Open Access

Table 1

Pearls and pitfalls.

Perform an EUA prior to skin incision to confirm the range at which the patella is unstable.
A medial sub-vastus approach is an ideal exposure as it facilitates graft passage and can also be used to access the joint if necessary.
Using quadriceps tendon autograft allows the graft to remain attached to the patella through its natural attachment and avoids any fixation into the patella being required.
Leaving a thin cuff myotendinous junction attached to the vastus medialis during harvest facilitates later closure of the defect and creates a small “reefing” effect by advancing the muscle slightly, which will add to the stability of the reconstruction.
Graft tensioning should be performed at 30–45° flexion.
Tendency for tensioning the graft should be to increase tightness, rather than avoiding over-tensioning like in native patellae MPFL reconstruction.
Tensioning is performed to correct dislocation, J-tracking, and tilt. Pay attention to the range of flexion that demonstrated patella sub-luxation in the pre-operative EUA to confirm adequate correction and graft tensioning.
Add cortical fixation to the graft after screw insertion and ensure the button is seated flush on the lateral cortex to avoid the “springing” effect of soft tissue interposition.
Quadriceps tendon graft may be bulky, and to facilitate passage into the tunnel, tubularization of the tip of the graft may be beneficial.
Not performing the TTO if it is indicated prior to the soft tissue reconstruction.
Failure to plan sufficient graft length may compromise the isometry of the graft and the stability of the graft fixation.
Reliance on interference fixation in the supracondylar region of the femur may lead to graft slippage and recurrence of instability due to low BMD in this region post-TKA.
Under tension, the graft is likely to lead to residual instability.
If any additional procedures to the patella are planned, they should be performed first, as the effect on graft tension is unpredictable and, if done following reconstruction, may lead to insufficient graft tension.

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