Medial Closing-Wedge Patellar Osteotomy in Patients With Patellofemoral Instability
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PROVIDER: S-EPMC10907901 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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Project description:A varus-producing distal femoral osteotomy (DFO) is an effective technique for the treatment of lateral patellar instability (LPI) in patients with concomitant moderate to severe valgus malalignment. Patellar maltracking and subluxation are corrected via neutralization of some of the laterally directed forces on the patella due to the valgus deformity. This can be accomplished with a distal femoral lateral opening-wedge or medial closing-wedge osteotomy and medial soft tissue stabilization. A medial closing-wedge osteotomy offers the advantages of immediate weight bearing and a single incision in cases requiring patellofemoral soft tissue stabilization. In this article, we describe our preferred operative technique for a medial closing-wedge DFO using a femoral locking plate and medial patellofemoral ligament imbrication for the correction of LPI.
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Project description:Lateral patellofemoral instability is multifactorial in etiology, with bony and soft-tissue factors contributing. Coronal plane alignment, in particular genu valgum, is important to consider when evaluating lateral patellofemoral instability. When genu valgum is present and thought to be a significant contributing factor, we typically address this with an extra-articular, biplanar, medial closing-wedge distal femoral osteotomy (DFO). This can be combined with a medial patellofemoral ligament reconstruction using a partial-thickness quadriceps tendon graft via the same incision. A medial closing-wedge DFO with locking plate fixation affords a highly stable construct suitable for early weight-bearing. The locking plate is less prominent as compared with a lateral opening-wedge DFO, and it does not irritate the iliotibial band or cause tightening of the illiopatellar expansion. The biplanar nature of the osteotomy prevents extension of the osteotomy into the proximal trochlear, helps to control rotation in both axial and sagittal plane after wedge removal, and increases the bony surface area for healing. The quadriceps tendon medial patellofemoral ligament reconstruction allows a graft that can be tailored in terms of length and diameter, does not require an anchor on the patellar, and can be performed through the same incision as for the DFO.
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Project description:Recurrent patellar instability can be very debilitating and may require surgical intervention. A thorough workup must be completed in this subset of patients. Risk factors for recurrent instability include patella alta, trochlear dysplasia, an increased tibial tubercle-trochlear groove distance, and insufficiencies in the medial retinacular structures. Necessary treatment of these risk factors, once identified, should be addressed surgically. Patellofemoral reconstruction must be individually tailored to each patient's anatomy and may necessitate medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, or trochleoplasty in any combination or as a standalone procedure. This article details our technique for surgical treatment of recurrent patellar instability with a medial patellofemoral ligament reconstruction, an open trochleoplasty, and a tibial tubercle osteotomy for patients with severe trochlear dysplasia, an increased tibial tubercle-trochlear groove distance, or patella alta.
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Project description:The primary indications for performing a medial closing wedge distal femoral osteotomy are valgus knee malalignment, lateral knee compartment overload, lateral meniscus insufficiency, and/or lateral compartment osteoarthritis or cartilage damage. Without correction of this malalignment, there is an increased risk for chondral damage in the lateral and patellofemoral compartment of the knee. The optimal candidates for this procedure are young, active individuals with moderate to severe arthritis in the lateral compartment. Recently, preoperative planning for high tibial and distal femoral osteotomies (HTOs and DFOs) using 3-dimensional (3D) patient-specific instrumentation (PSI) has increased in popularity. Successful patient outcomes have been reported using this technique. This Technical Note illustrates our preferred technique that uses 3D PSI in addition to a patellar OCA transplant when treating a symptomatic cartilage lesion associated with genu valgum.
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Project description:Recurrent patellar dislocations have been correlated with an elevated risk of further patellar dislocations, often requiring surgical treatment. Risk factors include medial patellofemoral ligament (MPFL) tears, patella alta, trochlear dysplasia, and an increased tibial tubercle-trochlear groove distance. Surgical management must be based on a patient's unique joint pathoanatomy and may require MPFL reconstruction with tibial tubercle osteotomy or trochleoplasty either alone or in combination. This article discusses our preferred technique for surgical treatment of recurrent patellar instability with MPFL reconstruction using a quadriceps tendon autograft, an open trochleoplasty, and a tibial tubercle osteotomy for patients with patella alta, trochlear dysplasia, and an increased tibial tubercle-trochlear groove distance.
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Project description:Patients with bidirectional patellar instability who are unresponsive to conservative management may benefit from a medial patellofemoral ligament (MPFL) reconstruction and lateral patellofemoral ligament (LPFL) reconstruction. If an isolated MPFL reconstruction does not provide adequate stabilization intraoperatively, combined MPFL and LPFL reconstruction allows independent reconstruction, which can be performed with a facile, reproducible technique. The purpose of this report was to describe our technique for performing an MPFL reconstruction with a concurrent soft-tissue LPFL reconstruction combined with a distalizing tibial tubercle osteotomy to correct patella alta.
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Project description:Patellar dislocation is a relatively common pediatric injury, which often results in recurrent patellofemoral instability. An increased tibial tubercle-trochlear groove distance predisposes to patellofemoral instability and can be corrected with a distal realignment procedure. Soft-tissue distal realignment procedures must be used in the pediatric population to avoid the risks of premature physeal closure associated with tibial tubercle osteotomies. Several soft-tissue distal realignment procedures have been described, with no consensus as to the optimal technique. When combined with medial patellofemoral ligament reconstruction, distal realignment procedures can restore patellofemoral stability through the entire flexion arc. This article describes a modification of the Grammont distal patellar realignment procedure in conjunction with medial patellofemoral ligament reconstruction for the management of pediatric patellofemoral instability.
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Project description:Valgus malalignment can be corrected with a medial closing-wedge proximal tibia osteotomy in patients with symptomatic lateral compartment disease. Advantages of this technique include the inherent stability of the closing wedge with direct bone contact and reliable healing that enables early weight bearing and shorter recovery time. In addition, a tibial-based osteotomy alters joint contact forces in both flexion and extension versus femoral-based osteotomies. The purpose of this article is to present a reproducible technique for medial closing-wedge proximal tibia osteotomy and review the indications, preoperative planning, rationale, and clinical outcomes.
| S-EPMC7372308 | biostudies-literature
Project description:Distal femoral varus osteotomy is a well-established procedure for the treatment of lateral compartment cartilage lesions and degenerative disease, correcting limb alignment and decreasing the progression of the pathology. Surgical techniques can be performed with a lateral opening-wedge or medial closing-wedge correction of the deformity. Fixation methods for lateral opening-wedge osteotomies are widely available, and there are various types of implants that can be used for fixation. However, there are currently only a few options of implants for fixation of a medial closing-wedge osteotomy on the market. This report describes a medial, supracondylar, V-shaped, closing-wedge distal femoral osteotomy using a locked anterolateral proximal tibial locking plate that fits anatomically to the medial side of the distal femur. This is a great option as a stable implant for a medial closing-wedge distal femoral osteotomy.
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Project description:Medial patellofemoral complex (MPFC) is considered as the primary medial patellar restraint and has a static, as well as dynamic, component. MPFL reconstruction (MPFL-R) restores only the static component of MPFC, is associated with multiple technical concerns, and has a steep learning curve. Need for physeal sparing techniques and relatively high rates of complications including patella fracture are some other concerns with MPFL-R. We propose a simple procedure for advancement of MPFC onto patella, which is indicated in most of the recurrent lateral instabilities (with a positive lateral glide test result and an intact MPFL on magnetic resonance imaging). The procedure is also indicated in selective acute primary dislocations-those with associated chondral lesions and magnetic resonance imaging-documented isolated patellar side avulsion/injury. MPFC advancement is a more anatomical procedure that also restores dynamic medial checkrein of patella and can be performed even by a novice surgeon. MPFC advancement is devoid of the multiple technicalities of MPFL-R, does not require intraoperative imaging or any postoperative immobilization, and renders complications like donor graft-site morbidity and patella fractures irrelevant. It requires no modifications in patients with open physes and can be performed in isolation or with other procedures as per à la carte principle.
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