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

Vogel, Laura A.; Pace, J. Lee

doi:10.1016/j.eats.2019.05.005

Cited by 13 publications

(7 citation statements)

References 21 publications

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“…9 During trochleoplasty, LRL may be used as an approach to access the dysplastic trochlea. 10 During quadricepsplasty for a complex patellar instability pattern, wide lateral releases are necessary. LRL during such procedures would prevent a large lateral void and synovial herniation and would provide a passive restraint to patellar eversion from medial over-pull of the transposed quadriceps mechanism.…”

Section: Discussionmentioning

confidence: 99%

Lateral Patellar Retinaculum Z-Lengthening

Hayden

Doshi

Parikh

2021

Arthroscopy Techniques

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The lateral retinaculum is a 2-layered structure. The plane between the superficial oblique fibers and the deep transverse fibers allows for coronal plane Z-lengthening of the lateral retinaculum. The lengthening procedure can be used for treatment of lateral patellar hypercompression syndrome or as an adjunct to surgical procedures undertaken to address patellar instability. This article describes the surgical technique for lateral retinacular lengthening. Level 1: Knee. Level 2: Malalignment, patellofemoral, other.

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Section: Discussionmentioning

confidence: 99%

Lateral Patellar Retinaculum Z-Lengthening

Hayden

Doshi

Parikh

2021

Arthroscopy Techniques

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“…Patients with Dejour C or D that underwent isolated MPFL went on to revision stabilization at almost four times the rate compared to if they had been given a combined MPFL‐R and TTO. It is possible that realignment of the patellar tracking mitigates some of the risk of the trochlear morphology; however, even though our surgeons were more likely to perform a combined procedure in patients with Dejour C or D, that group of patients still went on to revision stabilization at almost twice rate of patients with Dejour A or B. Trochleoplasty is the only procedure to directly change the offending bony morphology [3, 33]. Adoption has been slow in the US due to mixed early findings and concern for subchondral injury and early arthritis [8].…”

Section: Discussionmentioning

confidence: 99%

Outcomes and reoperation rates after tibial tubercle transfer and medial patellofemoral ligament reconstruction: higher revision stabilization in patients with trochlear dysplasia and patella alta

Gorbaty¹,

Varkey

Hong

et al. 2021

Knee Surg Sports Traumatol Arthrosc

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PurposeTo determine the reoperation rate, risk factors for reoperation, and patient‐reported outcomes after isolated or combined tibial tubercle transfer and medial patellofemoral ligament reconstruction, for patellofemoral instability surgery. MethodsPatient’s records who underwent medial patellofemoral ligament reconstruction and/or tibial tubercle transfer for patellar instability by 35 surgeons from 2002 to 2018 at a single academic institution were retrospectively reviewed using CPT codes. Four‐hundred‐and‐eighty‐six patients were identified. Radiographic measurements, demographic parameters, and subsequent revision procedures and their indications were identified. A modified anterior knee pain survey was conducted by mail and with follow‐up phone survey. ResultsThe overall rate of reoperation was 120/486 (24.7%). The most common cause for reoperation was removal of hardware 42/486 (8.6%). The rate of reoperation for isolated medial patellofemoral ligament reconstruction 43/226 (19%) was lower than that of isolated tibial tubercle transfer 45/133 (33.8%) or a combined procedure 32/127 (25.2%) (P = 0.007). Woman had a higher rate of reoperation (29.4%) compared to men (15.9%) (P = 0.002). Patients at risk for a revision stabilization procedure included those with severe trochlear morphology (C or D) (6.1%) and those with Caton–Deschamps index > 1.3 (7.3%). Patients who underwent reoperation of any kind had poorer patient‐reported outcomes. ConclusionThe overall reoperation rate after patellofemoral instability surgery remains high, and any reoperation portends worse patient‐reported outcomes. Re‐operations for instability are more likely in patients with trochlear dysplasia and patella alta and may benefit from more aggressive initial treatment, such as medial patellofemoral ligament reconstruction and tibial tubercle transfer in combination. Using the results of this study, surgeons will be able to engage in meaningful discussion with patients to counsel patients on expectations postoperatively. Level of evidenceIV.

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“…Arthroscopic or open lateral release can be performed in combination with MPFL reconstruction or medial plication 112 . To avoid potential iatrogenic medial instability, lateral retinacular lengthening in a Z-shape fashion may be an alternative to traditional lateral release [113][114][115][116][117][118] . A patellar tilt of >20°on imaging and the inability to evert the patella to neutral with the knee in full extension indicate lateral retinacular tightness 33,114 .…”

Section: Tibial Tubercle Osteotomymentioning

confidence: 99%

“…A patellar tilt of >20°on imaging and the inability to evert the patella to neutral with the knee in full extension indicate lateral retinacular tightness 33,114 . Various positions for retinacular closure have been described and range between 30°and 70°of knee flexion [113][114][115] . Adequate lateral retinacular lengthening can be verified with eversion of the patella to 30°past neutral and medial translation of 1 to 2 quadrants 114 .…”

Section: Tibial Tubercle Osteotomymentioning

confidence: 99%

Lateral Patellar Instability

Drapeau-Zgoralski

Swift

Caines

et al. 2023

Journal of Bone and Joint Surgery

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ä Patellar instability represents a common problem with an evolving understanding and multifactorial pathoetiology.Treatment plans should be based on the identification of contributing anatomical factors and tailored to each individual patient.ä Risks for recurrent instability are dependent on several patient-specific factors including patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, trochlear dysplasia, younger skeletal age, and ligamentous laxity.ä Cartilage or osteochondral lesions and/or fractures are commonly observed in first-time patellar dislocation, and magnetic resonance imaging (MRI) should be strongly considered. Advanced imaging modalities, such as computed tomography (CT) or MRI, should also be obtained preoperatively to identify predisposing factors and guide surgical treatment.ä Medial patellofemoral ligament (MPFL) reconstruction with anatomical femoral tunnel positioning is associated with lower recurrence rates compared with MPFL repair and has become a common and successful reconstructive surgical option in cases of instability.ä Lateral retinacular tightness can be addressed with lateral retinacular release or lengthening, but these procedures should not be performed in isolation.ä Tibial tubercle osteotomy is a powerful reconstructive tool in the setting of underlying skeletal risk factors for instability and can be of particular benefit in the presence of increased TT-TG distance (>20 mm), and/or in the setting of patella alta.ä The indications for trochleoplasty are still developing along with the clinical evidence, but trochleoplasty may be indicated in some cases of severe trochlear dysplasia. Several surgical techniques have indications in specific clinical scenarios and populations, and indications, risks, and benefits to each are progressing with our understanding.ä Combined femoral derotational osteotomy and MPFL reconstruction can be considered for patients with a femoral anteversion angle of >30°to improve patient outcomes and reduce recurrence rates.Patellar dislocations account for 3.3% of all knee injuries, with a reported rate of 42 per 100,000 persons per year 1,2 . These injuries most commonly occur in young girls and women, with >70% of first-time patellar dislocations taking place while participating in sport-related activity 1,3 . The majority of patellar dislocations occur in non-contact injuries when the knee is subject to valgus stress while extended during a planting or pivoting motion 3 . Common risk factors for recurrent lateral patellar instability include patella alta, increased tibial tubercleto-trochlear groove (TT-TG) distance, trochlear dysplasia, younger skeletal age, and ligamentous laxity 4,5 . The overall recurrence rate after a first-time patellar dislocation is approximately 30%, but can increase to >70% when multiple risk factors are present 4 . Predisposing clinical and anatomical variables should Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://l...

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

Cited by 13 publications

References 21 publications

Lateral Patellar Retinaculum Z-Lengthening

Lateral Patellar Retinaculum Z-Lengthening

Outcomes and reoperation rates after tibial tubercle transfer and medial patellofemoral ligament reconstruction: higher revision stabilization in patients with trochlear dysplasia and patella alta

Lateral Patellar Instability

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