Advertisement

Patellofemoral Instability: Distal Realignment

  • Suroosh Madhanipour
  • Kostas Michail
  • Sam Oussedik
Chapter

Abstract

Distal realignment is one of the most well-established treatments for patellar instability, allowing treatment of risk factors including patella alta and increased tibial tubercle-trochlear groove (TT-TG) distance. Prior to performing a distal realignment, the surgeon needs to perform a comprehensive assessment of the patient including measurement of patellar height and alignment. Distal realignment is best employed if either of these is abnormal—if trochlear dysplasia or rotational abnormalities of the limb are present, other surgical interventions may be more appropriate. This chapter outlines the rationale for distal realignment, the regime of preoperative assessment and the surgical technique. Performed properly, for the correct indications, and in the absence of complications including fracture, iatrogenic patella baja and nonunion, distal realignment can achieve excellent results, with a long-term rate of recurrent instability of around 7% overall.

Keywords

Patellofemoral Instability Distal realignment Surgical technique Outcomes Complications 

References

  1. 1.
    Filho RB, Monteiro A, Andrade R, Michael M, Sevivas N, Pereira B, et al. Modified Elmslie-Trillat procedure for distal realignment of patella tendon. Arthrosc Tech. 2017;6:e2277–82.CrossRefGoogle Scholar
  2. 2.
    Longo UG, Rizzello G, Ciuffreda M, Loppini M, Baldari A, Maffulli N, et al. Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures for the management of patellar dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy. 2016;32:929–43.CrossRefGoogle Scholar
  3. 3.
    Post WR, Fulkerson JP. Distal realignment of the patellofemoral joint. Indications, effects, results, and recommendations. Orthop Clin North Am. 1992;23:631–43.PubMedGoogle Scholar
  4. 4.
    Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc. 1994;2:19–26.CrossRefGoogle Scholar
  5. 5.
    Biedert RM, Albrecht S. The patellotrochlear index: a new index for assessing patellar height. Knee Surg Sports Traumatol Arthrosc. 2006;14:707–12.CrossRefGoogle Scholar
  6. 6.
    Biedert RM, Tscholl PM. Patella Alta: a comprehensive review of current knowledge. Am J Orthop (Belle Mead NJ). 2017;46:290–300.Google Scholar
  7. 7.
    Rhee SJ, Pavlou G, Oakley J, Barlow D, Haddad F. Modern management of patellar instability. Int Orthop. 2012;36:2447–56.CrossRefGoogle Scholar
  8. 8.
    Dornacher D, Reichel H, Lippacher S. Measurement of tibial tuberosity-trochlear groove distance: evaluation of inter- and intraobserver correlation dependent on the severity of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 2014;22:2382–7.CrossRefGoogle Scholar
  9. 9.
    Damasena I, Blythe M, Wysocki D, Kelly D, Annear P. Medial patellofemoral ligament reconstruction combined with distal realignment for recurrent dislocations of the patella: 5-year results of a randomized controlled trial. Am J Sports Med. 2017;45:369–76.CrossRefGoogle Scholar
  10. 10.
    Henderson I, Francisco R. Treatment outcome of extensor realignment for patellofemoral dysfunction. Knee. 2005;12:323–8.CrossRefGoogle Scholar
  11. 11.
    Caton JH, Dejour D. Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop. 2010;34:305–9.CrossRefGoogle Scholar
  12. 12.
    Magnussen RA, De Simone V, Lustig S, Neyret P, Flanigan DC. Treatment of patella Alta in patients with episodic patellar dislocation: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2014;22:2545–50.CrossRefGoogle Scholar
  13. 13.
    Cox JS. Evaluation of the Roux-Elmslie-Trillat procedure for knee extensor realignment. Am J Sports Med. 1982;10:303–10.CrossRefGoogle Scholar
  14. 14.
    Wang CJ, Chan YS, Chen HH, Wu ST. Factors affecting the outcome of distal realignment for patellofemoral disorders of the knee. Knee. 2005;12:195–200.CrossRefGoogle Scholar
  15. 15.
    Servien E, Verdonk PC, Neyret P. Tibial tuberosity transfer for episodic patellar dislocation. Sports Med Arthrosc Rev. 2007;15:61–7.CrossRefGoogle Scholar
  16. 16.
    Tecklenburg K, Feller JA, Whitehead TS, Webster KE, Elzarka A. Outcome of surgery for recurrent patellar dislocation based on the distance of the tibial tuberosity to the trochlear groove. J Bone Joint Surg Br. 2010;92:1376–80.CrossRefGoogle Scholar
  17. 17.
    Kuroda R, Kambic H, Valdevit A, Andrish JT. Articular cartilage contact pressure after tibial tuberosity transfer. A cadaveric study. Am J Sports Med. 2001;29:403–9.CrossRefGoogle Scholar
  18. 18.
    Mani S, Kirkpatrick MS, Saranathan A, Smith LG, Cosgarea AJ, Elias JJ. Tibial tuberosity osteotomy for patellofemoral realignment alters tibiofemoral kinematics. Am J Sports Med. 2011;39:1024–31.CrossRefGoogle Scholar
  19. 19.
    Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Patella infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot. 1982;68:317–25.PubMedGoogle Scholar
  20. 20.
    Insall J, Salvati E. Patella position in the normal knee joint. Radiology. 1971;101(1):101–4.CrossRefGoogle Scholar
  21. 21.
    Tsuda E, Ishibashi Y, Yamamoto Y, Maeda S. Incidence and radiologic predictor of postoperative patellar instability after Fulkerson procedure of the tibial tuberosity for recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc. 2012;20:2062–70.CrossRefGoogle Scholar
  22. 22.
    Kadambande SS, Auyeung J, Ghandour A, Mintowt-Czyz W. A review of wound healing following Maquet osteotomy. Knee. 2004;11:463–7.CrossRefGoogle Scholar
  23. 23.
    Tompkins M, Arendt EA. Complications in patellofemoral surgery. Sports Med Arthrosc Rev. 2012;20:187–93.CrossRefGoogle Scholar
  24. 24.
    Eager MR, Bader DA, JDt K, Moyer RA. Delayed fracture of the tibia following anteromedialization osteotomy of the tibial tubercle: a report of 5 cases. Am J Sports Med. 2004;32:1041–8.CrossRefGoogle Scholar
  25. 25.
    Koeter S, Diks MJ, Anderson PG, Wymenga AB. A modified tibial tubercle osteotomy for patellar maltracking: results at two years. J Bone Joint Surg Br. 2007;89:180–5.CrossRefGoogle Scholar
  26. 26.
    Bellemans J, Cauwenberghs F, Brys P, Victor J, Fabry G. Fracture of the proximal tibia after Fulkerson anteromedial tibial tubercle transfer. A report of four cases. Am J Sports Med. 1998;26:300–2.CrossRefGoogle Scholar
  27. 27.
    Stetson WB, Friedman MJ, Fulkerson JP, Cheng M, Buuck D. Fracture of the proximal tibia with immediate weightbearing after a Fulkerson osteotomy. Am J Sports Med. 1997;25:570–4.CrossRefGoogle Scholar
  28. 28.
    Cosgarea AJ, Freedman JA, McFarland EG. Nonunion of the tibial tubercle shingle following Fulkerson osteotomy. Am J Knee Surg. 2001;14:51–4.PubMedGoogle Scholar
  29. 29.
    Harrison RK, Magnussen RA, Flanigan DC. Avoiding complications in patellofemoral surgery. Sports Med Arthrosc Rev. 2013;21:121–8.CrossRefGoogle Scholar
  30. 30.
    Payne J, Rimmke N, Schmitt LC, Flanigan DC, Magnussen RA. The incidence of complications of tibial tubercle osteotomy: a systematic review. Arthroscopy. 2015;31:1819–25.CrossRefGoogle Scholar
  31. 31.
    Kline AJ, Gonzales J, Beach WR, Miller MD. Vascular risk associated with bicortical tibial drilling during anteromedial tibial tubercle transfer. Am J Orthop (Belle Mead NJ). 2006;35:30–2.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Suroosh Madhanipour
    • 1
  • Kostas Michail
    • 2
  • Sam Oussedik
    • 3
  1. 1.Department of Trauma and OrthopaedicsUniversity College London Hospitals NHS TrustLondonUK
  2. 2.Senior Knee FellowUniversity College London Hospitals NHS TrustLondonUK
  3. 3.Department of Orthopaedic SurgeonUniversity College London Hospitals NHS TrustLondonUK

Personalised recommendations