Advertisement

Derotational osteotomy at the distal femur is effective to treat patients with patellar instability

  • Florian B. Imhoff
  • Matthias Cotic
  • Franz Liska
  • Felix G. E. Dyrna
  • Knut Beitzel
  • Andreas B. Imhoff
  • Elmar Herbst
KNEE
  • 164 Downloads

Abstract

Purpose

Increased femoral antetorsion influences patellofemoral joint kinematics. The aim of this study was to retrospectively evaluate the clinical outcome after derotational osteotomies and combined procedures in patients with patellofemoral instability.

Methods

All patients with derotational osteotomies and combined procedures in patients with patellofemoral instability and increased femoral antetorsion performed between 2007 and 2016 were retrospectively analyzed. Exclusion criteria were open growth plates, posttraumatic deformities, and a follow-up period less than 12 months. Simple radiography and magnetic resonance imaging to evaluate cartilage lesions, trochlear dysplasia, tubercle distance, and osseous malalignment as frontal axis and torsion were performed on every patient. Patients were evaluated pre- and postoperatively using the visual analog scale (VAS) for pain, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the subjective IKDC evaluation form, the Lysholm score, and the Tegner activity score.

Results

Out of 222 femoral osteotomies, a total of 42 patients (44 knees) met the inclusion criteria. Mean preoperative femoral antetorsion of 31° (SD ± 9°) and mean valgus malalignment of 1° (SD ± 3°) were observed. An intended derotation of 12° (SD ± 5°) was set overall. The additional procedures included correction of valgus in 50% (n = 22), MPFL reconstruction in 64% (n = 28), patellofemoral arthroplasty in 18% (n = 8), trochleoplasty in 14% (n = 6), tibial tubercle transfer in 14% (n = 6). During the mean follow-up period of 44 months (SD ± 27, range 12–88), a total of five patients were lost to follow-up, resulting in a follow-up rate of 89% (n = 39). A significant pain relief from VAS 4 (SD ± 3) to VAS 2 (SD ± 2) (p = 0.006) as well as improved scores, WOMAC: from 80 (SD ± 14) to 88 (SD ± 16) (p = 0.007), Lysholm: from 46 (SD ± 21) to 71 (SD ± 24) (p < 0.001), IKDC: from 54 (SD ± 13) to 65 (SD ± 17) (p < 0.001), were observed postoperatively. During the follow-up period, no patellar re-dislocation was observed.

Conclusion

Combined derotational osteotomy is a suitable treatment for patellar instability due to torsional malformity, as it leads to a significant reduction of pain, and a significant increase of knee function with good-to- excellent results in the short-term follow-up.

Level of evidence

IV.

Keywords

Derotational osteotomy Torsional maltracking Patellofemoral instability Alignment correction 

Notes

Author contributions

FI had done several surgeries within the study group, carried out the study design and drafted the manuscript. MC helped with study design, patient acquisition, data processing and statistical analysis. FL helped with data collection and interpretation of the data, and performed surgeries. FD carried out coordination of the patient’s follow-up, participated in surgeries and helped to draft the manuscript. KB performed the surgeries, assessed the radiological analysis and served as internal reviewer of the manuscript. AI performed the surgeries, assessed the radiological analysis and served as internal reviewer of the manuscript. EH made substantial contribution to the study design, defined study variables and drafted the manuscript. All authors read and approved the final manuscript.

Funding

There was no financial conflict of interest with regards to this study.

Compliance with ethical standards

Conflict of interest

FI, MC, FL, FD report none. KB is a consultant of Arthrex GmbH. AI is a consultant for Arthrex and receives grants and royalties from Arthrex.

Ethical approval

Ethical approval was obtained from the Ethics Committee of the Technical University Munich. All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Ateschrang A, Freude T, Grunwald L, Schaffler A, Stockle U, Schroter S (2014) Patella dislocation: an algorithm for diagnostic and treatment considering the rotation. Z Orthop Unf 152:59–67CrossRefGoogle Scholar
  2. 2.
    Banke IJ, Kohn LM, Meidinger G, Otto A, Hensler D, Beitzel K et al (2014) Combined trochleoplasty and MPFL reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study. Knee Surg Sports Traumatol Arthrosc 22:2591–2598CrossRefGoogle Scholar
  3. 3.
    Beitzel K, Schottle PB, Cotic M, Dharmesh V, Imhoff AB (2013) Prospective clinical and radiological two-year results after patellofemoral arthroplasty using an implant with an asymmetric trochlea design. Knee Surg Sports Traumatol Arthrosc 21:332–339CrossRefGoogle Scholar
  4. 4.
    Buckens CF, Saris DB (2010) Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. Am J Sports Med 38:181–188CrossRefGoogle Scholar
  5. 5.
    de Carvalho LH Jr, Temponi EF, Soares LF, Goncalves MB, Costa LP (2014) Physical activity after distal femur osteotomy for the treatment of lateral compartment knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 22:1607–1611PubMedGoogle Scholar
  6. 6.
    Delgado ED, Schoenecker PL, Rich MM, Capelli AM (1996) Treatment of severe torsional malalignment syndrome. J Pediatr Orthop 16:484–488CrossRefGoogle Scholar
  7. 7.
    Dickschas J, Harrer J, Pfefferkorn R, Strecker W (2012) Operative treatment of patellofemoral maltracking with torsional osteotomy. Arch Orthop Trauma Surg 132:289–298CrossRefGoogle Scholar
  8. 8.
    Diederichs G, Kohlitz T, Kornaropoulos E, Heller MO, Vollnberg B, Scheffler S (2013) Magnetic resonance imaging analysis of rotational alignment in patients with patellar dislocations. Am J Sports Med 41:51–57CrossRefGoogle Scholar
  9. 9.
    Eckhoff DG, Montgomery WK, Kilcoyne RF, Stamm ER (1994) Femoral morphometry and anterior knee pain. Clin Orthop Relat Res 302:64–68Google Scholar
  10. 10.
    Fabry G, Cheng LX, Molenaers G (1994) Normal and abnormal torsional development in children. Clin Orthop Relat Res 302:22–26Google Scholar
  11. 11.
    Feucht MJ, Cotic M, Beitzel K, Baldini JF, Meidinger G, Schottle PB et al (2017) A matched-pair comparison of inlay and onlay trochlear designs for patellofemoral arthroplasty: no differences in clinical outcome but less progression of osteoarthritis with inlay designs. Knee Surg Sports Traumatol Arthrosc 25:2784–2791CrossRefGoogle Scholar
  12. 12.
    Franciozi CE, Ambra LF, Albertoni LJ, Debieux P, Rezende FC, Oliveira MA et al (2017) Increased femoral anteversion influence over surgically treated recurrent patellar instability patients. Arthroscopy 33:633–640CrossRefGoogle Scholar
  13. 13.
    Frings J, Krause M, Akoto R, Wohlmuth P, Frosch KH (2018) Combined distal femoral osteotomy (DFO) in genu valgum leads to reliable patellar stabilization and an improvement in knee function. Knee Surg Sports Traumatol Arthrosc.  https://doi.org/10.1007/s00167-018-5000-9 CrossRefPubMedGoogle Scholar
  14. 14.
    Fucentese SF, von Roll A, Koch PP, Epari DR, Fuchs B, Schottle PB (2006) The patella morphology in trochlear dysplasia—a comparative MRI study. Knee 13:145–150CrossRefGoogle Scholar
  15. 15.
    Gould D, Kelly D, Goldstone L, Gammon J (2001) Examining the validity of pressure ulcer risk assessment scales: developing and using illustrated patient simulations to collect the data. J Clin Nurs 10:697–706CrossRefGoogle Scholar
  16. 16.
    Howells NR, Barnett AJ, Ahearn N, Ansari A, Eldridge JD (2012) Medial patellofemoral ligament reconstruction: a prospective outcome assessment of a large single centre series. J Bone Jt Surg Br 94:1202–1208CrossRefGoogle Scholar
  17. 17.
    Liska F, Voss A, Imhoff FB, Willinger L, Imhoff AB (2018) Nonunion and delayed union in lateral open wedge distal femoral osteotomies—a legitimate concern? Int Orthop 42:9–15CrossRefGoogle Scholar
  18. 18.
    Mulliez A, Lambrecht D, Verbruggen D, Van Der Straeten C, Verdonk P, Victor J (2017) Clinical outcome in MPFL reconstruction with and without tuberositas transposition. Knee Surg Sports Traumatol Arthrosc 25:2708–2714CrossRefGoogle Scholar
  19. 19.
    Nelitz M, Dreyhaupt J, Williams SR, Dornacher D (2015) Combined supracondylar femoral derotation osteotomy and patellofemoral ligament reconstruction for recurrent patellar dislocation and severe femoral anteversion syndrome: surgical technique and clinical outcome. Int Orthop 39:2355–2362CrossRefGoogle Scholar
  20. 20.
    Nelitz M, Williams RS, Lippacher S, Reichel H, Dornacher D (2014) Analysis of failure and clinical outcome after unsuccessful medial patellofemoral ligament reconstruction in young patients. Int Orthop 38:2265–2272CrossRefGoogle Scholar
  21. 21.
    O’Malley MP, Pareek A, Reardon PJ, Stuart MJ, Krych AJ (2016) Distal femoral osteotomy: lateral opening wedge technique. Arthrosc Tech 5:e725–e730CrossRefGoogle Scholar
  22. 22.
    Post WR, Teitge R, Amis A (2002) Patellofemoral malalignment: looking beyond the viewbox. Clin Sports Med 21:521–546CrossRefGoogle Scholar
  23. 23.
    Schneider B, Laubenberger J, Jemlich S, Groene K, Weber HM, Langer M (1997) Measurement of femoral antetorsion and tibial torsion by magnetic resonance imaging. Br J Radiol 70:575–579CrossRefGoogle Scholar
  24. 24.
    Schottle PB, Hensler D, Imhoff AB (2010) Anatomical double-bundle MPFL reconstruction with an aperture fixation. Knee Surg Sports Traumatol Arthrosc 18:147–151CrossRefGoogle Scholar
  25. 25.
    Schottle PB, Romero J, Schmeling A, Weiler A (2008) Technical note: anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft. Arch Orthop Trauma Surg 128:479–484CrossRefGoogle Scholar
  26. 26.
    Strecker W, Dickschas J (2015) Torsional osteotomy: operative treatment of patellofemoral maltracking. Oper Orthop Traumatol 27:505–524CrossRefGoogle Scholar
  27. 27.
    Weber AE, Nathani A, Dines JS, Allen AA, Shubin-Stein BE, Arendt EA et al (2016) An algorithmic approach to the management of recurrent lateral patellar dislocation. J Bone Jt Surg Am 98:417–427CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Florian B. Imhoff
    • 1
  • Matthias Cotic
    • 1
  • Franz Liska
    • 1
  • Felix G. E. Dyrna
    • 1
  • Knut Beitzel
    • 1
  • Andreas B. Imhoff
    • 1
  • Elmar Herbst
    • 1
  1. 1.Department of Orthopaedic Sports Medicine, Klinikum Rechts der IsarTechnical University of MunichMunichGermany

Personalised recommendations