MPFL advancement : Dr Prathmesh Technique
This procedure is developed in advance knee and shoulder hospital by Dr Prathmesh Jain. The procedure is being done since 2017. The procedure has good good results.
Background : MPFL reconstruction has become a standard procedure in treatment of soft tissue patellar instablity. There are many techniques of MPFL reconstruction described by different authors. Most of these techniques have some or other shortcoming. There are also some complications described which include patellar fractures, overtensioning leading to painful medial facet syndrome, recurrent instablity, stiffness etc. Several modifications have been done to minimise these complication.
Conceptually MPFL fails to recreate the Normal MPFL anatomy. The reasons are that MPFL is not a tubular but a capsular kind of structure. Anatomically we equate this to the ATFL ligament of the ankle. we all know that brostrom procedure is actually an advancement of ATFL on the lateral malleolar insertion. The procedures which include reconstruction using peroneus tendon do not do as well.
Surgical technique: The surgical technique is simple and reproducible.
Medial side of patella is exposed sequentially in layers.VMO and quadriceps tendon is identified. Dissection is done to seperate medial retinaculum with the deep capsular layer. Meticulous dissection is done to prevent any rent in the capsule.Once the full capsular layer is identified it is seperated by a blunt dissction with a finger . One can easily appreciate the lax capsule in this region. MPFL is a part of this capsule itself running between the medial epicondyle to the superomedial border of patella. MQTFL is a newly descibed ligament which runs from medial epicondyle to quadriceps tendon. It is also a part of this Capsule. If you carefully see the consisitency of this capsular layer is much weak in patients with patellar instablity.
With a sharp dissection with a no. 15 knife blade the capsular layer is elevated as a sheath from lower pole of patella to 2 cm above the superior pole of patella.Thus with this exposure we have both MPFL and MQTFL in our sheath.With this exposure the undersurface of patella can be inspected. We use 2 5.5 mm PEEK anchors on the medial surface of patella. Patella is predrilled with 4mm drill or one can use an inserter that comes with the anchor set. Once the anchor is inserted all the four thread limbs from each anchor is sequentially passed into the capsular layer. Once all the threads are passed in a mattress fashion the threads are tied. This reduce and advances the MPFL. We now do a double row closure with the suture limbs passing through the soft tissue overlying the patella.This leads to a watertight double row advancement. The patellar tracking is reassesed. The lateral tracking and subluxation are significantly improved.vRetinaculum is closed over the repair in a standard fashion. Immediate ROM can be started in follow up. As it is an anatomical repair the chances of overtensioning is minimal.
This procedure prevents the many issues and problems of MPFL reconstruction surgery . MPFL is not a actual ligament but a capsular thickening.This techniques incorporates this principle and advance the capsular layer on the patella using 2 anchors on the medial surface of the patella. This leads to adequate tensioning of the patella and a strong medial check rein effect.
MPFL tear in an acute injury.
First episode of dislocation , treated with acute MPFL repair with 2 suture anchors. This is an innovative technique developed at advance knee and shoulder hospital. This procedure is particularly used for first time dislocation of the patella. MPFL tear is usually from patellar side.
After its success in acute cases we have starting using the same technique for chronic patellar instablity cases as well. The technique is due for publication. We do athrough MPFL repair after a sequentila release from patella. the fixation is done with 2 suture anchors on superomedial aspect of patella