(1800 patients X Rays analysis) - · PDF file10 < TA - GT < 15 Patellar Tilt > 20 ... Graft: for primary surgery preserve extensor mechanism . ... Patellar Tendon Tenodesis....

La PATELLA Lyon 2012 “ALRM”

1987


25 years

later…


1987 Findings (1800 patients X Rays analysis)

4 Instability factors (Statistical Threshold)

• Trochlear Dysplasia 96%

• Patella Alta > 1.2

• Excessive TT-TG > 20 mm

• Excessive Patellar Tilt > 20°


1987 Findings

Systematic use of true lateral view

3/ Trochlear depth

1/ Crossing Sign

2/ Bump : “la saillie”

1987


1987 Trochlear Dysplasia classification

The first classification

Normal

Dysplasia


1987 Findings

Patella Alta> 1.2 30% in dislocation population

VMO Dysplasia

J. Caton 1977

Tibial Landmark

G. Deschamps 1982

Patella Landmark

+ =

C&D Index AT/AP


1987 Findings Systematic use of CT Scan

Alignment – torsion measurements

TT-TG > 20 mm 56 % Dislocation population

1978 Goutallier & Bernageau TT-TG on axial view

1987

1987


1987 Findings

Patellar Tilt > 20° 83% in dislocation population

VMO Dysplasia

Systematic use of CT Scan

Alignment – torsion measurements

1987


Instability

factors Knee side

Proposed

procedure

Trochlear

dysplasia Type I, II, III ????

Patellar height Index AT / AP Distalization

Index = 1

TT-TG > 20 mm Medialization

10 < TA - GT < 15

Patellar Tilt > 20° VMO Plasty

1987 ”menu à la carte” for patella dislocation


What were the results… Elvire Servien, Rev Chir Orthop Reparatrice Appar Mot. 2004

All Patients Distalization Medialization Distalization +

Medialization

Préop TT-TG and post op 10 mm <TT-TG<15 mm

0

5

10

15

20

25

Isolated distalization Leads to Automatic medialization of 4 mm


What were the results… Elvire Servien,

Rev Chir Orthop Reparatrice Appar Mot. 2004

Good correlation between the planned TT-TG & the post op TT-TG

No patellar tendon shortening after TT Osteotomy (immediate

mobilisation)



WHAT REMAINS ?

WHICH UPDATE ?

WHICH CHANGES ?


WORLDWIDE WORK 41 Countries…


2012

Patellar Instability

Clinical Evaluation “some particular features”

• Torsional anomalies

• Foot angle

• Pelvis and back position

CT scan for Femoral & Tibial rotation measurement


Apprehension sign


Patella Alta

40/30

62 mm


J sign Muscular unbalance

+

Upper trochlear dysplasia

Abnormal tracking Trochlear dysplasia ++

Extension if normal quadriceps length

Normal tracking in flexion

Normal patellar engagement


Abnormal tracking Trochlear dysplasia +++

Flexion if SHORT extensor mechanism


Medial-Lateral Tilt Test

Soft tissue structures evaluation


Quadrant Test “Patellar mobility”

Medial structures resistance

MPFL competency

Extension Flexion Patella engages the trochlea

Gives a reference point


Don’t forget…

To look to your patient patient …

Nail Syndrome…

Down syndrome…


Trochlear Dysplasia Classification

4 types (2 new landmarks)

Inter and intra observer reliability +++


Patellar height Caton & Deschamps = X rays

Patellar tendon length = MRI

C&D = AT/AP >1.2

PT length > 52 mm

TT-TP length > 29 mm

TT-TP


MRI ANALYSIS

Cartilage

Trochlear Shape

Soft tissue (MPFL)

Classic measurement ( TT-TG, Patellar Tilt)

C. Chu


CT Scan MRI

TT-TG Yes Yes PT reference++

Patellar Tilt Yes + dynamic Yes static

Torsional anomalies Yes No

Bilateral Evaluation Yes No

Irradiation Yes +/- No

Cartilage Evaluation No Yes

Patellar height No Yes +/-

Patellar tendon length No +/- Yes

MPFL (soft tissue) No Yes

The CT scan when bilateral pathology +/- Torsion anomalies

CT Scan or MRI need a specific prescription with a protocol


1987 Instability factors ?

Trochlear dysplasia :

Patella Alta :

TT - TG:

Patellar Tilt :

YES

YES

YES

YES

Resulting factor of all the others

2012 Instability factors = 3

NO


2012 Surgical Algorithm …

VMO Plasty + LR

for the Patellar Tilt

MPFL isolated or combined

Lateral release if : Medial Tilt test negative

“Possible option”

All cases


MPFL has to be reconstruct

Restore “torn anatomy”

Primary restraint

Always torn or no competent after the first dislocation

Positioning rules : Fluoroscopy: lateral views+++

Indication for isolated:

C&D < 1.2

Avoid femoral malpositioning

Avoid hypercorrection and fixed patella

Graft: for primary surgery preserve extensor mechanism


TT osteotomy

Correct “abnormal alignment”

Procedure rules :

Prior to MPFL recontrsuction

No over correction

CT or MRI mandatory : objective measurement

Medialization 10 mm < TT-TG <15 mm

2

1


Distalization index C&D = 1

TT osteotomy

Correct “abnormal height”

Procedure rules :

Adapted to trochlear shape

Prior to MPFL reconstruction


If PT length > 52 mm

“”possible option”

Patellar Tendon Tenodesis

Correct “Normal Anatomy”

Procedure rules :

Adapted to MRI analysis

2 anchors on the native insertion


Proximal realignment + prominence removal Dysplasia Type B or D

Abnormal patellar tracking

1987

2012

Deepening Trochleoplasty

Restore“Normal Anatomy”


2012

Patellofemoral

Arthritis


Key Questions to the patient

PreviousTrauma Type of surgery

Infection

Mobilisation

Patella dislocation +++ Surgery ?

Operating report, X rays…

Swelling knee Hemarthrosis

Chondrocalcinosis XR


Note : Control population 3 % Patellar instability pop. 96 %

Anti Maquet effect

Predisposing factors

Trochlear dysplasia 78 %


Isolated PF OA Aetiologies ...

Chondrocalcinosis 9 %

“Primary arthritis”

No orthopedic history

49 %

“Instability arthritis”

Dislocation history

33 %

Post - trauma 9 %


Patelloplasty Patella Magna - Post traumatic

Osteophyte resection, global remodelling


Natural History Isolated patellofemoral arthritis

18 years

Slow evolution

Well tolerated


Lateral Patellectomy Facetectomy O’Donoghue

Procedure rules :

Ideal indication : Isolated PFA with Lateral

patella pain and TT-TG < 20mm

Ideal candidate : young and active

Ideal procedure : resection of 15mm,

lateral retinaculum release

Good option :

- Simple

- Quick recovery

- Can easily be converted to TKA

- ATT transfer : high rate of complication


ATT transfer Medial +/- anterior transfer

Ideal indication :

- Isolated PFA with Lateral patella pain

and TT-TG > 20mm

- Young and active patient

- Medialization +/- anterior transfer

Combined surgery :

- Lateral patellectomy

- Lateral retinaculum release

- Patellofemoral prosthesis

Complications

TT-TG>20 mm Procedure rules :


Patellofemoral arthroplasty indications

Procedure rules :

Ideal indication :

- Younger patient

- Active patient

- “Instability osteoarthritis” +++

- Normal femorotibial compartment

Different designs :

- Resurfacing

- Anatomic ++


Patellofemoral arthroplasty complications

Causes of failure

- Progression of OA++

- Mechanical failure (1st generation)

Revision by TKA

- Easy procedure

- Standard implants

- Good results but < primary TKA


UKA and patellofemoral osteoarthritis

UKA and lateral patellectomy - Symptomatic arthritis

- Joint space narrowing

- Lateral patella pain on physical examination

Alternatives - UKA + PFP (Parrate and Argenson…)

- Bicompartmental prosthesis


UKA and patellofemoral osteoarthritis

Progression of patellofemoral OA - Rare

- No influence of preoperative status

- Well tolerated

- Low revision rates due to the progression of

patellofemoral OA (2%)

- Not similar to the progression of OA after

PFP

Options? - TKA

- Bicompartmental prosthesis?

- Lateral patellectomy?


2012 Extensor Mechanism


Stretching & Cycling

“Plat du jour”

Anterior knee pain

1987

Anterior Knee

Pain

2012

FONCTIONNAL

STRUCTURAL

ANATOMICAL

NEUROLOGIC


X-Rays & MRI

“Le Menu s’il vous plait?”

Anterior knee pain

2012

Structural problems


Anterior knee pain

2012

Functional problems

EXTENSORS

“Normal” knee

“Painful” knee

20% NO ACCESS

Isokinetic

Evaluation and

Rehabilitation « Catalyzer »


New medical

treatment in 2012 Platelet Rich Plasma

Under US control

After failed classical treatment

- Analgesics, NSAIs, cryotherapy…

- Eccentric strengthening (Stanish)

- Repeat the procedure!

Patellar tendinosis


Bad tissue excision

Patellar Tendinitis :

failure of Conservative Treatment

SURGERY is a valuable option:

1. If persistant MRI signs

2. Analysis of Patellar Apex

Patellar Apex Resection

Warn the patient :

- Long recovery

- Possible residual pain


New surgical

treatment in 2012

In case of failure

Patellar tendinosis

Arthroscopic debridement

Safe and efficient (but >6 months+++)

- No nerve complication (Open 50%)+++


CONCLUSION


Enjoy this delicious “menu à la carte” from Lyon

with international flavours …

Have a nice trip back… you are always welcome to LYON

The LSKS ‘s Team …


Next ….”Rendez-vous”

16 -18

Octobre

2014

3 Dates … With

October 16 -18

2014

June 7 -11

2015

May 4 -7

2016

(1800 patients X Rays analysis) - · PDF file10 < TA - GT < 15 Patellar Tilt > 20 ... Graft: for primary surgery preserve extensor mechanism . ... Patellar Tendon Tenodesis....

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