Variation in Surgical Technique for Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients:...

Management approaches and surgical techniques for patellofemoral instability (PFI) continue to lack clear clinical guidelines and indications. Medial patellofemoral ligament reconstruction (MPFLR) is the most frequently used surgical procedure; however, variation in technique remains significant, particularly in skeletally immature patients.

The purpose of this study was to examine variations in MPFLR technique in skeletally immature patients as represented by 20 orthopaedic surgeons with different experience levels and specialty training backgrounds who perform a high volume of PFI surgery in this age group. The hypothesis was that variation would be high.

Cross-sectional study; Level of evidence, 3.

Operative records of skeletally immature patients who underwent a primary, single-stage MPFLR between 2016 and 2021 within the JUPITER (JUstifying Patellar Instability Treatment by Results) cohort, a multicenter prospective study involving 13 tertiary care academic centers, were analyzed, including demographic information, injury data, and surgical technique details.

Of the 305 surgical PFI cases in skeletally immature patients, 245 knees (46% female, 54% male; mean age, 13.6 ± 1.8 years; range, 5.1-19.0 years) met inclusion criteria. High variation was identified in MPFLR tendon graft type (59% allograft, 41% autograft), patellar fixation (62% suture anchor, 32% patellar bone bridge/tunnel), and femoral fixation (76% interference/tenodesis screw, 23% suture anchor). All cases (100%) used fluoroscopic guidance and physeal-sparing principles, with femoral implant placement distal to the distal femoral physis. High variation was seen in adjunctive procedures, including lateral retinacular release or lengthening (22%), osteochondral fracture treatment (13% overall; 53% of which underwent loose body removal, 44% fixation, and 3% osteochondral allograft implantation), concomitant hemi-epiphysiodesis for genu valgum (9%), and patellar tendon medialization (Grammont procedure, 2%).

Despite the presence of open physes, which generally limits PFI surgical technique options, variation in multiple aspects of MPFLR was high among this cohort of 20 high-volume surgeons.