin

imbrication repair