8/24/2015 1 Treatment Methods for Patellar Malalignment Issues presented by Murat Bozkurt Murat Bozkurt, Halil Ibrahim Acar, Safa Gursoy , Mustafa Akkaya Yildirim Beyazit University, School of Medicine Ankara, TURKEY Proximal Realignment August 25th, 2015 Disclosure • Educational activities Zimmer Biomet DePuy Synthes Stryker Proximal Realignment Murat Bozkurt Anatomy Proximal Realignment Murat Bozkurt
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Treatment Methods for Patellar Malalignment Issues
presented by
Murat Bozkurt
Murat Bozkurt, Halil Ibrahim Acar, Safa Gursoy, Mustafa Akkaya
Yildirim Beyazit University, School of Medicine
Ankara, TURKEY
Proximal Realignment
August 25th, 2015
Disclosure
• Educational activities
Zimmer Biomet
DePuy Synthes
Stryker
Proximal RealignmentMurat Bozkurt
Anatomy
Proximal RealignmentMurat Bozkurt
8/24/2015
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Treatment Methods for Patellar Malalignment
No single operation is universally accepted Several techniques have been described
• Decision needs of the individual patient extent of the malalignment patient’s age the level of activity the condition of the joint
The role of lateral retinacular release in the treatment of patellar instability. Lattermann C, Toth J, Bach BR Jr.Sports Med Arthrosc. 2007;15:57-60.
Don’t extend or detache vastus lateralis obliquus.
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Long-term results of lateral retinacular release.Panni AS, Tartarone M, Patricola A, Paxton EW, Fithian DC.
Arthroscopy. 2005 May;21(5):526-31.
• 50 patients
• 5-year follow-up
• In patellar instability the results are less favorable in long-term follow-up
Lateral Release
Proximal RealignmentMurat Bozkurt
Medial Procedures
• Since the recognition of the importance of the medial patellofemoral ligament (MPFL), there has been increasing interest in different techniques for managing the medial stabilizer.
Repair
Radio-frequency thermal reefing
Imbrication (reefing)
Plication
VMO advancement
Proximal RealignmentMurat Bozkurt
Medial Plication
• Surgical Techniques for Medial Plication
Arthroscopic All-Inside Medial Plication
Arthroscopically Assisted Medial Reefing
Mini-Open Medial Reefing
Proximal RealignmentMurat Bozkurt
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VMO advancementInsall technique
Patellar pain and incongruence. II: Clinical application.
Insall JN, Aglietti P, Tria AJ Jr.Clin Orthop Relat Res 1983;176:225-32.
Proximal RealignmentMurat Bozkurt
• 53 knees • 81% excellent or good • 19% fair or poor.
MPFL Reconstruction
First described by Kaplan 1957,but not named.
Superior medial border of the patella
Between the epicondyle and the adductor tubercle
Proximal RealignmentMurat Bozkurt
MPFL Reconstruction
• The MPFL is a thin fascial band approximately 53 (range 45–64) mm long , that links from the region of the medial epicondyle of the femur to the proximal part of the medial border of the patella.
• It has been shown that this structure is present in all knees and that it is the major medial stabilizer of thepatellofemoral joint.
• MPFL had a mean tensile strength of 208 N and it is surprisingly strong for such an insubstantial appearance.
Proximal RealignmentMurat Bozkurt
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MPFL Reconstruction
• MPFL is the primary restraint and provides 60% of the restraining force to lateral translation.
• Patellar dislocation is a disabling condition that often results in disruption of the MPFL.
• Tearing of the MPFL at or near its femoral insertion is present in 80% to 100% of cases.
• The MPFL reconstruction is an accepted surgical technique for treatment of chronic patellofemoral instability.
Proximal RealignmentMurat Bozkurt
MPFL ReconstructionPre-Op Planning
• X-ray • Measuring Q angle
Proximal RealignmentMurat Bozkurt
MPFL ReconstructionPre-Op Planning
• TT-TG lenght measurement on CT scan
Normal : < 15-20 mm
Proximal RealignmentMurat Bozkurt
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MPFL ReconstructionPre-Op Planning
Proximal RealignmentMurat Bozkurt
• MRI
MPFL Reconstruction
Single Patellar Tunnel Fixation withBioabsorbable Screws
Figure. Pressure analysis with Fuji FPD-8010 E Ver. 2.0 program after MPFL reconstruction
Use of contact pressure-sensitive surfaces as an indicator of graft tension in medial patellofemoralligament reconstruction Kadir Ilker Yildiz · Cetin Isik · Osman Tecimel · Nurdan Cay · Ahmet Firat · Ramazan Akmese · Murat Bozkurt Arch Orthop Trauma Surg (2013) 133:1657–1663
Conclusion:Contact pressure-sensitive surfacesprovided objective data when placedunder the graft in natural MPFL andduring surgery. Therefore, they maybe used as an objective markerproviding information about graftresistance.
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Treatment Methods for Patellar Malalignment Issues
• F. Antetorsion• G. Recurvatum• G. Valgum• Female
« Fundamental factor »
Trochlear Dysplasia
Crossing sign
Trochlear bump
H. Dejour, G Walch, Ph Neyret: RCO 1990, 76 : 45-54
crossing
>145°
Trochlear Dysplasia
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Crossing sign
EPD Control group
96% 3%
Trochlear Dysplasia
Trochlear bump
>3mm
EPD Control group
3.2mm±2.4 -0.8mm±2.9
66% 6%
Trochlear Dysplasia
Trochlear Dysplasia
H Dejour and G Walch
1987
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Trochlear Dysplasia
D Dejour
RCO 1998
KSSTA 2006
X-rays
CT-scan
Trochlear Dysplasia
X-rays
GRADE A
Crossing sign
Trochlear Dysplasia
CT-scan
GRADE A
Subnormal Trochlea
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Trochlear Dysplasia
X-rays
GRADE B
Crossing signSupra-trochlear spur
Trochlear Dysplasia
CT-scan
GRADE B
Trochlea flat or convex
Trochlear Dysplasia
X-rays
GRADE C
Crossing signDouble contour
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Trochlear Dysplasia
CT-scan
GRADE C
Asymmetry of facets :- Lateral = convex- Medial = hypoplastic
Trochlear Dysplasia
X-rays
GRADE D
Crossing signSupracondylar spur
Double contour
Trochlear Dysplasia
CT-scan
GRADE D
Asymmetry of facets
Cliff pattern
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Patellarmalalignment
H. Dejour, G Walch, Ph Neyret Trochlea dysplasia Rev Chir Orthop 1990, 76 : 45-54
Trochlear
Dysplasia
H Dejour, Ph Neyret, G Walch. Factors in patellar instability.
In P. Aichroth Knee Surgery Current Practice, NY, 1992
Principal
factors
Instability• Crossing sign
• Trochlear bump
Principal Factors3
Patellar height
TT-TG
Patellar tilt Threshold
P
A
T
Caton & Deschamps Index
AT/AP
1. Patella alta >1.2
T
1.0
H. Dejour
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To our knowledge no biomechanical studies has proven the negative effect of patella alta in case of trochlea dysplasia
Nevertheless it is logical to aim that the distal transferallows the patella to better engage in the trochlea.
Contact surfaces increases from 15 to 18% at 15°flexion after a 10% shortening of the Patellar tendon without augmentation of patellar forces
N Upadhyay,… AJSM. 2005: 1565-1573
Basic Sciences
• Patella alta is due to a too long patellar
tendon and not to an abnormal proximal
tibial insertion of the patellar tendon
Ph. Neyret, A.H.N. Robinson, …, P. Chambat
Patellar tendon length – the factor in patellar instability ?
The Knee 2002
TTd
What’ new ?
Ph. Neyret, A.H.N. Robinson, …, P. ChambatPatellar tendon length – the factor in patellar instability ? The Knee 2002
Patella alta
C Meyer, … Ph Neyret, S Lustig.Patellar Tendon Tenodesis …for the Treatment of Episodic Patellar Dislocation WithPatella Alta? AJSM 2011
>52mm
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Goutallier D, Bernageau J, Lecudonnec B Mesure de l'écart tubérosité tibiale
antérieure – gorge de la trochlée : TA-GT Rev. Chir. Orthop. (1978) 64 : 423-428
2. Excessive TT-TG
TT-TG >20mm
10mm
19.6
21.731mm
3. Patellar Tilt >20°
15°Quadriceps DysplasiaTrochlear DysplasiaMPFL
?
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.
Patella tilt > 20°
EPD Control
31.5° 10°
90% 3%
33
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Clinical assessment
Patellarmalalignment
H. Dejour, G Walch, Ph Neyret Trochlea dysplasia Rev Chir Orthop 1990, 76 : 45-54
Trochlear
Dysplasia
H Dejour, Ph Neyret, G Walch. Factors in patellar instability.
In P. Aichroth Knee Surgery Current Practice, NY, 1992
Principal
factors
Secondary
factors
Instability• Crossing sign
• Trochlear bump
• Patellar height
• TT-TG
• Patellar tilt
Secondary Factors4
•F. Antetorsion•G. Recurvatum•G. Valgum•Female No Threshold
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Conclusion
Trochlear
Dysplasia
Principal
factors
Secondary
factors
Diagnosis of Patellar malalignment
• Crossing sign
• Trochlear bump
• Patellar height > 1.2
• TT-TG > 20mm
• Patellar tilt > 20°
• F. Antetorsion• G. Recurvatum• G. Valgum
Thank you for your attention
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John P. Fulkerson, M.D.Orthopedic Associates of Hartford
Clinical Professor of Orthopedic Surgery University of ConnecticutFarmington, Connecticut
The author receives royalties his patent and design of the Trupull braces (DJ Ortho)
The author is president of the Patellofemoral Foundation that receives undirected funding from Smith and Nephew, DJ Ortho, Conmed-Linvatec, Kinamed, Sanofi, KFX and Hartman Newspapers
Tibial tubercle transfer places the patella into a better tracking relationship with respect to the trochlea- this corrects alignment which almost always improves stability
Medial imbrication and MPFL reconstruction stabilize only and should not be used to change the patella tracking pattern
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Never use MPFL reconstruction to move the patella
Move tibial tubercle only to restore optimal PF loading
and central tracking- never too far!!
Always optimize balance
first and reduce load on
damaged cartilage
whenever and however
possible.
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As trochlea dysplasia increases, the
need for precise, balanced tracking
and anatomic medial and lateral
retinacular balance increases
Consider trochleoplasty and/or
femoro-tibial derotation surgery
only in more extreme cases when
alignment and retinacular surgery
alone are insufficient
Dejour- Trochleoplasty for “high
grade trochlear dysplasia with patellar
instability and/or abnormal tracking.”
Differentiate functional from structural PF alignment disorders
Always exhaust non operative measures to optimize core stability and function (Teitge, Powers, Arendt)
See where the patella goes
with the quad contracted at
0 degrees and at 30 degrees
flexion
If you can’t center the patella
with your finger, centering by
medial reconstruction alone will
overload cartilageOPTIMIZE ALIGNMENT and
ARTICULAR LOADING
FIRST, THEN STABILIZE
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Tibial tubercle transfer is the most versatile and benign way to correct structural incongruity (high TT-TG, high Q angle) of patello-femoral tracking and also unload lateral and distal patella articular lesions
Tubercle transfer can compensate for structural femoral and tibial rotation problems that cause recurrent patella instability or lateral PF overload
Tibial tubercle transfer can optimize balance in a dysplastic trochlea
Tibial tubercle transfer aligns and unloads lesions.. TTT osteotomy is most appropriate when there is healthy cartilage onto which to transfer patella tracking
As trochlea dysplasia increases, need for MPFL/MQTFL graft and optimal alignment increases. Less containment (trochlea), more need for external support and perfect tracking
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Usually related to improper technique, inadequate fixation or a patient accident before bony union
Technical precision, secure internal fixation, supervision and proper rehabilitation are imperative-complications are rare.
Precise surgery and early motion will avoid complications
Result of non anatomic MPFL graft placement
Matt Bollier(Arthroscopy,
2011), Elvire Servien(AJSM,
2011),Christian Lattermann
(AJSM), Andy Cosgarea and
Miho Tanaka (AAOS Scientific
exhibit 2011) have shown that
MPFL grafts are too often
malpositioned Risk of patella fracture after
MPFL reconstruction (Parikh,
JBJS 2011)
The keys to success in patellofemoral surgery
are good decision making, technical
excellence and doing no more than is needed
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Relationship of the tibialtubercle(TT) to thetrochlear groove(TG)center (Neyret, Dejour)
TT transfer when elevated TT-TG and patella tracking laterally
Superimposed CT images
Recent data from Tanaka and Dahm have shown that TT-TG measurements are variable- use with caution!!!
Simply mark center of proximal
trochlea on computer screen of CT
or MRI axial cut, then scroll down to
tibial tubercle and use the ruler from
toolbar to measure TT-TG distance
The more you need to consider how tibial tubercle transfer might optimize PF tracking and articular loading
When there is a need to realign the patella , in any plane, or to unload a painful lesion permanently
To achieve stability of the extensor mechanism by establishing optimal vector alignment
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Inadequate health, poor bone quality, gross obesity
Diffuse patella or trochlea chondral degeneration
Proximal patella lesions (Crush)
RSD or diffuse pain Poor attitude or motivation Inadequate trial of non
operative measures Instability related to
retinacular and trochlear deficiency with no need for changing patella tracking vector
Resurface an area that will receive contact after TTT
Unload a surface that has been treated with ACI or OC graft
Farr, Cole, Minas, Gillogly, Lattermann, Peterson
High Q angle and TT-TG, no medial articular lesion(Pidoriano type 2)
Lateral facet lesion
No distal lesion (Pidoriano tyle 1)which will benefit from anteriorization-(tipping up the distal patella off of the lesion)
X
Pidoriano AJ, Am J Sports Med.
1997 Jul-Aug;25(4):533-7..
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My views:
Medial TTT effectively establishes balanced PF tracking and COMPENSATES for core deficiencies that cause chronic lateral tracking
Much less risk and more direct than femoral derotation (which also compensates for other structural and alignment problems)
Bringing the patella into balanced alignment with the trochlea creates improved knee function overall
External rotation of the tibia caused by medial TTT is preferable to the abnormal internal rotation caused by lateral PF tracking
Medial TTT, particularly AMZ, proven to result in overall less load to patella than MPFL reconstruction (Elias and Cosgarea)
Separate issue from MPFL or MQTFL reconstruction (balanced tracking vs stabilization)
Medial lesion from previous overzealous TT medialization
+/- medial subluxation
Intact lateral facet
In cases of patella infera, proximalization of the tibial tubercle may be necessary
With symptomatic patella alta, distalization will get patella into deeper trochlea earlier
Patella distalization becomes more important in the patient with combined patella alta and trochlea dysplasia
BOTH PROCEDURES MUST BE ACCOMPANIED BY APPROPRIATE SOFT TISSUE RELEASE AND/OR BALANCING
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Anteriorization is most helpful to diminish or eliminate load on distal patella lesions. These are common after a dislocation
Beware of proximal lesion(crush) as anteriorization will place load on proximal patella earlier in the flexion arc.
“TIP UP THE DISTAL POLE”
Uncommon procedure
Sagittal plane osteotomy vs Maquet
Sagittal plane osteotomy requires back cut from lateral side
Other option is anteromedial TTT with an offset bone graft
Unloads distal and lateral lesions(the principle lesions in patients with PF rotational alignment disorders)
Requires intact proximal medial cartilage (may be a problem after dislocation or crush)
Appropriate when TT-TG elevated and improved alignment is needed along with distal unloading
Highly effective for the right patients- improved stability and pain relief
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TTT or arthroplasty?
These patients do well with anteromedial tibialtubercle transfer, AS LONG AS THERE IS INTACT MEDIAL CARTILAGE onto which to transfer
Realign medial tracking patella
Unload medial lesion, overloaded from previous excessive or posteromedial TTT
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Precise osteotomy, tapered to anterior cortex distally
Move slightly distal to correct alta if needed and anteriorly to unload distal/lateral articular lesion
Secure fixation
Immediate motion
Protect weight bearing 6 weeks
Transfer such that PF loading will be onto better cartilage
Remove hardware late (>6 months)
Result depends to a large extent on effectively unloading the lesion causing pain
unloads distal lesion Selective use of cartilage
resurfacing broadens the indications for this procedure(Farr, Minas, Schepsis, Cole, Gillogly)
Safe and effective--properly done
Must taper osteotomy to anterior tibia distally-do not notch tibia shaft
Pidoriano et al, AJSM, 1997
Saranathan A, Kirkpatrick MS, Mani S, Smith LG, Cosgarea AJ, Tan JS, Elias JJ.
The effect of tibial tuberosity realignment procedures on the patellofemoral pressure distribution.
Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990 Sep-Oct;18(5):490-6; discussion 496-7.
Medialization normalizes or optimizes PF alignment and tracking
while
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AMTTTNo AMTTT
After a precise osteotomy stabilized with two cortical screws into the posterior cortex, patients should begin immediate range of motion
Partial weight bearing for 5-6 weeks, then rapid progression to quad strengthening and weight bearing off crutches
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Schepsis description of Anteromedial Tibial Tubercle Transfer- OKO on AAOS website
AMTTT presentations on www.vumedi.com
Farr, Schepsis, Cole, Fulkerson, Lewis Anteromedialization, Review and Technique. J Knee Surg. 2007;20:120-128
AAOS Blu-ray DVD Patella Instability and Arthrosis The Master’s Experience series (2013)
Once the tracking is optimized by TTT, restore retinacular support as needed
As trochlea dysplasia increases, need for retinacular support increases
MPFL and medial deficiency alone--no TTT
Much of medial retinacularsupport runs to quadriceps expansion- useful in reconstruction- option of MQTFL reconstruction to quad tendon instead of MPFL reconstruction to patella
Disastrous result of patella distalization in a 21 year old woman
Severe PF arthrosis as a result
Use an osteotomy when you can transfer cartilage tracking onto healthy cartilage (Ficatexcessive lateral pressure syndrome)
Osteotomy is particularly desireablein younger patients with distal and/or lateral patella articular degeneration
PF replacement when deterioration of the PFJ is diffuse
Each case is unique, and requires careful consideration of alignment, articular cartilage lesion location, trochlea dysplasia, and peripatella retinacular support.
Use tibial tubercle transfer to align, balance tracking, and unload an articular lesion
Balance alignment and articular loading as needed before medial restoration surgery to optimize long term results
Design surgery specifically for each patient to create retinacular, tracking and articular balance
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www.patellofemoral.org
Dedicated Patellofemoral Surgery Hands On Course at the Orthopedic Learning Center in Rosemont, IL---September 2016
www.AANA.org for Master’s Course catalog
Special Thanks to Smith and Nephew for generous support of the PF Foundation