“The Superficial Quad Technique” for Medial Patellofemoral Ligament Reconstruction: The Surgical Video Technique  Deepak Goyal, M.B.B.S., M.S.(Orthop), D.N.B.(Orthop), M.N.A.M.S.  Arthroscopy Techniques  Volume 4, Issue 5, Pages e569-e575 (October 2015) DOI: 10.1016/j.eats.2015.06.003 Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 1 Graft harvesting in a right knee in the supine position, viewed from the medial aspect. An anterior midline incision of around 7 to 8 cm is centered over the upper pole of the patella. A small vertical nick is made at the lateral-most part of the quadriceps tendinous structure, around 2 cm proximal to the upper pole of the patella. Fine scissors are used to gain access between the superficial and middle laminas. It should be noted that the usual breadth of the superficial lamina at this point is around 10 to 13 mm. A small T retractor is inserted between the 2 surgically separable laminas, and the superficial lamina is lifted. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 2 Graft harvesting in a right knee in the supine position, viewed from the medial aspect. The dissected superficial laminar graft is lifted with the T retractor, and sharp distal dissection is carried out to separate the superficial lamina from the middle lamina using sharp scissors until the proximal pole of the patella is reached. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 3 Graft harvesting in a right knee, viewed from the medial aspect. The dissected graft is pulled inferiorly with the help of a finger; the graft is then further sharply dissected proximally until the required length is achieved and is cut with sharp scissors. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 4 Graft harvesting in a right knee, viewed from the anteromedial aspect. The proximally cut end of the graft is grasped with Ellis forceps, and the scissors show the completely dissected graft until the upper pole of the patella is reached. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 5 Preparing the graft for repositioning in a right knee. The graft is dissected on the patella until the level of the superomedial corner of the patella is reached. This point is the anatomic point that matches the superior point of the attachment of the native medial patellofemoral ligament on the medial border of the patella. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 6 Preparing the graft for repositioning in a right knee. The graft is further dissected on the lateral side of the patella obliquely until the midpoint of the lateral border of the patella is reached. This point is in line with the midpoint of the medial border of the patella that matches the inferior point of the attachment of the native medial patellofemoral ligament on the medial border of the patella. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 7 Preparing the graft for repositioning in a right knee. The graft is rotated medially such that the deeper layer of the graft becomes superficial. This step converts the medial border of the graft to its superior border and converts the lateral border to its inferior border. The superior and inferior edges of the rotated graft thus match the anatomic points of the native medial patellofemoral ligament. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 8 Creation of the subvastus space in a left knee, viewed from the lateral aspect (different case than that shown in Figs 1-7). The insertion of the vastus medialis near the superomedial border of the patella is lifted using a toothed forceps, and with the help of sharp scissors, the subvastus space is created. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 9 Graft delivery in a right knee, viewed from the medial aspect. A 2-cm incision is made over the medial epicondyle, and dissection is carried out to locate the adductor tubercle and the medial epicondyle. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 10 Graft delivery in a left knee (different case than that shown in Figs 1-7 and 9), viewed from the anterior aspect. The rotated graft is pulled out through the medial incision through the subvastus space. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 11 Identifying the point of isometry in a left knee (different case than that shown in Figs 1-7 and 9), viewed from the medial aspect. The graft is rolled on the Beath pin, and the knee is then subjected to a complete range of motion. An unchanging graft length signifies that the Beath pin is at the isometric point. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 12 Femoral fixation in a left knee (different case than that shown in Figs 1-7 and 9), viewed standing near the opposite hip. A 6-mm reamer is used to over-drill the Beath pin for 3 to 4 cm. This allows around 2.5 to 3 cm of graft to be pulled in for intraosseous fixation. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 13 Femoral fixation in a left knee, viewed from the medial side. Interference screw fixation is performed over the Beath pin; generally, a 7 × 25–mm screw is sufficient. Arthroscopy Techniques 2015 4, e569-e575DOI: (10.1016/j.eats.2015.06.003) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions