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MPFL Reconstruction - Adult

Planning

A

Simulation

B

Preoperative Plan

1

Radiographic and MRI assessment

  • asses for physeal closure on femur and tibia.

2

Discuss options with the patient

3

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • description of potential complications and steps to avoid them
C

Room Preparation

1

Surgical Instrumentation

2

Room setup and Equipment

  • operative table

3

Exam under anesthesia

  • take a good feel of the patella and see how it tracks
  • assess how it rests with the leg in full extension
  • see how it moves as you flex the knee
  • translate the patella medially and laterally (push on it)
  • look for a J sign
  • grade the translation by quadrants
  • full quadrant means it moves the diameter of the patella
  • usually it moves ¼ or ½ of a quadrant
  • gently try to dislocate the patella with the knee in full extension to see if you can, and if it gets stuck there
  • do not do this aggressively to avoid chondral injury
  • try to dislocate the patella in slight flexion (moving patella apprehension test)
  • make sure you can evert the patella to neutral
  • it will be be tilted laterally, so try to correct this to neutral
  • if you can correct it, you likely don’t need a lateral release, but if you can’t it means the lateral side is tight

4

Patient positioning

  • place patient supine on the table.
  • thigh tourniquet is often used
  • Tape the non-operative leg loosely to table
  • place a lateral post just proximal to the break of the bed
  • place two 1000 drapes to drape out tourniquet
  • kick foot pedals to operative side
  • Prep the leg with betadine and chlorhexidine
  • have assistant holds the leg up and you use one chloraprep to prep the foot
  • put a blue bootie on the foot followed by cloth stockinet
  • grab the leg and prep the rest with chloraprep x2
  • let this dry for 3 minutes
  • roll the cloth stockinet up to the tourniquet

5

Patient Draping

  • place 2 half sheets down
  • drop the foot on the table
  • put a half sheet up top
  • use 2 plastic clips to hold the drapes together on either side of the leg
  • cut the stockinet at the level of the calf
  • roll the proximal part proximally and leave the distal part
  • Take a clear Ioban and place this on the bed
  • drop the leg in the middle of this and sandwich the leg in the Ioban
  • cut off excess
  • place extremity drape last

Technique

D

Portal Placement and Diagnostic Arthroscopy

1

Portals

  • anterolateral
  • use an 11 blade to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision
  • anteromedial
  • place knee in approximately 30 degrees of flexion with valgus moment applied.
  • use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal
  • the medial portal should be located just superior to the medial meniscus and able to provide access to the anatomic ACL footprint on the femur as well and the medial meniscal root if needed

2

Diagnostic

  • visualize
  • Suprapatellar pouch
  • undersurface of the patella and trochlear groove
  • lateral and medial gutters
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use probe to assess the ACL and PCL
  • lateral compartment
  • the leg can be put into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • use a probe to assess the lateral meniscus and cartilage line
E

Patellar Tracking Assessment

1

Assess Patellar tracking

  • ensure the patella is engaged in deep flexion
  • slowly extend the knee focusing attention on the patella
  • take pictures of the patella with the scope throughout extension of the knee
  • fully extend the knee and ensure you are in the suprapatellar pouch
  • meticulously look at the patella
  • take a picture of the medial facet
  • identify any wear
  • identify how the patella sits in extension
  • observe tracking of the patella as the knee flexes by looking at the trochlea
  • identify any wear on the trochlea which is usually seen laterally
  • try to evert the patella
  • if this cannot be done perform a lateral release
F

Semi-T Autograft Harvest HS Graft Harvest

1

Prep leg

  • esmark the leg and inflate the tourniquet (250mm Hg)

2

Make incision

  • identify the hamstring tendons on the medial tibia
  • make a 4-5 cm incision starting just distal to the level of the tibial tubercle about 1 cm medial to the tibial tubercle

3

Identify sartorial fascia

  • use a finger to give the incision a "face lift" and free up the skin
  • identify the gracilis and semitendinosus
  • clean off the sartorial fascia w/ a Raytek to better visualize the fascia
  • make a horizontal slit in the sartorial fascia
  • do not cut too deep or you’ll hit the tendons
  • use pickups and mets to dissect the sartorius off the semitendinosus and gracilis
  • peel this medially and laterally to expose the tendons

4

Harvest Semitendinosus tendon

  • take a right angle clamp and get this around the semitendinosus tendon
  • put the leg in a figure 4 position prior to doing this to relax the hamstrings
  • pass a penrose into the jaws of the right angle and pass this around the gracilis
  • now the penrose can be used to pull tension on the tendon
  • use the mets to clean this off and remove any attachments to the gracilis or sartorius
  • keep tips pointed away from tendon at all times
  • do not cut w/ the mets but rather just open the tips a little and push
  • make sure that all bands are freed that connect to the semitendinosus and gastrocnemius
  • slide your finger up the tendon proximally to make sure it is free
  • place a smaller version of a thyroid retractor around the tendon
  • pull on this to check your excursion
  • take a tendon stripper and place this around the graft
  • pull knob towards you and then rotate it to close the tendons stripper
  • close the tendon stripper so it will not slide off
  • be careful not to turn the dial to cut here as this will cut the tendon
  • advance this up to the ischial tuberosity while holding tension on the smaller thyroid retractor and pushing the tendon stripper
  • do not twist it the tendon stripper as you are advancing
  • do not cut the attachment to the tibia yet
  • now that the proximal end of the graft is harvested, lift it up and subperiostally take the tendon off the tibia

5

Prepare the graft

  • bring the graft to the back table
  • take a metal ruler and clean off all the muscle
  • fold the graft in half, excluding and wimpy part at the ends
  • put a mark w/ the marking pen at the center
  • the graft needs to be 90-100mm in length
G

Patella Exposure and Anchor Placement

1

Expose the patella

  • make a 3cm longitudinal incision just off the medial aspect of the patella
  • incisions over the anterior patella tend to stretch out and possible breakdown over time
  • the incision should be from the superior pole of the patella heading distal
  • will likely need a 5-6cm incision to begin with
  • dissect down to the VMO w/ mets but try not to cut into this

2

Place rakes

  • put 2 small rakes in the incision pulling anteriorly and posteriorly

3

Perform dissection

  • take a 15 blade and dissect just distal to the VMO until you get in the layer between capsule and retinaculum (tick through the tissue w/ the 15 blade)
  • the ideal location is medial to the patella as the tissue right next to the patella is thick and can be difficult to separate the proper planes
  • occasionally the VMO will extend distal
  • do not go into capsule here
  • if the capsule is penetrated work backwards to find you layer just superficial to capsule
  • when in the correct plane you should be able to dissect using a mets very easily heading posteriorly towards the medial epicondyle

4

Place stitches

  • once the plane is defined, use a 0 Vicryl to tag this layer for closure and for retraction
  • put a figure of 8 on either side of the incision
  • these will also help with retraction and to control each flap
  • on the patellar sided stitch, skive off the patella because this stitch will help control the patella later in the case

5

Create the landing strip

  • if the capsule is still intact (meaning you didn’t make an accidental arthrotomy) you can make the landing strip with your bovie on the medial side of the patella, just superficial to the capsule
  • if the arthrotomy has already been performed, then wait to do the landing strip
  • once these layers are defined, make a small arthrotomy big enough to put a finger in the joint and feel the undersurface patella
  • do not get fooled, make sure the proximal and distal poles can be felt
  • feel the patella to see where the tag suture on the patellar side is in relation to the patella
  • bovie on the medial side of the patella where the anchors will go
  • create a landing strip just anterior to the articular surface (just anterior to capsule)
  • this should not be any more distal than the 50 yard line of the patella

6

Prepare the patella

  • use a curette to roughen up the bone here to help with tendon healing
  • place the more distal anchor first

7

Drill holes

  • use the patella tag stitch and thumb to hold the patella steady while drilling
  • use a Blue drill guide and “hard bone” cutting drill
  • put the drill guide just anterior to the articular surface, aiming straight across (do not aim proximal or distal)
  • burry the drill to the hard stop of the drill guide

8

Create the landing strip

  • remove the drill and place the anchor (single loaded Peek Anchor)
  • seat slightly by hand, then mallet is down
  • the bone distally in the patella is softer than proximally

9

Repeat steps with second anchor

  • this should be about 8mm proximal to the first anchor
  • do not want a huge bone bridge here
  • aim slightly distal with the drill so it converges a little
  • secure the graft to the suture anchors

10

Place graft

  • lay the graft on the medial aspect of the patella
  • evert the patella slightly to make this easier
  • tie the sutures from the distal anchor and cinch the tendon down to the patella
  • push the knot posteriorly so it doesn’t bother the patient
  • especially important in small, skinny females
  • cut the suture using the open ended arthroscopic knot cutter
  • tie the sutures from the proximal anchor together and do as above
  • shove the graft into the wound to keep it moist
H

Femoral Tunnel Placement

1

Expose the medial epicondyle

  • place leg in a slight Figure 4 position to access the medial femoral condyle
  • feel the medial femoral condyle (can sometimes be difficult in larger people)
  • make a 3cm vertical incision over the medial femoral condyle
  • use a 10 blade through skin
  • this incision will be smaller than the patella incision, and should start distal to where the patella incision started, and end slightly distal to where the patella incision ended
  • place 2 senn rakes for retraction

2

Dissect down to medial epicondyle

  • slowly dissect down to fascia using mets
  • use a finger and feel the medial epicondyle and adductor tubercle
  • the MPFL inserts proximal and posterior to the medial epicondyle
  • CAUTION – POSTERIOR TO THE MEDIAL EPICONDYLE IS THE GASTROC TUBERCLE
  • do not confuse this w/ the medial epicondyle because the pin placement will be very posterior if you mix these up

3

Place guide pin

  • take the guide pin and put this where the isometric point is (often this is close to Schottles point which is just slightly anterior to the posterior femoral cortex and slightly proximal to Blumensaat’s line)
  • feel the sulcus between the medical epicondyle and the adductor tubercle
  • this is where the pin goes
  • drill the pin in heading from medial to lateral heading slightly from distal to proximal, and from slightly posterior to anterior
  • in a skeletally immature patient you will need to keep epiphyseal so the tunnel will be more distal and you cannot drill it all the way across because it will be in the knee

4

Check graft isometry

  • once the pin is in, check graft isometry
  • the graft has not been passed yet so this is done on top of the skin
  • first center the patella in the trochlea
  • if having trouble centering the patella, flex the knee to 30° to engage the patella, then set the length then extend to ensure the patella is centered at 0°, then flex through full range
  • even these up and wrap it around the guide pin

5

Test the graft

  • mark both limbs at the same point to identify if the graft moves
  • flex the hip up and extend the knee
  • now bend the knee slowly and see what happens to the graft
  • if the graft immediately starts to try to lengthen because it is too tight, the pin is too proximal
  • “High and tight” – if the pin is too proximal the graft will be too tight
  • “Low and loose” – if the graft is too distal it’ll be too loose
  • if the graft does not move at all until the knee flexes past 45°-60°, then it’s too loose and the pin must go proximally
  • the pin is in the appropriate spot when the graft needs to lengthen at around 60 degrees of flexion and the knee is able to be flexed without difficulty

6

Confirm placement of the pin

  • use mini C-arm to confirm the pin is in the ballpark of Schottles point

7

Drill femoral tunnel

  • place the 7mm reamer backwards over the pin, and then place a Kelly clamp on the pin to hold the reamer in place
  • where the reamer is on the X-Ray lets you know where you are entering the bone
  • remember there will be some periosteum on the bone as well, so the actual entry site into the bone is a little more proximal than what you’re looking at
  • be right near the “corner pocket” made by the posterior femoral cortex and Blumensaat’s line
  • drill the femoral tunnel using a 7mm cannulated drill bit to overdrill the beath pin to the second cortex (use a 6mm in a peds patient)
  • do not go through the second cortex

8

Place screw

  • use the 7mm reamer to get a 7mm x 23mm screw in
  • only use a 6mm x 15mm in skeletally immature people
  • this is really for small, skeletally immature females; in decent size guys a 7mm will still work
  • size is based on thickness of the graft that sized when prepping the graft
  • drill to, but not through the second cortex
  • this depth should be at least 35mm so you don’t bottom out the graft
I

Pass the Graft

1

Pass the graft

  • pass the graft through the already created plane
  • make sure to be superficial to capsule and deep to retinaculum
  • use a hemostat to help with this dissection if needed
  • place a snap from anterior to posterior

2

Place stitch

  • feed a passing stitch into the clamp, bringing the looped end anterior
  • pass the graft in the suture loop, and pull this out posteriorly

3

now both limbs should be coming out of the posterior incision by the epicondyle

  • place 2 hemostats on the end of the tendon
  • put the to ends of the tendon together and bring them to the orifice of the femoral tunnel
  • make sure the patella is engaged in the trochlea (flex the knee to about 20° and toggle the patella back and forth to make sure it’s engaged)
  • hold tension in the sutures such that a hard point is felt, while at the same time not reducing the patella medially
  • take the metal ruler and put this at the femoral tunnel orifice on top of the graft
  • mark this spot
  • then measure 2cm from this spot going away from the tunnel
  • mark this spot on the tendons
  • this is ensuring that there is 20mm of tendon in the femoral tunnel

4

Krackow both tendons

  • use a Orthocord to Krakow the two ends of the graft together, starting at the marking that is further from the femoral tunnel, then Krakow towards the femoral tunnel and back away from the femoral tunnel
  • start and end at the marks put on the tendons
  • make sure each pass goes through both tendons
  • cut off the excess tendon
  • you now have 2 sutures coming out of the tendon

5

Fix graft to the femur

  • use a 7mm biotenodesis screw to fix the graft on the femur
  • thread both ends of the suture into screwdriver and make sure the tip of the screwdriver is all the way down to the tendon
  • clamp the suture after it comes through the screwdriver
  • use a probe to loop the tendon over so it can be seen dunking into the femur
  • it’s a push-pull – pull on the sutures coming out of the screwdriver and push the screw in
  • screw this in about 2/3 of the way
  • someone needs to be holding the patella still so it does not over reduce it as the screw is advanced

6

Check the ROM, patellar mobility, etc.

  • finish screwing the biotenodesis screw in
  • do not leave this proud, especially in a skinny person
  • check patellar mobility
  • want a firm endpoint, about equal medial and lateral translation
  • make sure the patient has full knee ROM
  • irrigate copiously
J

Wound Closure

1

Deep closure

  • do not close the capsulotomy
  • 0 Vicryl to close the previously tagged retinaculum
  • don’t just tie the tag sutures together because this will leave a large knot
  • 0-Vicryl deep for all incisions

2

Superficial wound closure

  • the 2-0 Vicryl for deep dermal
  • running 3-0 Monocryl w/ tails for skin
  • dermabond longer incisions
  • interrupted buried 3-0 Monocryl for portals
  • dermabond, xeroform, steri-strips for the tails, telfa tegaderm x2 for all incisions, Ace, HKB locked in extension

Patient Care

K

Preoperative H & P

1

Perform focused orthopedic exam

  • check for effusion
  • Patellar instability
  • identify any instability through full range of motion
  • identify medial sided patellar tenderness
  • identify any patellar apprehension

2

Perform preoperative medical history and physical exam

3

Ensure biplanar images and MRI of the knee are present

4

Perform operative consent

  • describe complications of surgery including
  • surgical technical error
  • inadequate fixation
  • overaggressive rehab
  • infection
  • hardware failure
L

Perioperative Inpatient Management

1

Write comprehensive postoperative orders

2

Initiate PT POD1

  • initial ROM 0°-90° starting POD 1
  • want them at 60° by 2 week and to 90° by 4 weeks

3

Discharges patient appropriately

M

Intermediate Evaluation and Management

1

Obtains focused history and performs focused exam (e.g., mechanism of injury, past knee history, past treatments, Lachman, anterior drawer, pivot shift, meniscal pain).

  • Pattellar instability
  • identify any instability through full range of motion
  • identify medial sided patellar tenderness
  • identify and passive patellar instability
  • identify any patellar apprehension

2

Appropriately interprets basic imaging studies : alignment, joint space, patella alignment.

  • Radiographs
  • ensure biplanar radiographs of the knee and MRI of the knee are present
  • MRI

3

Prescribes and manages non-operative treatment : Closed Chain Quad strengthening

  • physical therapy & lifestyle modifications

4

Preop: Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation; WB status, brace, ROM, Quad strength.

  • Postop: 2-3 Week Postoperative Visit
  • wound check
  • diagnose and management of early complications
  • Postop: 4-6 Week Postoperative Visit
  • early rehab
  • if patient can perform straight leg raise, take out of brace
  • appropriate rehab
  • isometric hamstring contractions at any angle
  • isometric quadriceps, or simultaneous quadriceps and hamstrings contraction
  • emphasize closed chain (foot planted) exercises
  • avoid
  • isokinetic quadricep strengthening (15-30°) during early rehab
  • open chain quadriceps strengthening
N

Advanced Evaluation and Management

1

Recognizes concomitant associated injuries

2

Appropriately orders and interprets advanced imaging studies: Standing views, MRI, Segond fx, bone bruising

  • Radiographs
  • MRI

3

Provides complex non-operative treatment: WB status, Bracing as appropriate, vascular studies

4

Modifies and adjusts post-operative treatment plan as needed: Loss of knee motion treatment, sport specific drills, return to sport

  • Postop: 4-6 Week Postoperative Visit
  • identifies loss of knee motion
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

2

Surgically treats complex complications

 

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