Soft Tissue Fixation in Patellar Instability

Patellar instability is a common and potentially disabling condition in young active patients. The medial patellofemoral ligament (MPFL) is the primary passive restraint to lateral patellar translation at 0 to 30 degrees of flexion, and its reconstruction has become the cornerstone of surgical management for recurrent patellofemoral dislocation. The medial patellotibial ligament (MPTL), a secondary stabiliser whose contribution increases markedly at higher flexion angles, has attracted renewed interest as an adjunct to MPFL reconstruction. Femoral fixation of the graft has traditionally relied on interference screws or suture anchors; however, soft tissue fixation, looping the graft around the adductor magnus (AM) tendon, avoids the risks of tunnel malposition, hardware-related complications, and physis violation, while yielding equivalent clinical outcomes in adult populations. The only published randomised controlled trial directly comparing soft tissue and screw femoral fixation for MPFL reconstruction demonstrated no significant difference in Kujala score (89 vs. 88), redislocation rate (0% vs. 0%), or surgical morbidity, supporting the equivalence of the 2 approaches. In skeletally immature patients, soft tissue femoral fixation eliminates the risk of injury to the growth plate, and has been validated in dedicated paediatric series. This review summarises the anatomic and biomechanical basis for soft tissue fixation, describes the surgical technique for combined MPFL and MPTL reconstruction using an ipsilateral gracilis autograft, presents clinical outcomes from our series of 34 patients and a PRISMA systematic review of 197 operated knees, and discusses graft selection, prognostic factors, paediatric considerations, complications, and future directions.