Repair of the medial patellofemoral ligament with suture tape augmentation leads to similar primary contact pressures and joint kinematics like reconstruction with a tendon graft: a biomechanical comparison

  • Julian Mehl
  • Alexander Otto
  • Brendan Comer
  • Cameron Kia
  • Franz Liska
  • Elifho Obopilwe
  • Knut Beitzel
  • Andreas B. ImhoffEmail author
  • John P. Fulkerson
  • Florian B. Imhoff



To compare suture tape-augmented MPFL repair with allograft MPFL reconstruction using patellofemoral contact pressure and joint kinematics to assess the risk of patellofemoral over-constrainment at point zero.


A total of ten fresh frozen cadaveric knee specimens were tested in four different conditions of the MPFL: (1) native, (2) cut, (3) reconstructed with tendon graft, and (4) augmented with suture tape. The patellofemoral mean pressure (MP), peak pressure (PP) and contact area (CA) were measured independently for the medial and lateral compartments using pressure-sensitive films. Patellar tilt (PT) and shift (PS) were measured using an optical 3D motion tracking system. Measurements were recorded at 0°, 10°, 20°, 30°, 60° and 90° of flexion. Both the tendon graft and the internal brace were preloaded with 2 N, 5 N, and 10 N.


There was no significant differences found between surgical methods for medial MP, medial PP, medial CA, lateral MP and PS at any preload or flexion angle. Significant differences were seen for lateral PP at 20° knee flexion and 10 N preload (suture tape vs. reconstruction: 1045.9 ± 168.7 kPa vs. 1003.0 ± 151.9 kPa; p = 0.016), for lateral CA at 10° knee flexion and 10 N preload (101.4 ± 39.5 mm2 vs. 108.7 ± 36.6 mm2; p = 0.040), for PT at 10° knee flexion and 2 N preload (− 1.9 ± 2.5° vs. − 2.5 ± 2.3°; p = 0.033) and for PT at 0° knee flexion and 10 N preload (− 0.8 ± 2.5° vs. − 1.8 ± 3.1°; p = 0.040). A preload of 2 N on the suture tape was the closest in restoring the native joint kinematics.


Suture tape augmentation of the MPFL resulted in similar primary contact pressures and joint kinematics in comparison with MPFL reconstruction using a tendon graft. A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics.


Patellofemoral instability Medial patellofemoral ligament Internal ligament bracing Ligament reconstruction Contact pressure Joint kinematics 



The University of Connecticut Health Center/UConn Musculoskeletal Institute has received direct funding and material support from Arthrex (Naples, Fl, USA). The company had no influence on study design, data collection or interpretation of the results or the final manuscript.

Compliance with ethical standards

Conlict of interest

K. Beitzel is consultant for Arthrex. A.B. Imhoff is consultant for Arthrosurface and medi and receives royalties from Arthrex and Arthrosurface. All other authors declare, that they have no conflicts of interest.

Ethical approval

All study specimens were obtained from Science Care (Phoenix, AZ, USA). The study was reported via Human Research Determination Form to the institutional review board (IRB) of the University of Connecticut, Farmington, CT, USA (IRB JM-18-2) and was documented, that no IRB approval was required.


  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.
    Arendt EA, Moeller A, Agel J (2011) Clinical outcomes of medial patellofemoral ligament repair in recurrent (chronic) lateral patella dislocations. Knee Surg Sports Traumatol Arthrosc 19:1909–1914CrossRefGoogle Scholar
  3. 3.
    Bicos J, Carofino B, Andersen M, Schepsis AA, Fulkerson JP, Mazzocca A (2006) Patellofemoral forces after medial patellofemoral ligament reconstruction: a biomechanical analysis. J Knee Surg 19:317–326CrossRefGoogle Scholar
  4. 4.
    Bouras T, Edmond U, Brown A, Gallacher P, Barnett A (2019) Isolated medial patellofemoral ligament reconstruction significantly improved quality of life in patients with recurrent patella dislocation. Knee Surg Sports Traumatol Arthrosc. Google Scholar
  5. 5.
    Camp CL, Krych AJ, Dahm DL, Levy BA, Stuart MJ (2010) Medial patellofemoral ligament repair for recurrent patellar dislocation. Am J Sports Med 38:2248–2254CrossRefGoogle Scholar
  6. 6.
    Desio SM, Burks RT, Bachus KN (1998) Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 26:59–65CrossRefGoogle Scholar
  7. 7.
    Farahmand F, Senavongse W, Amis AA (1998) Quantitative study of the quadriceps muscles and trochlear groove geometry related to instability of the patellofemoral joint. J Orthop Res 16:136–143CrossRefGoogle Scholar
  8. 8.
    Farahmand F, Tahmasbi MN, Amis AA (1998) Lateral force-displacement behaviour of the human patella and its variation with knee flexion—a biomechanical study in vitro. J Biomech 31:1147–1152CrossRefGoogle Scholar
  9. 9.
    Hardy A, Casabianca L, Andrieu K, Baverel L, Noailles T (2017) Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: systematic review of literature. Orthop Traumatol Surg Res 103:S245–S248CrossRefGoogle Scholar
  10. 10.
    Kang H, Zheng R, Dai Y, Lu J, Wang F (2019) Single- and double-bundle medial patellofemoral ligament reconstruction procedures result in similar recurrent dislocation rates and improvements in knee function: a systematic review. Knee Surg Sports Traumatol Arthrosc 27:827–836CrossRefGoogle Scholar
  11. 11.
    Lippacher S, Dreyhaupt J, Williams SR, Reichel H, Nelitz M (2014) Reconstruction of the medial patellofemoral ligament: clinical outcomes and return to sports. Am J Sports Med 42:1661–1668CrossRefGoogle Scholar
  12. 12.
    Lorbach O, Haupert A, Efe T, Pizanis A, Weyers I, Kohn D et al (2017) Biomechanical evaluation of MPFL reconstructions: differences in dynamic contact pressure between gracilis and fascia lata graft. Knee Surg Sports Traumatol Arthrosc 25:2502–2510CrossRefGoogle Scholar
  13. 13.
    Lubowitz JH, MacKay G, Gilmer B (2014) Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing. Arthrosc Tech 3:e505–508CrossRefGoogle Scholar
  14. 14.
    Maenpaa H, Huhtala H, Lehto MU (1997) Recurrence after patellar dislocation. Redislocation in 37/75 patients followed for 6–24 years. Acta Orthop Scand 68:424–426CrossRefGoogle Scholar
  15. 15.
    Maenpaa H, Lehto MU (1997) Patellar dislocation. The long-term results of nonoperative management in 100 patients. Am J Sports Med 25:213–217CrossRefGoogle Scholar
  16. 16.
    Magnussen RA, Verlage M, Stock E, Zurek L, Flanigan DC, Tompkins M et al (2017) Primary patellar dislocations without surgical stabilization or recurrence: how well are these patients really doing? Knee Surg Sports Traumatol Arthrosc 25:2352–2356CrossRefGoogle Scholar
  17. 17.
    Nwachukwu BU, So C, Schairer WW, Green DW, Dodwell ER (2016) Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review. Knee Surg Sports Traumatol Arthrosc 24:760–767CrossRefGoogle Scholar
  18. 18.
    Ostermeier S, Holst M, Bohnsack M, Hurschler C, Stukenborg-Colsman C, Wirth CJ (2007) Dynamic measurement of patellofemoral contact pressure following reconstruction of the medial patellofemoral ligament: an in vitro study. Clin Biomech (Bristol, Avon) 22:327–335CrossRefGoogle Scholar
  19. 19.
    Ostermeier S, Holst M, Bohnsack M, Hurschler C, Stukenborg-Colsman C, Wirth CJ (2007) In vitro measurement of patellar kinematics following reconstruction of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 15:276–285CrossRefGoogle Scholar
  20. 20.
    Ostermeier S, Stukenborg-Colsman C, Hurschler C, Wirth CJ (2006) In vitro investigation of the effect of medial patellofemoral ligament reconstruction and medial tibial tuberosity transfer on lateral patellar stability. Arthroscopy 22:308–319CrossRefGoogle Scholar
  21. 21.
    Philippot R, Boyer B, Testa R, Farizon F, Moyen B (2012) Study of patellar kinematics after reconstruction of the medial patellofemoral ligament. Clin Biomech (Bristol, Avon) 27:22–26CrossRefGoogle Scholar
  22. 22.
    Saper MG, Meijer K, Winnier S, Popovich J Jr, Andrews JR, Roth C (2017) Biomechanical evaluation of classic solid and all-soft suture anchors for medial patellofemoral ligament reconstruction. Am J Sports Med 45:1622–1626CrossRefGoogle Scholar
  23. 23.
    Schneider DK, Grawe B, Magnussen RA, Ceasar A, Parikh SN, Wall EJ et al (2016) Outcomes after isolated medial patellofemoral ligament reconstruction for the treatment of recurrent lateral patellar dislocations: a systematic review and meta-analysis. Am J Sports Med. 44:2993–3005 (Epub 2016 Feb 2912) CrossRefGoogle Scholar
  24. 24.
    Schottle PB, Romero J, Schmeling A, Weiler A (2008) Technical note: anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft. Arch Orthop Trauma Surg 128:479–484CrossRefGoogle Scholar
  25. 25.
    Steensen RN, Bentley JC, Trinh TQ, Backes JR, Wiltfong RE (2015) The prevalence and combined prevalences of anatomic factors associated with recurrent patellar dislocation: a magnetic resonance imaging study. Am J Sports Med 43:921–927CrossRefGoogle Scholar
  26. 26.
    Stephen JM, Kittl C, Williams A, Zaffagnini S, Marcheggiani Muccioli GM, Fink C et al (2016) Effect of medial patellofemoral ligament reconstruction method on patellofemoral contact pressures and kinematics. Am J Sports Med 44:1186–1194CrossRefGoogle 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.
    Stephen JM, Lumpaopong P, Dodds AL, Williams A, Amis AA (2015) The effect of tibial tuberosity medialization and lateralization on patellofemoral joint kinematics, contact mechanics, and stability. Am J Sports Med 43:186–194CrossRefGoogle Scholar
  29. 29.
    Wang Q, Huang W, Cai D, Huang H (2017) Biomechanical comparison of single- and double-bundle medial patellofemoral ligament reconstruction. J Orthop Surg Res 12:29CrossRefGoogle Scholar
  30. 30.
    Webster KE, Wittwer JE, O'Brien J, Feller JA (2005) Gait patterns after anterior cruciate ligament reconstruction are related to graft type. Am J Sports Med 33:247–254CrossRefGoogle Scholar
  31. 31.
    Wilharm A, Hurschler C, Dermitas T, Bohnsack M (2013) Use of Tekscan K-scan sensors for retropatellar pressure measurement avoiding errors during implantation and the effects of shear forces on the measurement precision. Biomed Res Int 2013:829171. CrossRefGoogle Scholar
  32. 32.
    Yang JS, Fulkerson JP, Obopilwe E, Voss A, Divenere J, Mazzocca AD et al (2017) Patellofemoral contact pressures after patellar distalization: a biomechanical study. Arthroscopy 33:2038–2044Google Scholar
  33. 33.
    Zaffagnini S, Colle F, Lopomo N, Sharma B, Bignozzi S, Dejour D et al (2013) The influence of medial patellofemoral ligament on patellofemoral joint kinematics and patellar stability. Knee Surg Sports Traumatol Arthrosc 21:2164–2171CrossRefGoogle Scholar
  34. 34.
    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) 2019

Authors and Affiliations

  • Julian Mehl
    • 1
    • 2
  • Alexander Otto
    • 3
  • Brendan Comer
    • 1
  • Cameron Kia
    • 1
  • Franz Liska
    • 2
  • Elifho Obopilwe
    • 1
  • Knut Beitzel
    • 2
  • Andreas B. Imhoff
    • 2
    Email author
  • John P. Fulkerson
    • 4
  • Florian B. Imhoff
    • 2
  1. 1.Department of Orthopaedic SurgeryUniversity of ConnecticutFarmingtonUSA
  2. 2.Department of Orthopaedic Sports MedicineTechnical University MunichMunichGermany
  3. 3.Department of Trauma, Orthopaedic, Plastic and Hand SurgeryUniversity Hospital of AugsburgAugsburgGermany
  4. 4.Orthopaedic Associates of HartfordFarmingtonUSA

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