Elevation of the tibial tubercle for patellofemoral pain syndrome. An 8- to 15-year follow-up

Tibial Tubercle Osteotomies: a Review of a Treatment for Recurrent Patellar Instability

PURPOSE OF REVIEW

The goal of this review is to provide an overview of current surgical treatment options for tibial tubercle osteotomies as a treatment for recurrent patellofemoral instability. As such we sought to provide the reader with the most current answers to why treatment practices have changed and how this has affected the outcome of surgical treatment for patellar instability.

RECENT FINDINGS

As our understanding of patellofemoral biomechanics have grown, appropriate surgical and non-surgical treatment options have followed suit to address these findings. A clear understanding of the pathomechanics causing the patient's patellar instability is germane to choosing the most appropriate surgical intervention to address this instability. Likewise, understanding the goal of the intervention chosen-e.g., unloading, realignment-is paramount. These surgical techniques may be technically challenging and surgical specialists with experience in these techniques are recommended for optimal outcomes.

Arthroscopic deepening trochleoplasty for chronic anterior knee pain after previous failed conservative and arthroscopic treatment. Report of two cases

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This study acknowledge that chronic anterior knee pain or patellofemoral can be caused based on trochlear dysplasia.

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The paper discuss the scientific background for this.

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By restoring the patient anatomy performing an arthroscopic trochleoplasty, the patients anterior knee pain was reduced significantly.

Purpose

A proportion of patients having years of chronic anterior knee pain(AKP) that have not responded to non-operative modalities. Trochlear dysplasia have been found to be a cause for AKP. By restoring the anatomy with a trochleoplasty procedure the patellofemoral joint is unloaded. This study is a prospective 2 year follow-up study, based on two cases with chronic AKP for several years and having severe trochlear dysplasia and both were successfully treated by arthroscopic deepening trochleoplasty.

Methods

Case one was a 46 year old women with chronic anterior knee pain (AKP). Imaging showed lateral trochlear inclination angle of 2°, trochlear asymmetry 0.36, central height 81% and medial height 83%. Thepreoperative Kujala score was 70 and Knee injury and Osteoarthritis Outcome Score (KOOS) subscale for pain was 67. Case two was a 26 year old man troubled by AKP and knee knee joint effusion for >8 years without any instability in the history. Imaging showed lateral trochlear inclination angle of 6°, trochlear asymmetry 0.25, central height 76% and medial height 78%. The preoperative Kujala score was 49 and KOOS subscale for pain was 72.

Results

The postoperative Kujala score was for case one 82 and for case two 81. The postoperative KOOS subscale for pain was for case one 89 and for case two 92. Improvement in the KOOS subscale for sport and recreational activities and quality of living were also found.

Conclusion

This is the first case report to demonstrate that patient having had years of chronic AKP and trochlear dysplasia can be successfully treated by arthroscopic trochleoplasty.

Tibial Tuberosity Anteromedialization for Patellofemoral Chondral Disease: Prognostic Factors

BACKGROUND

Tibial tuberosity anteromedialization (TTA) is a well-established treatment option for patellofemoral chondral disease that is resistant to nonoperative treatment. However, the prognostic factors of this procedure are unknown.

PURPOSE

To analyze the prognostic factors correlated with the midterm outcomes of TTA for patellofemoral chondral disease and determine the survivorship.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Indications of TTA for chondral disease included skeletal maturity, age <65 years, <grade 3 Kellgren-Lawrence degeneration, and isolated patellofemoral pain for ≥6 months despite nonoperative treatment. Inclusion criteria were (1) patellofemoral chondral disease, (2) TTA with or without lateral release, and (3) minimum 2-year follow-up. Exclusion criteria were (1) previous knee surgeries, (2) previous patellar dislocations, (3) inflammatory/rheumatic conditions, (4) major combined procedures other than lateral release, (5) focal chondral lesions amenable to cartilage repair, and (6) severe trochlear dysplasia. The patients were prospectively evaluated radiographically and clinically using the Western Ontario and McMaster Universities Osteoarthritis Index-Short-Form (WOMAC-SF) and Kujala scores. Different clinical and radiological data were collected (preoperative, intraoperative, and postoperative) and correlated with the outcomes using multiple logistic regression. The Kaplan-Meier survivorship was also evaluated.

RESULTS

From January 2003 to December 2013, among 76 eligible patients, 69 patients (78 knees, 74.4% female) were included, with a mean follow-up of 67.9 ± 34.5 months (range, 24-163 months) and a mean age at the time of surgery of 43.5 ± 16.1 years. The mean preoperative WOMAC-SF (17.8 ± 5.3) and Kujala (49.3 ± 15.6) scores significantly ( P < .001) improved after surgery (WOMAC-SF: 6.6 ± 6.9; Kujala: 74.2 ± 20.5). The patients graded their operated knee as 7.2 ± 2.1 of 10 points, on average, and stated that they would undergo the surgery again in 58 (74.4%) cases. A WOMAC-SF score of >7 points (34.6% of knees) in the multiple regression model was associated with age >45 years (odds ratio [OR], 10.4; 95% CI, 2.0-55.0) and increased femoral anteversion (OR, 7.9; 95% CI, 1.4-44.1). A Kujala score of <80 points (61.5% of knees) was associated with age >45 years (OR, 12.0; 95% CI, 2.6-56.2) and foot pronation (OR, 5.1; 95% CI, 1.3-20.4). Patient satisfaction of <7 of 10 points (32.1% of knees) was associated with positive postoperative patellofemoral crepitus (OR, 3.6; 95% CI, 1.1-11.7). The Kaplan-Meier survivorship of TTA with dissatisfaction (<5/10 points) as an end point was 94% at 43 months, 88% at 77 months, and 77% at 108 months.

CONCLUSION

Overall, good outcomes and survivorship (77% at 108 months) were obtained in this case series. However, 25.6% of the patients would not undergo the surgery again. Increased age, increased femoral anteversion, foot pronation, and postoperative patellofemoral crepitus were identified as negative prognostic factors.

Tibial tubercle osteotomy for patello-femoral joint disorders

Tibial tubercle osteotomy has a long history in the management of patella instability and patello-femoral arthritis. This review aims to provide a comprehensive review of the literature describing the biomechanics of the patello-femoral joint and the rationale behind the use of the tibial tubercle osteotomy in modern day practice. Several different tibial tubercle osteotomies are available and we aim to detail the concepts behind their use and the subsequent clinical results. With continued developments of chondrocyte implantation techniques, the potential to fill defects on the chondral surface of either the patella or trochlea in conjunction with a tibial tubercle osteotomy may well become more commonplace in a group that is commonly young and difficult to manage. Level of evidence III.

Patellofemoral replacement

Isolated patellofemoral arthritis is a common condition and there are varying opinions on the most effective treatments. Non-operative and operative treatments have failed to demonstrate effective long-term treatment for those in an advanced stage of the condition. Newer designs and increased technology in patellofemoral replacement (PFR) have produced more consistent outcomes. This has led to a renewed enthusiasm for this procedure. Newer PFR prostheses have addressed the patellar maltracking issues plaguing some of the older designs. Short-term results with contemporary prostheses and new technology are described here.

Cite this article: Bone Joint J 2013;95-B, Supple A:124–8.

The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: A five-year prospective study

OBJECTIVES

To assess the effectiveness of a modified tibial tubercle osteotomy as a treatment for arthroscopically diagnosed chondromalacia patellae.

METHODS

A total of 47 consecutive patients (51 knees) with arthroscopically proven chondromalacia, who had failed conservative management, underwent a modified Fulkerson tibial tubercle osteotomy. The mean age was 34.4 years (19.6 to 52.2). Pre-operatively, none of the patients exhibited signs of patellar maltracking or instability in association with their anterior knee pain. The minimum follow-up for the study was five years (mean 72.6 months (62 to 118)), with only one patient lost to follow-up.

RESULTS

A total of 50 knees were reviewed. At final follow-up, the Kujala knee score improved from 39.2 (12 to 63) pre-operatively to 57.7 (16 to 89) post-operatively (p < 0.001). The visual analogue pain score improved from 7.8 (4 to 10) pre-operatively to 5.0 (0 to 10) post-operatively. Overall patient satisfaction with good or excellent results was 72%. Patients with the lowest pre-operative Kujala score benefitted the most. Older patients benefited less than younger ones. The outcome was independent of the grade of chondromalacia. Six patients required screw removal. There were no major complications.

CONCLUSIONS

We conclude that this modification of the Fulkerson procedure is a safe and useful operation to treat anterior knee pain in well aligned patellofemoral joints due to chondromalacia patellae in adults, when conservative measures have failed.

Patellofemoral osteoarthritis treated by partial lateral facetectomy: results at long-term follow up

Excision of the eroded lateral patellar facet has been suggested as an acceptable treatment for short-term pain reduction in patients with isolated patellofemoral osteoarthritis. The outcome of this procedure at long-term is however not known. We therefore reviewed the results of 155 consecutive patients (168 knees) treated at our institution with lateral facetectomy at an average follow up of 10.9 years (± 6.9 years SD). During follow up 62 knees (36.9%) had failed and were revised to either TKA (60 knees), patellofemoral arthroplasty (one case) or total patellectomy (one case). Average time to reoperation in the failure group was 8.0 years (± 6.2 years SD). Kaplan-Meier survival rates with reoperation as endpoint were 85% at 5 years, 67.2% at 10 years, and 46.7% at 20 years respectively. At final follow up 79 (74.5%) of the knees that had not been re-operated were rated as either good or fair, which corresponds to 47% of the original group. Our study therefore demonstrates that a satisfactory outcome after lateral patellar facetectomy for isolated patellofemoral osteoarthritis can be expected in approximately half of the cases at 10 year follow up.

Tibial tubercle advancement osteotomy with bone allograft for patellofemoral arthritis: a retrospective cohort study of 50 knees

PATIENTS AND METHODS

Forty consecutive patients (21 females and 19 males) in a single centre underwent 50 tibial tubercle advancement osteotomy procedures for patellofemoral arthritis between January 1993 and April 2007. Twenty knees with patellar maltracking also underwent medialisation of the tibial tubercle (6-12 mm) in addition to the standard 10-15 mm elevation. Femoral head bone allograft blocks were utilised in all cases, and all patients achieved bony union without further surgery. Forty-five knees had previously undergone arthroscopy, 18 with arthroscopic lateral releases.

RESULTS

Ninety-four percentage of knees had sustained improvement in visual analogue pain scores (mean improvement of 37.4, P < 0.05) at a mean follow-up of 81 months (range 26-195 months), with 96% of patients still satisfied; and 92% of knees had sustained improvement in Shelbourne and Trumper anterior knee function scores (mean improvement of 39.8, P < 0.05). Overall clinical outcomes were rated excellent/good in 77%, fair in 35% and poor in 8% of knees. Two knees required arthroplasty surgery over the follow-up period (at 18 months and 8 years), and their anterior knee pain and function scores were not included in the analyses. Six knees (12%) suffered major complications: 1 temporary common peroneal neuropraxia; 2 intraoperative tibial metaphyseal fractures; and 3 tibial tuberosity fractures (at 8 days, 3 weeks and 3 months). Four knees (8%) suffered superficial wound infections, 31 knees had some numbness around the midline scar, 7 knees had scar pain lasting up to 12 months, and 22 knees (44%) experienced some discomfort relating to the metalwork, which was removed in all these cases.

CONCLUSIONS

Tibial tubercle advancement osteotomy can be an effective treatment for anterior knee pain and for patients with arthroscopic evidence of patellar chondral damage. It can provide excellent/good long-term functional results in the majority of patients, with very high satisfaction levels and sustained improvement in pain symptoms. The use of femoral head bone allograft is both effective in obtaining bony union and by definition avoids the donor-site morbidity. Knees with patellar malalignment may also undergo individualised medialisation of the tibial tubercle such that the patella lies in the centre of the femoral trochlea, and may benefit from lateral trochleaplasty surgery in the presence of trochlear dysplasia. However, the major operative complication rate is high at 12%, and fracture of the tibial tubercle is associated with a poorer outcome. One can expect 10% of operated knees to have had some clinical deterioration in the patellofemoral joint by a mean follow-up of 93 months.

Treatment of patellofemoral chondropathy with the Bandi tibial tubercle osteotomy More than 10years follow-up

Isolated degenerative patellofemoral chondropathy is a prevalent disease. There is still controversy regarding its ideal type of management. A retrospective study was performed to assess the outcomes of 28 patients with a minimum of 10-year follow-up, in whom the Bandi tibial tubercle osteotomy was performed. The Bentley score was applied pre and postoperatively to evaluate the clinical results. Preoperatively, 21 (67%) patients were rated as fair and seven (33%) as poor according to the Bentley functional scale for patellofemoral osteoarthritis. At 5 years of follow-up, one case was rated as excellent, 23 (81%) cases as good, three as fair and one as poor. At 10 years of follow-up no cases were rated as excellent, 17 (61%) cases as good, four (14%) as fair and seven (25%) as poor. The difference in terms of poor results evaluated at five and 10 years after the surgery was statistically significant (p<0.05). We concluded that excellent and good short-term results can be expected with the use of the Bandi tibial tubercle osteotomy in patients with isolated degenerative patellofemoral chondropathy; however, such outcomes tend to deteriorate over the time, especially in patients with advanced chondromalacia, making its indication controversial.

Tantalum is a good bone graft substitute in tibial tubercle advancement

BACKGROUND

Porous tantalum is reportedly a good substitute for structural bone graft in several applications. So far, its use has not been reported in tibial tuberosity anteriorization (TTA) for treatment of isolated degenerative chondral lesions of the patellofemoral joint.

QUESTIONS/PURPOSES

We asked whether the use of this material would produce similar standardized functional scores, pain (VAS), fusion rates, complications, and patient satisfaction to those for bone graft.

PATIENTS AND METHODS

We performed a randomized, controlled trial in 101 patients (108 knees) scheduled for TTA comparing a porous tantalum implant (57 knees) with an autologous local tibial bone graft (51 knees). The minimum followup was 5 years (mean, 6.2 years; range, 5-8 years).

RESULTS

At the last followup, clinical scores, fusion rates, and maintenance of the anteriorization either were better or similar for the TTA using the tantalum implant depending on the respective parameter. The operative technique was easier and shorter with the tantalum device. Complication and failure rates were greater using bone graft. Patient satisfaction was greater using the tantalum implant.

CONCLUSIONS

Porous tantalum provided a reasonable alternative to bone graft in TTA.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Isolated arthrosis of the patellofemoral joint in younger patients (<50 years)]

In the majority of cases, arthrosis of the patellofemoral joint (PFJ) is combined with arthrosis of the femorotibial compartment and thus assumes a somewhat secondary role. Nevertheless, it can occur as an isolated entity. Several radiological studies evidenced isolated degenerative alterations in the PFJ in the age group >55 years (13.6-24.0% in women and 11.0-15.4% in men). In younger patients the incidence is lower and is mainly associated with patellar instability or post-traumatic arthrosis. Just the same, the choice of appropriate treatment for these patients is challenging. Total replacement can be recommended for older and less active patients. In contrast, for younger and more active patients, various conservative treatment options and more demanding operative techniques are available to the surgeon to avoid arthroplasty. This article describes the different therapeutic possibilities for managing arthrosis of the PFJ in patients aged <50 years.

Imaging of postoperative knee extensor mechanism

Disorders of the anterior knee are common and include patellofemoral syndrome, patella instability, patella fracture, and patellar and quadriceps tendon ruptures. Depending on the operative procedure performed, the post-operative imaging appearance of these knees may be confusing. It is crucial for the radiologist to be familiar with the procedures performed in order to recognize the postoperative findings. Radiologists must be able to interpret hardware (anchors, screw and wires) and disruptions in soft tissue planes that may persist with these types of procedures.

Patellofemoral malalignment: looking beyond the viewbox

A clear understanding of the pathophysiology of anterior knee pain is inhibited by the use of imprecise, poorly defined, and often interchanged words, such as malalignment, patellar alignment, maltracking, subluxation, dislocation, and congruence. The literature is filled with articles regarding the diagnosis, "malalignment of the patella," most of which give no precise diagnosis. This article presents a definition of malalignment and a plea for rational descriptive and scientific analysis. Much of what is described is based on theory, not facts. These ideas are supported by clinical experience and logical analysis, but very little in the way of scientific data. Most of the data involve radiographic images, which present only one piece of the puzzle.

Diagnosis and treatment of patients with patellofemoral pain

The patient-athlete with patellofemoral pain requires precise physical examination based on a thorough history. The nature of injury and specific physical findings, including detailed examination of the retinacular structure around the patella, will most accurately pinpoint the specific source of anterior knee pain or instability. Radiographs should include a standard 30 degrees to 45 degrees axial view of the patellae and a precise lateral radiograph. Nonoperative treatment is effective in most patients. Prone quadriceps muscle stretches, balanced strengthening, proprioceptive training, hip external rotator strengthening, patellar taping, orthotic devices, and effective bracing will help most patients avoid surgery. When surgery becomes necessary, indications must be specific. Lateral release is appropriate for patella tilt (abnormal rotation). Painful scar or retinaculum, neuromas, and pathologic plicae may require resection. Proximal patellar realignment may be accomplished using arthroscopic or a combined arthroscopic/mini-open approach. Symptomatic articular lesions and more profound malalignments may require medial or anteromedial tibial tubercle transfer. Clinicians should be particularly alert for symptoms of medial subluxation in postoperative patients and should use the provocative medial subluxation test followed by lateral displacement patellar bracing to confirm a diagnosis of medial patellar subluxation. This problem may be corrected in most patients using a lateral patellar tenodesis. Current thinking emphasizes precise diagnosis, rehabilitation involving the entire kinetic chain, restoration of patella homeostasis, minimal surgical intervention, and precise indications for more definitive corrective surgery.