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1 Management of Patellofemoral Compartment Jack Farr, M.D. Cartilage Restoration Center of Indiana OrthoIndy Knee Care Institute Indianapolis, IN Royalties Arthrex DePuy/Synthes Consulting Arthrex Advanced Biosurfaces DePuy (JNJ company) DePuy/Mitek (JNJ company) Eli Lilly MedShape Moximed NuTech Genzyme Osiris RTI Regenerative Biologics SBM Sanofi (Prior Genzyme) Regeneration Technologies Zimmer Financial Disclosures Step One Why is there pain? Improper Rehab? Relate the pathology to biomechanics Is there instability? Chondrosis does NOT = pain 1

2 Assigning Pathology to Chondrosis: Diagnosis by Exclusion Articular cartilage is aneural Pain therefore originates from: Soft tissue (Synovium, Capsule, Tendons and Ligaments) Nerves (Local or Remote, e.g., saphenous, neuroma) Bone (Local or Remote, subchondral BML, referred hip) Step Two Why is there a chondral lesion? Distal medial post patellar instability Lateral with chronic patellar subluxation Post Trauma (e.g., superior pole) Osteochondritis dissecans First site of genetically programmed OA Step Three Design a patient/ pathology specific treatment plan: Demand matching concept Treat patients with pain on the basis of the mechanically identifiable factors and associated chondral defects Exclude ill-defined pain, CRPS, debilitation and those exceeding their Scott Dye Envelope of Function 2

3 Importance of Mapping Chondrosis Pidoriano & Fulkerson Classification 1997 Proximal Medial Lateral AMZ best for distal lateral Inferior Pole and Lateral Facet: 87% G/E Medial Facet: 55% G/E Proximal Pole and Diffuse: 20% GE Concomitant Central Trochlear Involvement: All Poor Step Four Applying the Specific Surgery Concomitant Surgeries Lateral lengthening for pathologic tilt and/or chronic patellar subluxation MPFL Reconstruction for recurrent patellar instability Tuberosity osteotomy to improve PF stress (force/ area) 3

4 Tibial Tuberosity Osteotomy TT-TG distance > 20mm BUT DON T STOP THERE It s just a number that is not infallable Assess Femoral/Tibial rotational abnormalities e.g., Increased femoral anteversion: CT (Teitge); MRI (Noyes) to assess hip/knee/ankle rotation Tibial Tuberosity- Trochlear Groove Distance Affect by femoral anteversion, tibial/femoral rotation, knee flexion angle 13 mm nl; > 20 mm abnl: Dejour. KSSTA mm: Pandit. Int Orthop, 2011 CT = MRI: Schoettle. Knee 2006 MRI CT Camp, Levy, Dahm et al AJSM 2013 Varies with remeasurement mean 3.2 mm: Lustiq 2006 PT vs TT varies to 4.2 mm; PT less variable Wilcox 2012 May be altered when alta present; Caton. Int Orth 2010 Tibial Tuberosity-Trochlear Groove Distance Cannot estimate clinically: Shakespeare. Knee, 2005 Q angle and TT-TG poorly coorelate: Cooney. Knee Surg Sport Traum Arthr 2012 Difficult to impossible to measure with dysplasia 4

5 If Marked Dysplasia, There is no TG TT-Posterior Cruciate Ligament Seitlinger et al AJSM 2012 Control 18.4 mm 95% < 24 mm Instability Patients 38% > 24 mm Seitlinger AJSM % with TT-TG > 20 had TT-PCL > 24 mm 43% with TT-TG > 20 had TT-PCL < 24 mm (could these have femoral and/or TF rotation?) Take Away All radiographic assessments need validating per meta-analysis of 27 studies: Smith. Skeletal Rad 2011 Consider whole limb and local anatomy before focusing on tuberosity position as pathological Do NOT make new pathology, e.g., Hauser 5

6 When TTO needed: How Much? Degree of Anterization: Ferrandez 10 mm Clin Ortho 1989 Ferguson 12.5 JBJS 1979 Fulkerson 15 mm AJSM 1990 Medialization Do NOT over-medialize Kuroda et al 2005 Goal to normalize in range of TT-TG mm FEA Patient-Specific Models for TTO: AMZ 20% mean decrease in stress BUT Variable Preop Maquet 15 Maquet 20 AMZ 8/8 AMZ 15/8 AMZ 15/8 Uniform thickness Cohen et al AJSM 2003 Planning Tuberosity Transfer Preop Planning: Knee Specific Steepest slope approx. 60 degrees Applying Trigonometry to a constant elevation of 15mm: 60 degree slope & elevation 15 = 8.7 mm medialization Example of Typical Excessive TT-TG of 22 treated with: 60 degree slope or 8.7 = 13.3 post op TT-TG 6

7 Medialization with Anterization 15mm anteriorization 8.7 medialization 60 degrees AMZ-Indications TT-TG - abnormally elevated and distal lateral chondrosis of the patella without trochlear involvement Very steep AMZ in severe lateral PF compartment overload (excessive lateral compression/ tilt) Straight anterization when TT-TG is within normal limits and the goal is to decrease PF forces (Fulkerson osteotomy modified for straight anterization). AMZ-Contraindications Proximal pole, medial, panpatellar chondrosis or concomitant chondrosis of the trochlea TT-TG within normal limits (Straight anterization is an option in this setting) Pain is not directly related to a biomechanical abnormality that will be reversed by AMZ 7

8 AMZ Literature Fulkerson JP (11) Pidoriano AJ (5) Buuck D (12) AMZ AJSM pts12 pts > 2 y F/U>5 y F/U AMZ AMZ AJSM 1997 Op Tech Spt Med 89-93% G/E Advance DJD subgroup: No E; 75% G 23 pts 10 F/U 87% G/E distal/lateral chondrosis 55% G/E medial chondrosis poor results with trochlear chondrosis 42 knees in 36 pts 8.2 mean F/U 86% G/E Bellemans J (13) AMZ AJSM patients 32 mon mean (25-44 mon) 28 successful Naranja RJ (14) Elmslie-Trillat Maquet AJSM knees in 51 patients 74.2 mon ( mon) 73-84% G/E AMZ example: Chronic Patellar Subluxation Lateral Lengthening Exposure for concomitant patellar chondral restoration with AMZ IT band layer of lateral retinaculum divided adjacent to patella 8

9 Lateral Lengthening A second retinacular cut is 2 cm posterior to the patella to allow lateral lengthening Anterior compartment is reflected and the patellar tendon is released Creating Sloped Osteotomy AMZ cutting block with slope selector Conflict of Interest Disclosure Saw through cutting block and tibia exiting on retractor Farr on Design team for the Tracker AMZ Jig System (DePuy Mitek) and T3 (Arthrex) Alternative AMZ Jig System Conflict of Interest Disclosure: Design Surgeons Farr, Cole, Nawab; Arthrex 9

10 Completing the Osteotomy Saw using first cut as captured guide Osteotomes connect posterior cut proximally Steep osteotomy completed with free tuberosity pedicle Tuberosity fixed with 2 interfragmentary screws Anterized 15mm; medialized 7mm 10

11 Post Op Radiographs TT Straight Medialization Indications: NOT Indicated for PF Chondrosis treatment Lyon France school of thought: Patellar alta and trochlear dysplasia are the main problems to be addressed for patellar instability Distalization of the tuberosity only US surgeons are divided: patellar instability is treated with good reported results by: TTO alone (medialization +/- distalization) MPFL repair/ reconstruction alone MPFL surgery concomitant with TTO Farr TTM Indications TTO concomitant with MPFL Recon if elevated TT- TG / TT-PCL with goals of: Normalization of the lateral resultant vector to aid in the PF tracking when there is minimal chondrosis (grade 2 or less) To optimize PF contact area when this is static lateral position of the patella 11

12 TTM Contraindications TT-TG distance is within normal limits Greater than grade 2 chondrosis or if the TTM will increase loading to areas of chondrosis TTM Carney JR (6) Roux-Elmslie- Trillat AJSM 2005 instability 14 pts. 3 and 26 y mean F/U 7% 3y7% 26 y54% G/ENo radiograph F/U Karataglis D (7) Modified Elmslie- Trillat Knee 2006 Instability and/or pain 44 knees in 38 pts 40 mon mean; mon F/U 73% G/Ebetter if for instability than pain or Grade II or less chondrosis Kumar A (8) Elmslie-Trillat Knee 2001 instability 9 pts 3 y mean F/U No recurrent instability Nakagawa K (9) Elmslie-Trillat JBJS 2002 instability 45 knees in 39 pts 13.5 y mean F/U 13 % instabilityg/e decreased from 91% at 45 mon to 64% at final secondary to pain Shelbourne KD (10) Modified Elmslie- Trillat AJSM instability 11 pain 45 knees in 40 pts 2 yr mean F/U 20% recurrent sublux, no dislocation Excessive lateral position of tibial tuberosity (verified preoperatively by CT and normal axial alignment) 12

13 excessive lateral position of tuberosity patellar tendon released, incision continues along lateral border of tibial tuberosity Proximal axial cut just proximal to patellar tendon attachment to tuberosity; anterior compartment musculature elevated 1.5cm posteriorly Coronal plane cut medial to lateral Angled distal-medial to complete the 6-8cm coronal plane osteotomy 13

14 Osteoclasis to rotate the tuberosity medially: normalize TT-TG Tuberosity secured with two 4.5 interfragmentary screws V shape cuts Distalization to treat Patellar Alta Mayer et al. AJSM 2012 Measure bone to be resected allowing for saw blade kerf Fixation followed +/- tendodesis Neyret et al AJSM

15 Requeste Tuberosity Distalization Caton-Deschamps 26mm 28 mm 28 mm 36.4mm 42 mm 36.5mm 26.3mm = mm 27.2mm = 1.03 Proximalization to treat Patellar Infra (NOT PI Contraction Syndrome) Caton, Deschamps, Lerat, Dejour. Rev Chir Ortho Rep App Mot 1982 Skeletonize Tuberosity Remove proximal expose bone Sturgill, William D MR /9/ YEAR Tuberosity M Proximalization O K 11/ * mm * mm = * mm =

16 Straight Anteriorization Fulkerson Modification N/V protected with retractor Cut to, NOT through posterior wall Anterior to Posterior Cut Lateral Wall Cut 16

17 Proximal and Distal Cuts SA complete Lateral to Medial Fixaton 17

18 Thank You JackFarrMD YouTube Channel 18