Distal Femoral Osteotomy to Treat Patellar Instability with Valgus Lower Extremity Alignment in Adolescents Sheena R. Black, MD, Henry B. Ellis, MD, Philip L. Wilson, MD, David A. Podeszwa, MD LLRS Annual Meeting July 22, 2016 Charleston, S.C.
DistalFemoralOsteotomytoTreatPatellarInstabilitywithValgusLowerExtremity
AlignmentinAdolescents
SheenaR.Black,MD,HenryB.Ellis,MD,PhilipL.Wilson,MD,DavidA.Podeszwa,MD
LLRSAnnualMeetingJuly22,2016Charleston,S.C.
Disclosures
TheauthorshavenosigniKicantdisclosures
Introduction
Genuvalgumisariskfactorforrecurrentpatellarinstability
Introduction
• Avarusproducingdistalfemoralosteotomy(DFO)maybeutilizedforthetreatmentofsymptomaticpatellarinstabilityintheskeletallymatureadolescent.
• >3yrclinicalandradiographicresultsandincidenceofrecurrentdislocationarereported
Methods
• Retrospectivelyreview,IRBapproved
• ConsecutivepatientswhounderwentanISOLATEDopeningwedgeDFOforrecurrentpatellarinstability
• Patients:• <18yearsold• Skeletallymature• >3ormorepatellardislocationepisodes• Moderatetoseveregenuvalgum
(≥ZoneIImechanicalaxisorlateraldistalfemoralangle<81°)
• Failednon-operativetreatment
Methods
• Exclusioncriteria:• <3yearsfollow-up• Anypriorsurgicaltreatment• Congenitalpatellarinstability• Bi-planarosteotomies(includingrotational)
• Allosteotomieswereperformedbyaseniorauthor(DAP)usinganopeningwedgetechnique.
Methods
• DataAnalysis:• Demographic• Clinical• Radiographicdatameasures
• Outcomesmeasures:• Kujala• TegnerActivity
• FailuresDeKined:• Documentedrecurrentpatellardislocation• Symptomsofpatellarinstability
Results
• 11patientswithIsolatedDFOforPFI
• 10withminimumof3yearfollowup• Avgage=16years(range14-18yrs)
• 3Males/7Females
• Avgfollow-upof4.25years(range3.2-6.0yrs)
Results
• Allpatientsinitiallypresentedwithposttraumaticpatellarinstability• 9fromsportsrelatedinjuries.• Avg#DislocationPre-op:6.8(2-30)
• BMI• Avg=31.3(range19.7-46.8)• Allbut1withBMI>25• 5/10(50%)withBMI>30
• AvgHipIR:27.5°(20-45°)
Results
Pre-operative
• AvgSulcusAngle:134°(119–156°)
• AvgTTTG:21mm (18-23.5mm)
• Trochleardysplasia(Dejourgrading)• gradeAn=1• gradeB4• gradeC1• gradeD2
Results
Pre-op Post-op SigniKicance Pre–oppatellaalta
Insall-Salvati 1.33(0.89–1.6)
1.16(0.70–1.66)
p=0.169 7(64%)
Caton-Deschamps
1.46(1.07-1.75)
1.08(0.86–1.3)
p<0.005 9(82%)
PatellarHeight
Results
• ValgusCorrection:
• Avgpre-oplateraldistalfemoralanglewas75.7°
• Avgcorrection=10.4°(range7-12degrees)
Results
• ValgusCorrection:
• Avgpre-opLDFA75.7°(72-79°)• Avgpost-opLDFA88.8°(86-91°)
• Avgcorrection=10.4°(7-12°)
Results
Outcomes• 8/10(80%)
• Nofurtherepisodesofinstabilityorsubluxation.
• Post-operativeKujalascore-Avg83.6• Post-operativeTegnerscore-Avg5.5
• Allreportiitnessactivity• 6/10reportjoggingorrunning
Results-Failures
• 2/10(20%)• RecurrentPatello-femoralsubluxationsymptoms• OneunderwentaTTTosteotomywithaMPFLreconstruction
• Oneelectedfornofurthersurgery
• Non-PFIRe-Operations:• 3patients
• 2HWRforsymptomaticImplant• 1lateralfemoralOCAllografttoaddressindexchondralinjury
Discussion
• Genuvalgum
• Riskfactorforrecurrentpatellarinstability• ProducesanincreasedQangleandanincreasedlateralforceplacedonthepatella
DejourD,LeCoultreB.Osteotomiesinpatello-femoralinstabilities.Sportsmedicineandarthroscopy review.2007;15:39-46.PostWR,TeitgeR,AmisA.Patellofemoralmalalignment:lookingbeyondtheviewbox.Clinicsinsports medicine.2002;21:521-546
• CorrectionofValgus• improvepatellartracking,allowsforreductionintheQangle• relativemedializationofthetibialtubercle
PudduG,CipollaM,CerulloG,etal.Whichosteotomyforavalgusknee?Internationalorthopaedics.2010;34:239-247.
Discussion
• Reportonthesuccessfuluseofselectiveisolatedhemi-epiphyseodesisforchildrenthatpresentwithpatello-femoralinstabilityinthepresenceofgenuvalgumKearneySP,MoscaVS.Selectivehemiepiphyseodesisforpatellarinstabilitywithassociatedgenuvalgum.JournalofOrthopaedics.2015;12:17-22
Summary
• 8/10inourcohortofpatientshadresolutionoftheirpatellofemoralinstabilitysymptomsaftersurgery
• Onlyonepatienthadtoundergoarecurrentoperationtoaddresstheirongoingpatellofemoralinstabilitysymptoms
Discussion
Cohortexhibited• ModeratetoSevereValgus• LowerActivityDemands• HighincidenceofoverweightandObesity
• DFOmayprovideutilityinaspeciKic,butnotuncommon,populationwithvalgusandloweractivitydemands
• Co-existingValgusandBMI• Alignmentcorrectiondesirableforlateralcompartmentreducedarthrosis
• Improvedpatellartracking
Discussion
• Limitations• retrospectivenature• smallnumberofpatients
Conclusion
• IsolatedDFOformoderatetoseverefemoralvalgusinthesettingofpatellofemoralinstabilitymayresolvepatellarinstability
• DFOseemstoprovidesatisfactoryfunctionaloutcomesinaspeciiiccohortofskeletallymatureadolescents
ThankYou!
ThankYou!