Name: Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction
Uploaded: 2025-12-22T00:00:00Z
Channel: Arthrex
Description: J. Lee Pace, MD (Plano, TX), demonstrates a technique for medial patellofemoral ligament (MPFL) reconstruction using onlay patellar fixation with Hybrid Knee FiberTak® anchors and femoral fixation with the FiberTag® TightRope® II PF implant.

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J. Lee Pace, MD (Plano, TX), demonstrates a technique for medial patellofemoral ligament (MPFL) reconstruction using onlay patellar fixation with Hybrid Knee FiberTak® anchors and femoral fixation with the FiberTag® TightRope® II PF implant.

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VID1-007719-en-US | A | Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction

J. Lee Pace

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction

Hello, my name is Lee pace from Plano, Texas. I am an orthopedic surgeon with a specialty in sports medicine and knee surgery, and I'm here today to show the new Mpfl reconstruction technique using a patellar inlay technique as well as a new mpfl fiber tag tightrope for femoral fixation. So we have a graft here on this disposable graft prep and sizing table. And this is really nice when you're using autograft tissue because you can use this as we're going to show here to scrape muscle off just like this. This stuff just comes right off. Just like that. You can see you can really very easily get all that muscle off of a tendon when you're doing your mpfl reconstruction. So here we have a prepared gracilis graft for an mpfl reconstruction. We want to make sure that this portion of the graft is going to fit through a six millimeter femoral tunnel. So we're going to size that right now. So we're just going to bring this through here and pull this up. And there you can see that that fits very easily through that. We can probably pull that all the way through just like that. So we have a good graft size here. And then another thing to highlight on this graft prep table is at any point during graft prep, if you if you need to or want to, you can actually use these cleats to be able to hold the graft steady and add some tension. So I can just wrap this around here just like this. And now this one side of the graft is is going to be held stationary just like that. And then also if I want to I can also do the same thing on the other side as there's cleats on both sides of this graph prep table. So we've done a standard medial two incision approach for an mpfl reconstruction. Here is our femoral incision right here. That's typically going to be made under fluoroscopic control. Here is our patellar incision. And you can see we've got the medial aspect of the patella exposed. There's a medial patella. There's the joint right there. You can see I've marked out our anchor placement. This is about midway on the patella. And this is about 25% down from the superior pole. So we're going to place an anchor here and here. And then we're going to do an on lay technique to secure the graft between these two anchors. So here is the knee fiber tack ratcheting guide that we're going to use to drill our patellar sockets as well as place our anchors. So you can see this has a ratcheting mechanism with a release mechanism right there. And it's got a spike on one side. And that is meant to anchor in to one side. You can do this percutaneously and just kind of stab through the skin. Or if you would like to, you can also get an idea of where you want to put it. And you can make a small stab incision like this. So usually you want to start and get the lateral side in first. So I'm going to get this down. I can feel very firmly that I am on the lateral aspect of the patella. And then this just simply ratchets down. And I'm going to put this right over my purple mark. So I've got the ratcheting fiber tack guide in place. You can see that it's secured against the lateral patella and the medial patella. So I can kind of move the patella back and forth like this. This is very secure. This will allow very reproducible socket drilling as well as anchor placement. This is just going to bottom out. And then this fiber tack has a blunt inserter to allow for easier insertion on the mobile patella. Take this off. Move this. And then the anchor is in. And now I'm going to set it. So I'm going to pull. And you can see that that is very firmly in place. That is not coming out. Okay. So then I can place the second one. So I'm going to just kind of put it over the spot where I want to put the second anchor. I'll take a second. I'll make sure that that gets right down on the patella. That's very firmly on the patella right there on the lateral patella. We're going to come in here and we're going to just retract that up just a little bit. So I can see where that second mark is. And that looks good right there. Ratchet that down again. You can see very firm control of the patella right there 2.8mm hard bone drill. Bottom it out. And then look at that. Look at how much that actually inserts just with hand pressure. Finish it off with the mallet. And now we'll set this anchor. And again that is firm in there that is not pulling out. Okay. We're going to drill and prepare the femoral tunnel next. This is the Radiolucent Fluoroscopic guide for Shuttles Point which you can use at this point with lateral fluoroscopy. We've already determined where we want our femoral socket to be. So we're going to then take our Beath pin our spade tip Beath pin. And we're going to drill this across the femur. That's just going to poke out the skin of the lateral thigh. So now we can take our low profile six millimeter reamer. And we'll take that over the Beath pin. And you can honestly just take this to the next cortex and don't violate that. But that way you've got all the room you need in case your graft is a little long. And then from there we can switch this out to a fiber snare. And then we can just luggage tag this for later. Okay. Now we're going to fix our allograft on the patella. We've made a mark here at the midway of the graft like so. The first thing we're going to do is we're going to shuttle it through these two loops. Okay. And then we can just start tensioning this down. And we just take it each one at a time. And we're just going to make sure that as we get close that we keep that midpoint in between these two loops. And as we bring it down, you can see we've got our purple midway point basically perfectly between those two. And so we can just continue to cinch that down and cinch that down like that. And so we've got very good fixation now of that gracilis graft right on our medial patella. And you can see I can pull very firmly on that. And those anchors are not coming out. We've got very good onlay fixation of that graft on the patella. Now the next step, we're going to take a little measurement of how much gracilis graft we still have. You see if I can drag it down here that it is definitely going to be long enough. The question is, is it too long? The answer is probably not, because we have such a long femoral socket. But if we want to take an extra measure of precaution, we can measure how much length we have here. And you can see that we've got almost 9cm or 90mm of length. And we know that the mpfl is roughly about, on average, 65mm long. So if we want to, we could actually shorten this graph down. Maybe a centimeter, centimeter and a half. And we know that we're still going to get probably, you know, 15, 10 to 15mm of graft inside the femoral socket. So once we've kind of made that determination, if we do want to shorten it or if we're happy with what we've got, we can then remove our graph prep sutures and we can apply our fiber tag tightrope. So next we are going to fix this new mpfl fiber tag tightrope to the free ends of this gracilis graft. Okay, so the thing to point out is that this fiber tag is slightly smaller than what you would use for an ACL. So this is designed specifically for an mpfl reconstruction. And so what we do is we take this off of this backer card just like this. This will unroll. And this comes off. And now we've got this. And this is going to be very similar to an ACL reconstruction. So I'll take the tenaculum clamp next. And so this works just like it would for an ACL is we're going to take keep this little slot on top right there. Keep that little slot on top. This is going to feed into that. So we have the fiber tag now snared through the superior jaw of the tenaculum. And then once we have that then we can get the graft and we can pinch it all down together just like that. Okay. And then from there, it's just a basic suturing exercise. And now once we've got this, take the tenaculum clamp off, and then we can just simply just remove this just like that. And now we have our loop and we have our pull stitch, and we have our tightening sutures right here you can see that this loop is a little short. So we are going to lengthen it to make sure we have enough to get across the distal femur. So that should be we just even this out a little bit. That should be enough to to get us across the distal femur. The last thing to point out is that this is like the original tightrope, in that the tensioning sutures are actually going to be back here, and we're going to tension through the medial side. It's not going to be like an HT tightrope where we're tensioning on the lateral side. Now as we get ready to pass we can go ahead and we can cut these sutures right here. Now we're going to dissect out the plane between layers two and three, so that we can pass the graft from the patellar side down to the femoral side and then shuttle it into the femoral tunnel. So just dissect down like this. And I often will just get my my finger in here and just make sure that I can feel my scissors. I also want to make sure I do not cut my suture and I am. So now we're going to take a snare, bring that up, and then we're going to take all of our suture. Fold it over. Pull it down just like that. Okay. And now what we're going to do is we're going to take our blue sutures only. To pass the graft into the femoral tunnel. Okay. And now we can pull that through. Let me take this. And I'm just going to hold a little bit of back tension here. Okay. Go ahead and pull the button through. And you can do this with fluoroscopy in a live situation to make sure your button flips properly. But it feels like we just got the button through. So I'm going to just kind of pull back. And again we can usually check this with fluoroscopy, but it feels like the button is flipped because I am pulling back on the graft and I'm not getting anything to come back on me. Now we are just going to tighten the adjustable loop of our tightrope. So I like to have an assistant hold this. And we'll just shuttle this down until we're close. And I'll usually stop there. And then we'll bring it up through the under the patellar side of things. And this is my check rein to make sure that I don't over tension it. So I've got the knee flexed roughly 4550 degrees. That way, the patella is solidly engaged in the central to distal trochlea. So I know it's exactly where I want it to be. And now this is going to prevent me from over tensioning the tightrope. So if we look you can watch the graft tension over the clamp. Just like that. And once you feel like you've got some resistance there. Again, this prevents this allows you that one quadrant of translation. Once you've got a little bit of residual slack, you can then take it out. And then you can check your translation. So you can see here that I've got still about a quadrant of lateral patellar translation. So that's going to be pretty perfect. That's exactly what we want. So this is our way with this clamp to minimize the chance of over tensioning. It makes the tightrope technique very reliable. Now, typically what I would do at this point is I would take the knee through a range of motion, and I would confirm that there was no increased tension on the graft in deep knee flexion. And if that is confirmed, we can then proceed with cutting these sutures. We can remove the blue pull stitch. And now we can use these sutures to close our retinaculum. This is a 1.3mm suture tape. And as you can see this is all one long suture with a needle on either end. So we can come through the retinaculum here. So you can see the final retinacular closure here is complete. We've got good knots placed here and that is completely closed down.

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Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction

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