Medial Patellofemoral Ligament Reconstruction Using a Femoral Loop Button Fixation Technique  Jonathan A. Godin, M.D., M.B.A., Vasili Karas, M.D., M.S., Julia D. Visgauss, M.D., William E. Garrett, M.D., Ph.D.  Arthroscopy Techniques  Volume 4, Issue 5, Pages e601-e607 (October 2015) DOI: 10.1016/j.eats.2015.06.005 Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 1 Instrumentation. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 2 Preparation of drill holes in medial patella. (A) Two parallel holes are drilled on the medial side of the patella through a 2-cm skin incision. (B) Two suture anchors are then passed through each drill hole. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 3 Tunnel for graft placement. In the right knee of a male cadaver, proper tunnel dissection for graft placement during medial patellofemoral ligament reconstruction is shown. The tunnel is made between anatomic layers 2 (medial retinaculum and fascia) and 3 (capsule) of the knee. The sutures in the image stem from single-loaded suture anchors already placed in the medial aspect of the patella. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 4 Radiographic placement of femoral starting point. This is a fluoroscopic perfect lateral image of a cadaveric left knee with the radiopaque guide placed on the medial aspect of the knee. The guide is placed in line with the posterior cortex of the femur, with the distal intersection overlying the posterior-most aspect of the Blumensaat line and the proximal intersection over the point at which the posterior cortex meets the medial condyle proximally. The black cross indicates proper placement of the pin. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 5 Reaming of femoral tunnel. On the basis of the sizing guide, an appropriately sized reamer is selected, and the guide pin is over-reamed beginning at the femoral insertion of the medial patellofemoral ligament. The tunnel is drilled unicortically, with the lateral cortex spared to have a stable resting place for the flipped button. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 6 Graft preparation. A 20-cm gracilis graft has been prepared and looped within the TightRope. Two knots affix the ends of the graft to form a loop. As shown in Video 1, these knots are placed approximately 2 cm apart by initially passing a suture through both limbs of the graft, looping around the limbs twice, and finally, passing the suture through the free ends of the graft before tying the knot. In this fashion the knot lies between the 2 limbs of the graft. The placement and spacing of knots for affixing the looped graft to the patella are depicted here with the free ends of suture from 2 anchors. These knots should be tied between the graft retention knots. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 7 Graft fixation to medial patella. After the placement of 2 suture anchors, the graft is sutured to the medial side of the patella. Suturing the graft in the described fashion decreases the interosseous surface area removed from within the patella and may reduce the likelihood of patellar fracture as compared with interference fit. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 8 Tightening of graft. After graft passage and flipping of the TightRope button, the graft is tightened with alternating pulls on the medial side while tension is kept on the graft with a hemostat through the loop. Arthroscopy Techniques 2015 4, e601-e607DOI: (10.1016/j.eats.2015.06.005) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions