Radiographic Location Does Not Ensure a Precise Anatomic Location of the Femoral Fixation Site in Medial Patellofemoral Ligament Reconstruction

Background: A frequently used method to determine the anatomic femoral fixation point in the operating room during medial patellofemoral ligament (MPFL) reconstruction is the radiographic method. However, the ability of this radiological method to establish an anatomic femoral attachment point might not be as accurate as expected. Purpose: (1) To evaluate the accuracy of the radiological method to locate the anatomic femoral fixation point in MPFL reconstruction surgery and (2) to determine the factors influencing the predictability of this method to obtain this objective. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 100 consecutive 3-dimensional computed tomography (3D CT) knee examinations were performed at 0 degrees of extension in 87 patients treated for chronic lateral patellar instability. For each knee, 2 virtual 7 mm-diameter femoral tunnels were created: 1 using the adductor tubercle as a landmark (anatomic tunnel) and the other according to the radiological method described by Schottle et al (radiographic tunnel). We measured the percentage of overlap between both tunnels. Moreover, of the 100 included knees, 10 were randomly selected for a variability study. Results: Considering an overlap area greater than 50% as reasonable, the radiographic method achieved this in only 38 of the 100 knees. Intrarater and interrater reliability were excellent. There was a trend for female patients with severe trochlear dysplasia to have less overlap. This model accounted for 64.2% of the initial variability in the data. Conclusion: An exact anatomic femoral tunnel placement could not be achieved with the radiographic method. Radiography provided only an approximation and should not be the sole basis for the femoral attachment location. Moreover, in female patients with severe trochlear dysplasia, the radiographic method was less accurate in determining the anatomic femoral fixation point, although differences were not statistically significant.