*4.10.4 Step 4: Soft Tissue Tunneling*

Using the adductor tubercle and the medial femoral epicondyle as anatomical reference points, a blunt instrument is used to develop an intra-articular, extrasynovial plane, tunneling toward the anatomic insertion of the MPFL on the femur (**Figure 9**).

#### **Figure 7.**

*With the patient in the supine position and the left knee flexed at 45°, a longitudinal incision is made over the pes anserinus and dissection is performed down to the level of the sartorial fascia, indicated by the asterisk (\*) in Figure A. The sartorial fascia is then incised proximally and in line with the gracilis tendon (the arrow denotes the gracilis tendon in Figure B). Blunt dissection of the sartorial fascia off of the gracilis tendon is performed. Reproduced with permission from: Kurowicki et al. [130].*

#### **Figure 8.**

*With the patient in the supine position and the left knee flexed at 45°, a longitudinal incision is made over the medial aspect of the patella just medial to the border. Dissection is carried out down to the level of the capsule, and a longitudinal arthrotomy is performed just medial to the patellar border. The proximal-third of the medial aspect of the patella is debrided with a rongeur down to a base of bleeding bone, creating a footprint for graft insertion. The asterisks (\*) indicate the placement of 2 GRYPHON suture anchors (DePuy Mitek) approximately 5 mm to 10 mm from each other. Reproduced with permission from: Kurowicki et al. [130].*

#### **Figure 9.**

*Formation of an intra-articular, extrasynovial plane for tunneling toward the anatomic insertion of the MPFL on the femur using a blunt instrument with the patient positioned supine and the left knee flexed at 45°. The blue star represents the medial femoral epicondyle, and the green star represents the adductor tubercle. The anatomic origin of the MPFL on the femur can be found in the saddle area between the proximal-posterior to the medial epicondyle and distal-anterior to the adductor tubercle. Reproduced with permission from: Kurowicki et al. [130].*
