Basket-Weave Technique for Medial Patellofemoral Ligament Reconstruction  Pranjal S. Kodkani, M.S.(Ortho), D.(Ortho), M.B.B.S.  Arthroscopy Techniques  Volume 4, Issue 3, Pages e279-e286 (June 2015) DOI: 10.1016/j.eats.2015.02.008 Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 1 Medial patellar incision and second incision over region between adductor tubercle and medial epicondyle, shown in a left knee. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 2 First layer of medial retinaculum lifted with forceps from second layer of medial retinaculum, shown in a left knee. This is just medial to the medial border of the patella. The tip of the scissors can be seen placed between the 2 layers. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 3 Tissue Elevator–Suture Passer prototype (all rights reserved to author). This instrument allows easy passage and shuttling of sutures and graft between the layers of the retinaculum and underneath the extensor sleeves. The slot in the elevator portion provides for feeding of the sutures holding the graft to pull it across. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 4 Graphic representation of medial aspect of a left knee. The green areas show the native medial patellofemoral ligament (MPFL). The blue areas show the capsule. The first layer is not shown. The yellow areas show the ligamento-periosteal sleeve (asterisks). This is a 1-cm-thick tissue sleeve elevated between the adductor tubercle and medial epicondyle. (AM, adductor magnus; MCL, medial collateral ligament.) Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 5 (A) A right-angle (Mixter) forceps is hooked underneath the ligamento-periosteal sleeve elevated from the region between the medial epicondyle and adductor tubercle, as shown in the medial aspect of a left knee. (B) The hamstring graft is looped underneath the ligamento-periosteal sleeve to its halfway mark. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 6 (A) The Tissue Elevator–Suture Passer (all rights reserved to author) is passed from the medial patellar incision between the first and second layers across and emerges from the medial incision over the medial epicondyle, as shown in the medial aspect of a left knee. (B) Sutures of proximal limb of graft fed into Tissue Elevator–Suture Passer. (C) Superior limb of graft pulled across to be delivered through medial patellar incision. (D) Superior and inferior limbs of graft delivered through medial patellar incision looped over ligamento-periosteal sleeve. The graft is fixed to the ligamento-periosteal sleeve by a pretzel stitch, and the first layer of the medial retinaculum is sutured back over it in this medial epicondylar region. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 7 Extensor retinaculum sleeve elevated over anterior aspect of patella. The first upper medial sleeve for the first passage of the superior limb of the graft is shown. The Tissue Elevator–Suture Passer (all rights reserved to author) is passed underneath the sleeve for passage of the graft. The first pass for both the superior and inferior limbs of the graft is underneath the medial-most sleeve. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 8 Incision retracted open to show basket-weave pattern of graft fixation on patella, shown from the top view of a left knee. The graft alternates above and below the extensor retinacular sleeves and the proximal and distal limbs to give a basket-weave pattern. One should note that the first medial pass for both the superior and inferior limbs of the graft is underneath the sleeve. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 9 (A) Pretzel stitch (which appears as a pretzel in cross section), shown through a patellar incision from the top view of a left knee. Fixation of the inferior limb of the graft to the extensor retinaculum is shown at one level at which the graft passes over the retinaculum. No. 1 Vicryl is used for suturing. The first pass of suture transfixes the upper three-quarters of graft to the extensor retinaculum. (B) The second pass goes deep to the extensor retinaculum and around the graft. The needle is being retrieved by a needle holder. (C) The second pass is completed with the cinching pass deep to the graft and extensor retinaculum. (D) The third pass transfixes the lower three-quarters of graft to the extensor retinaculum. The needle is retrieved with a needle holder after this transfixing pass. (E) The third pass has been completed, showing both the upper and lower transfixing passes. (F) The final throw of knots is performed to complete the pretzel stitch by tightening the transfixing and cinching passes around the graft and extensor retinaculum. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 10 Graphic representation of medial aspect of a left knee showing final basket-weave medial patellofemoral ligament reconstruction (MPFL) construct. The graft (red) extends in a precisely anatomic manner on the femoral side between the adductor tubercle and medial epicondyle. The arrow marks the graft fixed to the femoral ligamento-periosteal sleeve with a pretzel stitch and the first layer (translucent) sutured over it. The construct overlies the native MPFL (green area) between the first and second layers of the medial retinaculum. On the patellar side as well, it is precisely anatomic, congruent with the superior and inferior margins of the MPFL. The superior limb interdigitates with the vastus intermedius just like the native MPFL. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 11 Close-up view through a patellar incision, from the top view of a left knee. The first layer of the medial retinaculum is lifted with an Adson forceps to show the inferior limb of the graft (over the artery forceps). One should note the inferior limb of graft attached to the middle of the medial margin of the patella and deeper to the extensor retinaculum over the patella. The superior limb (not seen) is deeper to the vastus medialis muscle fibers seen in the upper part of the incision. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 12 Postoperative arthroscopic view of a left knee from the anterolateral portal. This view shows the medial patellofemoral ligament (MPFL) construct to be extracapsular, indenting the capsule with its 2 graft limbs and anatomically extending from the upper half of the medial border of the patella to the femoral site. The medial patellar plica can be seen traversing the construct. The medial edge of the medial crista of the trochlea is seen on the lower right. The upper half of the medial margin of the patella is seen on the upper right. Arthroscopy Techniques 2015 4, e279-e286DOI: (10.1016/j.eats.2015.02.008) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions