Medial Patellofemoral Ligament Reconstruction Procedure Using a Suspensory Femoral Fixation System  Shuji Nakagawa, M.D., Ph.D., Yuji Arai, M.D., Ph.D., Hiroyuki Kan, M.D., Keiichiro Ueshima, M.D., Ph.D., Kazuya Ikoma, M.D., Ph.D., Ryu Terauchi, M.D., Ph.D., Toshikazu Kubo, M.D., Ph.D.  Arthroscopy Techniques  Volume 2, Issue 4, Pages e491-e495 (November 2013) DOI: 10.1016/j.eats.2013.07.009 Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

Fig 1 Bone tunnel preparation and determination of tendon graft length. For MPFL reconstruction, the patient is positioned in the supine position. Two 2.4-mm-diameter K-wires are inserted from the proximal one-third and one-half site toward the lateral side of the patella. Another 2.4-mm-diameter K-wire is inserted from distal to the adductor tubercle toward the lateral femoral bone cortex. By use of this K-wire as a guidewire, a bone tunnel with a 30-mm depth is prepared in the femur with a reamer with a diameter of 6 mm (bone tunnel 1). In the patella 2 bone tunnels with a depth of 15 mm are prepared with a reamer with a diameter of 4.5 mm (bone tunnels 2 and 3). The tendon graft length is determined from distance X, representing the distance between bone tunnel 1 and bone tunnel 2 (usually 50 to 60 mm); distance Y, representing the distance of the tendon graft insertion into bone tunnel 1; and distance Z, representing the distance of tendon graft insertion into bone tunnel 2 or 3. The length of the tendon graft is determined according to the following equation: 2 × (X + Y + Z). It is about 180 mm. Arthroscopy Techniques 2013 2, e491-e495DOI: (10.1016/j.eats.2013.07.009) Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

Fig 2 Explanation of ToggleLoc parts and tendon graft preparation. The semitendinosus tendon is harvested as tendon graft. The No. 2 FiberWire is baseball sutured to both ends of the tendon graft. The tendon graft is passed through the loop of the ToggleLoc to prepare a double bundle. The loop size is reduced by pulling the zip suture. A passing suture is used to pass through the femoral bone tunnel, and the ToggleLoc device is hung on the lateral femoral cortex. Arthroscopy Techniques 2013 2, e491-e495DOI: (10.1016/j.eats.2013.07.009) Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

Fig 3 Guidance of tendon graft. First, the patellar side of the tendon graft is fixed. The FiberWire at 1 end of the tendon graft is passed through the patellar bone tunnel with a passing pin. Similarly, the FiberWire at the other end is passed through bone tunnel 3 to guide the tendon graft into another patellar bone tunnel. By use of the EndoButton, the ends of the FiberWire that have passed through the patellar bone tunnels are tied. (A) Fixation of femoral side. The passing suture of the ToggleLoc is passed through the femoral bone tunnel with a passing pin and is exposed on the skin on the lateral femoral side. The ToggleLoc device is passed through the femoral bone tunnel and hung on the lateral cortex of the femur. (B, C) The knee joint is positioned at 60° of flexion. The tendon graft is guided into the femoral bone tunnel by pulling the zip suture. (D) While one is observing the axial image of the patella, the zip suture is pulled until subluxation of the patella is reduced. The zip suture is carefully pulled because once it has been pulled, it cannot be returned to the previous position. It is better to insert a levator between the tendon graft and lateral femur to avoid loading excessive tension on the tendon graft. Arthroscopy Techniques 2013 2, e491-e495DOI: (10.1016/j.eats.2013.07.009) Copyright © 2013 Arthroscopy Association of North America Terms and Conditions