Allograft Medial Patellofemoral Ligament

Reconstruction in Adolescent Patients Results in a

Low Recurrence Rate of Patellar Dislocation or
Subluxation at Midterm Follow-Up
Sachin Allahabadi, M.D., and Nirav K. Pandya, M.D.

Purpose: To evaluate rates of recurrent instability in adolescent patients with medial patellofemoral ligament (MPFL)
reconstruction with allograft and associations of anatomic risk factors with complications. Methods: A retrospective
review identified patients of a single surgeon who underwent MPFL reconstruction with allograft for recurrent patellar
instability with minimum 2-year follow-up. Surgical management was recommended after a minimum 6 weeks of
nonoperative management and included MPFL reconstruction with gracilis allograft using a double-bundle technique.
Preoperative radiographs were evaluated to assess physeal closure, lower-extremity alignment, trochlear morphology, and
Insall-Salvati and Caton-Deschamps ratios. Magnetic resonance images were reviewed to evaluate the MPFL, trochlear
morphology, and tibial tubercle trochlear groove distance (TT-TG). Descriptive statistics were used to characterize data.
The primary outcome was recurrent instability. Results: 20 patients (24 knees; 18 knees in 14 females and 6 knees in 6
males; average age 15.7 years; range 11.5 to 19.6) underwent MPFL reconstruction with allograft (mean
standard
deviation follow-up 5.2
1.7 years; range 2.2 to 8.1). Physes were open in 9 knees. The Insall-Salvati ratio was 1.09

0.16, and the Caton-Deschamps index was 1.17
0.15. Preoperatively, 19 patients were noted to have trochlear dysplasia,
and TT-TG was 15.3
3.9 mm. Three of 4 knees (16.7%) with nonehardware-related complications had open physes: 3
(12.5%) had recurrent instability, 2 of which underwent subsequent operation, and 1 sustained a patella fracture after a
fall, requiring open reduction and internal fixation. The average Insall-Salvati ratio of these 4 patients was 1.21
0.20,
Caton-Deschamps index was 1.18
0.17, and TT-TG was 17.5
3.3 mm, none of which were statistically different from
the group without complications. There were no clinically noted growth disturbances postoperatively. Con-
clusions: MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population
with good outcomes at midterm follow-up, few complications, and a low rate of recurrent instability. Level of Evi-
dence: IV, case series.

P atellar dislocations are common knee injuries in

the pediatric population, and a large majority of
From the Department of Orthopaedic Surgery, University of California, San
Francisco, San Francisco, California, U.S.A. (S.A.); and the Department of
Orthopaedic Surgery, Benioff Children’s Hospital Oakland, University of
California, San Francisco, San Francisco, California, U.S.A. (N.K.P.).
The authors report the following potential conflicts of interest or sources of
funding: N.K.P. is a consultant for OrthoPediatrics and received educational
support/payment from Evolution Surgical, Inc. Full ICMJE author disclosure
forms are available for this article online, as supplementary material.
Received February 3, 2021; accepted May 6, 2021.
Address correspondence to Nirav K. Pandya, M.D., Department of Ortho-
paedic Surgery, Benioff Children’s Hospital Oakland, University of Califor-
nia, San Francisco, 747 52nd St, Oakland, CA 94609, U.S.A. E-mail: nirav.
pandya@ucsf.edu
Ó 2021 by the Arthroscopy Association of North America
0749-8063/21122/$36.00
https://doi.org/10.1016/j.arthro.2021.05.005
these injuries occur in a young and active popula-
tion.1-6 After an initial patellar dislocation, there is a
high risk of recurrent dislocation, particularly in those
who are younger with open physes or trochlear
dysplasia.7,8 These risk factors in addition to female sex
and patella alta have been cited as risks for recurrence
and earlier time to subsequent instability event.9
Dislocation or subluxation of the patella typically oc-
curs laterally, with the medial patellofemoral ligament
(MPFL) serving as the primary soft tissue restraint to
this patellar instability.10
Although first-time dislocations may be managed
nonoperatively, recurrent dislocations are typically
managed surgically. Several soft tissue and bony sur-
gical options are available to address patellar instability
and its associated anatomic risk factors, but it has been
suggested that the most effective surgical procedure for
recurrent patellar instability in the skeletally immature

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2021: pp 1-11 1
2 S. ALLAHABADI AND N. K. PANDYA
population is reconstruction of the MPFL.11 MPFL
reconstruction surgeries are increasing in number, and
the literature on this procedure, including a variety of
surgical techniques, is expanding.12 Reconstruction
may be performed with either autograft or allograft,
and the types of grafts selected and specific surgical
techniques vary widely.
Some of the benefits of allograft over autograft
include quicker surgical time and obviating donor-site
morbidity, in addition to having the advantage of use
in those having disorders with soft tissue laxity.13,14
Hesitation to use allograft in MPFL reconstruction in
the pediatric and adolescent population partially stems
from studies demonstrating higher failure rates in this
age group with allograft in anterior cruciate ligament
(ACL) reconstruction,15,16 and data suggesting that al-
lografts may take longer to incorporate and may
attenuate over time.17,18 However, whether similar
trends in failure rates and attenuation apply to MPFL
reconstruction is not clear. The MPFL has a much lower
tensile strength than the ACL, particularly in young
patients, and therefore may be more amenable to
allograft tissue.10,19 Whereas the data support favorable
outcomes with use of allograft reconstruction of the
MPFL in the general population,20-22 there is less data
available on adolescent groups.
The senior author has previously reported outcomes
on an adolescent patient cohort after MPFL recon-
struction in a short-term study with a minimum 1-year
follow-up (mean 24 months).23 Although that study
provides some information with regard to surgical
complications and short-term functional outcomes, the
longevity of pediatric/adolescent reconstructive tech-
niques is critical given their participation in high-risk
activities. Longer-term studies on adolescent patients
undergoing MPFL reconstruction with allograft are
limited, and it is unknown whether allograft tissue has
sustainable longevity in preventing recurrent patello-
femoral instability. The purposes of this study were to
evaluate (1) rates of recurrent instability in adolescent
patients having MPFL reconstruction with allograft at
midterm follow-up and (2) associations of anatomic risk
factors with complications. The authors hypothesized
that recurrent instability rates would remain low at
midterm follow-up, with few additional dislocations,
and that anatomic risk factors would not correlate with
complication rate in this cohort.
Methods
Patients and Preoperative Data
The study was given an exemption by the IRB of the
University of California, San Francisco, Benioff Chil-
dren’s Hospital Oakland. A retrospective chart review
was performed on patients from June 2012 through
December 2015 who underwent primary MPFL
reconstruction with allograft by the senior surgeon
(N.K.P.). Patients were included only if they had a min-
imum 2-year follow-up or complications in <2 years
regardless of final follow-up time. No patients during this
study period without the minimum 2-year follow-up
who were excluded had recurrent instability.
Patients were included as surgical candidates if they
had recurrent patellar dislocations or subluxations and
had tried 6 weeks of nonoperative management
including bracing, physical therapy, and activity modi-
fications. All patients undergoing MPFL reconstruction
with allograft during the study period were included. All
patients were required to have preoperative magnetic
resonance imaging (MRI). Exclusion criteria were pa-
tients with concomitant guided growth procedures,
metabolic bone disease, neuromuscular disorders, or
connective tissue disease. MPFL reconstruction with
allograft was performed as the preferred surgical tech-
nique by the senior surgeon throughout this time frame
to mitigate donor site morbidity from autograft harvest.
No MPFL reconstructions were performed with autograft
during this time frame; however, some patients in this
study period underwent other patella-stabilizing pro-
cedures such as MPFL repair for partial MPFL tears and
tibial tubercle osteotomies for excessive tibial tubercle-
trochlear groove (TT-TG) distances, as determined by
the senior surgeon (N.K.P.), and were excluded.
Preoperative data collection included demographic
data such as age, sex, medical and surgical histories,
laterality of injury, and history of dislocations. Physical
examination evaluated for lower-extremity alignment
abnormalities. Patients who had clinical valgus (defined
as intermalleolar distance >4 cm in males or >8 cm in
females24 in our adolescent age group) were noted, but
full-length alignment films were not consistently
available for all patients to record mechanical axis de-
viation measurements. Clinical anteversion was defined
as >65 hip internal rotation25 or asymmetry of hip
internal rotation of >25 as tested in the prone position;
in those with suspicion for anteversion, MRI studies of
the full lower extremity were obtained to evaluate the
true presence and degree of anteversion. A clinical
evaluation for generalized ligamentous laxity was per-
formed, and documentation in the clinical chart was
available if the patient had ligamentous laxity (defined
as Beighton score26 4 of 9), but specific Beighton
scores were not noted; therefore, only the presence of
ligamentous laxity was recorded. Preoperative x-rays
were used to assess whether the physes were open and
calculate Insall-Salvati and Caton-Deschamps ratios.
The intra- and interobserver reliability of Insall-Salvati
ratios has previously been cited as intraclass correla-
tion coefficient (ICCs) of 0.72 and >0.80 on radio-
graphs, respectively,27,28 although in adolescents, the
interobserver reliability has been found to be lower,
with ICC of 0.64.29 Intra- and interobserver reliability
 ADOLESCENT ALLOGRAFT MPFL RECONSTRUCTION
of Caton-Deschamps indices have been previously cited
to be 0.71 and 0.76 on radiographs,
respectively.27,28
In patients determined to have substantial growth
remaining, the practice of the senior surgeon is to
obtain lower-extremity limb alignment radiographs and
repeat these at 1-year intervals until physes are closed.
A growth disturbance was defined as 1 cm change in
limb length discrepancy or 1 cm deviation in me-
chanical axis.30 MRI of the knee was evaluated in each
case with particular attention to the status of the MPFL,
patellofemoral joint cartilage, and trochlear
morphology, among other findings. Trochlear
morphology was classified as per the description of
Dejour and Saggin,31 using information from both
lateral knee radiographs and cross-sectional axial im-
aging from MRI to determine class.32 Trochlear
morphology per the Dejour and Saggin classification of
C and D are referred to as “high-grade,” whereas clas-
sificationsA and B are referred to as “low-grade.” TT-TG
distances were also calculated from MRIs (Table 1).
Intra- and interobserver variation of TT-TGs has been
shown to be high on MRI, with ICC values typically
>0.84 for interobserver reliability.33,34
Surgical Technique
Signed written informed consent was provided by the
patients’ parents before surgery. All patients underwent
MPFL reconstruction with allograft tissue by the senior
surgeon (N.K.P.). An examination under anesthesia
was performed to evaluate gross patellar mobility in full
extension and at 30 knee flexion and tracking
throughout range of motion. In all cases, there was
excessive patellar lateral translation without firm
endpoint relative to the contralateral side. All proced-
ures were performed after ultrasound-guided femoral
nerve block. A tourniquet was applied and elevated.
Diagnostic Arthroscopy and Graft Preparation
A diagnostic knee arthroscopy was performed to
evaluate patellofemoral tracking and motion
throughout knee flexion via the anterolateral arthro-
scopic portal. The knee joint was evaluated arthro-
scopically for additional injuries, including loose bodies
and chondral damage. A gracilis allograft was used for
each case. After the graft was thawed and measured, it
was whip-stitched on both ends using #2 FiberLoop
(Arthrex, Naples, FL). The typical graft size in the senior
author’s experience is a length of 190 mm and diameter
of 4.5 mm on each of the tapered ends, or 5.0 mm
when doubled over. The graft was kept in a saline-
soaked sponge.
Patellar Preparation
A 4-cm skin incision was made from the super-
omedial corner of the patella to the center of the medial
3
edge, and dissection was carried through the medial
layers of the knee, taking care to not violate the joint
capsule. Fluoroscopic imaging was used to identify a
location 3 to 5 mm distal to the superomedial corner of
the patella, and a guide pin was advanced across the
patella, avoiding the articular surface and remaining
parallel to the joint line. A second guide pin was placed
parallel to the first, approximately 15 to 20 mm distal.
After the position of the 2 guide pins was confirmed,
the entry sites were tapped, and pins were overreamed
using a 4.5-mm cannulated reamer to a depth of 25
mm. Fluoroscopy was again used to confirm the socket
positions (Fig 1).
Patellar Graft Passage and Securing
The first whipstitched suture limb was passed into the
patella and secured using either biocomposite interfer-
ence screw fixation or a knotless twist-in anchor (bio-
composite): if patellar length was short and a minimum
15-mm distance between anticipated interference
screws could not be safely obtained or there was
concern for poor-quality bone with heightened patellar
fracture risk, twist-in anchors were used. If twist-in
anchors were used for patellar size concerns, the graft
was trimmed from 4.5 to 3.5 mm on the tapered ends.
This process of securing the graft on the patella was
repeated with the other limb. Fluoroscopy was used to
again evaluate for intraoperative patellar fractures.
Femoral Preparation
A lateral fluoroscopic image was obtained to deter-
mine the femoral insertion point of the MPFL. The
selected insertion point is proximal to Blumensaat’s
line, 1 mm anterior to the posterior cortex extension
line, and 2 mm below the posterior border of the medial
femoral condyle. A small incision was made over the
desired location on the medial knee with dissection
carried to bone. A 3.2-mm guide pin was advanced
across the femur and through the lateral skin, taking
care to avoid the intercondylar notch and the physis in
skeletally immature patients. An incision was made
over the medial knee around the guide pin, with
dissection carried down to bone. The guide pin was
overreamed at a diameter of 6 to 7 mm to the far cortex
of the femur, again avoiding the physis in skeletally
immature patients.
Femoral Graft Passage and Securing
On the patellar incision, the interval between the
vastus medialis and the capsule was developed. Blunt
dissection was used to dissect toward the femoral inci-
sion. The graft was passed from the patellar incision to
the femoral incision, applying equal tension to both
graft bundles.
A Nitinol guide wire (Smith & Nephew, London, UK)
was placed into the drill hole for the femoral guidewire,
 4
Table 1. Baseline Cohort Data and Preoperative Radiographic Findings

Physeal Type of Trochlear

Final Status at Tibial Tubercle- Dysplasia per Lower-Extremity
Age at Prior Knee Follow- Time Insall-Salvati Caton-Deschamps Trochlear Groove Classification Alignment
Knee Surgery (y) Sex Laterality Surgeries Up (y) of Surgery Ratio Index Distance (mm) of Dejour Abnormalities
1 16.6 M R No 5.9 Closed 0.8 1.0 14 Normal
2 16.2 F L No 4.5 Closed 1.2 1.1 13 B
3 15.3 F R No 2.2 Closed 1.0 0.9 15 A
4 15 F L No 3.1 Open 1.3 1.3 20 B Valgus
5 13.3 F R No 7.1 Open 1.1 0.9 15 D
6 17.9 F L No 8.1 Closed 1.0 1.1 13 Normal Valgus, history of
femoral anteversion

S. ALLAHABADI AND N. K. PANDYA

(prior femoral
derotation osteotomy
with “excessive
anteversion”)
7 16 F L No 4.3 Closed 1.0 1.1 12 Normal
8 16 F L No 6.3 Closed 1.1 1.1 15 A
9 17.3 M L No 5.3 Closed 1.1 1.4 18 C
10 17.4 F L No 6.4 Closed 1.0 1.3 15 B
11 17.1 F R No 3.2 Closed 0.8 1.1 6 A
12 19.2 F R No 6.8 Closed 1.0 1.2 7 Normal
13 18.6 F L No 5.9 Open 0.9 1.3 21 A Valgus
14 15.2 M L Medial 6.2 Closed 1.1 1.2 14 B Valgus
imbrication and
lateral release
1 y prior
15 13.8 F R No 2.4 Open 1.4 1.4 17 B
16 15.8 F R No 4.9 Closed 1.0 1.2 18 D
17 15.7 M L No 4.5 Closed 1.2 1.3 16 B
18 12.6 F L No 5.7 Open 1.0 1.1 14 D Femoral anteversion,
clinical (19 measured)
19 13.6 F R No 4.8 Open 1.3 1.0 13 D Femoral anteversion
(35 measured)
20 19.6 F R No 4.8 Closed 1.1 1.5 21 A Valgus
21 12.5 F L No 6.7 Open 1.2 1.1 15 Normal
22 11.5 M L No 5.5 Open 1.5 1.4 22 D Valgus
23 14.3 M L No 5.6 Open 1.1 1.0 18 C Valgus
24 16.2 F L No 4.2 Closed 1.o 1.2 15 A
 ADOLESCENT ALLOGRAFT MPFL RECONSTRUCTION
Fig 1. Intraoperative fluoroscopic image of the knee
demonstrating socket positions in the patella. First, a location
approximately 3 to 5 mm distal to the superomedial corner of
the patella is identified, and a guide pin is advanced across the
patella from medial to lateral, parallel to the joint line,
avoiding the articular surface. A second pin is placed parallel
to the first, approximately 15 to 20 mm distal. After con-
firming pin positioning on fluoroscopy, the entry sites are
tapped and overreamed using a cannulated reamer. This im-
age demonstrates the socket sites after reaming.
and a passing suture was looped over the gracilis allo-
graft. The sutures were placed into the pin eyelet, and
the suture tails were delivered through the tunnel out
the lateral femoral skin incision. As the tunnel was
longer than the looped graft end, the sutures were
pulled and toggled on the lateral side of the knee to
apply tension on the graft.
While tension was held on the graft, the lateral patella
was placed flush with the lateral femoral condyle at 30
knee flexion. Range of motion and patellar tracking
were evaluated grossly. While tension was maintained,
a biocomposite screw was placed on the femoral side.
Tracking throughout full range of motion was again
evaluated grossly, seeking a firm endpoint with gentle
lateral translation of the patella at 30 knee flexion.
Rehabilitation
All patients underwent a standard rehabilitation
protocol. The patient is placed in a hinge knee brace
postoperatively. Range of motion is allowed in the
hinge knee brace from 0 to 60 , with toe-touch
weightbearing permitted with the brace locked in
extension for the first 2 weeks. Beginning 2 weeks
postoperatively, full weightbearing with crutch assis-
tance is permitted in extension, and gradual range of
motion (ROM) is permitted to reach 0 to 90 by 4
weeks postoperatively. At 6 weeks, the brace and
crutches are discontinued, and physical therapy con-
tinues for ROM and strengthening. Straight-ahead
5
running is allowed at 12 weeks. At the 16-week
mark, agility and sport specific drills are allowed. Pa-
tients are permitted full return to sports by 24 weeks if
they have pain-free running and 90% strength
compared with the nonoperative side.
Postoperative Data Collection
Retrospective postoperative chart review was per-
formed to evaluate operative dictations for intra-
operative findings, including those on diagnostic
arthroscopy. Postoperative documentation was
reviewed for recurrent instability events (defined as
recurrent subluxation or dislocation), additional sur-
geries, or additional complications, including patellar
fractures, persistent laxity on examination, loss of knee
motion/arthrofibrosis, symptomatic hardware, and
wound complications.35 Time of final follow-up was
noted.
Statistical Analyses
Demographic data were reported as either mean

standard deviation or mean (range). Comparisons were
made between those who experienced complications
(including the outcome of recurrent instability and
overall complications aside from symptomatic hard-
ware) postoperatively and those without complications
using Mann-Whitney/Wilcoxon rank sum test for
Insall-Salvati, Caton-Deschamps, and TT-TG measure-
ments. Fisher’s exact test was performed to evaluate
differences between groups in those with or without
trochlear dysplasia. Descriptive assessments were made
comparing complications between the prior report23
and the current data. All statistical analysis was per-
formed with Stata version 16.1 (StataCorp, College
Station, TX) with statistical significance set to a < 0.05
for 2-tailed differences.
Results
Demographics/Study Population
A total of 20 patients (24 knees) including 6 males (6
knees) and 14 females (18 knees) underwent MPFL
reconstruction with allograft tendon in the study period
with minimum 2-year follow-up (follow-up 5.2
1.5
years, range 2.2 to 8.1) (Table 1). Age at the time of
surgery was 15.7
2.1 years (range 11.5 to 19.6), and
15 left knee and 9 right knees were treated. None of the
patients were identified to have generalized ligamen-
tous laxity preoperatively on Beighton score screening.
One patient underwent medial imbrication and lateral
release 1 year before the MPFL reconstruction with
allograft.
Physes were open on radiographic evaluation preop-
eratively in 9 knees and closed in 15. The age of those
with open physes was 13.9
2.2 years. Total cohort
6 S. ALLAHABADI AND N. K. PANDYA
Insall-Salvati ratio was 1.09
0.16, and Caton-
Deschamps index was 1.17
0.15 (Table 1).
Lower-extremity alignment evaluation was normal in
15 knees, and clinical abnormalities of valgus existed in
6, clinical valgus plus history of femoral anteversion in
1 (patient underwent varus derotational osteotomy of
the femur previously with documentation of “excessive
anteversion”), and confirmed femoral anteversion in 1
(measured 35 ) (Table 2).
Nineteen patients were noted to have trochlear
dysplasia preoperatively. TT-TG distance was 15.3

3.85 mm. MRI findings, intraoperative arthroscopic
findings, and additional procedures performed are
documented in Table 2.
Recurrent Instability
Three patients (12.5%) had recurrent instability
(Table 3), with 2 having subsequent procedures: 1 pa-
tient underwent repeat MPFL reconstruction, and 1
underwent a tibial tubercle osteotomy. These 2 opera-
tive instability patients had open physes and clinical
valgus alignment preoperatively. The patient who did
not undergo subsequent surgery had closed physes,
normal clinical lower-extremity alignment, and a body
mass index of >41. This patient was the only one
included in the prior study23 who had an additional
instability event.
Additional Complications
One patient suffered a patellar fracture after a fall
when descending stairs 1 week after being cleared to
return to full sport, approximately 6 months post-
operatively, requiring subsequent open reduction and
internal fixation (Table 3). This patient had patellar
fixation with two 4.75-mm Arthrex Bio-SwiveLock
anchors. There were no infections. No detectable
growth disturbances were noted in those with open
physes clinically or on subsequent imaging.
Two patients (8.3%) underwent hardware-related
procedures, 1 of which was new since the prior
report.23 One patient underwent hardware removal
from the femoral incision for symptomatic hardware
(7-mm diameter BioScrew; ConMed, Utica, NY) 2.3
years postoperatively. Another underwent a debride-
ment of a cyst that formed at the site of the femoral
screw (7-mm diameter BioComposite Interference
Screw; Arthrex) 2.8 years postoperatively.
All 3 of the patients who underwent subsequent
surgery for complications aside from symptomatic
hardware (recurrent instability or patellar fracture) had
open physes, with average age 12.8 years (11.5, 12.5,
and 14.3 years). None of these patients had post-
operative complications from the subsequent
procedures.
No differences existed in anatomic evaluations be-
tween the groups with or without complications,
excluding symptomatic hardware. The Insall-Salvati
ratio was 1.21
0.20 versus 1.06
0.15 in the
groups with and without complications, respectively
(P ¼ .22), and the Caton-Deschamps index was 1.18

0.17 versus 1.17
0.15 (P ¼ .98). The TT-TG was 17.5

3.3 mm versus 14.8
3.9 mm (P ¼ .23) in the group
with and without complications, respectively. There
was no difference when classifying patients by the
presence of dysplasia (P ¼ 1.0), high-grade dysplasia
(P ¼ .51), or specific dysplasia morphology (P ¼ .54).
Discussion
The most important finding of this study is a low
recurrent instability rate of 12.5% at midterm follow-
up after MPFL reconstruction with gracilis allograft in
the adolescent population. This study expands on prior
literature, demonstrating the maintained efficacy of the
graft in patients with longer follow-up by 3.2 years
compared with previously reported outcomes, with
only 1 additional patient having recurrent instability in
that time frame.23
Although recurrent patellar instability has been
shown to be higher in those of younger age in natural
history studies,9,36,37 a similar increased risk in younger
patients has not been consistently reported after MPFL
reconstruction, with different studies demonstrating
variable impacts of age.21,38-40 Given that in a series of
239 MPFL reconstructions, failure occurred at mean 3
years (range, 2 to 6),40 however, it is critical to continue
to monitor patients in the longer term to identify
recurrence. Recurrence may also vary with surgical
technique by age.
The efficacy of MPFL repair compared with recon-
struction, and that of reconstruction with autograft
compared with allograft, is debated, particularly in the
pediatric population. Bryant and Pandya,41 in a 16-
patient cohort of MPFL repairs and average follow-up
of 1.5 years, found no complications or recurrent
instability at time of last follow-up. In comparison to
the cohort of patients with overlap in the present study,
repair had more favorable outcomes in terms of insta-
bility, although numbers are small and difficult to draw
conclusions from.41 Puzzitiello et al.39 performed a
retrospective comparison of patients with MPFL
imbrication/repair versus reconstruction and found a
significantly higher rate of recurrent dislocation in the
repair group (36.9%) relative to the reconstruction
group (6.3%) (P ¼ .01), although there was no differ-
ence in return to activity or Kujala scores between
groups. In general, the level of evidence quality is low
with regard to these surgeries, but MPFL reconstruction
may have outcomes superior to repair.11,42
Most studies on MPFL reconstruction in the pediatric
population use autografts, with many demonstrating
favorable outcomes. However, allograft offers the
advantage of no donor-site morbidity and shorter
 ADOLESCENT ALLOGRAFT MPFL RECONSTRUCTION 7

Table 2. MRI evaluation, Intraoperative Arthroscopy, and Additional Concomitant Procedures

Additional Concomitant
Knee MRI Findings Notable Arthroscopic Findings Procedures
1 MPFL attenuation Laterally subluxated patella, healed OCD of MFC, Loose body removal,
10  15-mm OCD of nonarticular LFC, loose microfracture LFC
body
2 Mild trochlear dysplasia, MPFL attenuation Grade 1 changes medial patellar facet None
3 Avulsion of MPFL from patella Medial patellar chondral defect grade 2 Chondroplasty
4 Attenuated MPFL, bipartite patella Mild trochlear dysplasia, bipartite patella Bipartite patella excision
5 MPFL tear, tight retinaculum Chondral fraying of medial patella and LFC None
6 MPFL attenuation, patellar tendon edema None None
7 MPFL attenuation Lateral subluxation (3 quadrants) None
8 MPFL attenuation Laterally dislocatable patella (4 quadrants), None
trochlear dysplasia
9 MPFL attenuated, patellar chondral wear Lateral subluxation (3 quadrants), lateral patellar Lateral release
tilt
10 MPFL attenuation, medial meniscus contusion Laterally subluxatable patella (3 quadrants), LFC Synovectomy,
grade 1/2 changes (non-weightbearing) chondroplasty
11 MPFL attenuation Lateral subluxation (3 quadrants) None
12 MPFL attenuation, cartilage disruption on superior Lateral subluxation (3 quadrants), lateral tibial None
lateral pat facet plateau grade 1/2 changes
13 MPFL attenuation, fibrous cortical defect in Lateral subluxation (3 quadrants), grade 1/2 Lateral release
proximal tibia changes LFC, patellar tilt
14 Chronic avulsion of MPFL, LFC and medial patellar Lateral subluxation (3 quadrants), medial patellar Chondroplasty of medial
facet chondral wear grade 1/2 changes, generalized grade 1/2 patellar facet
changes on trochlea and LFC
15 Attenuated MPFL, medial patellar facet/lateral Lateral subluxation (3 quadrants), Outerbridge 1 Patellar chondroplasty
femoral condyle bruising and 2 changes lateral femoral condyle,
Outerbridge 2 and 3 changes medial patellar
facet
16 Torn MPFL, lateral patellar tilt with patellar Lateral subluxation (3 quadrants), medial patellar Loose body removal,
subluxation, chondral changes patella and facet exposed subchondral bone (Outerbridge 4, patellar microfracture,
medial patellar facet 3  3 mm), Outerbridge 2 changes LFC, 2  3- patellar chondroplasty,
mm loose body in lateral gutter, lateral patellar lateral femoral condyle
tilt chondroplasty, lateral
release
17 Partial MPFL tear, bone bruises in the medial facet Lateral subluxation (3 quadrants), Outerbridge 2 Partial lateral
of the patella and lateral femoral condyle with changes medial patellar facet, small radial tear of meniscectomy, medial
likely cortical break in the medial facet of the lateral meniscus, completely torn medial patellar facet
patella retinaculum inferiorly chondroplasty
18 Attenuated MPFL, lateral patellar tilt Laterally dislocatable patella (4 quadrants), positive Lateral release
patellar tilt, severe dysplasia
19 Attenuated MPFL, lateral patellar tilt Lateral patellar tilt, trochlear dysplasia, torn MPFL Lateral release
20 Attenuated MPFL Lateral subluxation (3 quadrants), positive patellar Lateral release
tilt
21 Attenuated MPFL Lateral subluxation (3 quadrants) None
22 Torn MPFL None Chondroplasty
23 Torn MPFL, chronic avulsion of medial patellar Lateral subluxation (3 quadrants), HO on Heterotopic ossification
facet inferomedial patella, grade 2 changes medial excision from patella,
patella facet, grade 1/2 changes LFC chondroplasty
24 Medial patellar facet avulsion, torn MPFL, bruising Lateral subluxation (3 quadrants), general chondral None
LFC wear patellar undersurface (Outerbridge 1 and
2), MPFL bony avulsion from patella
HO, heterotopic ossification; LFC, lateral femoral condyle; MFC, medial femoral condyle; MPFL, medial patellofemoral ligament; OCD,
osteochondral lesion.

operating times.13,14 In a meta-analysis including
largely adult-based studies, failure and revision rates
were equivalent between autograft and allograft.43
Kumar et al.44 published a retrospective chart review
comparing outcomes in pediatric patients undergoing
MPFL reconstruction with autograft and allograft, and
in the 59-patient study, there were no significant dif-
ferences in return to sports, pain scores, or failure rates.
On the other hand, a retrospective study by Hendawi
et al.13 comparing autograft versus allograft gracilis
tendon used for MPFL reconstruction found that those
undergoing reconstruction with autograft had higher
8 S. ALLAHABADI AND N. K. PANDYA

Table 3. Time to Complications

Approximate time to
Knee Complication Surgery complication/surgery (y)
7 Symptomatic hardware Cyst debridement at site of femoral incision/screw 2.8
16 Symptomatic hardware Removal of femoral screw 2.3
21 Recurrent instability Revision MPFL reconstruction with allograft 1.3
22 Recurrent instability Tibial tubercle osteotomy 2.8
23 Patellar fracture Patella ORIF 0.6
24 Recurrent instability Not applicable 2.1
MPFL, medial patellofemoral ligament; ORIF, open reduction and internal fixation.

rates of graft failure (28.6% in 21 patients with auto-
graft; 0% in 35 patients with allograft), secondary to
patellar instability events at an average of 13.8 months
postoperatively. Furthermore, the allograft group had
higher Kujala outcome scores, with a difference of 11.8
points (P ¼ .003).13 However, the graft size was also
significantly greater in the allograft group (5.7 versus
5.29 mm for autograft).13 The authors of the present
study suggest using gracilis allograft, which in our
experience has provided a satisfactory size of approxi-
mately 4.5 to 5.5 mm depending on the patient’s size.
In younger females, the authors have also seen success
with semitendinosus grafts, which may be of more
appropriate diameter and length. Biomechanical studies
suggest minimal difference in graft selection in restoring
joint contact pressures and patellar tracking; malposi-
tioned tunnels and improper graft tensioning have a
more significant impact.45
In the present study, 4 of the 24 knees had a post-
operative complication, excluding symptomatic hard-
ware, with 3 (12.5%) relating to instability and 1
(4.2%) to patellar fracture after a fall. Two patients
(8.3%) had subsequent surgeries related to symptom-
atic femoral hardware >2 years postoperatively. Insta-
bility rates may be higher in the pediatric population
than in adults in MPFL reconstruction, with a meta-
analysis demonstrating 10.0% recurrent instability in
patients <16 years old compared with 1.2% for patients
>16.21 Other literature also suggests a higher rate of
instability in the pediatric population, with 24 re-
constructions in a study by Lind et al.38 with autograft
gracilis tendon resulting in 20% redislocations within 1
year postoperatively compared with a separate adult
cohort demonstrating 5%. However, MPFL recon-
struction on patients with open physes has been
demonstrated to be safe,46 and no clinical complications
were found directly related to the physes (i.e., growth
disturbances) in the present cohort, although distur-
bances may be difficult to detect in a cohort nearing
skeletal maturity with average age 15.7 years. The
present study identified 1 additional patient with
instability relative to the prior cohort 23 at approxi-
mately 2 years postoperatively. This time to recurrence
highlights the importance of evaluating mid- and long-
term follow-up outcomes. Other data also suggest that
recurrent instability in the pediatric population may
occur after 1 year postoperatively.13
Anatomic risk factors include but are not limited to
patella alta and increased TT-TG distance. In the present
group, there was no difference in Insall-Salvati or
Caton-Deschamps ratios between the groups with and
without complications. The Caton-Deschamps index
averaged 1.17, which is less than a cited contributing
factor of failure of Caton-Deschamps 1.3 from 1 meta-
analysis.40 Furthermore, the TT-TG did not differ for
those with complications, similar to the findings of
Hendawi et al.13 in pediatric patients, although age-
related changes, axial scan orientation, and the use of
MRI should be taken into account when interpreting
values.47-49 Dickens et al.47 reported a median TT-TG of
12.1 mm in a pediatric population with patellar insta-
bility, which was significantly higher than the median
of 8.5 mm in those with normal knees. Although these
risk factors have been described, the impact of these
anatomic abnormalities on outcomes after surgery are
less clear. Pesenti et al.,50 in a group of 25 patients
undergoing MPFL reconstruction with hamstring
autograft, did not find bony abnormalities to be pre-
dictive of recurrent instability, although this is possibly
limited by sample size.
In terms of patient-reported outcomes, a recent
analysis evaluating 224 isolated MPFL reconstructions
did not find anatomic risk factors to be predictive of 2-
year quality-of-life outcome scores, whereas factors
such as bilateral symptoms, younger age at initial
dislocation, and farther deviated femoral tunnel posi-
tion all were significant predictors, albeit with a low R2
value of 0.07.51 However, these are in contrast to
studies suggesting negative outcomes with increased
TT-TG distance.52-54 Increased Beighton scores and
ligamentous laxity have also been associated with fail-
ure of reconstruction, although this risk factor is also
debated in adult studies53,55; in the present study, none
of the patients had a Beighton score 4 of 9.
The risk of patellar fracture after MPFL reconstruction
is likely related to increased stress risers from tunnels or
anchor placement,56 and 1 patient (4.2%) did sustain a
fracture after a traumatic fall. Schiphouwer et al.57
 ADOLESCENT ALLOGRAFT MPFL RECONSTRUCTION
found a 3.6% rate of patellar fracture in 192 knees
undergoing MPFL reconstruction using 2 transverse
patellar tunnels. The surgical technique in the present
study also used 2 patellar tunnels and a double-limb
configuration. Newer techniques are being tried
without the use of bone tunnels or anchors in the pa-
tella to mitigate patellar fracture risk.58 In skeletally
immature patients, surgical options may differ relative
to adult reconstruction in effort to spare physes. Aiming
the femoral guide pin more anteriorly and distally,
while avoiding the notch, may help avoid physeal
injury.
Limitations
There are several limitations of the present study. This
was a retrospective, noncomparative study evaluating a
series of pediatric patients undergoing isolated MPFL
reconstruction with allograft. There were no matched
controls or other surgical techniques, including auto-
graft, and therefore it is not possible to compare the
efficacy of this technique to others. However, many of
the studies available on MPFL reconstruction, particu-
larly in the adolescent population, are retrospective in
nature. The small sample size at this length of follow-up
makes comparisons of risk factors in those with and
without complications underpowered, and conclusions
should be evaluated with caution. We did not analyze
return to sporting activity and used a primary outcome
of recurrent instability, which may not fully capture the
patient experience or recovery from the procedure.
Furthermore, no patient-reported outcomes or data on
the level of activities patients were able to achieve
postoperatively were captured.
Conclusions
MPFL reconstruction using allograft tissue may be
performed safely in the pediatric and adolescent pop-
ulation, with good outcomes at midterm follow-up, few
complications, and a low rate of recurrent instability.
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