Patellofemoral instability: what’s new?...MPFL disrupted MPFL competent Reconstruction of MPFL...
Transcript of Patellofemoral instability: what’s new?...MPFL disrupted MPFL competent Reconstruction of MPFL...
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Patellofemoralinstability: what’s new?
Pr Jacques MenetreyCentre de Médecine du Sport et de l’’Exercice (CMSE)
Hirslanden Clinique la CollineGenève SuisseHUG, Genève
Faculté de médecine, Université de Genève
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Outline
Intro Patella height – patella engagement MPFL ? Trochleoplasty
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Epidemiology
Incidence of primary patella dislocation:
6 to 112/100’000 persons Depending upon the age of the population
Nietosvaara et al J Pediatr Orthop 1994Fithian et al Am J Sports Med 2004 Sillanpaa et al Med Sci Sports Exerc 2008Colvin J Bone Joint Surg 2008Hsiao et al Am J Sports Med 2010
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Mechanism of injury
Knee valgus stress and internal rotation of the femur with the foot fixed on the ground
Risk factors: Tall height and excess weight
Sillanpaa et al Med Sci Sports Exerc 2008Colvin J Bone Joint Surg 2008Nikku et al Acta Orthop 2009
Sillanpaa et al Med Sci Sports Exerc 2008
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Challenge
44% to 70% recurrent dislocations Depending upon the patient cohort
Results in a partial or complete MPFL disruption 50-60% of the restraining force against lateral patellar
displacement
Stefancin et al COOR 2007Smith et al KSSTA 2011Hing et al Cochrane Database Syst Rev 2011
Conplan et al J Bone Joint Surg 1993Desio et al Am J Sports Med 1998Hautamaa et al Clin Orthop 1998
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Major predisposing factors
1987
Major predisposing
factors
Major predisposing
factors
Trochlea dysplasiaTrochlea dysplasia
TT-TG > 20 mm
TT-TG > 20 mm
Patellar tilt > 20°Patellar tilt > 20°
Patella alta > 1.2Patella
alta > 1.2
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Major predisposing
factors
Major predisposing
factors
Trochlea dysplasiaTrochlea dysplasia
TT-TG > 20 mm
TT-TG > 20 mm
Patellar tilt > 20°Patellar tilt > 20°
Patella alta > 1.2Patella
alta > 1.2
2012
Major predisposing factors
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2012
Major predisposing
factors
Major predisposing
factors
Trochlea dysplasiaTrochlea dysplasia
TT-TG > 20 mm
TT-TG > 20 mm
Tear of the MPFLTear of
the MPFL
Patella alta > 1.2Patella
alta > 1.2
Major predisposing factors
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Patella alta
Measure of patella height
Caton-Deschamps index:
infera AT/AP < 0.6 normal 0.6 ≤ AT/AP ≤ 1.2 alta 1.2 < AT/AP
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Sagittal Patellofemoral Engagement (SPE)
SPE index: 2 cuts:
Longest patellar cartilage surface Longest trochlear cartilage
PL/TL: 0.42 normal PL/TL: <0.39 beware
Dejour D OTSR 2013
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Sagittal Patellofemoral Engagement (SPE)
Dejour D OTSR 2013
Caton-Deschamps: 1.66SPE index: 0.88
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Sagittal Patellofemoral Engagement (SPE)
Dejour D OTSR 2013
Caton-Deschamps: 0.81SPE index: 0.19
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Patella alta Distalisation osteotomy of the TT
Objective: index Caton-Deschamps = 1
Always before the MPFL reconstruction !!
Associated tenodesis of the patellar if > 52 mm
Attention: distalisation medializes automatically of 4 mm
Mayer C. et al. AJSM 2012
Servien E. RCO 2004
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Surgical ttr
Avulsion du MPFL sur la patellaP0 P1 P2
Only P2 lesions are susceptible to surgical fixation
Sillanpää P. et al. KSSTA 2014
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Surgical ttr
Osteochondral fracture of the patella
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Surgical ttr Osteochondral fracture of the patella :
fixation by resorbables pins
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Surgical ttr Osteochondral fracture of the lateral condyle :
fixation by resorbable pins
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Recurrent dislocations - Ttr “à la carte”
Predisposing factors Normal Surgical ttr
MPFL disrupted MPFL competent Reconstruction of MPFL
TT-TG > 20 mm TT-TG = 12 mm ± 4 mm Medialisation osteotomy of the TT
Patella alta-Index C-D > 1.2
- patellar tendon > 52 mm
Index de C-D = 0.8 – 1Patellar tendon = 42 mm
Distalisation osteotomy of the TT ± tenodesis of the patellar
tendon
Trochlea dysplasia type B or D Normal trochlea Deepening trochleoplasty
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MPFL Medial PatelloFemoral Ligament (MPFL) 50-60% of the restraining force against lateral patellar
displacement (Primary stabiliser) Passive restrainer
MPFL
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Types of graft: - Gracilis or semi-tendinosus tendon - Quad tendon - Patellar tendon- Fascia lata
Reconstruction of the MPFL
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Graft tensioning Objective: to restore native MPFL tension
- Tensioning at 30-60° of flexion
- Graft tensioning in extension with a proximal traction in the patella
Fithian DC. et al. Tech Knee Surg 2006
Christiansen SE et al. Arthroscopy 2008Deie M. et al. JBJS 2003Nomura E et al. AJSM 2007
Reconstruction of the MPFL
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Medialisation osteotomy of the TT Objective : 10 < TT-TG < 15
Always before the MPFL reconstruction !!
2
1
Reconstruction of the MPFL
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And the solid science…
Stephen et al Am J Sports Med 2012
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And the solid science…
The 40/50/60% rule
Stephen et al Am J Sports Med 2012
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Radiological landmarks
Palpation
Isometry
Surgical orientation for femoral tunnel positioning in MPFL reconstruction
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Radiological landmarks
Schöttle et al. Study on 8 cadaveric knees
Relatively uniform femoral insertion site of the MPFL
Schöttle et al Am J Sports Med 2007
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Radiological landmarks – the downside 1 Redfern et al seeking to confirm Schöttle’s point Found difference of 5mm in the A-P and 7 mm proximal to distal
Redfern et al Am J Sports Med 2010
« Bony architecture varies as a consequence of weight bearing activity undertaken by the patients. Therefore, the posterior femoral cortex may not represent a consistent anatomic landmark for use in determination of the femoral tunnel »
Stephen et al Am J Sports Med 2012
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Radiological landmarks -the downside 2
Barnett et al. Study on 10 cadaveric knees
Relatively uniform femoral insertion site of the MPFL
Barnett et al KSSTA 2012
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Radiological landmarks - the downside 2
Barnett et al.Study on 10 cadaveric knees
In accordance with Schoettle pointMalrotation of 5-10° may lead to tunnel malplacement
Ziegler et alStudy on 10 cadaveric knees
4mm difference to Schoettle point5° of malrotation causes 7-9mm points displacement
Barnett et al KSSTA 2012Ziegler et al Am J Sports Med 2016
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Surgical anatomy
The MPFL and its relation to: VMO
Quadriceps tendon
Posteromedial capsule
MCL prox insertion
Adductor tubercle
Nomura et al KSSTA 2005
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Post-operative results
No recurrence of instability in 3-10%
25% of complications Up to 30% tunnel malpositioning
Up to 30% with medial knee pain
12-30% loose 10° or more of flexion
Steensen et al Am J Sports Med 2004Servien et al Am J Sports med 2012Shah et al Am J Sports Med 2012Enderlein et al KSSTA 2015
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Post-operative results
Gobbi et al KSSTA 2016
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Mr C. 20 y. old, football player3 years post-MPFL reconstruction. No recurrence of dislocation or even instability. But painful !
Trochleoplasty ?
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Trochlea dysplasia 4 types
Reproducible and reliable classificationLippacher S. et al AJSM 2012Rémy F. et al. JBJS 2002
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Trochlea dysplasia
Lateral facet-elevating trochleoplasty by Albee
Thin osteochondral flap byBereiter
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Trochlea dysplasia
Sulcus-deepening trochleoplasty for type B and D dysplasia
Ntagiopoulos et al AJSM 2013, Ntagiopoulos et al KSSTA 2014
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Take home message Management of primary acute patella dislocation can be
challenging as well as chronic patello-femoral instability Radiographs + MRI + Ct (?) Characterization of the MPFL lesion Characterization of the bony morphology
(patellofemorometry) Ttr « à la carte »
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Principle
Patellofemoral stability
Static structural stabilizer
(ligaments)
Static structural stabilizer
(ligaments)
Dynamic structural stabilisers(muscles)
Dynamic structural stabilisers(muscles)
Osteo-articular
conformation
Osteo-articular
conformation
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