I started off using autografts for my MPFL reconstructions back in 2011, but I found that sometimes I had issues with poor quality and length, which meant I was not happy with femoral tunnel fixation.

I then moved towards LARS, as I wanted something with more robust strength, but the LARS tubular ligament was palpable beneath the skin of the medial patella and medial knee.

Then I moved to a flat tape (10mm Poly-Tape). That worked reasonably well, substituting for the MPFL, but the handling properties were quite tricky in terms of trying to whip stitch; there was a lot of fraying of the whip-stitched ends.

I then moved to the Infinity-Lock 5mm and have been using that for the last 10 years or so. It is an excellent graft to mimic the MPFL in terms of its length; it is an inert polyester flat tape, which is not palpable underneath the skin, and it’s very easy to whip stitch and handle, so I'm very happy with that for the last 10 years.

A benefit from a patient's perspective of using synthetics is one less scar; certainly, you don’t need to take the hamstring tendon, which tends to be semitendinosus, a quite important tendon for hamstring strength. You’re rehab and pain post-operatively are less with a synthetic, you don’t get complications of graft harvest issues, such as haematoma or numbness around the graft harvest site.

The rehab is also a lot less strict than using an autograft. I don’t use a brace at all; I let them fully weight bear straight away.

I’ve had no problems; zero re-dislocations of my synthetic MPFL, and I’ve had very little in the way of stiffness.

A synthetic graft is similar to any graft that you use for the MPFL. Put it in a de-tensioned state, and it is really easy to handle. You're not overly worried about graft length, as it is more than enough. You treat it exactly as you would an autograft, and you put it in the correct femoral tunnel position using fluoroscopy, and I attach it to the patellar using all-suture anchors, with no issues.

I see it as pretty much overtaking or superseding allograft. As we know, these are difficult to get, are extremely expensive, and sometimes the allograft you order is not the allograft you receive.

More and more, we’re looking for something that is going to never stretch, going to be structurally sound, will synovialize with the host tissue, which is exactly what the modern synthetics do, so I don’t really see the need for an allograft, which is still a very popular choice, and I don’t see why.

Reluctance to use synthetics is a legacy from the use of poor synthetics used in the past for knee surgery, and when people think of synthetics in the knee, they immediately think of Gore-Tex or Dacron grafts that we used in ACL, which catastrophically failed. These modern synthetics have a long heritage, going back to the Leeds-Keio Polyester ligaments.

There’s a host of very good papers out there to say that it is safe and effective, and certainly my experience over the last 10 years; I have had no real issues with my grafts, in terms of soft tissue reactions, stiffness, osteolysis. I’ve had 0 re-dislocation as it will never stretch, so I would say it is particularly useful if you’re thinking about changing to start using it in collagen-deficient patients, revision cases and even paediatrics, when you are resistant to take a hamstring tendon from a young age.

The other advantage of synthetic MPFL would be as part of a multi-ligament surgery scenario or when you want to use the hamstring for another reconstruction.