**4.3 At What Knee Flexion Angle the Graft Should be Fixed?**

There is still no clear consensus of opinion regarding the ideal knee flexion angle at which the tendon graft should be fixed during MPFL reconstruction. Most authors prefer to fix the graft with the knee at 30 to 60 degrees of flexion. Patel et al. [137] conducted a systematic review to determine the effect of knee flexion angle during graft fixation on outcomes and complications following MPFL reconstruction. Of the 3399 studies, 17 studies satisfied the inclusion criteria. A total of 556 patients with a mean age of 24 years underwent MPFL reconstructions, with 458 patients in the 0° to 30° fixation group and 98 in the 45° to 90° fixation group. The authors concluded that the knee flexion angle during MPFL graft fixation ranges from 20° to 90°. Graft fixation at both low and high knee flexion angles during MPFL reconstruction showed excellent patient-reported outcomes and low patellar redislocation rates overall, with no clear differences between the 2 groups based on the available data.
