Selective bundle tensioning in double-bundle MPFL reconstruction to improve restoration of dynamic patellofemoral contact pressure

  • N. ZumbansenEmail author
  • A. Haupert
  • D. Kohn
  • O. Lorbach



To evaluate the optimal graft tension angles in a medial patellofemoral ligament (MPFL) reconstruction with selective bundle tensioning in order to restore patellofemoral contact pressure distributions closest to the native state.


Twelve human cadaveric knee specimens were mounted with the femur on a custom-made fixation device allowing free range of motion in the knee joint for testing. Using a sensitive pressure film (Tekscan) patellofemoral contact pressure was measured in 15° intervals during a dynamic flexion movement from 0°–90° in the native state, in cut MPFL and after MPFL-reconstruction with a gracilis tendon.

The graft was separated in two bundles and was fixed independently on the patella using two knotless anchors. Two groups were made with either the proximal or distal bundle fixed at the femur at a knee flexion angle of 30° and the corresponding other bundle subsequently fixed at the femur at 15°, 45°, 60°, 75° and 90° of knee flexion using extra-cortical fixation and controlled tension of 2N in both groups. The sequence of the flexion angles at the graft fixation was alternated. Pressure measurements were repeated after every fixation of the graft.


Cutting the MPFL resulted in significantly reduced patellofemoral contact pressure at all flexion angles. After MPFL reconstruction the patellofemoral contact pressure remained significantly reduced during dynamic knee flexion in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°. Selective evaluation of lateral patellofemoral contact pressure, however, showed significant reduction in all tested double-bundle combinations (p < 0.05) from 15° to 90°. Evaluation of isolated medial patellofemoral pressure changes showed no significant difference in all tested combinations compared to the intact knee. Furthermore, evaluation of the isolated proximal and distal patellofemoral contact pressure also revealed a significantly reduced contact pressure in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°.


According to this study, selective bundle tensioning in anatomic MPFL-reconstruction should be considered as an easy and more anatomic alternative to current popular techniques to restore patella kinematics and give clear recommendation about knee flexion angle and tension during fixation. Although tensioning two bundles separately may further improve clinical results. If performed, fixation of the graft is recommended under low tension (2N) with the proximal bundle at 30° and the distal bundle at 75° of knee flexion.


MPFL Double-bundle Patellofemoral Knee kinematics Biomechanical Patella 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


No special funding as the study was supported by Saarland University, Department of Orthopaedic Surgery, Kirrberger Straße, Geb. 37, D-66421 Homburg (Saar), Germany.

Ethical approval

In Germany is no need for a specific consent of the ethic committee for biomechanical study. Therefore, only approval from the university board was obtained.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic Sports MedicineTrauma Surgery and Hand Surgery, Helios Clinic Munich WestMunichGermany
  2. 2.Department of Orthopaedic SurgerySaarland UniversityHomburgGermany
  3. 3.Department of Shoulder Surgery and Sports TraumatologySchön-Kliniken LorschLorschGermany

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