8/9/2017. Case Based: Beyond Medial Patellofemoral Ligament. Editorial Board AJSM Social Media. Consultant. Not talking about PF pain/chondrosis Rehab

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1 Case Based: Beyond Medial Patellofemoral Ligament Dr Alan Getgood MD FRCS(Tr&Orth) DipSEM Assistant Professor Orthopaedic Sport Medicine Fellowship Director The Fowler Kennedy Sport Medicine Clinic University of Western Ontario London, Ontario Canada Disclosures Research Support Canadian Foundation for Innovation ISAKOS/OREF Musculoskeletal Transplant Foundation Canadian Institute for Health Research Arthritis Society Ontario Research Fund Smith & Nephew Inc. Arthrex Inc. Conmed Inc. Depuy Synthes Inc. Eupraxia Inc. SBM Inc. Editorial Board AJSM Social Media Consultant Smith & Nephew Inc. Conmed Inc. Depuy Synthes Inc. Ferring Inc. Ossur Inc. Overview Not talking about PF pain/chondrosis Rehab Predisposing pathology My surgical algorithm Cases 1

2 Predisposing factors INSTABILITY Physical Generalized ligamentous laxity (GLL) Valgus alignment Increased internal rotation of distal femur (persistent femoral neck anteversion) (Miserable malalignment syndrome) GLL Beighton Score Persistent Femoral Anteversion Femoral Torsion Angle N=15 0 +/ 6 0 2

3 Predisposing factors INSTABILITY Physical Generalized ligamentous laxity (GLL) Valgus alignment Increased Q angle Increased internal rotation of distal femur (persistent femoral neck anteversion) (Miserable malalignment syndrome) Radiological/Anatomic Increased patella tilt Patella Alta Trochlea dysplasia Increased TT TG Imaging Plain XR Lateral Retinacular Tension 3

4 Patella Tilt Patella Tilt Patella Alta Caton Deschamps n = 1 >1.2 = alta Insal Salvati n = 1 >1.3 = alta 4

5 Trochlea Dysplasia Crossing Sign Double contour Supratrochlear spur Trochlea Dysplasia Dejour Classification Tibial tuberosity trochlear groove distance (TTTG) Normal <15mm; Borderline 15 20mm; Abnormal >20mm Courtesy of Andrew Amis 5

6 PCL TT Distance TT TG correlates with the rotation of the knee joint and the sulcus angle; TT PCL does not TT PCL 24mm appears abnormal MPFL The MPFL is the principal passive patellar medial restraint Anatomy & biomechs: Amis et al, The Knee 10: , 2003 Lateral trochlea facet is primary restraint Mean lateral stability of the patella Restraining forces (N) intact VMO released Flat lateral condyle Mli ruptured Knee flexion (deg) Senavongse, Amis JBJS

7 Investigations Plain XR AP/Lat/Skyline Hip to ankle standing alignment view CT Dejour protocol TT TG Femoral Rotation MRI Chondral surfaces MPFL injury TT TG PCL TT Other pathology Surgical Algorithm De rotation osteotomy PROXIMAL MPFL No Dysplasia No patella alta Normal TTTG Dysplasia +/ Patella alta +/ Increased TTTG Trochloeoplasty MPFL +/ TTO Medial TTO + MPFL No patella alta Increased TTTG Patella alta Increased TTTG Distal & medial TTO MPFL DISTAL 25 yr old female librarian History Recurrent patella instability Pain on activity running walking Otherwise healthy Exam Neutral alignment Normal rotation +ve J sign +ve apprehension Effusion 7

8 Type A Trochlea Dysplasia TT TG 18mm TT PCL 19mm CD 1.42 TTO (Distalisation) + MPFL (gracilis) 14 yr old female History Recurrent patella instability Full dislocation every 2 months Pain and swelling Failed non op Exam Generalized ligament laxity Beighton 8/9 Neutral alignment Normal rotation J sign Apprehension Dry knee Tight lateral retinaculum 8

9 Skeletally mature Type B Dysplasia CD = 1.25 TT TG = 17mm TT PCL 20mm LLL/Trochleoplasty/MPFL(QT) 9

10 LLL/Trochleoplasty/MPFL(QT) 22F student History Long standing patellar instability right knee Starting at 12 years old Progressive, occurring now with simple twisting motions/flex ext Problems driving, unable to play sports Now also associated with pain Physiotherapy little help Exam Obese Valgus alignment Positive J sign Patella dislocates at 30 degrees of flexion. Patellofemoral crepitus Full ROM Ligamentous testing normal Type D Dysplasia MRI TT TG 21 mm TT PCL 18mm Lost 100lbs waiting for MRI! 10

11 DFVO (MCW)/Trochleoplasty/MPFL(QT) Outcomes for Trochleoplasty Study Sample size Follow up Indications Complications Goutallier (24 72) Schottle (24 48) Crossing sign, One increase in trochlear bump, pre existing OA reduced trochlear depth Verdonk (8 34) Donell (12 108) Bump 6 11mm No arthrosis Von Knoch (48 168) TD, bump 0 Doesn t prevent 10mm arthritis Fucentese (24 48) Utting (12 58) Domed trochlear No chondrolysis or non union Zaki (12 72) Thaunat (12 71) Crossing sign and (14 instability) trochlear bump (0 8mm) Fucentese years Dejour A,B,C,D Some lateral deterioration n=555 Up to 19 year follow up Minimal complications Koch Faruqui Dejour (24 191) Nelitz (24 42) Severe TD No arthrosis Ntagiopoulos 31 84(24 108) Dejour B, D No arthrosis 2013 Banke / 5.9 Dejour B,C,D No arthrosis Blond (12 57) Dejour B,C,D No arthrosis Rouanet years 3 9 mm bump Progression to arthritis McNamara years When do you Address Trochlear Dysplasia? 203 subjects post isolated MPFL R 24 months post op Banff Patellar Instability Instrument (BPII) Low grade and high grade dysplasia Stratified into bump <4mm> and <5mm> Hiemstra et al

12 When do you Address Trochlear Dysplasia? Results BPII scores had a significant correlation to type of dysplasia (low or high) presence of a trochlear bump A trochlear bump > 5mm was associated with lower BPII scores (but not >4mm) Hiemstra AJSM yr old female History Nail Patella Syndrome Bilateral knee pain since birth (L>R) No hx trauma Progressively worse (primarily anterior) Feels her knee caps give out Otherwise healthy No regular meds, no allergies Exam Neutral limb alignment No clinical femoral anteversion Medial sided tenderness (over medial retinaculum) Lateral glide to dislocation Patellar tracking J sign 12

13 Surgical plan Lateral Retinacular Release/lengthening Recession Trochleoplasty MPFL Reconstruction +/ Tibial Tubercle Osteotomy 13

14 6 months post op 14

15 56 yr old male History Nail Patella Syndrome Pain + recurrent patella instability Otherwise healthy Previous scope and injections no benefit. Exam Antalgic gait Dislocation in flexion Crepitus +++ Symmetrical varus Rotation ok CT TT TG = 23mm TTO + PFA 15

16 Summary Neuromuscular rehab Understand risk factors for recurrent instability Physical exam and appropriate imaging important Number of techniques to address the abnormal anatomy Trochleoplasty is a rarely indicated, but very important technique in management of complex patella instability Thank you! Acknowledgements Dr. Jack Farr Dr. Laurie Hiemstra 16