Proximal Soft tissue Realignment Darren L. Johnson, MD Professor and Chief: Orthopaedic Surgery Medical Director of Sports Medicine University of Kentucky School of Medicine Conflict of Interest Disclosure • Consultant: smith nephew endoscopy • Institutional support: Research/Education – Smith-Nephew Endoscopy – DJO Orthopaedics 2 Patellofemoral Joint • • Over 100 techniques have been described to manage patella disorders Divided into bony procedure, soft tissue procedure, or combination Soft Tissue Balancing of the Patella Increased TT-TG: Definition: • Tibial tubercle-trochlear groove distance Radiographic equivalent to the Q-Angle – Normal: 10-15mm – Abnormal :>20 • 56% of patients with patella dislocation have a TT-TG >20 (Dejour H et al.KSSTA 1994) • No clear correlation of TTTG to instability (OR 1.1-1.3) (Balcarek et al. KSSTA 2013) Underlying PF instability / malalignment • Lateral maltracking due to : – Increased TT-TG – Insufficiency of MPFL – Increased Distal femoral rotation – Patella Alta – Trochlea Dysplasia Insall’s Proximal Realignment Procedure • • Medializes and distalizes the femoral extensors proximal to the patella “Less demanding and less invasive” Operative Morbidity Open • Pain: Patient is Worse • Prolonged rehab – VMO Atrophy • Recurrent Instability – Medial???? • Stiffness: Really Bad!!! Historic Results of Proximal Realignment Author Year Diagnosis % Satisfactory Result Insall et al 1983 Pain and subluxation 91 1988 Subluxation and dislocation 81 Abraham et al 1989 Pain and dislocation 62 Aglietti et al 1989 Dislocation 91 Scuderi et al Treatment: Soft tissue Operative • Arthroscopic: Technique dependant!!!!!!! – Lateral retinacular release: Not in Isolation!!! – Medial capsular repair/plication +/- LRR – Medial patellofemoral ligament repair +/- LRR – Loose body removal/ repair Treatment: Arthroscopic • Benefits:Not for Bony Pathology: RARE CASE – Prevent recurrence & limit morbidity – Direct visualization – Real time evaluation of tracking – Recreate more normal anatomy/biomechanics Case Study • • • • 15 y.o. wrestler Acute patellar dislocation No h/o patellar instability Exam – Osseous Factors Okay – Large effusion – +Apprehension – Ligaments stable OSSEOUS EVAL Medial Patella MPFL Avulsion MPFL Repair Case Study • • • • 15 y.o FB player Acute patellar dislocation No h/o instability Exam – Osseous Normal – Large effusion – Limited ROM – Ligaments stable MRI EVAL Retinacular/MPFL Tear Retinacular/MPFL Repair Case Study • • • • 14 yo female:elite soccer Acute patellar dislocation No h/o patellar instability Exam – Increased Q angle – Large effusion – + Apprehension – Pronated feet • • • • • • Conclusions Chondral lesions; Watch Out/Long term Associated Ligament Injury: ACL/MCL Patient Evaluation of RISK: MRI/CT Scan Restore normal anatomy surgically Avoid “To Tight” Repair Instability is better than PAIN
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