International Journal of Surgery Open 43 (2022) 100482

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International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Case Series

Medial patellofemoral ligament reconstruction using superficial layer of

quadriceps tendon autograft: A case series of three patients
Andri Maruli Tua Lubis a, *, Muhammad Ade Refdian Menkher b, Riky Setyawan b
a
Sport Division, Department of Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
b
Department of Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Recurrent patellar dislocation which caused by Medial Patellofemoral Ligament (MPFL) injury could
MPFL be treated by MPFL reconstruction. This study evaluated MPFL reconstruction using superficial layer of quad­
Superficial layer riceps tendon autograft with knee functional outcome.
Quadriceps tendon
Method: Three patients with recurrent patellar dislocation underwent MPFL reconstruction with superficial layer
IKDC
of quadriceps tendon autograft. The central quadriceps tendon was harvested at the superficial layer of the
Tegner-lysholm
Modified cincinnati tendon. Then the proximal autograft routed medially on the periosteal hinge through vastus medial muscle.
Functional outcome using IKDC, Tegner-Lysholm, and Modified Cincinnati were assessed pre and post-operative.
Result: A good stability and painless knees were achieved. IKDC score, Tegner-Lysholm, and Modified Cincinnati
was improved from pre-operative to post-operative. No severe postoperative complication was recorded.
Discussion: The superficial layer of quadriceps tendon has similar biomechanical and anatomical macroscopic
attribute to native MPFL. The procedure using quadriceps tendon was simple and has fewer complication than
using other autografts, such as hamstring tendon, adductor tendon, and patellar tendon. The one-year follow-up
outcome of this procedure is excellent.
Conclusion: MPFL reconstruction with superficial layer of quadriceps tendon autograft was proven to prevent
patellar dislocation without deteriorating quadriceps muscle strength and produced knee stabilization with
functional score improvement.

1. Introduction tendon has similar morphology to the MPFL and the technique is simple
and easily reproducible with low morbidity and good functional
The medial patellofemoral ligament (MPFL), the primary passive outcome in patellar stability [1]. The objective of this series is to eval­
restraint to patellar lateral displacement is a 55 mm long band of reti­ uate the short-term results of MPFL reconstruction using superficial
nacular tissue connecting the femoral medial epicondyle to the medial layer of quadriceps tendon autograft with recurrent patellar dislocation
edge of the patella [1]. The patella is usually dislocated laterally, and caused by MPFL injury. To evaluate functional outcome, several scorings
therefore causing ruptures of the MPFL in approximately 90% of the are used including IKDC, Tegner-Lysholm, and Modified Cincinnati. This
patients [2]. Recurrent patellar dislocation defines as two or more epi­ work has been reported in line with PROCESS criteria [6].
sodes of dislocation of the patella [1,2]. It commonly affects adolescent
and young adults, particularly among females. The MPFL acts as the 2. Methods
main ligament restricting lateral translation of the patella. Hence the
MPFL reconstruction is the primary procedure in preventing further We reported a case series of 3 patients with recurrent patellar
dislocation [1]. dislocation. The first patient, a 22-year-old female, presented with pain
The reconstruction of MPFL can be performed with either a on her left knee for one year. In 2008, she experienced first time patellar
hamstring tendon, adductor tendon, patellar tendon, or quadriceps dislocation after injured while playing badminton. Physical examination
tendon autograft [3,4]. Based on Calapodopulos et al. [5], quadriceps of bilateral knee demonstrated dislocated patella on 0 to 45◦ of flexion.

* Corresponding author. Sport Division, Department of Orthopaedic and Traumatology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo
Hospital, Jakarta, Indonesia, Jl. Diponegoro no. 71, Jakarta, 10430, Indonesia.
E-mail address: [email protected] (A.M.T. Lubis).

https://doi.org/10.1016/j.ijso.2022.100482
Received 1 September 2021; Received in revised form 26 April 2022; Accepted 1 May 2022
Available online 19 May 2022
2405-8572/© 2022 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.M.T. Lubis et al. International Journal of Surgery Open 43 (2022) 100482

Evaluation of left knee movement flexion to extension was 0-125◦ . Modified Cincinnati [10] as shown in Table 1. There was no severe
Physical examination of the patient was shown J-sign (Fig. 1, Fig. 2). complication reported according to this procedure.
The second patient, a 21-year-old female presented with pain on his
left knee for 1.5 years. The patella was dislocated after she fell with 4. Discussion
flexed knee and her left knee directly hit the floor, but spontaneously
reduced. Physical examination of left knee revealed dislocated patella There are many graft choices for MPFL reconstruction including
on 40 to 50◦ flexion. Evaluation of left knee movement flexion to hamstring tendon, adductor tendon, patellar tendon, and quadriceps
extension was 0-100◦ . Physical examination of the patient was shown J- tendon. Hamstring tendon has adequate mechanical property to provide
sign. graft strength. However, hamstring tendon has rounded and cord like
The third patient, a 28-year-old male, presented with pain on his left appearance, unlike the MPFL that is thin and flat band. The patellar
knee for 1 year. The patella was dislocated after he had injured at tunnel drilling was performed for the reconstruction hence it could in­
football match. Physical examination showed dislocated patella on 20 to crease risk of patellar fracture [11–15]. The adductor magnus tendon
40◦ flexion and valgus deformity. Evaluation of left knee movement has similar morphology with native MPFL, however it was compound of
flexion to extension: 0-135◦ . Physical examination of the patient was the saphenous nerve, or the saphenous branch of the descending gen­
shown J-sign. Prior to surgery, we conduct consultations regarding the icular artery [16]. Patellar tendon is used in MPFL reconstruction with
patient’s preoperative condition with the department of anesthesia and several advantages including good result in quality of life, sport activity,
internal medicine. or pain sensation, and no tubercle bony attachment was involved.
We then proceed to performed MPFL reconstruction in all the pa­ However, it can caused anterior knee pain and kneeling pain because of
tients using superficial layer of quadriceps tendon autograft. Arthro­ tendon harvesting procedure [17].
scopic evaluation for patella and lateral patellar soft tissue release were Superficial layer of quadriceps tendon autograft has morphology that
performed using anterolateral portal. Then the central superficial layer mimics the native MPFL and easy to harvest [5]. The patellar bone
of quadriceps tendon autograft was harvested with longitudinal incision structure was minimally disrupted during the harvesting procedure, and
starting at upper pole of the patella (Fig. 3). The autograft is routed minimize the risk to violate the patellar articular surface [18]. The
medially on the periosteal hinge and the proximal autograft was shifted procedure does not require bone tunnel in the patella and the patellar
below through vastus medial muscle (Fig. 4). bone insertion is preserved. It also has a minimal surgical scar compared
Then the autograft was fixated into Schottel node of the medial to other procedure which make a better cosmetic aspect. However the
femoral condyle using bio-absorbable interference screw. All surgical quadriceps tendon has several disadvantages including the different site
procedures were performed in our hospital by the author (Andri Maruli of native MPFL origin that can cause patellar malrotation or patellar tilt,
Tua Lubis), an experienced orthopaedic sport surgeon. After surgery, the and shorter autograft length to correct isometry [19,20].
patients were immobilized with knee brace for 6 weeks and then did a Study conducted by Goyal et al. demonstrated there was a significant
rehabilitation. The patient was allowed to mobilize with partial weight difference between preoperative and postoperative Kujala score in
bearing for 3 weeks post-operation with the gradual ROM exercise to quadriceps tendon autograft for MPFL reconstruction. This study also
achieve 90◦ flexion. After 3 weeks, patient was started to do full flexion compared the results with other autograft options and showed relatively
exercise gradually, and allowed to do active daily living (ADL). The pre similar results. However, the use of hamstring as the autograft is asso­
and post-operative outcome scores were then obtained in three scorings; ciated with patellar fracture attributed to patellar fixation of the auto­
IKDC [7], Tegner-Lysholm [9], and Modified Cincinnati [10] as shown graft. Quadriceps tendon autograft does not require bony fixation on
in Table 1. patella and indirectly eliminates complications associated with patellar
fixation [21].
3. Results The superficial layer of quadriceps technique has several advantages
on its appearance including breadth, length, and thickness of the graft. It
The patient had no complaints about the knee after surgery. A good has similar strength and stiffness to the native MPFL. The graft provides
stability was achieved by evaluation of the pre and one-year post- continuous patellar attachment at superomedial edge of the patella.
operative outcome scores using IKDC [7], Tegner-Lysholm [9], and Hence, the quadriceps tendon strength can be maintained. The disad­
vantage of this autograft is the difficulty in the superficial layer of
quadriceps tendon harvesting procedure [4].
There is various techniques performed in MPFL reconstruction using
quadriceps tendon. The autograft could be harvested in central or
medial of the quadriceps tendon; the medial routing could be sub-
cutaneous, sub-retinacular, or sub-periosteal; and the fixation could be
using femoral fixation technique, suturing technique to bone and soft
tissue, interference screw, and anchors [8]. In this case, we performed
the central quadriceps tendon harvesting and rerouting the tendon
below vastus medialis to minimalize the risk of prepatellar tissue dam­
age. The fixation were performed using bio-absorbable interference
screw in the Schottel node at medial distal femur and construct more
anatomical fixation of the autograft [8,22,23].
There was several knee evaluation score used in this study, including
IKDC Score, Tegner Lysholm, and Modified Cincinnati. IKDC score
consists of symptoms, sport activities, and function with the result range
from 0 to 100 with higher result has higher functional outcome [7,24].
Tegner-Lysholm and Modified Cincinnati score consists of pain intensity,
stability, daily and sports activity living with Tegner-Lyshom adding the
gait and meniscus injury in the point. Tegner-Lysholm has range from
0 to 100 [9,25], while Modified Cincinnati has range from 6 to 100 [26].
Fig. 1. Physical examination of the left knee showed J-sign on flexion and This study evaluated these scores within 1 year interval from
extension movement. pre-operative to post-operative.

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A.M.T. Lubis et al. International Journal of Surgery Open 43 (2022) 100482

Fig. 2. Pre-operative x-ray AP and Lateral (Insall Salvati Ratio 1.18), skyline view, and MRI of left knee.

et al. [27,28] Nelitz et al. report results in 25 consecutively treated

children and adolescents who underwent MPFL reconstruction with a
pedicled superficial quadriceps tendon autograft [28]. At the 2-year
follow-up, a significant improvement in functional scores (Kujala Knee
Function Score and Tegner Activity Score) with no re-dislocations was
documented. Another study conducted by Rhatomy et al. also high­
lighted significant improvement in IKDC and Kujala score after quadri­
ceps autograft use in MPFL reconstruction after 2 years follow up [29].
This study also showed no complication including patellar fractures or
recurrent dislocation. Most importantly, all patients did not suffer from
decrease in ROM in the knee.
There was no study that evaluated the Modified Cincinnati Score and
Tegner Lysholm score. In this study, we provided the both score and the
result was improved between pre and post operation. The results are

Table 1
Evaluation Score in Pre-operative and Post-Operative MPFL reconstruction using
quadriceps tendon.
Scoring Patient 1 Patient 2 Patient 3
Fig. 3. The quadriceps tendon of left knee was split and dissected sub­
IKDC Pre-operative 43.7 50.6 46.0
periosteally over the anterior aspect of patella [7,8]. Post-operative 83.9 96.6 97.7
Tegner-Lysholm Pre-operative 64.0 66.0 64.0
In our study, there was mean improvement 98.3% of IKDC score, Post-operative 85.0 94.0 96.0
Modified Cincinnati Pre-operative 50.0 54.0 53.0
41.7% in Tegner-Lysholm score, and 71.4% in Modified Cincinnati
Post-operative 80.0 92.0 98.0
score. This result was similar with study By Nelitz et al. and Rhatomy

Fig. 4. Harvesting quadriceps tendon autograft of left knee, re-routing medially through vastus medial, fixation using interference screw in the Schottel node of
medial femoral condyle.

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A.M.T. Lubis et al. International Journal of Surgery Open 43 (2022) 100482

consistent with our findings, in which all of the three patients included Guarantor
in this case series showed improvement in all functional outcome scores
after quadriceps autograft. There was several complications of quadri­ Andri Maruli Tua Lubis, MD.
ceps tendon use in MPFL reconstruction reported in several studies
including: loss of flexion compared to the other side after 12 months, Declaration of competing interest
and infection that requires surgical debridement [8].
Meta-analysis study also compared the recurrent instability among The authors declare that they have no known competing financial
different autografts, including gracilis, semitendinosus, quadriceps, and interests or personal relationships that could have appeared to influence
adductor tendons. All autografts showed relatively low rate of recurrent the work reported in this paper.
instability, respectively 0%–11% in gracilis, 0%–6.3% in semite­
ndinosus, 0% in quadriceps, and 5.6–8.3% in adductor tendons [3].
Acknowledgement
However, one study showed stiffness and hypertrophic scars in MPFL
reconstruction using quadriceps tendon autograft. Our case series did
We thank to all staffs, residents, and patients for the support for our
not show any related complication [30].
study.

5. Conclusion
Appendix A. Supplementary data

In conclusion, we recommend the use of superficial layer of quad­

Supplementary data to this article can be found online at https://doi.
riceps tendon autograft in MPFL reconstruction in patients with recur­
org/10.1016/j.ijso.2022.100482.
rent patellar dislocation caused by MPFL injury. It presents the
advantages that no bone tunnels in patella are needed, no quadriceps
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