A Comprehensive Guide to Revision Medial Patellofemoral Ligament Reconstruction in Adolescents

Revision medial patellofemoral ligament reconstruction (MPFL-R) in adolescents is uncommon and typically results from unappreciated or unaddressed anatomic risk factors (high-grade trochlear dysplasia, distal malalignment, patella alta, genu valgum, etc.), technical errors (graft malpositioning and length), or inappropriate patient selection. These cases pose unique challenges that demand meticulous attention to technical detail. This comprehensive review critically examines key surgical considerations to optimize outcomes in this complex patient population. It includes detailed preoperative evaluation to identify failure mechanisms, precise surgical planning that accounts for skeletal immaturity and potential growth disturbances, advanced techniques for revision graft placement and fixation, and the essential role of adjunctive procedures such as trochleoplasty, osteotomies, or guided growth techniques in addressing underlying anatomic risk factors. By synthesizing current literature and expert insights, this guide aims to provide surgeons with a framework to enhance the success of revision MPFL-R in adolescents. (1)Successful medial patellofemoral ligament revision requires distinguishing among technical errors, unaddressed anatomic risk factors, traumatic failure, and biological complications.(2)Anatomical femoral tunnel placement is a primary determinant of success because nonanatomic positioning can lead to graft overtightening, premature failure, and inferior clinical outcomes.(3)To prevent growth-related complications, such as limb-length discrepancies or angular deformities, surgeons must use biplane fluoroscopy to ensure that intraepiphyseal grafts are placed distal to the physis.(4)Comprehensive stabilization often requires concomitant procedures.