Knee Surg Sports Traumatol Arthrosc. 2014 Oct;22(10):2484-90. doi: 10.1007/s00167-013-2422-2.

Combined arthroscopic deepening trochleoplasty and reconstruction of the medial patellofemoral ligament for patients with recurrent patella dislocation and trochlear dysplasia.

Blønd L, Haugegaard M.

Department of Orthopaedic Surgery, Gildhøj Private Hospital, Falkevej 6, 2670, Greve Strand, Copenhagen, Denmark, lars-blond@dadlnet.dk.

 

Abstract

PURPOSE: Prospectively, a consecutive group of patients troubled by recurrent patella dislocation and trochlear dysplasia has been followed after a combined arthroscopic deepening trochleoplasty and reconstruction of the medial patellofemoral ligament. The purpose of this follow-up study is to report the clinical results.

METHODS: Indications for combined arthroscopic deepening trochleoplasty and reconstruction of the medial patellofemoral ligament were two or more patellar dislocations with a persistent apprehension sign above 20° of flexion and trochlear dysplasia grade B or more. Prospectively, the Tegner, Kujala and KOOS scores were recorded. Thirty-one consecutive patients (37 knees), 21 women and 10 men, with a median age of 19 (12-39) underwent the procedure.

RESULTS: Results were obtained for 29 knees with a minimum of 12-month follow-up (average 29 months; range 12-57). No complications, redislocations or arthrofibrosis have been recorded. Five patients needed further surgery. The median pre- and postoperative scores (range) are as follows: Kujala 64 (12-90) to 95 (47-100); Tegner 4 (1-6) to 6 (4-9); KOOS score pain 86-94; symptoms 82-86; ADL 91-99; sport 40-86; QDL 25-81. No significant correlation was found with respect to the results and recorded parameters. Significant improvement for all of the scores was observed (p<0.001).

CONCLUSIONS: The use of arthroscopic deepening trochleoplasty in combination with reconstruction of the medial patellofemoral ligament was found to be a safe and reproducible procedure. Considering the stability achieved, the knee scores and the patient’s level of satisfaction, the results are encouraging.

LEVEL OF EVIDENCE: Prospective consecutive case series, with evaluation of confounding factor. No control group, Level IV.

PMID: 23370988

 

Supplements:

The Trochleoplasty procedure in combination with reconstruction of the medial patellofemoral ligament is a well established procedure for these patients troubled by recurrent patella instability based on higher degrees of trochlea dysplasia in the knee. Today, several case series have demonstrated favorable results of the procedure, with negligible risk of redislocation and high kneescores for pain, activity of daily living, return to sport and quality of life1–3. However, still there are some concerns regarding the extent of the open operation with respect to pain and scar formation and, furthermore, it is well recognized that the open procedures are related to an increased risk of infection and arthrofibrosis. The here highlighted paper of a consecutive series of patients troubled by patella instability and having Trochlear Dysplasia, demonstrates that the trochleoplasty procedure can be performed by a gentle, simple and precise arthroscopic technique and this gives significantly subjective good results. Since the results from the first case series was published, new results from a subsequent consecutive series, presented at the 1st Annual World Congress of Orthopaedics, Xian, China in 2014, have confirmed this4.

The technique of the arthroscopic deepening trochleoplasty has been minor modified and presented in Operative Technique of Sports Medicine (In Print). Lately other centers has implemented the technique as well. The indications for the surgery has recently been widened to include patient with Trochlear Dysplasia and chronic Anterior Knee Pain. This is based on the theory of increased pressure in the patellofemoral joint in patients, and that the deepening of the trochlea can unload the PF joint5–7. In these cases the MPFL reconstruction is omitted. Also patients with more degenerative cartilage changes in the trochlea has recently been included, based on the positive result from Neumann et al.8. The short time results for both indication has been promising. One patient has not responded positive and continued to have subluxations after the trochleoplasty procedure. Further examination has demonstrated severe increased femoral anteversion and an external rotational femoral osteotomy is scheduled.

fig1

fig2

Figure 1 & 2. These demonstrates the pre and postoperatively results for further 12 knees (minimum 12 month follow-up) were the indications for combined arthroscopic deepening trochleoplasty and reconstruction of the medial patellofemoral ligament were two or more patellar dislocations with a persistent apprehension sign above 20° of flexion and trochlear dysplasia grade B or more. Prospectively, the Tegner, Kujala and KOOS scores were recorded and significant improvement for all of the scores was observed (p<0.05).

 

fig3Figure 3. This demonstrates an example of a pre and postoperative ultrasound examination of the most proximale part of the trochlea. The ultrasound is an easy and fast screening method for trochlea dysplasia, however as a preoperative planning tool before the trochleoplasty procedure it has limited value and the MRI scan must be used.

fig4Figure 4. On the left is an example of a postoperative MRI and the ultrasound image at precisely the same level. A PushLock anchor for fixation of the cartilage is placed just in the center of the trochlea.

 

Conclusions: The first series of arthroscopic deepening trochleoplasty in combination with reconstruction of the medial patellofemoral ligament highlighted here, demonstrated that the procedure is safe and reproducible technique for stabilizing the patella when trochlear dysplasia is present and that the method gives significantly good results for all measured subjective parameters. Our last follow up of further 12 knees supports these previous findings. Only few complications has been registered.

 

References

  1. Banke IJ, Kohn LM, Meidinger G, et al. Combined trochleoplasty and MPFL reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study. Knee Surg Sport. Traumatol Arthrosc 2014;22(11):2591-8. doi:10.1007/s00167-013-2603-z.
  2. Ntagiopoulos PG, Byn P, Dejour D. Midterm results of comprehensive surgical reconstruction including sulcus-deepening trochleoplasty in recurrent patellar dislocations with high-grade trochlear dysplasia. Am. J. Sports Med. 2013;41(5):998-1004. doi:10.1177/0363546513482302.
  3. Nelitz M, Dreyhaupt J, Lippacher S. Combined trochleoplasty and medial patellofemoral ligament reconstruction for recurrent patellar dislocations in severe trochlear dysplasia: a minimum 2-year follow-up study. Am J Sport. Med 2013;41(5):1005-12. doi:10.1177/0363546513478579.
  4. Blønd L. Arthroscopic trochleoplasty belongs to the future. In: The 1st Annual World Congress of Orthopaedics, Xian, China. Xian, China; 2014:s 131.
  5. Ho KY, Hu HH, Colletti PM, Powers CM. Recreational runners with patellofemoral pain exhibit elevated patella water content. Magn. Reson. Imaging 2014;32(7):965-968. doi:10.1016/j.mri.2014.04.018.
  6. Draper CE, Fredericson M, Gold GE, et al. Metabolic Activity At the Patellofemoral Joint. J Orthop Res 2012;30(2):209-213. doi:10.1002/jor.21523.Patients.
  7. Van Haver A, De Roo K, De Beule M, et al. The Effect of Trochlear Dysplasia on Patellofemoral Biomechanics: A Cadaveric Study With Simulated Trochlear Deformities. Am J Sport. Med 2015. doi:10.1177/0363546515572143.
  8. Neumann M V, Stalder M, Schuster a J. Reconstructive surgery for patellofemoral joint incongruency. Knee Surg Sport. Traumatol Arthrosc 2014. doi:10.1007/s00167-014-3397-3.

 

Contact:

Lars Blønd, MD, Teres Private Hospital Parken, Copenhagen, Øster Alle 42, 3, DK-2100 Kbh Ø, Denmark

University of Køge, Lykkebækvej 1, DK-4600 Køge, Denmark

 

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