Surgical Treatment of Patellar Instability

Surgical Treatment of Patellar Instability,
Including MPFL Reconstruction
Dave Shenton MD
Big Sky Sports Medicine Conference
6/14/13 - 6/15/13
Introduction
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Common
Controversial – still learning
Recently a “hot topic” again
No cookbook answers
Patellar dislocation - Hx
• 2:1 women more than
men?
• Conservative often
effective
• “Pop” with giving
away in flexion and
ER
• Rapid swelling
Patellar dislocation - evaluation
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Effusion (Aspirate)
Full extension
Tender medial
Increased lateral
subluxation/apprehension
Larger Q-angle, loose
kneecap,etc.
Often MCL sprain
X-rays useful
MRI?
X - Ray
MRI
• MPFL rupture - CJ, 15
yo WM
– 2/09 R knee injury
boxing, backing up and
twisted, “pop”, swelling
– 3/09 again with
snowboard
– 4/09 crawling
– MRI +
Components of patellar instability
• Dynamic/complex
• Distant/general - overall
alignment
– Femoral anteversion Frontal plane
knee
– Knee alignment –valgus, varus
• Knee hyper extension
– Tibial torsion, varus, valgus
– Foot and ankle alignment –
hyperpronation
Components of patellar stability
• Local alignment
– Patellar alignment in three
planes
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Q angle
Patellar tilt
Rotation in the coronal plane
Dynamic – versus knee flexion, “J”
sign
– Patellar height
• Patella alta, infera/Baja
– Tubercle-trochlear distance
Components of patellar stability
• Local bony elements
– Patellar shape
• Wiberg type I, II, III
• Jagerhut?
– Trochlear shape
• Trochlear depth
• Trochlear dysplasia
Components of patellar stability
• Static soft tissues
– Medial retinaculum
– Medial patellofemoral ligament
• The MPFL is the hot new topic
– Lateral patella femoral
structures
• Actually stronger than medial
– Implications for lateral release?
• Iliotibial band
Components of patellar stability
• Muscular/dynamic
– Core strength
• Gluteal
• Hip abductors
– Anterior thigh strength
• VMO – fiber orientation ~ 50°
– First to go, last to come back
– Coordination/neuromuscular
• Complex interaction
• Speed and timing
What is patellar instability?
• Dislocation
– Acute
– Chronic/recurrent
• Subluxation
– Versus patellofemoral arthralgia/crepitus/etc.?
• Significant overlap/blurring in the symptoms,
findings, treatment options
Patellar dislocation - treatment
• Conservative initially?
• Limited early surgical
– German article
• Late surgery occasionally (realignment)
Surgical options for patellar
instability
• MANY !!!
– Most review articles – “over 100 procedures
described”
• Therefore little consensus and no”gold standard”
• Nothing works well?
Factors to consider
• Many and complex/interactive
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Age and activity level
Psychosocial – e.g. work comp
Etiology – traumatic versus not
Distant structures/overall alignment
Clear instability versus pain
syndrome
– Local structures/alignment
– muscle atrophy, trochlear
dysplasia, patellar dysplasia,
patella alta, patella infera, Q angle
– Patellofemoral chondrosis/arthritis
– Other – associated injuries (ACL,
MCL, etc), tibiofemoral DJD, etc.
Surgical options for patellar
instability – Local soft tissue
• Lateral release
– Little support as isolated procedure
• Potentially make things worse?
• Medial repair – retinaculum/MPFL
– Good support in certain situations
– Appealing if surgery for loose body, etc.
• MPFL reconstruction
– Gaining popularity
– Learning curve, both profession and
individual
• Failures, patella fractures, over tightening with
medial arthrosis, etc.
Surgical options for patellar
instability – Bony
• Tibial tubercle transfer - Elmslie-Trillat
(Fulkerson, Macquet, Hauser, etc)
– Common, popular
– Good results for specific indications
• Increased Q angle/increased tubercle-trochlear
distance, no significant chondrosis/arthrosis
(esp med, prox patella, ctr troch)
• patella alta ?
• Trochleoplasty
– Controversial. Mixed results. Early adhesive
capsulitis. Late patellofemoral arthritis.
• Rotational osteotomy femur, tibia
• Varus osteotomy
Macquet
Elmslie-Trillat distal patellar
realignment
Before
After
Distal realignment – Skeletally Immature
• Roux-Goldthwait
– Adolescent split P.T. Transfer
Examples
• Acute traumatic, general alignment OK, no
trochlear dysplasia or significant previous
patellofemoral chondrosis
– Consider arthroscopy and repair of the medial
retinaculum/MPFL ( opened versus arthroscopic
plication)
• With/without lateral release
• Especially if loose body removal/repair
– Very good results
– Necessary?
• Recurrence rate ranges from 15% to 44% with nonoperative;
highest in young active patients
MW
5-09 Healthy 18-year-old white male senior High School Tennis player.
• 2/23 left knee BB injury. Patellar dislocation. ER. Knee immobilizer.
• 2/24/09 visit with Dr. Conservative. Crutches
• 3/12/09 “curbside” DWS at Heights Physical Therapy. The left knee joint
was sterilely aspirated for about 90 cc of serosanguineous fluid.
• Second aspiration
• 4/09 2nd “curbside”. Still with swelling and crepitus.
• 5/12/09 left knee arthroscopic removal of chondral loose body,
debridement grade 3 and 4 lesion (2.5 cm by 1.25 cm) center of patella,
open repair medial retinaculum/medial patellofemoral ligament and a
lateral release, with chondral biopsy lateral notch sent to Carticel for
possible later ACI
• 6/11/09 Skyline x-ray of both knees reveals symmetrical reduction of the
patellae with a small area of ossification in the medial retinaculum
• 9/09 . Full weightbearing and starting some strengthening and full ROM.
Some crepitus but no pain. Headed to the University of Oregon
Normal previous AP and lateral
xrays (fr “down the street”).
Abnormal axial patella view –
loose body in medial gutter and lat
sublux of Lt patella
MRI reveals medial retinaculum
tear and osteochondral defect
patella
• Before (above) and after (below) Med retinac repair
Examples
• Recurrent dislocation and subluxation, originally
traumatic, general alignment OK. No significant
trochlear dysplasia. Not much pain. Increased
tubercle trochlear distance/Q angle.
– Consider arthroscopy with/without lateral release,
tibial tubercle transfer ( Elmslie-Trillat), possible
MPFL reconstruction
– Good results, widely accepted, predictable
• Healthy 40 y/o white male Hardware Sales
left knee. hunting, fishing, golfing.
– 3 weeks earlier- skiing moguls in Red Lodge
when he took a hard fall dislocating his left
patella, unable to reduce – Beartooth Hospital
reduced
– recurrent dislocation 2 days later reduced by
his brother (SM PA) at home.
• patellar stabilizing brace
– continued sensation of instability since
– aspirated by PA ~30 mL of dark bloody fluid.
– Recurrent persistent swelling, pain and a sense of
instability
Left Knee
• Some "aching" mild pain. Some swelling. Occasional catching or
grinding.
• Moderate effusion. Positive apprehension. Mild quadriceps atrophy.
20° Q angle. No palpable MPFL B/L. Skyline x-rays suspicious for
osteochondral fragment probably off the patella. Therapy. Surgery?
• Previous: ~1987- 2008 right knee multiple recurrent subluxation
episodes but no fixed dislocation. Doesn't give them a lot of trouble
at this point.
• ●. ~1982 - 2006 recurrent left knee lateral patellar instability before
this more recent injury. These were apparently subluxation
episodes.
• 3/29/2013 skyline of both x-rays OrthoMontana Heights reveals
Wiberg type II patella well seated bilaterally. Dominate lateral facet.
On the left side there is a slight radiodensity sitting near the medial
facet of the patella, suspicious for an osteochondral fracture. DWS
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3/1/13 2 views left knee Bearthooth Clinic reveals lateral patella
dislocation with post reduction films showing no sign of fracture.
TAS.
4/16/13 GS
Elmslie-Trillat distal patellar realignment
(possible MPFL reconstruction)
4/16/13 GS
Findings at arthroscopy
4/16/13 GS
Limited lateral release
4/16/13 GS
Elmslie-Trillat distal patellar realignment (possible
MPFL reconstruction)
4/16/13 GS
4/22/13 postop X-rays
4/22/13 GS
Patellar Realignment Rehab Protocol:
Standard
• 1st 2 weeks - crutches, toe-touch WB, post-op brace 0°
to 40°, quad sets, no SLRs
• 3- 6 wks post-op - crutches, advance WB ~ 25%/wk and
flexion 20° to 30°/wk as tolerated, gentle
strengthening
• 7 wks to 3 mos - gradually advance range of motion and
strengthening as tolerated
• 3-6 mos - functional rehab and return to activities as
tolerated
Examples
• Recurrent dislocation/subluxation, originally
traumatic, general alignment OK, no significant
patellofemoral chondrosis or trochlear dysplasia.
Not much pain. Unremarkable tubercle trochlear
distance/Q angle and patellar height
– Consider arthroscopy with/without lateral release,
tibial tubercle transfer ( Elmslie-Trillat), possible
MPFL reconstruction
– Good results, widely accepted, predictable
• . Generally healthy, 16 year-old Nashua high school sophomore.
Strengthening exercises for ongoing right anterior knee pain with
recurrent lateral patellar subluxations. Problems with his knee for
2.5 months now after twisting his knee while playing soccer in gym
class. Patellar stabilization not significantly helpful. Popping and
giving way. Recurrent patellar subluxation. Home exercise
program.
• - 12/24/09. Dr Phipps. While driving home after his last visit, he
was involved in a motor vehicle accident in which his right knee was
slammed into the dashboard of their car
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4/13/10 right knee arthroscopic lateral release and open medial
patellofemoral ligament reconstruction using semi-tendinosis
hamstring autograft
After
Examples
• Recurrent subluxation? No specific clear
original trauma – history more unclear/insidious.
Problems with pain, “catching”. Young female.
Some patellar chondrosis? Mild general
malalignment with increased Q angle, positive
“J” sign. Failed conservative management.
– Tricky, beware
– Lateral release can make this worse – appropriate if
clearly tight
– Distal realignment and/or MPFL reconstruction?
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14 y/o WF referred from Wyoming – difficult patellofemoral problem. 8th grade.
Dance/cheerleading - out with knee over 1 yr. Complex history:
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9/15/05 - 10 y/o Dr.- Bilateral knee pain, two or three years. "Popping". Recent fall on right swell. Multiple sports and horseback riding. X-rays negative. Exam - "sensitive to light touch".
"Possible patellofemoral syndrome". Physical Therapy.
11/30/07 Wrestling with father- hip "popped out". Still missing VB with bilateral knee pain/
"popping". X-rays of hips normal. 10° scoliosis.
3/08 F/u left greater than right knee. Patellofemoral braces not very helpful. 3/24 possible left
patellar dislocation. ER - X-rays unremarkable. Some swelling. Excused from Phys Ed. MRI
showed patellar subluxation only.
3/31/08 left knee arthroscopic lateral release with chondroplasty patella. "Acute cartilage
damage large flaps and fissures on the medial facet of the patella" treated with heat. WY.
4/08-5/08 follow-up's. Still "giving way“, moderate effusion. Repeat MRI
6/16/08 2nd opinion. PT/conservative. Distal realignment after physes close?
7/08 better after 21 Physical Therapy visits. Discharged from PT.
9/8/08 follow-up with 1st Dr. on an urgent basis. Kneecap "subluxed" when pushed in the school
hallway. Swelling. Big Sky Orthopedics - custom-made patellar brace 9/18. Later realign?
12/22/08 left knee arthroscopy with distal realignment, Elmslie-Trillat, and also medial
patellofemoral ligament reconstruction using a double gracilis hamstring autograft.
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Hatfield - pat sublux pre-op.wmv
Examples
• Possible subluxation with pain and
functional problems, significant lower
extremity malalignment issues along with
increased Q angle, failed extensive
Physical Therapy and conservative
management
– Consider femoral and or tibial rotational
osteotomies
K F LE malalignment
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~ 2002 DWS. Bilateral gait problems and knee pain with significant lower extremity malalignment.
"Miserable malalignment" including femoral anteversion, varus recurvatum right knee greater than
left. Discussed with Dr Lewallen and specialists at the Mayo Clinic.
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1/05 and 5/05 follow-ups with Dr Lewallen and me. Attending high school. Working hard to try to
maintain some fitness. .
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7/05 consultation with Dr. Peter Stevens, Un of Utah. Article in the Journal of Pediatric
Orthopedics in 2004.
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11/8/05 rotational osteotomy right distal tibia done by Dr. Peter Stevens in Salt Lake City.
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12/05 and 1/06 follow-ups with me. Weightbearing as tolerated. Sympathetic effusion knee.
Physical Therapy. Slow progress.
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2/14/06 rotational osteotomy right femur done by Dr. Stevens. Improved foot-thigh angle
noted.
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6/06 hairline fracture through the osteotomy site right tibia, status post previous rod. Seen in St.
Vincent's ER.
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6/06 left femur and tibia rotational osteotomies done by Dr. Peter Stevens in Salt Lake City.
Also locking screws removed to "dynamize" right tibia rod.
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7/06 follow-up. Still two crutches and difficulty ambulating.
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8/06 follow-up. X-rays left femur - good callus. X-rays left tibia - no bridging callus. Advance
slowly.
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10/06 follow-up regarding left leg. X-rays - good bony callous left tibia. Continue strengthening personal trainer. No snowboarding. 1/07 follow-up. X-rays left leg reveals good callous formation.
Continue strengthening and advance as tolerated. Talked about hardware removal.
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Summer 2007 removal of all of the hardware/IM rods done in Utah
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2009. DWS Now 20-year-old going to the Un of Kansas for petroleum engineering. Spent some
time in Wales. Right knee anterior pain with running or aggressive hiking. Some swelling.
Conservative.
2003 and 2005
R tib 11-05, R fem 2-06
L tib/fem 6-06, L tibia healed 7-07
Examples - Other
• Combined acute lateral patellar dislocation
with large osteochondral fragment/loose
body and open physes.
– Consider ORIF loose body with repair of the
medial retinaculum/MPFL and possible
modified distal realignment
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CM
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12/18/09 left knee injury when he planted with the left foot to kick a ball with his right.
He did feel "two pops". Twisting left knee injury with sharp pain and rapid swelling.
12/18/09 BC ER. XRs reveal possible “tibial tubercle fracture” and “femoral avulsion
injury”. Knee immobilizer. Ortho consult.
12/23/09 with PA. Some pain with lateral tilt of the patella. Negative Lachman's. Xrays “unremarkable”. Left knee aspirated for 80cc of bloody fluid. Compression
wrap. MRI. Knee immobilizer and crutches
1/4/10 DWS. Minimal discomfort. Continues knee immobilizer and crutches, most of
the time. 12/18/09 left knee x-rays reviewed. Open physes. Sliver of bone in the
lateral gutter on the axial patella view concerning for osteochondral fragment
from the patella. Possible defect of the patella medial facet and central
ridge.1/4/10 AP, lateral left, skyline both -open physes. Large medial OC fragment
with defect medial and central ridge patella.
MRI Scan: 12/23/09 left knee, BC. Large OC fragment from medial and central
portion patella, now in medial gutter. Bone bruise lateral femoral condyle consistent
with lateral patellar dislocation. Rupture of medial retinaculum at patella.
Impression:Left knee acute lateral patellar dislocation with rupture of the medial
retinaculum at the patella and also a displaced large osteochondral fragment from the
patella, medial facet and central ridge. Extensor mechanism malalignment with
physiologically increased patellar laxity both sides and no palpable medial
patellofemoral ligament opposite side.
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13wm, 8th grader, skateboarding, basketball, football
1/22/10 left knee arthroscopic lateral release, ORIF osteochondral fracture
medial patella (2.5 cm) Acutrak absorbable screws and platelet rich plasma,
distal patellar realignment (Roux-Goldthwaite), proximal patellar realignment
(medial retinaculum repair/imbrication and VMO advancement
Roux-Goldthwait
Left knee
Right knee
Examples - Other
• Combined lateral patellar instability with
ACL deficiency
– Consider a combination of patellar
realignment with ACL reconstruction
• Lateral one third patellar tendon autograft?
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MC
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small HS basketball, volleyball, track, mostly hurdles and sprinting.
2007 "pillow polo" in gym class. She landed, shoved, felt left knee "go out". Buckled and
she fell. Swelling. Limped. Seen by Ortho. Some PF changes. Conservatuive.
11/07 MRI revealed a small OCD of the medial femoral condyle. ACL OK.
2008 and 2009. Multiple episodes and multiple physician visits left. Diagnosis unclear.
Therapy with ATC. ACL? patellar instability?
1/20/10 DWS. Junior from Joliet- chronic left knee problem with recurrent giving
way/swelling. She feels like something moves. Some clicking. Patellar subluxation problems
- patellofemoral brace.
2/1510 basketball practice, twisted her right knee. A "wobble." Immediate pain.
Stopped. Mild swelling. She does not use regularly. Still negative Lachman's.
3/2/10 Dr Phipps. continued problems in BB subluxation of the patella despite brace.
Pain,swelling. Last night, during a practice, she had a giving way episode of the right
knee which was somewhat different. She did feel two pops. Increasing swelling. She
had pain in the posterior aspect of her knee instead of the usual anterior portion. Now with
positive Lachman's. Aspirated for 50 cc of bloody fluid. MRI ordered
3/10 MRI revealed ACL rupture with damage to medial retinaculum of the patella and
lateral patellar subluxation
3/23/10 right knee arthroscopic ACL reconstruction using a lateral 1/3 patellar
tendon autograft, medial meniscus repair, lateral release. DWS
Left - 2007
Right - 2010
Right 2010
Right 2010
Initial Results – MPFL reconstruction
• First 3 cases (2008 and 2009)
– Published technique drilling straight across patella,
using hamstring autograft and interference screw
– Complications (2 of 3 patients)
• One failed graft and infection requiring
debridement(patient did okay anyways – combined
with distal patellar realignment)
• One partial failure with “bioabsorbable” screw
extruding backing out and becoming symptomatic
requiring removal
– Consistent with literature showing fairly high
complication rate and steep learning curve
• Over tightening/malpositioning with pain and loss of motion,
failures, patella fractures, etc.
Early results – Modified MPFL
reconstruction
• Last 13 cases (4/2010-1/2013)
– 8 revisions of previous surgery, mostly lateral releases,
some with medial retinacular imbrication, 1 Elmslie
• My modification with diverging bone tunnels at the
medial patella coming out on the anterior medial
surface (no fixation required patella)
– Last 9 gracilis allograft
– Still with bone tunnel at femoral insertion with
biocomposite interference screw
– 5 in combination with distal patellar realignment
• All patients doing well with no recurrent instability
– MPFL graft palpable on all follow-ups
– No complications except occ superficial wound problem
Conclusions
• Acute and recurrent lateral patellar
instability is common
– Intra-articular pathology, eg osteochondral
damage, is common and often overlooked
• Not cook book – many factors to consider
• Newer technology/procedures promising
– Very encouraged by results with my modified
MPFL reconstruction using gracilis allograft
• Several examples given
Questions?