A review of wound healing following Maquet osteotomy

Fifteen-Year Minimum Follow-Up of Anteromedial Tibial Tubercle Transfer for Lateral and/or Distal Patellofemoral Arthrosis

PURPOSE

To evaluate a minimum 15-year clinical and radiographic follow-up after anteromedial tibial tubercle transfer (anteromedialization [AMZ]) for lateral and/or distal patellar facet arthrosis.

METHODS

Patients treated from 1996 to 2000 were contacted. The inclusion criteria were a minimum of 15 years' follow-up after AMZ for isolated persistent retropatellar pain related to lateral and/or distal patellar chondrosis. The exclusion criteria were clinical patellar instability, revision, and significant medial patellar facet or adjacent compartment chondrosis. The anatomic location(s) and severity of arthrosis, as well as the degree of lateral maltracking, were documented. Follow-up data included pain, activity level, and satisfaction.

RESULTS

Of 23 patients, 15 met the inclusion criteria. All were women (17 knees) followed up for a mean of 17.1 years (range, 15.4-18.8 years). The mean age at surgery was 29.5 years. Satisfactory results were reported in 94% of knees (16 of 17), based simply on patients' subjective evaluation of the degree of success perceived. An important criterion of satisfaction was that these patients stated they would opt to undergo surgery again under the same circumstances. For 35% of knees, patients reported engaging in recreational activities, whereas for 18%, patients were minimally active. The average pain score (range, 0-10) for 75% was 2.1, and most of these patients showed grade I or II arthrosis. Post-AMZ symptomatic medial patellar subluxation was corrected successfully in 2 patients. Removal of hardware was performed in 59% of knees, and additional procedures were required in 41%. No cases of postoperative lateral patellar instability or conversion to knee arthroplasty occurred.

CONCLUSIONS

Anteromedial tibial tubercle transfer without articular cartilage implantation is effective in patellofemoral joint preservation, ameliorating symptoms and facilitating active lifestyles for a minimum of 15 years to nearly 20 years in patients with lateral and/or distal patellofemoral arthrosis. For 94% of knees, patients would choose to undergo the procedure again under the same circumstances. Fifty-nine percent underwent screw removal, and 41% required additional procedures, mostly arthroscopic. No patients in this therapeutic case series underwent an arthroplasty procedure.

LEVEL OF EVIDENCE

Level IV, therapeutic cases series.

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.

Incidence of Deep Venous Thrombosis After Tibial Tubercle Osteotomy: A Single Case Series Study

BACKGROUND

Tibial tubercle osteotomy (TTO) is performed in a predominantly young and often female population due to the prevalence of patellofemoral disorders in this group. While considered a procedure that falls within the realm of sports surgeries, the procedure can carry significant morbidity, including infection, fracture, and deep vein thrombosis (DVT). The incidence of postoperative DVT in this population has not been described in the literature, although it has been mentioned anecdotally, and current guidelines do not address the issue of DVT prophylaxis in postoperative TTO patients.

PURPOSE

To describe the incidence of DVT after TTO and identify any predisposing factors.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Subjects who had undergone TTO by the senior author from 2002 to 2013 were identified, and a retrospective chart review was performed. Those who presented with symptomatic DVT confirmed with ultrasonography were reported. Demographic data, as well as potential risk factors such as body mass index, family history of bleeding/clotting disorders, duration of the nonweightbearing period, total tourniquet time, use of contraceptive medication, smoking status, and use of anticoagulants, were collected from the chart and analyzed for correlation with development of DVT.

RESULTS

A total of 156 patients were included in this study. Six patients were found to have developed symptomatic DVT during the first 6 weeks after surgery. The mean age at the time of surgery in the DVT group was 34.94 ± 6.57 years, compared with 26.26 ± 10.20 years in the non-DVT group (P = .04). Due to the small number of patients with positive findings, there was no statistically significant correlation between the development of DVT and factors such as nonweightbearing duration, tourniquet time, or the use of contraceptives.

CONCLUSION

The incidence of postoperative DVT in arthroscopic and sports procedures has been thought to be low. This case series reported a rate of 3.8% with symptomatic DVT after TTO, and patients diagnosed with DVT were significantly older than unaffected patients. It is anticipated that the actual rate including asymptomatic DVT would be higher, as only 60% of patients with DVT are symptomatic. More studies are needed to define the actual incidence in this population. Given the number of common risk factors in this population, including nonweightbearing duration and the use of oral contraceptive pills, future studies may show the advantage of chemical prophylaxis for DVT in this group.

Complications in patellofemoral surgery

The complexity of patellofemoral morphology, combined with its injuries and degenerative patterns, leads to varied pathologic diagnoses, as well as surgical procedures to address these problems. Surgical procedures in the patellofemoral joint include tibial tubercle osteotomy, medial patellofemoral ligament surgery, soft tissue procedures on the lateral aspect of the patella, trochleoplasty, and patellofemoral arthroplasty. Understanding potential complications related to the various surgical procedures in the patellofemoral joint is critical to successful surgery. The purpose of this article is to discuss potential surgical complications in procedures performed to address patellofemoral pathology and describe ways to avoid these pitfalls.

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.

Isolated patellofemoral osteoarthritis

BACKGROUND AND PURPOSE

The optimal treatment for isolated patellofemoral osteoarthritis is unclear at present. We systematically reviewed the highest level of available evidence on the nonoperative and operative treatment of isolated patellofemoral osteoarthritis to develop an evidenced-based discussion of treatment options.

METHODS

A systematic computerized database search (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), and EMBASE) was performed in March 2009. The quality of the studies was assessed independently by two authors using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We extracted data from 44 articles. The best available evidence for treatment of isolated patellofemoral osteoarthritis is sparse and of generally low methodological quality. Nonoperative treatment using physiotherapy (GRADE: high quality, weak recommendation for use), taping (GRADE: moderate quality, weak recommendation for use), or injection therapy (GRADE: very low quality, weak recommendation for use) may result in short-term relief. Joint-preserving surgical treatment may result in insufficient, unpredictable, or only short-term improvement (GRADE: low quality, weak recommendation against use). Total knee replacement with patellar resurfacing results in predictable and good, durable results (GRADE: low quality, weak recommendation for use). Outcome after patellofemoral arthroplasty in selected patients is good to excellent (GRADE: low quality, weak recommendation for use).

INTERPRETATION

Methodologically good quality comparative studies, preferably using a patient-relevant outcome instrument, are needed to establish the optimal treatment strategy for patients with isolated patellofemoral osteoarthritis.