Triple positioning of tibial tubercle osteotomy for patellofemoral disorders
Introduction
Patellofemoral disorder is one of the most common knee disorders and is often associated with patellofemoral malalignment [1], [2], [3]. Diagnosis of patellofemoral disorder was made by history and physical examination, and radiographic evaluation of the knee. Patellofemoral disorder occurs predominantly in young to middle-age active individuals. Patients frequently present with anterior knee pain and crepitus, weakness and limping with or without overuse in daily activities. The symptoms are aggravated in stair climbing and kneeling or squatting, and somewhat relieved with rest in extension. Physical findings reveal patellofemoral compression pain, tenderness and crepitus, increased Q angle and laterally tilted patella in flexion. The medial excursion of the patella is usually decreased. Radiographic examination in anteroposterior, lateral and Merchant views often revealed increases in patellar height and congruence angle, and lateral displacement of the patella.
Patellofemoral malalignment may be translational subluxation of the patella or torsional patella tilt with or without patellar instability [4], [5], [6], [7]. Patellofemoral malalignment can cause anterior knee pain associated with chondromalacia or patellofemoral arthritis. Patellofemoral disorder secondary to arthritis shows distinction from patellar instability, and usually affects older patients with pain as the predominant symptom. The presenting symptoms include anterior knee pain and crepitus, weakness in extension and limping. The etiology of patellofemoral disorder is multi-factorial including soft tissue imbalance and bony abnormality [8], [9], [10]. The initial treatment is conservative treatment that includes anti-inflammatory drugs, knee brace, physical therapy, muscle strengthening exercises and modification of activity levels [11]. Surgery is indicated in knees refractory to at least 6 months of conservative treatment [12], [13]. Proximal realignment or medial patellofemoral ligament reconstruction is generally performed for knees with patellar instability [8], [10], [14], [15], whereas distal realignment with tibial tubercle transfer for knees with patellofemoral malalignment [16], [17], [18], [19], [20]. For distal realignment with tibial tubercle osteotomy, many surgical techniques with different magnitudes of tibial tubercle transfer are described in the literature including Elmslie-Trillat and Fulkerson procedures, and the results varied considerably [13], [18], [19], [20], [21], [22], [23]. There is no consensus of opinions on the magnitude of tibial tubercle transfer in the treatment of patellofemoral disorder [5], [13], [16], [17], [18]. Likewise, there was no agreement on the best method of tibial tubercle transfer [16], [17]. Based on cadaver study, triple positioning of tibial tubercle osteotomy that includes anterior, medial and proximal positioning of the tibial tubercle was developed to optimize the patellofemoral alignment [24]. The purpose of this retrospective study was to analyze the long-term effects of this procedure in 56 patients with 62 knees with 10-year follow-up.
Section snippets
Materials and methods
The Institutional Review Board of our institution approved this study protocol. Informed consent was signed prior to the participation in the study.
Between July 1997 and August 2000, 66 patients with 72 knees that met the inclusion criteria were operated on for patellofemoral disorders by a single surgeon. Surgery is indicated when conservative treatments had failed. The inclusion criteria for surgery included knees with progressive pain and functional disability with failure to at least 6
Results
The pain score, Kujala patellofemoral score, Lysholm score and the Q angle are shown in Table 3. Significant improvements in pain score, Kujala score and Lysholm score were noted at 1 year and 10 years postoperatively. The Q angle was 17.6 ± 5.2 (10–30) preoperatively and 15.3 ± 3.0 (9–22) postoperatively. Significant improvement in Q angle was noticed after surgery (p = 0.001). Overall, satisfactory result was 78.9% at one-year, and 70.9% at 10-year follow-up. There was a trend of increase in pain
Discussion
The results of the current study showed that this new surgical technique produced satisfactory outcome in 78.9% at one-year and 70.9% at 10-year follow-up. Eighteen knees (21%) showed unsatisfactory results at 10 years due to reasons including the natural progression of osteoarthritis with age, the articular cartilage damage, inadequate surgical technique and socioeconomic factors. In this technique, arthroscopy provides prudent information in the assessment of articular cartilage damage and the
Conflict of interest statement
No external funding from a commercial party was received for this project. The authors declared that they did not receive any honoraria or consultancy fee for the writing of this paper. The authors further declaimed no conflict of interest in term of stock or option ownerships from any company.
Acknowledgment
No fund was received or will be received from a commercial party directly or indirectly related to the subject in this study.
Disclosure
The authors declare that they did not receive any honoraria or consultancy fee in the writing of this article. The authors further disclose no conflict of interest.
References (32)
- et al.
Patellar instability
J Bone Joint Surg Am
(2008) - et al.
Patellofemoral pain syndrome
Clin Sports Med
(2010) - et al.
Factors of patella instability: an anatomical radiographic study
Knee Surg Sports Traumatol Arthrosc
(1994) - et al.
Regulation of the patellofemoral contact area: an essential mechanism in patellofemoral joint mechanics?
J Biomech
(2010) - et al.
Tibial tuberosity osteotomy for patellofemoral realignment alters tibiofemoral kinematics
Am J Sports Med
(2011) Changes in patellofemoral compression force after anterior or anteromedial displacement of tibial tuberosity for chondromalacia patellae
Clin Orthop Relat Res
(1991)- et al.
The influence of anterior displacement of the tibial tuberosity on patellofemoral biomechanics
Int Orthop
(1987) - et al.
Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients
Am J Sports Med
(2011) - et al.
Tibial tuberosity transfer for episodic patellar dislocation
Sports Med Arthrosc
(2007) - et al.
Patellofemoral arthrosis: the treatment options
Am J Orthop (Belle Mead NJ)
(1998)
Can patellar brace reduce the patellar malalignment and pain associated with patellofemoral osteoarthritis?
Arthritis Rheum
Patellofemoral osteoarthritis treated by partial lateral facetectomy: results at long-term follow up
Knee
Elmslie-Trillat procedure for the treatment of recurrent patellar instability
Arthroscopy
Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy
Arthroscopy
In vitro investigation of the effect of medial patellofemoral ligament reconstruction and medial tibial tuberosity transfer on lateral patellar stability
Arthroscopy
Anteromedialization of the tibial tuberosity for patellofemoral malalignment
Clin Orthop Relat Res
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Both authors contributed equally in this paper.