Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 12, pp 3547–3552 | Cite as

Intraoperative fluoroscopy during MPFL reconstruction improves the accuracy of the femoral tunnel position

  • P. KoenenEmail author
  • S. Shafizadeh
  • T. R. Pfeiffer
  • A. Wafaisade
  • B. Bouillon
  • A. C. Kanakamedala
  • V. Jaecker



Reconstruction of the medial patellofemoral ligament (MPFL) has been established as standard of care for patellofemoral instability. An anatomic femoral tunnel position has been shown to be a prerequisite for restoration of patellofemoral stability and biomechanics. However, the incidence of malpositioning of the femoral tunnel during MPFL reconstruction continues to be notable. Palpation of anatomic landmarks and intraoperative fluoroscopy are the two primary techniques for tunnel placement. The aim of this study was to compare the accuracy of these two methods for femoral tunnel placement.


From 2016 to 2017, 64 consecutive patients undergoing MPFL reconstruction for patelllofemoral instability were prospectively enrolled. During surgery, the presumed femoral MPFL insertion was identified by both palpation of anatomic landmarks and using fluoroscopy, both of these points were separately documented on true lateral radiographs. They were then analysed and deviations from the Schoettle’s Point were measured as anterior–posterior and proximal–distal deviations. A tunnel position within a radius of 7 mm around the Schoettle’s Point was designated as an “accurate tunnel position”.


Compared to the method of palpation, fluoroscopy led to significantly more anatomic femoral tunnel positoning (p < 0.0001). The mean proximal–distal and anterior–posterior distances between the femoral insertion site identified by palpation and the Schoettle’s Point were 5.7 ± 4.5 mm (0.3–20.3 mm) and 4.1 ± 3.7 mm (0.1–20.3 mm), respectively, versus 1.7 ± 0.9 mm (0.1–3.6 mm) and 1.8 ± 1.3 mm (0.1–4.8 mm) for fluoroscopy, respectively. Using fluoroscopy, all femoral insertion sites were identified within a 7 mm radius around the centre of the Schoettle’s Point. In contrast, only 52% (33) of femoral insertion sites identified by palpation were within this radius. These data were independent of patients’ age, gender and BMI. No improvement in accuracy of femoral tunnel positions was detected over time.


The main finding of this study was that, compared to the method of palpation of anatomic landmarks, the use of intraoperative fluoroscopy in MPFL reconstruction leads to more accurate femoral tunnel positioning. Based on these results, the use of intraoperative fluoroscopy has to be recommended for femoral tunnel placement in daily surgical practice to minimize the incidence of malpositioning and to restore native patellofemoral biomechanics.

Study design

Level III Case-control study.


MPFL reconstruction Femoral tunnel position Intraoperative fluoroscopy 



Medial patellofemoral ligement


Body mass index


Computer-aided design


Author contributions

PK participated in the design of the study, collected data, performed the statistical analysis and drafted the manuscript. SS, TP and AK have been involved in drafting the manuscript and revising it critically. SS performed all surgeries. AW helped to perform the statistical analysis and interpretation of data. BB participated in the design and coordination of the study. VJ conceived of the study and participated in its design. All authors read and approved the final manuscript.

Compliance with ethical standards

Conflict of interest

All authors declare that there is no conflict of interests.

Ethical approval

Ethical approval was obtained from the ethics committee of the University of Witten/Herdecke, Germany (ID 146/2014). All procedures involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments.

Informed consent

Informed consent was obtained from all participants.


  1. 1.
    Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220CrossRefGoogle Scholar
  2. 2.
    Arshi A, Cohen JR, Wang JC, Hame SL, McAllister DR, Jones KJ (2016) Operative management of patellar instability in the United States: an evaluation of national practice patterns, surgical trends, and complications. Orthop J Sport Med SAGE Publications 4:2325967116662873Google Scholar
  3. 3.
    Balcarek P, Walde TA (2015) Accuracy of femoral tunnel placement in medial patellofemoral ligament reconstruction: the effect of a nearly true-lateral fluoroscopic view. Am J Sports Med 43:2228–2232CrossRefGoogle Scholar
  4. 4.
    Baldwin JL (2009) The anatomy of the medial patellofemoral ligament. Am J Sports Med 37:2355–2361CrossRefGoogle Scholar
  5. 5.
    Barnett AJ, Howells NR, Burston BJ, Ansari A, Clark D, Eldridge JD (2012) Radiographic landmarks for tunnel placement in reconstruction of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 20:2380–2384CrossRefGoogle Scholar
  6. 6.
    Clark D, Metcalfe A, Wogan C, Mandalia V, Eldridge J (2017) Adolescent patellar instability. Bone Joint J 99-B:159–170CrossRefGoogle Scholar
  7. 7.
    Conlan T, Garth WP, Lemons JE (1993) Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 75:682–693CrossRefGoogle Scholar
  8. 8.
    Elias JJ, Cosgarea AJ (2006) Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. Am J Sports Med 34:1478–1485CrossRefGoogle Scholar
  9. 9.
    Feller JA, Amis AA, Andrish JT, Arendt EA, Erasmus PJ, Powers CM (2007) Surgical biomechanics of the patellofemoral joint. Arthroscopy 23:542–553CrossRefGoogle Scholar
  10. 10.
    Herschel R, Hasler A, Tscholl PM, Fucentese SF (2016) Visual-palpatory versus fluoroscopic intraoperative determination of the femoral entry point in medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25:2545–2549CrossRefGoogle Scholar
  11. 11.
    Hiemstra L, Kerslake S, O’Brien C, Lafave M (2017) Accuracy and learning curve of femoral tunnel placement in medial patellofemoral ligament reconstruction. J Knee Surg 30:879–886CrossRefGoogle Scholar
  12. 12.
    Hopper GP, Leach WJ, Rooney BP, Walker CR, Blyth MJ (2014) Does degree of trochlear dysplasia and position of femoral tunnel influence outcome after medial patellofemoral ligament reconstruction? Am J Sports Med 42:716–722CrossRefGoogle Scholar
  13. 13.
    Jaecker V, Brozat B, Banerjee M, Otchwemah R, Bouillon B, Shafizadeh S (2015) Fluoroscopic control allows for precise tunnel positioning in MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc 25:2688–2694CrossRefGoogle Scholar
  14. 14.
    LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L (2007) The anatomy of the medial part of the knee. J Bone Joint Surg Am 89:2000–2010PubMedGoogle Scholar
  15. 15.
    McCarthy M, Ridley TJ, Bollier M, Wolf B, Albright J, Amendola A (2013) Femoral tunnel placement in medial patellofemoral ligament reconstruction. Iowa Orthop J 33:58–63PubMedPubMedCentralGoogle Scholar
  16. 16.
    Nomura E, Inoue M, Osada N (2005) Anatomical analysis of the medial patellofemoral ligament of the knee, especially the femoral attachment. Knee Surg Sports Traumatol Arthrosc 13:510–515CrossRefGoogle Scholar
  17. 17.
    Panagiotopoulos E, Strzelczyk P, Herrmann M, Scuderi G (2006) Cadaveric study on static medial patellar stabilizers: the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 14:7–12CrossRefGoogle Scholar
  18. 18.
    Philippot R, Chouteau J, Wegrzyn J, Testa R, Fessy MH, Moyen B (2009) Medial patellofemoral ligament anatomy: implications for its surgical reconstruction. Knee Surgery, Sport Traumatol Arthrosc 17:475–479CrossRefGoogle Scholar
  19. 19.
    Placella G, Tei M, Sebastiani E, Speziali A, Antinolfi P, Delcogliano M, Georgoulis A, Cerulli G (2015) Anatomy of the medial patello-femoral ligament: a systematic review of the last 20 years literature. Musculoskelet Surg 99:93–103CrossRefGoogle Scholar
  20. 20.
    Redfern J, Kamath G, Burks R (2010) Anatomical confirmation of the use of radiographic landmarks in medial patellofemoral ligament reconstruction. Am J Sports Med 38:293–297CrossRefGoogle Scholar
  21. 21.
    Schöttle PB, Schmeling A, Rosenstiel N, Weiler A (2007) Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 35:801–804CrossRefGoogle Scholar
  22. 22.
    Servien E, Fritsch B, Lustig S, Demey G, Debarge R, Lapra C, Neyret P (2011) In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med 39:134–139CrossRefGoogle Scholar
  23. 23.
    Shafizadeh S, Balke M (2014) Medial patellofemoral ligament reconstruction: a new technique for graft fixation at the patella without implants. Arthrosc Tech 3:e115–e117CrossRefGoogle Scholar
  24. 24.
    Smirk C, Morris H (2003) The anatomy and reconstruction of the medial patellofemoral ligament. Knee 10:221–227CrossRefGoogle Scholar
  25. 25.
    Steensen RN, Dopirak RM, McDonald WG (2004) The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med 32:1509–1513CrossRefGoogle Scholar
  26. 26.
    Stephen JM, Kaider D, Lumpaopong P, Deehan DJ, Amis AA (2014) The effect of femoral tunnel position and graft tension on patellar contact mechanics and kinematics after medial patellofemoral ligament reconstruction. Am J Sports Med 42:364–372CrossRefGoogle Scholar
  27. 27.
    Stephen JM, Lumpaopong P, Deehan DJ, Kader D, Amis AA (2012) The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and nonanatomic attachments. Am J Sports Med 40:1871–1879CrossRefGoogle Scholar
  28. 28.
    Trinh TQ, Ferrel JR, Bentley JC, Steensen RN (2017) The anatomy of the medial patellofemoral ligament. Orthopedics 40:e583–e588CrossRefGoogle Scholar
  29. 29.
    Tuxøe JI, Teir M, Winge S, Nielsen PL (2002) The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc 10:138–140CrossRefGoogle Scholar
  30. 30.
    Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, Engebretsen L (2009) Radiographic identification of the primary medial knee structures. J Bone Joint Surg Am 91:521–529CrossRefGoogle Scholar
  31. 31.
    Wijdicks CA, Westerhaus BD, Brand EJ, Johansen S, Engebretsen L, LaPrade RF (2010) Sartorial branch of the saphenous nerve in relation to a medial knee ligament repair or reconstruction. Knee Surgery, Sport Traumatol Arthrosc 18:1105–1109CrossRefGoogle Scholar
  32. 32.
    Ziegler CG, Fulkerson JP, Edgar C (2016) Radiographic reference points are inaccurate with and without a true lateral radiograph: the importance of anatomy in medial patellofemoral ligament reconstruction. Am J Sports Med 44:133–142CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne Merheim Medical CenterUniversity of Witten/HerdeckeCologneGermany
  2. 2.Department of Orthopaedic Surgery, Center for Sports MedicineUniversity of PittsburghPittsburghUSA

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