Sulcus-Deepening Trochleoplasty and Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability

Laidlaw, Michael S.; Feeley, Scott M.; Ruland, Jeffrey R.; Diduch, David R.

doi:10.1016/j.eats.2017.08.061

Cited by 25 publications

(16 citation statements)

References 26 publications

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“…Clinically, trochlear dysplasia is one of the common causes of patellar instability [ 17 , 18 ]. Some realignment surgeries, including sulcus-deepening trochleoplasty and plication of the medial retinaculum, have been performed for decades [ 19 ]. However, the long-term outcome of these procedures is still debatable [ 20 ], which might be due to the insufficiency of restoring patellofemoral kinematics (including FHA) by surgery.…”

Section: Discussionmentioning

confidence: 99%

Relationship between patellofemoral finite helical axis and femoral trans-epicondylar axis using a static magnetic resonance-based methodology

Cai

Yang

et al. 2021

J Orthop Surg Res

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Background To manage patellofemoral joint disorders, a complete understanding of the in vivo patellofemoral kinematics is critical. However, as one of the parameters of joint kinematics, the location and orientation of the patellofemoral finite helical axis (FHA) remains unclear. The purpose of this study is to quantify the location and orientation of the patellar FHA, both in vivo and non-invasively at various flexion angles, and evaluate the relationship of the FHA and the trans-epicondylar axis (TEA). Methods The magnetic resonance (MR) images of 18 unilateral knees were collected at full extension, 30°, 60°, 90°, and maximum angle of knee flexion. Three-dimensional models of the knee joint at different flexion angles were created using the MR images, and then used to calculate the patellar tracking and FHA with a spline interpolation algorithm. By using a coordinate system based on the TEA, the FHA tracking was quantified. Six parameters concerning the location and orientation of the patellar FHA were analysed. Results The average patellar FHA drew an L-shaped tracking on the midsagittal plane moving from the posteroinferior to the anterosuperior side of the TEA with knee flexion. Before 90° flexion, the patellar rotational radius decreased slightly, with an average value of 5.65 ± 1.09 cm. During 20° to 90° knee flexion, the average angle between the patellar FHA and the TEA was approximately 10° and that between the FHA and the coronal plane was maintained at about 0°, while that between the FHA and the level plane fluctuated between − 10° and 10°. Conclusions This study quantitatively reported the continuous location and direction of the patellar FHA during knee flexion. The patellar FHA was close to but not coincident with the femoral TEA both in location and orientation, and the patellar rotational radius decreased slightly with knee flexion. These findings could provide a clear direction for further studies on the difference in patellofemoral FHA among various types of patellofemoral disorders, and provide a foundation for the application of FHA in surgical evaluation, preoperative planning and prosthesis design, thereby assisting in the diagnosis and treatment of patellofemoral disorders.

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Section: Discussionmentioning

confidence: 99%

Relationship between patellofemoral finite helical axis and femoral trans-epicondylar axis using a static magnetic resonance-based methodology

Cai

Yang

et al. 2021

J Orthop Surg Res

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“…It is our preference to perform the thin-flap trochleoplasty for the following reasons: (1) a lateral approach can allow lateral retinacular lengthening and thus more complete soft-tissue rebalancing, (2) the scar from a lateral approach is smaller and is less likely to cause kneeling pain than a midline scar, and (3) a thin-flap trochleoplasty allows for more thorough molding of the cartilage. In contrast to other described techniques, 21 our technique does not require a formal split in the articular cartilage while still allowing for precise cartilage molding.…”

Section: Discussionmentioning

confidence: 99%

Trochleoplasty, Medial Patellofemoral Ligament Reconstruction, and Open Lateral Lengthening for Patellar Instability in the Setting of High-Grade Trochlear Dysplasia

Vogel

Pace

2019

Arthroscopy Techniques

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Trochlear dysplasia is the most commonly encountered pathoanatomy in patients who present with patellar instability. Outcomes of trochleoplasty procedures have shown low rates of recurrent instability and high patient-reported outcome scores. This article describes a “thin-flap” groove-deepening trochleoplasty combined with medial patellofemoral ligament reconstruction with a gracilis allograft and lateral retinacular lengthening to treat recurrent patellar instability due to high-grade trochlear dysplasia. This technique can obviate tibial tubercle osteotomy by normalizing the position of the trochlear groove and, subsequently, decreasing the tibial tubercle–to–trochlear groove distance.

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“…Sulcus-deepening trochleoplasty with MPFL reconstruction was performed in every patient as described previously by Laidlaw et al 21 A medial parapatellar arthrotomy was used to expose the dysplastic trochlea. The goal of the procedure was to reduce the supratrochlear spur, beginning with removal of subchondral bone at the articular margins with a ½-inch straight osteotome.…”

Section: Methodsmentioning

confidence: 99%

“…As previously described by Laidlaw et al, 21 the physical therapist can assist with flexion 15° beyond each brace setting and guide the patient in performing heel slides with the brace removed. At 6 to 12 weeks, quadriceps activation and strengthening are performed, progressing toward stationary bicycle, elliptical, and leg press.…”

Section: Methodsmentioning

confidence: 99%

Manipulation Under Anesthesia With Lysis of Adhesions Is Effective in Arthrofibrosis After Sulcus-Deepening Trochleoplasty: A Prospective Study

Carstensen

Feeley

Diduch

2019

Orthopaedic Journal of Sports Medicine

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Background: Sulcus-deepening trochleoplasty has been established as an effective treatment for patellar instability due to trochlear dysplasia. However, arthrofibrosis is a known complication following trochleoplasty, which may require manipulation under anesthesia (MUA) with or without lysis of adhesions (LOA) to increase the knee range of motion (ROM), especially flexion. Purpose: To prospectively follow patients for ROM improvements and subsequent complications after undergoing MUA with or without LOA in the setting of sulcus-deepening trochleoplasty. Study Design: Case series; Level of evidence, 4. Methods: A total of 76 knees with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty, with a mean (±SD) follow-up of 32.5 ± 19.3 months. Concomitant procedures included medial patellofemoral ligament reconstruction, lateral retinacular release, and tibial tubercle osteotomy. Physical examination including ROM and findings of recurrent patellar instability were collected for all patients. Arthrofibrosis was defined as active and passive flexion less than 90° within 3 months of surgery combined with a plateau in progress with physical therapy. Paired-samples and independent-samples t tests were used. A P value less than .05 was considered significant. Results: A total of 62 knees met inclusion and exclusion criteria and were included in the study. Of these patients, 11 experienced arthrofibrosis as a complication and underwent MUA within 3 months of their index procedure. Of these 11 patients, 9 subsequently underwent arthroscopic LOA following MUA because acceptable ROM could not be achieved with manipulation alone. Patients with arthrofibrosis had a premanipulation mean ROM that was significantly different from those without arthrofibrosis (77.3° ±18.6° vs 133.3° ± 12.7°, respectively; P < .001). In the arthrofibrotic group, postoperative ROM increased significantly after MUA and/or LOA compared with the preoperative ROM (127.3° ± 12.5° vs 77.3° ± 18.6°, respectively; P < .001). ROM in the arthrofibrotic group after MUA/LOA was not significantly different from that in the nonarthrofibrotic group (flexion, 127.3° ± 12.5° vs 133.3° ± 12.7°, respectively; P = .156). No complications from the MUA or LOA were reported at subsequent follow-up visits. Conclusion: When indicated in the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty is a treatment for disabling recurrent patellar instability with a known complication of arthrofibrosis. Initiation of postoperative physical therapy within 3 days of surgery may reduce the incidence of arthrofibrosis. If arthrofibrosis is encountered after a sulcus-deepening trochleoplasty, MUA without LOA is not as effective as when following other procedures of the knee, whereas MUA with LOA is an effective procedure likely to result in ROM and patient outcome scores similar to those of a nonarthrofibrotic knee after the same procedure. Both MUA and LOA appear to be safe based on the limited number of patients in this study without complication.

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Sulcus-Deepening Trochleoplasty and Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability

Cited by 25 publications

References 26 publications

Relationship between patellofemoral finite helical axis and femoral trans-epicondylar axis using a static magnetic resonance-based methodology

Relationship between patellofemoral finite helical axis and femoral trans-epicondylar axis using a static magnetic resonance-based methodology

Trochleoplasty, Medial Patellofemoral Ligament Reconstruction, and Open Lateral Lengthening for Patellar Instability in the Setting of High-Grade Trochlear Dysplasia

Manipulation Under Anesthesia With Lysis of Adhesions Is Effective in Arthrofibrosis After Sulcus-Deepening Trochleoplasty: A Prospective Study

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