Technique Variation for MPFL Reconstruction in Skeletally Immature Patients: Data from the Jupiter Cohort

BACKGROUND: Management approaches and surgical techniques, when applied for pediatric and adolescent patellofemoral instability (PFI), continue to lack clear clinical guidelines and indications. Medial patellofemoral ligament reconstruction (MFPLR) is among the most popular surgical options. However, variation in technique remains significant, particularly in skeletally immature sub-populations. PURPOSE: The purpose of this study was to examine the variation in MPFLR technique in skeletally immature patients within a cohort of 20 orthopedic surgeons with different experience levels and specialty training backgrounds. Methods: All operative records of skeletally immature patients from 2016 to 2021 were retrieved from the JUPITER cohort, a multi-center prospective study involving 13 different tertiary care academic centers. Patients who underwent a primary single-stage MPFLR were evaluated in this study. Demographic information and operative details were collected for each knee. RESULTS: Of the 306 knees, 205 (53% female, 47% male) met inclusion criteria and comprised the final cohort (Table 1). The average age was 13.6 ± 1.8 yrs (5.1-19.0). The initial injury mechanism was of a non-contact nature in 73% and a result of contact in 17%. 47% of surgeons utilized autograft while 53% utilized allograft. Suture anchors (including small tenodesis screws) were the most popular patellar fixation technique (61%), followed by the use of tunnel under a bone bridge (37%). The majority of surgeons utilized 2 suture anchors (59%). Interference screws were the most popular femoral fixation technique (84%), followed by suture anchors (12%). The majority of surgeons used either 1 interference screw 97(%) or 1 suture anchor at the femur (96%). In addition to MPFLR, 15% of patients underwent osteochondral fracture treatment: 36% underwent loose body removal, while 61% underwent fixation. Lateral Retinacular Release was performed in 13% of cases, and lateral retinacular lengthening was performed in 2%. 10% of patients underwent concomitant hemi-epiphysiodesis for genu valgum, 3% underwent medial quadriceps tendon-femoral ligament reconstructions, and 3% underwent a Grammont realignment (patellar tendon medialization) procedure. CONCLUSION: Variation in different aspects of MPFLR technique is substantial among this cohort of orthopedic surgeons. Given the well-established importance of decreasing variation for healthcare cost containment and optimization of outcomes, comparative studies and sub-stratified analyses are needed to better elucidate the most favorable techniques and their components.