Surgical Treatment Of Habitual Dislocation Of The Patella

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Surgical Treatment Of Habitual Dislocation Of The Patella In Young Children: A 13 Year

Surgical Treatment Of Habitual Dislocation Of The Patella In Young Children: A 13 Year Follow-up Retrospective Study Benoit, MD Yves Laflamme, MD Benoit Morin, MD Guy Grimard, MD Dominique Rouleau, MD

Habitual Patellar Dislocation = Severe Functional Disability

Habitual Patellar Dislocation = Severe Functional Disability

Habitual Patellar Dislocation Ø Dislocation occurs with activities of daily living Ø Sporting activities

Habitual Patellar Dislocation Ø Dislocation occurs with activities of daily living Ø Sporting activities are almost impossible

Factors* Of Patellar Instability (Six) *Insall and Salvati, 2001

Factors* Of Patellar Instability (Six) *Insall and Salvati, 2001

Factors of patellar instability 1) Patella alta A L T A

Factors of patellar instability 1) Patella alta A L T A

Radiologic Patellar Height Assessment In The Immature Patient l Koshino-Sugimoto l Caton-Deschamps

Radiologic Patellar Height Assessment In The Immature Patient l Koshino-Sugimoto l Caton-Deschamps

FF PT/FT = 1 P P T Koshino-Sugimoto

FF PT/FT = 1 P P T Koshino-Sugimoto

P AT/PA: 0. 6 -1. 3 P A A T T Caton-Deschamps

P AT/PA: 0. 6 -1. 3 P A A T T Caton-Deschamps

Factors of patellar instability 2) Hypoplastic Femoral Sulcus 160°

Factors of patellar instability 2) Hypoplastic Femoral Sulcus 160°

N = 138° > 150° = Trochlear dysplasia

N = 138° > 150° = Trochlear dysplasia

Factors of patellar instability 3) Patellar Dysplasia Wiberg Classification

Factors of patellar instability 3) Patellar Dysplasia Wiberg Classification

Factors of patellar instability 4) Muscle Imbalance (VMO dysplasia)

Factors of patellar instability 4) Muscle Imbalance (VMO dysplasia)

Factors of patellar instability 5) Increased Q angle

Factors of patellar instability 5) Increased Q angle

Factors of patellar instability 6) Lower Limb Malalignment

Factors of patellar instability 6) Lower Limb Malalignment

Treatment options?

Treatment options?

Ø No study addresses specifically habitual patellar dislocation in the young child

Ø No study addresses specifically habitual patellar dislocation in the young child

Treatment Options Ø Conservative l Physical therapy l Knee bracing Ø Surgical

Treatment Options Ø Conservative l Physical therapy l Knee bracing Ø Surgical

Does knee bracing prevent habitual patellar dislocation ?

Does knee bracing prevent habitual patellar dislocation ?

Does physical therapy prevent habitual patellar dislocation ?

Does physical therapy prevent habitual patellar dislocation ?

Recurrence rate: 40% + Garth, Am J Sports Med, 1996

Recurrence rate: 40% + Garth, Am J Sports Med, 1996

Ø Surgical treatment

Ø Surgical treatment

Literature “Patella alta must absolutely be treated to obtain a satisfactory result” Caton, J.

Literature “Patella alta must absolutely be treated to obtain a satisfactory result” Caton, J. Revue Chir. Ortho. , 1990 A L T A

Literature “Most common technical error in distal realignment is failure to correct patellar height”

Literature “Most common technical error in distal realignment is failure to correct patellar height” Insall J. , JBJS, 1976 Scuderi G. R. , OCNA, 1992 A L T A

Distal realignment ØExcessive medialization ØPosterior recessing Late osteoarthritis Insall, JBJS, 1976

Distal realignment ØExcessive medialization ØPosterior recessing Late osteoarthritis Insall, JBJS, 1976

Surgical Options In The Patient With Open Physis Ø Roux-Golthwait Ø Galeazzi

Surgical Options In The Patient With Open Physis Ø Roux-Golthwait Ø Galeazzi

Roux. Goldthwait

Roux. Goldthwait

Galeazzi

Galeazzi

Roux-Goldthwait VS Galeazzi P A T E L L A A L T A

Roux-Goldthwait VS Galeazzi P A T E L L A A L T A

Roux-Goldthwait Galeazzi P A T E L L A A L T A

Roux-Goldthwait Galeazzi P A T E L L A A L T A

Bony procedures not appropriate Elmslie-Trillat Fulkerson

Bony procedures not appropriate Elmslie-Trillat Fulkerson

Tibial tubercule transfer on the knee with open physis Genu recurvatum

Tibial tubercule transfer on the knee with open physis Genu recurvatum

Goal of our study Clinical evaluation of a new procedure to correct patella alta

Goal of our study Clinical evaluation of a new procedure to correct patella alta in children with patellar instability Long term follow-up (13. 8 years)

Materials and methods Ø Retrospective study

Materials and methods Ø Retrospective study

Materials and methods Ø Retrospective study Ø 12 consecutive knees treated surgically in young

Materials and methods Ø Retrospective study Ø 12 consecutive knees treated surgically in young children from 1988 to 1994

Materials and methods Ø Retrospective study Ø 12 knees in young children treated surgically

Materials and methods Ø Retrospective study Ø 12 knees in young children treated surgically Ø Follow-up: 10 -17 years (mean 13. 8 years)

Materials and methods Ø Retrospective study Ø 12 knees in young children treated surgically

Materials and methods Ø Retrospective study Ø 12 knees in young children treated surgically Ø Follow-up: 10 -17 years (mean 13. 8 years) Ø Mean age at surgery: 10 years 14 years) (6 -

Materials and methods Ø Retrospective study Ø 12 knees in young children treated surgically

Materials and methods Ø Retrospective study Ø 12 knees in young children treated surgically Ø Follow-up: 10 -17 years (mean 13. 8 years) Ø Mean age at surgery: 10 years (6 -14 years) Ø Mean age at last follow-up: 25 years

Materials and methods Ø Inclusion criterias l Habitual patellar dislocation l Functional limitations in

Materials and methods Ø Inclusion criterias l Habitual patellar dislocation l Functional limitations in activities of daily living l Symptoms of more than 1 year duration

l Failure of conservative treatment (bracing and physical therapy) l Growth plates opened at

l Failure of conservative treatment (bracing and physical therapy) l Growth plates opened at time of surgery

Materials and methods Preoperative clinical evaluation l High-riding patella l VMO dysplasia l Normal

Materials and methods Preoperative clinical evaluation l High-riding patella l VMO dysplasia l Normal Q-angle l Positive apprehension test l Lateral patellar laxity IV/IV

Radiographic measures Ø Sulcus angle Ø Patellar height

Radiographic measures Ø Sulcus angle Ø Patellar height

Surgical technique Proximal realignment: üLateral release Hughston technique üVMO advancement Distal realignment: üComplete patellar

Surgical technique Proximal realignment: üLateral release Hughston technique üVMO advancement Distal realignment: üComplete patellar tendon lowering NEW!

Patellar tendon dissection Tibial tubercule Patellar tendon Templated advancement: 2. 5 cm

Patellar tendon dissection Tibial tubercule Patellar tendon Templated advancement: 2. 5 cm

Patellar tendon elevation Tendon Tibial tubercle

Patellar tendon elevation Tendon Tibial tubercle

Tendon preparation Receiving bed Transosseous sutures

Tendon preparation Receiving bed Transosseous sutures

Distal tendon transfer

Distal tendon transfer

Tendon attached

Tendon attached

Results

Results

Ø Mean patellar tendon lowering: 1. 6 cm (1 cm to 2. 5 cm)

Ø Mean patellar tendon lowering: 1. 6 cm (1 cm to 2. 5 cm)

Results Last follow-up Ø Instability: 0/12 Ø Pain: 1/12

Results Last follow-up Ø Instability: 0/12 Ø Pain: 1/12

Results Last follow-up Ø Lateral glide test Normal in 11/12 Ø Apprehension test

Results Last follow-up Ø Lateral glide test Normal in 11/12 Ø Apprehension test

Results Lysholm knee score at last follow-up: Ø Mean: 98/100

Results Lysholm knee score at last follow-up: Ø Mean: 98/100

Results Recreational activities Preop Last f-up (13. 8 y) Limited 12/12 1/12

Results Recreational activities Preop Last f-up (13. 8 y) Limited 12/12 1/12

Results Sulcus Angle Preop 6 m 3. 8 y 13. 8 y Mean 160°

Results Sulcus Angle Preop 6 m 3. 8 y 13. 8 y Mean 160° 157° 147°

Results Patellar Height Mean Patellar Height (Caton. Deschamps) N: 0. 6 -1. 3 Preop

Results Patellar Height Mean Patellar Height (Caton. Deschamps) N: 0. 6 -1. 3 Preop 6 m 3. 8 y 1. 53 0. 96 0. 97 1. 11

Early postoperative complications (3) Ø 1 redislocation (undercorrection) l l Early reoperation Now stable

Early postoperative complications (3) Ø 1 redislocation (undercorrection) l l Early reoperation Now stable Ø 1 wound abcess l l Surgical drainage, Antibiotics Healed Ø 1 peroneal nerve neurapraxia l l Recovered completely Cast compression?

Late postoperative complications Ø Two patella bajas (Caton ratio) in children operated at 6

Late postoperative complications Ø Two patella bajas (Caton ratio) in children operated at 6 and 7 years old

Discussion

Discussion

Discussion Risks of osteoarthritis minimized by: Ø no unnecessary medialization Ø no posterior recessing

Discussion Risks of osteoarthritis minimized by: Ø no unnecessary medialization Ø no posterior recessing Ø high rate of patellofemoral stability

Discussion Anatomic repositioning of the patella Ø eliminates delay of patellar engagement Ø maximizes

Discussion Anatomic repositioning of the patella Ø eliminates delay of patellar engagement Ø maximizes buttressing effect of the lateral condyle, and…

…seems to remodel the shallow throchlea in the immature patient

…seems to remodel the shallow throchlea in the immature patient

Conclusion Ø Realistic goals were achieved: l Functional knee stability l Return to active

Conclusion Ø Realistic goals were achieved: l Functional knee stability l Return to active life

Conclusion Ø Addressing patellar height is paramount in the immature patient

Conclusion Ø Addressing patellar height is paramount in the immature patient

Conclusion Ø Patella baja occurred in two patients l No clinical or radiological consequence

Conclusion Ø Patella baja occurred in two patients l No clinical or radiological consequence l Consequences in the futur? ?

Conclusion Ø Trochlear remodeling occurs secondary to distal tendon transfer in the immature patient

Conclusion Ø Trochlear remodeling occurs secondary to distal tendon transfer in the immature patient

Thank you

Thank you

Who is right? Caton normal Insall: Patella baja

Who is right? Caton normal Insall: Patella baja

Lateral retinacular release alone in reccurent patellar dislocation Ø 21% redislocation rate (7/33 knees)¹

Lateral retinacular release alone in reccurent patellar dislocation Ø 21% redislocation rate (7/33 knees)¹ Ø 35% redislocation rate (7/20 knees)² 1) Dandy and Desai, JBJS Br, 1989 2) Aglietti et al, J Orthop, 1994

Radiographic Evaluation Ø AP Ø Preoperative Ø Lateral 45° Ø Postoperative Ø Lateral 90°

Radiographic Evaluation Ø AP Ø Preoperative Ø Lateral 45° Ø Postoperative Ø Lateral 90° Ø Intermediate follow-up Ø Merchant view (mean 3. 8 years) Ø Latest follow-up (mean 13. 8 years)

Results Patellar Height Mean Patellar Height (Caton. Deschamps) Preop 6 m 3. 8 y

Results Patellar Height Mean Patellar Height (Caton. Deschamps) Preop 6 m 3. 8 y 1. 53 0. 96 0. 97 1. 11 1. 28 0. 97 1. 06 N: 0. 6 -1. 3 Mean Patellar Height (Koshino. Sugimoto)

Conclusion Ø The described surgical procedure is a comprehensive and effective approach to habitual

Conclusion Ø The described surgical procedure is a comprehensive and effective approach to habitual patellar dislocation in young children

Lateral release

Lateral release

Patient preparation

Patient preparation

Physical exam (under anesthesia)

Physical exam (under anesthesia)

Lateral release

Lateral release

VMO advancement

VMO advancement

Wound closed

Wound closed