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Patellofemoral Pain and Instability
Patellofemoral Pain and InstabilityWhen Conservative Treatment Fails American Medical Society for Sports Medicine April 6, 2014 New Orleans Beth E. Shubin Stein, MD Sports Medicine & Shoulder Surgery Hospital for Special Surgery Patellofemoral Pain/ Arthritis Patellofemoral Joint Anatomy • Cartilage thickness ~ 5mm • PFJ Loads 4-7x bodyweight with daily activities • Up to 10x with landing from jump The Problem Patellofemoral Pain/ Overload • PFPS vs. Early chondral wear • Surgery last resort---Or is it?? Terminology • • • • • • PFPS LPCS LPOS PFS Anterior knee pain Chondromalacia patella The Problem Patellofemoral Pain • Tailor treatment to individual patient – Not all pts have PF pain for the same reasons • Manage expectations – Not running a marathon after 6 wks of PT • • • • Patellofemoral Pain Physical Examination Feet Knees Hips Tight structures – ITB – Lateral retinculum • Strength deficiencies – Hips/ quads Patellofemoral Pain Imaging • Initial visit plain radiographs – AP, PA flex, lat, merchant • • • • Patella height Alignment Subluxation Tilt Patellofemoral Pain Treatment Options • 2 sides to the menu Non-op Operative • • • • Meds Injections Braces PT Lots Patellofemoral Pain My Initial Approach • • • • Shut them down NSAIDS ICE Injections – Cortisone vs. Visco • Patches • Taping Patellofemoral Pain Physical Therapy • All above to allow improved PT Patellofemoral Pain • What if PT doesn’t work • More PT • What if PT still doesn’t work??? Patellofemoral Pain Imaging • Look back at plain xrays • MRI – If not responding to non-op tx • Bone Scan – Can help to demonstrate overload Initial Visit H&P • • • • • • Acute vs. Chronic Traumatic vs. Atraumatic/ overuse Mechanical sx’s Swelling** Crepitus Localized ttp Initial Visit-Imaging AP, PA flexion, Lat, Merchant • • • • • • Patella height Alignment Subluxation Tilt Joint space Early osteophytes Patellar Chondral Degeneration • When DON’T I start with non operative Tx? • Young patients with crepitus and/or swelling or findings on plain radiographs – MRI after initial visit – *Young patients with malalignment and early chondral wear Patellar Chondral Wear The Options • Debridement • Lateral release • Cartilage resurfacing procedures • • • • Microfracture OATS ACI Particulated Juvenille Cartilage • Unloading osteotomy • PF replacement vs. TKA Isolated Lateral Release Literature • Arthroscopic • Low rate complications • Mixed results reported • Results for PF OA worse • Deteriorate with time Isolated Lateral Release Sparse Literature • Arthroscopy 1989 Aglietti et al. – Subset 6/45 with PF arthrosis – Uniformly poor results • Arthroscopy 2002 Aderinto – Avg f/u 31mos – 59% satisfied – 41% dissatisfied • Use as adjunct to other procedures to address PF arthritis Marrow Stimulation • Stimulates Fibrocartilage – Weaker than hyalin cartilage • Poor results in PF joint – High sheer forces • Patella technically difficult – Hard bone – Difficult angles – Patella is mobile Steadman et al, Op Tech Orthop, 1997 OATS • Rob Peter to pay paul • Difficult to restore normal articular geometry • OATS to the patella NOT as successful as femoral condyles Bently et al JBJS br, 2003 Hangody et al JBJS 2003 Karataglis et al, Knee 2006 PFJ Chondral Injury OATS Autologous Chondrocyte Implantation • Multiple surgeries • Open procedure • Peterson ~35% unsatisfactory results Particulated Juvenille Cartilage How Do We Change the Biomechanics? • Distal Realignment Distal Realignment Tibial Tubercle Osteotomy • Medialization (Elmslie-Trillat) – Correcting malalignment • Anteriorization (Maquet) – Unloads distal pole – Does not correct malalignment • Anteromedialization (Fulkerson) – unloads distal and lateral facets – Corrects alignment AMZ Anteromedial tibial tubercle transfer without bone graft JOHN P. FULKERSON, MD, GERALD J. BECKER, MD, JOHN A. MEANEY, MD, MICHAEL MIRANDA, AND MARILYN A. FOLCIK, RN, MPH -AJSM 1990 • 30 pts > 2 year f/u • 93% G/E • Advanced PF OA group 75% good- No excellent *Indications: instability, PFPS and arthritis AMZ ‘location, location,location…’ Clinical Study • 36 pts • Avg f/u 46 mos • Inferior and Lateral – > 87% G/E • Proximal/medial or Central – < 50% G/E Pidoriano and Fulkerson AJSM 1997 • **No correlation w grade of lesion AMZ Unloading Osteotomy • 51 consecutive cases with no serious complications • 65% decrease in lateral facet pressures when tubercle is elevated 14.8 mm » AJSM 1990 AMZ Unloading Osteotomy Biomechanical Study • Fuji Pressure Sensitive Film AMZ (13.5 mm anterior, 7.5 mm medial) • Decreased lateral pressures at all flexion angles • Decreased mean total PF contact pressures at all angles Beck and Cole AJSM 2005 Unloading Osteotomy Risks • Early ROM protected WB • Early WB associated with risk of tibial fracture – Stetson AJSM 1997 • Oblique osteotomy higher risk of tibial fx – Cosgarea AJSM 1999 Case History • • • • • • 25 y.o woman chronic L>>R knee pain since HS Collegiate lacrosse 4 yrs Effusions with activity beginning junior year No instability PT with minimal improvement Now pain with daily activities – Stairs, squatting, prolonged sitting Physical Exam • • • • No effusion + Crepitus bilaterally L>>R Mildly valgus alignment Tight lateral retinaculum – Cannot evert patellae to neutral • Bilateral lateral facet & Inferior pole tenderness Imaging Imaging Treatment Options • • • • • • Physical Therapy Injections Arthroscopic debridement Resurfacing procedure Lateral release Unloading osteotomy Conclusion • Young women with malalignment and chondral wear • Consider early unloading osteotomy • Address cartilage defect if focal or full thickness Patella Instability Beth E. Shubin Stein, MD Sports Medicine & Shoulder Surgery Hospital for Special Surgery What is the Problem??? THIS IS THE PROBLEM Patella Stability Articular geometry • Trochlea • Patella Patella Stability Trochlear Dysplasia Patella Stability Patella Alta Patella Stability TT-TG Patella Stability Soft tissue stabilizers • Medial patellofemoral ligament MPFL Anatomy • Originates sadle between adductor tubercle and medial epicondyle • Inserts medial patella • Blends with the deep fascia of the VM – the passive and dynamic stabilizers may act in concert MPFL Biomechanics Restraint to lateral translation • MPFL 60% • Lateral retinaculum 10% Desio et al Patella Stability Dynamic Stabilizers – Vastus medialis Acute Patellar Dislocation History • 2nd and 3rd decade • Twisting non-contact injury • Rapid effusion • Locking catching • Men=Women • *They do not tell you they dislocated Acute Patellar Dislocation Physical Exam • Effusion • Tenderness and ecchymosis medially over adductor tubercle • Apprehension*** • R/O ACL, MCL injury – Same MOI Imaging • Axial radiograph – *best view for tilt or subluxation • Lateral radiograph – Patella height – Trochlear morphology • MRI – Cartilage lesions – Ligament damage – TT-TG Acute Patellar Dislocation MRI Acute Patellar Dislocation Predisposing Factors • • • • • • Patella alta VMO dysplasia Increased Q angle Contracted ITB Valgus knee deformity Hypoplastic lateral condyle Characteristics of Patients with Primary Acute Lateral Patellar Dislocation: their Recovery within the First 6 Months of Injury Atkin, Fithian et al AJSM 2000 • Few patients had abnormal physical features, contradicting the stereotype of a overweight, sedentary, adolescent girl whose patella dislocates with little or no trauma Natural History Non-Operative Treatment Epidemiology and Natural History of Acute Patellar Dislocation Fithian et al. Am J Sports Med 2004 32: 1114 • 17 % after 1st dislocation • ~50% after 2nd dislocation What is the Problem? Chondral injury •Medial facet patella •Lateral trochlea Who Needs Surgery? • Not always clear • 1st time dislocators – Non op treatment (unless Osteochond fx/ loose body) • **Recurrent dislocators – Atraumatic – Traumatic Patellar Instability Surgical Options • Proximal realignment – Acute repair MPFL – Open/Arthroscopic imbrication – MPFL reconstruction • Distal realignment – Tibial tubercle transfer • Both Patellar Instability Surgical Options • Proximal realignment – Acute repair MPFL – Open/Arthroscopic imbrication – MPFL reconstruction • Distal realignment – Tibial tubercle transfer • Both Patellar Instability Surgical Options • Proximal realignment – Acute repair MPFL – Open/Arthroscopic imbrication – MPFL reconstruction • Distal realignment – Tibial tubercle transfer • Both Patellar Instability Surgical Options • Proximal realignment – Acute repair MPFL – Open/Arthroscopic imbrication – MPFL reconstruction • Distal realignment – Tibial tubercle transfer • Both Patellar Instability Surgical Options • Proximal realignment – Acute repair MPFL – Open/Arthroscopic imbrication – MPFL reconstruction • Distal realignment – Tibial tubercle transfer • Both Patellar Instability Surgical Options • Proximal realignment – Acute repair MPFL – Open/Arthroscopic imbrication – MPFL reconstruction • Distal realignment – Tibial tubercle transfer • Both Patellar Instability Surgical Options • Proximal realignment – Acute repair MPFL – Open/Arthroscopic imbrication – MPFL reconstruction • Distal realignment – Tibial tubercle transfer • Both • Trochleaplasty MPFL Repair MPFL repair Indications • 1st time dislocation • loose body • osteochondral fracture Goals • Same as reconstruction • Restore anatomy • Restore biomechanics/function • Optimize strength of fixation Imaging MRI Arthroscopy Results Acute MPFL Repair Salley et al AJSM 1996 • Open MPFL repair • 16 patients • Ave follow-up 34 mos • No recurrent dislocations Results Acute MPFL Repair Ahmad et al AJSM 2000 • Open MPFL and VMO repair • 8 patients • Ave f/u 3.0 years • No recurrent dislocations • Ave Kujala score was 91.9 • Return to 86% of their pre-injury athletic level • Subjective satisfaction was 96% MPFL Reconstruction Imaging MRI IntraOp MPFL Reconstruction MPFL Reconstruction MPFL Reconstruction Post Op Radiographs Pre-op Results MPFL Reconstruction Gomes et al Arthroscopy 2004 • Semitendinosus autograft • Patella bone tunnel • Suture fixation to lateral retinaculum • Fixed at 60 deg flexion • 15 patients (16 knees) • Minimum 5-year follow-up • No recurrent dislocations Results MPFL Reconstruction • Steiner et al AJSM 2006 – – – – – – 34 patients Multiple grafts Min 2yr f/u; mean 66.5 mos No recurrent dislocations 85% kujala; 91% lysholm G/E ** in patients with TROCHLEAR DYSPLASIA Results MPFL Reconstruction The Docking Technique for Medial Patellofemoral Ligament Reconstruction Surgical Technique and Clinical Outcome Christopher S. Ahmad, MD, Gabriel D. Brown, MD, and Beth Shubin Stein,MD -AJSM 2009 • • • • 20 patients Min f/u 24 mos; avg 31 mos No recurrent dislocations or subluxations Kujala 88; Lysholm 89 Distal Realignment Distal Realignment • Indications – Coronal malalignment • Defined by Q angle or more accurately by TT-TG – Patella alta • Goals – Restoration of normal tracking – Unloading of articular lesions AMZ results • 93% G/Ex results • No Ex results in pts with advanced arthrosis • Complications – Persistent pain (with proximal/ medial lesions) – Tibial fracture (with early weight-bearing) Proximal/ Distal Realigment EUA MPFL Reconstruction and Fulkerson Osteotomy Arthroscopy Proximal/ Distal Realignment Proximal/ Distal Realignment Lateral Release Contraindications • NOT for patellar instability • NOT for arthritis • Not for hypermobile pts – Don’t release it if it isn’t tight Thank You
