**4. Methods**

Routine diagnostic intraarticular arthroscopy is performed from anterolateral (AL) portal. In cases of lateral release procedures, a 1 cm superolateral (SL) portal is made with care not to penetrate the joint. The subcutaneous space is then developed to establish the working space. The lifting hanger is applied. Through the superolateral portal, the ring-shaped end is inserted into the subcutaneous space, and rolled up until the end of the hanger buries under the skin (Fig.2).

Fig. 1. A: Semi-circular hanger, B: Coil shaped lifter

Routine diagnostic intraarticular arthroscopy is performed from anterolateral (AL) portal. In cases of lateral release procedures, a 1 cm superolateral (SL) portal is made with care not to penetrate the joint. The subcutaneous space is then developed to establish the working space. The lifting hanger is applied. Through the superolateral portal, the ring-shaped end is inserted into the subcutaneous space, and rolled up until the end of the hanger buries under

**4. Methods** 

the skin (Fig.2).

Fig. 2. Coil shaped lifter is inserted into the subcutaneous space

Once pulling the lifter, the working space is established. Care must be taken to avoid inserting the end of the hanger into the underlying muscle. Dry arthroscopy can be performed in the subcutaneous working space created by the lifter (Fig.3,4). Lastly, the hanger is removed by turning it in the opposite direction.

Fig. 3. Subcutaneous space created by the lifter.

muscle with a 4.5-mm shaver to create a gap between the muscle and fragment, which

Fig. 5. SL portal view. A 4.5 mm shavor is used in order to create a gap between muscle and

It should ideally be done from outside the joint with care not to penetrate the joint, so that the joint capsule can be maintained intact to help minimize the postoperative leakage of the

While numbers of MPFL reconstructions are reported, this procedure allows doing under a minimum incision. Authors' prefferred method is as follows; a 1 cm incision at the superomedial corner of the patella is made. An oblique bone tunnel through the patella is drilled with a guide pin and overdrilling method. This tunnel should be obliquely routed from the superomedial corner of the patella to the anterior center of the patella, trying to recreate the original fan-shaped attachment of the MPFL (Steensen et al., 2004). The lifting hanger is introduced into the prepatellar space, to be able to perform extraarticular dry arthroscopy. The harvested semitendinosus tendon is introduced to this space through the

fragment. VL, vastus lateralis muscle; P, patella.

**4.2 Medial patellofemoral ligament reconstruction** 

bone tunnel, pulled using a passing pin (Fig.6).

joint fluid.

decreases the risk of the muscle scarring back down to the fragment (Fig.5).

Fig. 4. Operational field during surgery. A) The hanger lifts up the skin, affording the operator a view from outside the joint. B) Likewise, coil shaped lifter is creating the space. Instruments (scissors) are introduced to the operative field. In these situations, the arthroscope is introduced from the AL portal and the hanger lifts the skin from the superolateral portal.
