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Combined Total Knee Arthroplasty and Medial Patellofemoral Ligament Reconstruction for Chronic Patellar Dislocation and Severe Osteoarthritis.

ABSTRACT: Chronic patellar dislocation in the setting of severe knee osteoarthritis is a rare clinical problem. Surgical management often consists of total knee arthroplasty combined with realignment of the extensor mechanism. Several techniques have been described to anatomically restore the extensor apparatus, and literature regarding this topic consists mainly of case reports. We describe a technique using combined medial patellofemoral ligament reconstruction using allograft tissue and total knee arthroplasty with patellar resurfacing for the treatment of chronic patellar dislocation and severe osteoarthritis.

SUBMITTER: Garcia-Mansilla I

PROVIDER: S-EPMC7818631 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

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Combined Total Knee Arthroplasty and Medial Patellofemoral Ligament Reconstruction for Chronic Patellar Dislocation and Severe Osteoarthritis.

Garcia-Mansilla Ignacio I Jones Kristofer J KJ Sassoon Adam A AA

Arthroplasty today 20201226

Chronic patellar dislocation in the setting of severe knee osteoarthritis is a rare clinical problem. Surgical management often consists of total knee arthroplasty combined with realignment of the extensor mechanism. Several techniques have been described to anatomically restore the extensor apparatus, and literature regarding this topic consists mainly of case reports. We describe a technique using combined medial patellofemoral ligament reconstruction using allograft tissue and total knee arth ...[more]

PMID: 33521197

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Project description:BackgroundHabitual patellar dislocation in extension (HPD-E) is a distinctive subtype of recurrent patellar dislocation (RPD); HPD-E represents the most severe type of patellar maltracking in RPD. It has been reported that the presence of preoperative patellar maltracking is associated with a worse clinical outcome after medial patellofemoral ligament (MPFL) reconstruction (MPFL-R).PurposeTo describe the radiological characteristics of HPD-E and to compare clinical outcomes after MPFL-R among patients with and without preoperative HPD-E.Study designCohort study; Level of evidence, 3.MethodsFrom January 2012 to December 2015, a total of 230 consecutive patients (246 knees) with RPD were treated with MPFL-R alone or combined with tibial tubercle osteotomy. Among them, 28 patients diagnosed with HPD-E by preoperative 3-dimensional computed tomography (CT; HPD-E group) were matched in a 1:1 fashion to 28 control participants who did not show HPD-E (control group). Routine radiography and CT were performed to evaluate patellar height, trochlear dysplasia, tibial tubercle-trochlear groove distance, and torsional deformities. The mean patellar laxity index and lateral patellar translation assessed with stress radiography were measured preoperatively and postoperatively to quantify MPFL laxity. At minimum 2-year follow-up, patient-reported outcomes (Kujala, Lysholm, and Tegner scores), patellar maltracking, and redislocation rates were compared between the HPD-E and control groups.ResultsThe radiological characteristics of the HPD-E group were as follows: 89% (25/28) of patients had severe trochlear dysplasia (Dejour type B or D), and the mean femoral anteversion angle was 35.5° ± 4.7°. At the final follow-up, the HPD-E group had a significantly lower Kujala score (76.2 vs 84.5, respectively; P = .001), Lysholm score (75.4 vs 86.6, respectively; P < .001), and Tegner score (4.1 vs 5.8, respectively; P = .021) compared with the control group. The postoperative patellar laxity index (43% vs 19%, respectively; P < .001) and redislocation rate (25% vs 0%, respectively; P = .01) were significantly higher in the HPD-E group than in the control group.ConclusionPreoperative 3-dimensional CT is a reliable method of identfying patients with HPD-E. Treatment of HPD-E by MPFL-R alone or combined with tibial tubercle osteotomy resulted in a higher redislocation rate, more severe MPFL residual laxity, and lower patient-reported outcome scores compared with patients without HPD-E who underwent MPFL-R.

Project description:Background:Interest in bicompartmental knee arthroplasty (BKA) for the treatment of medial patellofemoral osteoarthritis (MPFOA) has grown in recent years because BKA offers a bone and ligament-preserving alternative to total knee arthroplasty (TKA). BKA only resurfaces the diseased compartments, while preserving proprioception and native knee kinematics. Therefore, the objective of this study is to assess knee function, perioperative morbidity, and implant survivability in patients undergoing BKA vs TKA for MPFOA. Methods:The databases MEDLINE, PUBMED, and EMBASE were systematically searched. Randomized controlled trials and nonrandomized comparative studies comparing BKA with TKA for the treatment of MPFOA were included for further analysis. The primary outcome of interest was knee function. Secondary outcomes included range of movement, operation length, intraoperative blood loss, hospital length of stay, postoperative complications, and rate of revision length. The quality of evidence was evaluated using the GRADE approach. Meta-analysis was performed by pooling the results of the selected studies when possible. Results:Six studies were selected for inclusion (4 prospective studies and 2 retrospective cohort studies). In total, 274 patients and 277 knees were included for analysis. There were no significant differences between the 2 groups at any time points in terms of knee function, length of stay, complication rate, or revision rate, when monolithic BKA designs were controlled for. BKA did result in significantly decreased intraoperative blood loss, at the expense of increased operative length compared with TKA. Conclusions:The use of modular BKA for MPFOA is comparable with TKA in terms of short-term function, complication rate, and revision rate. BKA reduces intraoperative blood losses, but it is also more technically demanding, resulting in increased operation length. The use of modular BKA has acceptable short-term outcomes, but more long-term data are needed before it can be recommended for routine use in the treatment of MPFOA. The selection of modular BKA should be determined on a patient-specific basis. Currently, there is no evidence to suggest the use of monolithic BKA designs because of their high revision and failure rate.

Project description:Medial patellofemoral ligament (MPFL) reconstruction is a common procedure to address MPFL deficiency. Various techniques have been reported, with the best method still being pursued. Previous studies have revealed the advantage of internal bracing and possible advantage of wide patellar insertion in MPFL reconstruction. Thus, we would like to introduce a technique that combines the internal bracing and wide patellar insertion in MPFL reconstruction, in which the critical points are proper location of the patellar and femoral tunnels and proper tensioning of the augmenting sutures and the whole graft complex. Our clinical experience indicates that the proper application of this technique can lead to satisfactory clinical outcome. We consider the introduction of this technique will provide more insight to MPFL reconstruction. Technique Video Video 1 Wide patellar insertion medial patellofemoral ligament reconstruction with internal bracing. This procedure is performed in the left leg. The anterior half of the peroneus longus tendon is harvested. Both ends of the tendon are braided with nonabsorbable sutures. All parts of the knee are examined and debrided. The MPJ point on the medial edge of the patella is defined. A medial patellar incision is made over the MPJ (junction of the medial and proximal one-third). Two tunnels are created from the medial edge of the patella to the midline of the anterior surface of the patella. A longitudinal incision is made over the medial femoral epicondyle and the adductor tubercle. The femoral tunnel is located and created. Two guide sutures are passed though the patellar tunnels. The graft tendon along with 2 augmenting sutures are passed through the proximal tunnel and pulled back through the distal tunnel. Lateral retinaculum release is performed as indicated. The tendon and the augmenting sutures are pulled subcutaneously out of the medial incision. A cortical suspensory fixation device with an adjustable loop is passed through the femoral tunnel from the medial to the lateral side. Each tendon end, as well as the augmenting sutures are tied to the adjustable loop. A lateral incision is made. The sutures from the adjustable loop are pulled through the soft-tissue fissure resulting from the lateral retinaculum release out of the lateral incision. The cortical fixation device is pulled through the femoral tunnel till the tendon ends are pulled into the femoral tunnel. The arthroscope is placed to the lateral gutter of the knee though the anterolateral portal. The adjustable loop is reduced until the cortical fixation button is pulled back against the lateral orifice of the femoral tunnel. At 30? flexion of the knee, lateral displacement of the patella is checked to make sure that the medial stability of the patella is restored. (MPJ, medial–proximal junction.)

Dataset Information

Combined Total Knee Arthroplasty and Medial Patellofemoral Ligament Reconstruction for Chronic Patellar Dislocation and Severe Osteoarthritis.

Publications

Combined Total Knee Arthroplasty and Medial Patellofemoral Ligament Reconstruction for Chronic Patellar Dislocation and Severe Osteoarthritis.

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