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Surgical Technique for Obligate Flexion Patellar Dislocation: Medial Patellofemoral Ligament Reconstruction, Distal Femoral Osteotomy, Quadricepsplasty, and Lateral Retinacular Reconstruction with Dermal Allograft.

ABSTRACT: Lateral patellar dislocation is a relatively common pathology that can be surgically treated with a medial patellofemoral ligament reconstruction. In rare occurrences patients can present with patellar maltracking that results in obligate patellar instability in flexion but central tracking in extension. This presentation can be much more complicated to treat surgically and may require a combination of multiple patellofemoral procedures. In this technique we describe a four-pronged treatment approach for improving patellar tracking in a patient with obligate flexion patellar dislocation and valgus malalignment including VY quadricepsplasty, distal femoral osteotomy, medial patellofemoral ligament reconstruction, and lateral retinacular and capsular reconstruction with a dermal allograft.

SUBMITTER: Huddleston HP

PROVIDER: S-EPMC8322671 | biostudies-literature |

REPOSITORIES: biostudies-literature

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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:BackgroundOpen-wedge high tibial osteotomy (OWHTO) may cause adverse changes in the mechanical environment of the patellofemoral joint. For patients with lateral patellar compression syndrome or patellofemoral arthritis, intraoperative management is still challenging. The effect of lateral retinacular release (LRR) on patellofemoral joint mechanics after OWHTO remains unclear. Our study aimed to evaluate the effect of OWHTO and LRR on the patellar position based on lateral and axial radiographs of the knee joint.MethodsThe study comprised 101 knees (OWHTO group) undergoing OWHTO alone and 30 knees (LRR group) undergoing OWHTO and concomitant LRR. The following radiological parameters were statistically analyzed preoperatively and postoperatively: femoral tibial angle (FTA), medial proximal tibial angle (MPTA), weight-bearing line percentage (WBLP), Caton-Deschamps index (CDI), Insall-Salvati index (ISI), lateral patellar tilt angle (LPTA), and lateral patellar shift (LPS). The follow-up duration ranged from 6 to 38 months, with a mean of 13.51±6.84 months in the OWHTO group and 12.47±7.81 months in the LRR group. The Kellgren-Lawrence (KL) grading system was used to evaluate changes in patellofemoral osteoarthritis (OA).ResultsRegarding the patellar height, preliminary analysis demonstrated a statistically significant decrease in the CDI and ISI in both groups (P<0.05). However, there was no significant difference in changes in CDI or ISI between the groups (P>0.05). In the OWHTO group, although there was a significant increase in the LPTA (P=0.033), the postoperative decrease in the LPS was not significant (P=0.981). In the LRR group, both the LPTA and LPS significantly decreased postoperatively (P=0.000). The mean changes in LPS were 0.03 mm in the OWHTO group and 1.44 mm in the LRR group, indicating a significant change in LPS (P=0.000). However, there was no significant difference in changes in LPTA between the groups, which was contrary to our expectations. Imaging showed no change in patellofemoral OA in the LRR group and progressive changes (from KL grade I to II) in patellofemoral OA in 2 (1.98%) patients in the OWHTO group.ConclusionsOWHTO can cause a significant decrease in patellar height and an increase in lateral tilt. LRR can significantly improve the lateral tilt and shift of the patella. The concomitant arthroscopic LRR should be considered for the treatment of patients with lateral patellar compression syndrome or patellofemoral arthritis.

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Surgical Technique for Obligate Flexion Patellar Dislocation: Medial Patellofemoral Ligament Reconstruction, Distal Femoral Osteotomy, Quadricepsplasty, and Lateral Retinacular Reconstruction with Dermal Allograft.

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