Table 1.

Step-by Step Implant-Free, Medial Patellofemoral Ligament Reconstruction Technique

Step	Description
1	The patient is placed in a supine position on the operating table. A well-padded high-thigh tourniquet is subsequently placed on the operative leg.
2	Standard anteromedial skin incision is performed to harvest the gracilis tendon using a closed tendon stripper.
3	A 2-cm vertical skin incision is then made over the superior medial border of the patella to expose its proximal third
4	In the proximal two-thirds of the medial aspect of the patella, a V-shaped tunnel is drilled using a 4.5-mm reamer, leaving a cortical bone bridge of 10 mm between them to avoid a fracture.
5	A 2- to 3-cm skin incision is made along the adductor magnus tendon. Once this tendon is identified, gently dissect around it.
6	Place a looped suture around the adductor tendon to aid graft passage.
7	Pass the graft through the patella and place it in the interval between layers 2 and 3 of the medial retinaculum. The graft should not be deeper than layer 3 so that it remains in the extra-articular environment.
8	Loop around the adductor magnus tendon back to the patella.
9	Both graft ends are sutured together at 30° of flexion with no. 0 high-resistance nonabsorbable sutures.