Five “Plusses” for New Superficial Quadriceps Graft

Around the world, surgeons are working to find better ways to reconstruct the medial patellofemoral ligament (MPFL). We reported on a previous study from China on this topic. Now here is another from India.

The MPFL is the stabilizing ligament that helps keep the patella (knee cap) tracking up and down over the knee. When the patella is dislocated, this ligament is almost always ruptured. And once a ligament is torn, it does not repair or heal itself. Chronic, recurrent patellar dislocation with MPFL rupture is referred to as medial patellofemoral insufficiency.

In order to regain patellar stability and prevent repeated dislocations (ligament insufficiency leading to patellar instability), (surgical) reconstruction is needed. There are many different ways to reconstruct the damaged ligament. Most techniques involve a tendon graft to replace the ligament. Attaching the graft in place (called fixation) creates problems of its own. That’s one reason why surgeons are looking for better ways to accomplish the reconstruction procedure.

In this study, one surgeon from the Saumya Orthocare: Centre for Advanced Surgeries of the Knee Joint in India investigated the use of the superficial quad technique. A superficial slip of the quadriceps tendon is used as the graft. The quadriceps muscle is the large four-part muscle along the front of the thigh. The quadriceps tendon attaches to and around the patella. There are five advantages or “plusses” to this new technique.

First, the graft is a better anatomic match to the original medial patellofemoral ligament (MPFL) in terms of width, breadth, and length. The natural or native MPFL is thin, broad, and sheet-like; so is the quadriceps slip used in this procedure. Two, the superficial quadriceps tendon graft is not as stiff as the commonly used hamstring tendon graft. A strong, stiff graft puts more load on the patellofemoral joint and can cause patellar fracture later.

Three, the superficial quadriceps graft does not have to be held in place with screws or wires. This makes it possible to attach the graft to the medial border of the patella where the MPFL is located normally. The result is a more accurate re-creation of patella biomechanics and elimination of complications from patellar fixation. This is helpful because most common problems that develop after MPFL reconstruction can be traced back to either the type of graft material or the way in which the graft is held (i.e., fixation technique used) in place.

Four, the graft can be harvested arthroscopically with a very small incision. And five, at least in the short-run (first three years), the results are equal to outcomes when compared with using the hamstring tendon.

For those surgeons who are interested in taking a closer look at the superficial quadriceps tendon graft technique to reconstruct a ruptured medial patellofemoral ligament, this article includes a description and photographic display of the 10 steps for the surgical procedure.

The author begins with arthroscopic examination to assess all injuries and damage inside and around the knee joint. Graft harvest, preparation of the graft, and attachment of the graft are part of steps two through eight. The final steps involve getting the most optimal graft length and then repairing any other soft tissue injuries (e.g., medial retinaculum).

In the follow-up of these 32 patients, no one had recurrent patellar dislocations or other patellar complications. One-fourth of the group had problems bending the knee fully and went to physical therapy to resolve the issue. The author suggests that future improvements of the superficial quadriceps procedure (e.g., better fixation points at the femur, elimination of scarring, better arthroscopic techniques) may help prevent this complication and further improve results.