presented by august 25th, 2015 proximal realignment · pdf filepatellar tendon tenodesis ......

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Treatment Methods for Patellar Malalignment Issues

presented by

Murat Bozkurt

Murat Bozkurt, Halil Ibrahim Acar, Safa Gursoy, Mustafa Akkaya

Yildirim Beyazit University, School of Medicine

Ankara, TURKEY

Proximal Realignment

August 25th, 2015

Disclosure

• Educational activities

Zimmer Biomet

DePuy Synthes

Stryker

Proximal RealignmentMurat Bozkurt

Anatomy


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Treatment Methods for Patellar Malalignment

No single operation is universally accepted Several techniques have been described

• Decision needs of the individual patient extent of the malalignment patient’s age the level of activity the condition of the joint


Proximal realignment lateral retinacular release medial plication VMO advancement MPFL repair and recons.

Distal realignment

Combined proximal and distalrealignment

Treatment Methods for Patellar Malalignment


Lateral ReleaseIndications

• episodic patellar dislocation (EPD),

• Patellofemoral osteoarthritis (PF OA),

• excessive lateral hyperpression syndrome (ELHS)

• total knee replacement (TKR).

Technique• 5 mm lateral to the patellar border,

• Hemarthrosis; electrocautery


The role of lateral retinacular release in the treatment of patellar instability. Lattermann C, Toth J, Bach BR Jr.Sports Med Arthrosc. 2007;15:57-60.

Don’t extend or detache vastus lateralis obliquus.

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Long-term results of lateral retinacular release.Panni AS, Tartarone M, Patricola A, Paxton EW, Fithian DC.

Arthroscopy. 2005 May;21(5):526-31.

• 50 patients

• 5-year follow-up

• In patellar instability the results are less favorable in long-term follow-up

Lateral Release


Medial Procedures

• Since the recognition of the importance of the medial patellofemoral ligament (MPFL), there has been increasing interest in different techniques for managing the medial stabilizer.

Repair

Radio-frequency thermal reefing

Imbrication (reefing)

Plication

VMO advancement


Medial Plication

• Surgical Techniques for Medial Plication

Arthroscopic All-Inside Medial Plication

Arthroscopically Assisted Medial Reefing

Mini-Open Medial Reefing


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VMO advancementInsall technique

Patellar pain and incongruence. II: Clinical application.

Insall JN, Aglietti P, Tria AJ Jr.Clin Orthop Relat Res 1983;176:225-32.


• 53 knees • 81% excellent or good • 19% fair or poor.

MPFL Reconstruction

First described by Kaplan 1957,but not named.

Superior medial border of the patella

Between the epicondyle and the adductor tubercle


MPFL Reconstruction

• The MPFL is a thin fascial band approximately 53 (range 45–64) mm long , that links from the region of the medial epicondyle of the femur to the proximal part of the medial border of the patella.

• It has been shown that this structure is present in all knees and that it is the major medial stabilizer of thepatellofemoral joint.

• MPFL had a mean tensile strength of 208 N and it is surprisingly strong for such an insubstantial appearance.


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MPFL Reconstruction

• MPFL is the primary restraint and provides 60% of the restraining force to lateral translation.

• Patellar dislocation is a disabling condition that often results in disruption of the MPFL.

• Tearing of the MPFL at or near its femoral insertion is present in 80% to 100% of cases.

• The MPFL reconstruction is an accepted surgical technique for treatment of chronic patellofemoral instability.


MPFL ReconstructionPre-Op Planning

• X-ray • Measuring Q angle



• TT-TG lenght measurement on CT scan

Normal : < 15-20 mm


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• MRI

MPFL Reconstruction

Single Patellar Tunnel Fixation withBioabsorbable Screws


MPFL Reconstruction

Double Patellar Tunnel Fixation withBioabsorbable Screws


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MPFL Reconstruction

Patellar Tunnel Fixation withEndobutton


MPFL Reconstruction

Patellar Tunnel Fixation withAnchor


MPFL Reconstruction


Figure. Pressure analysis with Fuji FPD-8010 E Ver. 2.0 program after MPFL reconstruction

Use of contact pressure-sensitive surfaces as an indicator of graft tension in medial patellofemoralligament reconstruction Kadir Ilker Yildiz · Cetin Isik · Osman Tecimel · Nurdan Cay · Ahmet Firat · Ramazan Akmese · Murat Bozkurt Arch Orthop Trauma Surg (2013) 133:1657–1663

Conclusion:Contact pressure-sensitive surfacesprovided objective data when placedunder the graft in natural MPFL andduring surgery. Therefore, they maybe used as an objective markerproviding information about graftresistance.

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Treatment Methods for Patellar Malalignment Issues

presented by

[email protected]

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Diagnosis of patellar malalignment

Sébastien LUSTIG MD, PhD, Prof

J Caton, E Servien, Ph NeyretAlbert Trillat Center, Lyon, france

Clinical situation

PatelloFemoral Instability


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Patellarmalalignment


Trauma

Al

Episodic

Patellar

Dislocation

No

Dislocation

Morphological

abnormalitiesNo morphological

abnormalities

Potential

Patellar

Dislocation

Morphological abnormalitiesIn Patellofemoral Instability

One or more

P. dislocationsNo Symptom

Morphological

AbnormalitiesControl Group

vs

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Morphological abnormalitiesIn Patellofemoral Instability

Trochlear

Dysplasia

Principal

factors

Secondary

factors


• Crossing sign

• Trochlear bump

• Patellar height

• TT-TG

• Patellar tilt

• F. Antetorsion• G. Recurvatum• G. Valgum• Female

« Fundamental factor »

Trochlear Dysplasia

Crossing sign

Trochlear bump

H. Dejour, G Walch, Ph Neyret: RCO 1990, 76 : 45-54

crossing

>145°

Trochlear Dysplasia

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Crossing sign

EPD Control group

96% 3%

Trochlear Dysplasia

Trochlear bump

>3mm

EPD Control group

3.2mm±2.4 -0.8mm±2.9

66% 6%

Trochlear Dysplasia

Trochlear Dysplasia

H Dejour and G Walch

1987

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Trochlear Dysplasia

D Dejour

RCO 1998

KSSTA 2006

X-rays

CT-scan

Trochlear Dysplasia

X-rays

GRADE A

Crossing sign

Trochlear Dysplasia

CT-scan

GRADE A

Subnormal Trochlea

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Trochlear Dysplasia

X-rays

GRADE B

Crossing signSupra-trochlear spur

Trochlear Dysplasia

CT-scan

GRADE B

Trochlea flat or convex

Trochlear Dysplasia

X-rays

GRADE C

Crossing signDouble contour

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Trochlear Dysplasia

CT-scan

GRADE C

Asymmetry of facets :- Lateral = convex- Medial = hypoplastic

Trochlear Dysplasia

X-rays

GRADE D

Crossing signSupracondylar spur

Double contour

Trochlear Dysplasia

CT-scan

GRADE D

Asymmetry of facets

Cliff pattern

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H. Dejour, G Walch, Ph Neyret Trochlea dysplasia Rev Chir Orthop 1990, 76 : 45-54

Trochlear

Dysplasia

H Dejour, Ph Neyret, G Walch. Factors in patellar instability.

In P. Aichroth Knee Surgery Current Practice, NY, 1992

Principal

factors

Instability• Crossing sign

• Trochlear bump

Principal Factors3

Patellar height

TT-TG

Patellar tilt Threshold

P

A

T

Caton & Deschamps Index

AT/AP

1. Patella alta >1.2

T

1.0

H. Dejour

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To our knowledge no biomechanical studies has proven the negative effect of patella alta in case of trochlea dysplasia

Nevertheless it is logical to aim that the distal transferallows the patella to better engage in the trochlea.

Contact surfaces increases from 15 to 18% at 15°flexion after a 10% shortening of the Patellar tendon without augmentation of patellar forces

N Upadhyay,… AJSM. 2005: 1565-1573

Basic Sciences

• Patella alta is due to a too long patellar

tendon and not to an abnormal proximal

tibial insertion of the patellar tendon

Ph. Neyret, A.H.N. Robinson, …, P. Chambat

Patellar tendon length – the factor in patellar instability ?

The Knee 2002

TTd

What’ new ?

Ph. Neyret, A.H.N. Robinson, …, P. ChambatPatellar tendon length – the factor in patellar instability ? The Knee 2002

Patella alta

C Meyer, … Ph Neyret, S Lustig.Patellar Tendon Tenodesis …for the Treatment of Episodic Patellar Dislocation WithPatella Alta? AJSM 2011

>52mm

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Goutallier D, Bernageau J, Lecudonnec B Mesure de l'écart tubérosité tibiale

antérieure – gorge de la trochlée : TA-GT Rev. Chir. Orthop. (1978) 64 : 423-428

2. Excessive TT-TG

TT-TG >20mm

10mm

19.6

21.731mm

3. Patellar Tilt >20°

15°Quadriceps DysplasiaTrochlear DysplasiaMPFL

?

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.

Patella tilt > 20°

EPD Control

31.5° 10°

90% 3%

33

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Clinical assessment


H. Dejour, G Walch, Ph Neyret Trochlea dysplasia Rev Chir Orthop 1990, 76 : 45-54

Trochlear

Dysplasia

H Dejour, Ph Neyret, G Walch. Factors in patellar instability.

In P. Aichroth Knee Surgery Current Practice, NY, 1992

Principal

factors

Secondary

factors

Instability• Crossing sign

• Trochlear bump

• Patellar height

• TT-TG

• Patellar tilt

Secondary Factors4

•F. Antetorsion•G. Recurvatum•G. Valgum•Female No Threshold

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Conclusion

Trochlear

Dysplasia

Principal

factors

Secondary

factors

Diagnosis of Patellar malalignment

• Crossing sign

• Trochlear bump

• Patellar height > 1.2

• TT-TG > 20mm

• Patellar tilt > 20°

• F. Antetorsion• G. Recurvatum• G. Valgum

Thank you for your attention

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John P. Fulkerson, M.D.Orthopedic Associates of Hartford

Clinical Professor of Orthopedic Surgery University of ConnecticutFarmington, Connecticut

The author receives royalties his patent and design of the Trupull braces (DJ Ortho)

The author is president of the Patellofemoral Foundation that receives undirected funding from Smith and Nephew, DJ Ortho, Conmed-Linvatec, Kinamed, Sanofi, KFX and Hartman Newspapers

Tibial tubercle transfer places the patella into a better tracking relationship with respect to the trochlea- this corrects alignment which almost always improves stability

Medial imbrication and MPFL reconstruction stabilize only and should not be used to change the patella tracking pattern

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Never use MPFL reconstruction to move the patella

Move tibial tubercle only to restore optimal PF loading

and central tracking- never too far!!

Always optimize balance

first and reduce load on

damaged cartilage

whenever and however

possible.

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As trochlea dysplasia increases, the

need for precise, balanced tracking

and anatomic medial and lateral

retinacular balance increases

Consider trochleoplasty and/or

femoro-tibial derotation surgery

only in more extreme cases when

alignment and retinacular surgery

alone are insufficient

Dejour- Trochleoplasty for “high

grade trochlear dysplasia with patellar

instability and/or abnormal tracking.”

Differentiate functional from structural PF alignment disorders

Always exhaust non operative measures to optimize core stability and function (Teitge, Powers, Arendt)

See where the patella goes

with the quad contracted at

0 degrees and at 30 degrees

flexion

If you can’t center the patella

with your finger, centering by

medial reconstruction alone will

overload cartilageOPTIMIZE ALIGNMENT and

ARTICULAR LOADING

FIRST, THEN STABILIZE

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Tibial tubercle transfer is the most versatile and benign way to correct structural incongruity (high TT-TG, high Q angle) of patello-femoral tracking and also unload lateral and distal patella articular lesions

Tubercle transfer can compensate for structural femoral and tibial rotation problems that cause recurrent patella instability or lateral PF overload

Tibial tubercle transfer can optimize balance in a dysplastic trochlea

Tibial tubercle transfer aligns and unloads lesions.. TTT osteotomy is most appropriate when there is healthy cartilage onto which to transfer patella tracking

As trochlea dysplasia increases, need for MPFL/MQTFL graft and optimal alignment increases. Less containment (trochlea), more need for external support and perfect tracking

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Usually related to improper technique, inadequate fixation or a patient accident before bony union

Technical precision, secure internal fixation, supervision and proper rehabilitation are imperative-complications are rare.

Precise surgery and early motion will avoid complications

Result of non anatomic MPFL graft placement

Matt Bollier(Arthroscopy,

2011), Elvire Servien(AJSM,

2011),Christian Lattermann

(AJSM), Andy Cosgarea and

Miho Tanaka (AAOS Scientific

exhibit 2011) have shown that

MPFL grafts are too often

malpositioned Risk of patella fracture after

MPFL reconstruction (Parikh,

JBJS 2011)

The keys to success in patellofemoral surgery

are good decision making, technical

excellence and doing no more than is needed

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Relationship of the tibialtubercle(TT) to thetrochlear groove(TG)center (Neyret, Dejour)

TT transfer when elevated TT-TG and patella tracking laterally

Superimposed CT images

Recent data from Tanaka and Dahm have shown that TT-TG measurements are variable- use with caution!!!

Simply mark center of proximal

trochlea on computer screen of CT

or MRI axial cut, then scroll down to

tibial tubercle and use the ruler from

toolbar to measure TT-TG distance

The more you need to consider how tibial tubercle transfer might optimize PF tracking and articular loading

When there is a need to realign the patella , in any plane, or to unload a painful lesion permanently

To achieve stability of the extensor mechanism by establishing optimal vector alignment

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Inadequate health, poor bone quality, gross obesity

Diffuse patella or trochlea chondral degeneration

Proximal patella lesions (Crush)

RSD or diffuse pain Poor attitude or motivation Inadequate trial of non

operative measures Instability related to

retinacular and trochlear deficiency with no need for changing patella tracking vector

Resurface an area that will receive contact after TTT

Unload a surface that has been treated with ACI or OC graft

Farr, Cole, Minas, Gillogly, Lattermann, Peterson

High Q angle and TT-TG, no medial articular lesion(Pidoriano type 2)

Lateral facet lesion

No distal lesion (Pidoriano tyle 1)which will benefit from anteriorization-(tipping up the distal patella off of the lesion)

X

Pidoriano AJ, Am J Sports Med.

1997 Jul-Aug;25(4):533-7..

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My views:

Medial TTT effectively establishes balanced PF tracking and COMPENSATES for core deficiencies that cause chronic lateral tracking

Much less risk and more direct than femoral derotation (which also compensates for other structural and alignment problems)

Bringing the patella into balanced alignment with the trochlea creates improved knee function overall

External rotation of the tibia caused by medial TTT is preferable to the abnormal internal rotation caused by lateral PF tracking

Medial TTT, particularly AMZ, proven to result in overall less load to patella than MPFL reconstruction (Elias and Cosgarea)

Separate issue from MPFL or MQTFL reconstruction (balanced tracking vs stabilization)

Medial lesion from previous overzealous TT medialization

+/- medial subluxation

Intact lateral facet

In cases of patella infera, proximalization of the tibial tubercle may be necessary

With symptomatic patella alta, distalization will get patella into deeper trochlea earlier

Patella distalization becomes more important in the patient with combined patella alta and trochlea dysplasia

BOTH PROCEDURES MUST BE ACCOMPANIED BY APPROPRIATE SOFT TISSUE RELEASE AND/OR BALANCING

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Anteriorization is most helpful to diminish or eliminate load on distal patella lesions. These are common after a dislocation

Beware of proximal lesion(crush) as anteriorization will place load on proximal patella earlier in the flexion arc.

“TIP UP THE DISTAL POLE”

Uncommon procedure

Sagittal plane osteotomy vs Maquet

Sagittal plane osteotomy requires back cut from lateral side

Other option is anteromedial TTT with an offset bone graft

Unloads distal and lateral lesions(the principle lesions in patients with PF rotational alignment disorders)

Requires intact proximal medial cartilage (may be a problem after dislocation or crush)

Appropriate when TT-TG elevated and improved alignment is needed along with distal unloading

Highly effective for the right patients- improved stability and pain relief

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TTT or arthroplasty?

These patients do well with anteromedial tibialtubercle transfer, AS LONG AS THERE IS INTACT MEDIAL CARTILAGE onto which to transfer

Realign medial tracking patella

Unload medial lesion, overloaded from previous excessive or posteromedial TTT

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Precise osteotomy, tapered to anterior cortex distally

Move slightly distal to correct alta if needed and anteriorly to unload distal/lateral articular lesion

Secure fixation

Immediate motion

Protect weight bearing 6 weeks

Transfer such that PF loading will be onto better cartilage

Remove hardware late (>6 months)

Result depends to a large extent on effectively unloading the lesion causing pain

unloads distal lesion Selective use of cartilage

resurfacing broadens the indications for this procedure(Farr, Minas, Schepsis, Cole, Gillogly)

Safe and effective--properly done

Must taper osteotomy to anterior tibia distally-do not notch tibia shaft

Pidoriano et al, AJSM, 1997

Saranathan A, Kirkpatrick MS, Mani S, Smith LG, Cosgarea AJ, Tan JS, Elias JJ.

Knee Surg Sports Traumatol Arthrosc. 2012 Oct;20(10):2054-61. Epub 2011 Dec 2.

The effect of tibial tuberosity realignment procedures on the patellofemoral pressure distribution.

Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990 Sep-Oct;18(5):490-6; discussion 496-7.

http://www.ncbi.nlm.nih.gov/pubmed?term=Saranathan%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22134408

http://www.ncbi.nlm.nih.gov/pubmed?term=Kirkpatrick%20MS%5BAuthor%5D&cauthor=true&cauthor_uid=22134408

http://www.ncbi.nlm.nih.gov/pubmed?term=Mani%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22134408

http://www.ncbi.nlm.nih.gov/pubmed?term=Smith%20LG%5BAuthor%5D&cauthor=true&cauthor_uid=22134408

http://www.ncbi.nlm.nih.gov/pubmed?term=Cosgarea%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=22134408

http://www.ncbi.nlm.nih.gov/pubmed?term=Tan%20JS%5BAuthor%5D&cauthor=true&cauthor_uid=22134408

http://www.ncbi.nlm.nih.gov/pubmed?term=Elias%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=22134408

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Fulkerson%20JP%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Becker%20GJ%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Meaney%20JA%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Miranda%20M%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Folcik%20MA%22%5BAuthor%5D

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Buuck D, Weinstein R and Fulkerson J Anteromedialization of the Tibial

Tubercle: a 4-12 Year Follow up. Op Tech Sports Med 8(2): 131-137, 2000.

Stable painfree results maintained at 4-12 year

Tjoumakaris FP, Forsythe B, Bradley JP. Patellofemoral instability in athletes: treatment via modified Fulkerson osteotomy and lateral release. Am J Sports Med. 2010 May;38(5):992-9.

97% return to sports

Excellent exposure laterally

Note the distal taper of osteotomy anteriorly

http://www.ncbi.nlm.nih.gov/pubmed/20212100

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Medialization normalizes or optimizes PF alignment and tracking

while

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AMTTTNo AMTTT

After a precise osteotomy stabilized with two cortical screws into the posterior cortex, patients should begin immediate range of motion

Partial weight bearing for 5-6 weeks, then rapid progression to quad strengthening and weight bearing off crutches

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Schepsis description of Anteromedial Tibial Tubercle Transfer- OKO on AAOS website

AMTTT presentations on www.vumedi.com

Farr, Schepsis, Cole, Fulkerson, Lewis Anteromedialization, Review and Technique. J Knee Surg. 2007;20:120-128

AAOS Blu-ray DVD Patella Instability and Arthrosis The Master’s Experience series (2013)

Once the tracking is optimized by TTT, restore retinacular support as needed

As trochlea dysplasia increases, need for retinacular support increases

MPFL and medial deficiency alone--no TTT

Much of medial retinacularsupport runs to quadriceps expansion- useful in reconstruction- option of MQTFL reconstruction to quad tendon instead of MPFL reconstruction to patella

Fulkerson, J and Edgar C. Arthrosc Tech. 2013

Apr 12;2(2):e125-8. 2013. 2013 May.

Medial quadriceps tendon-femoral ligament:

surgical anatomy and reconstruction

technique to prevent patella instability.

Available at www.arthroscopytechniques.org

http://www.vumedi.com

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Disastrous result of patella distalization in a 21 year old woman

Severe PF arthrosis as a result

Use an osteotomy when you can transfer cartilage tracking onto healthy cartilage (Ficatexcessive lateral pressure syndrome)

Osteotomy is particularly desireablein younger patients with distal and/or lateral patella articular degeneration

PF replacement when deterioration of the PFJ is diffuse

Each case is unique, and requires careful consideration of alignment, articular cartilage lesion location, trochlea dysplasia, and peripatella retinacular support.

Use tibial tubercle transfer to align, balance tracking, and unload an articular lesion

Balance alignment and articular loading as needed before medial restoration surgery to optimize long term results

Design surgery specifically for each patient to create retinacular, tracking and articular balance

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www.patellofemoral.org

Dedicated Patellofemoral Surgery Hands On Course at the Orthopedic Learning Center in Rosemont, IL---September 2016

www.AANA.org for Master’s Course catalog

Special Thanks to Smith and Nephew for generous support of the PF Foundation

http://www.AANA.org

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Patellofemoral Arthroplasty

Pr Sébastien Parratte MD, PhD

Matthieu Ollivier, JM Aubaniac,

Jean-Noël Argenson

Institute for Locomotion

Sainte Marguerite Hospital

Marseille

VuMedi Webinar Treatment Methods

for Patellar Malalignment Issues

25 /08/2015

30 % rate of complications after PFA at a

median follow up of 5.3 years

C. J. Dy, KSSTA 2011 Complications after patello-femoral versus

total knee replacement in the treatment of isolated patello-femoral

osteoarthritis. A meta-analysis

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Qualité de vie

Questionnaire de santé perçue

Survie est utile pour les cancers

« Qu’est- ce qu’un bon résultats

chirurgical? »

WHAT !

PFP : Survivorship

50

60

70

80

90

100

0 5 10 15

Pou

rcen

tag

e

Délai (années)

90 %

at 10 years

72 %

at 10 years

Revision for F-Tib OA

Revision for P-F complication

SOFCOT 2003 Isolated Patellofemoral Arthritis, J.Allain - D.Dejour

211 PFA, 5 designs

Global : 65% à 10 ans

PF Arthroplasty :

Update

Tauro, JBJS Br 2001

Kooijman, JBJS Br 2003

Lonner, CORR 2004

Cartier, CORR 2005

Merchant, CORR 2005

Lotke, J Arthroplasty 2005

Ackroyd, CORR 2005

Argenson, CORR 2005

Cossey, J Arthroplasty 2006

Sisto, JBJS Am 2006

Ackroyd, JBJS Br 2007

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3 modes of failures

1. Femoro-tibial arthritis +++

2. Loosening

3. Problems related to tracking

Instability

Pain and stiffness

Indication

Implant

Implant

2008 : New

Generation

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Patello-Femoral Arthroplasty

1. Indication

2. Implant

3. Technique

4. Results

Pain:

Where?

When?

Indications

Preoperative analysis: Clinical

symptoms

IndicationsRadiological preoperative

analysis

Stress

X rays

Full-length

X rays

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From our experience

Bone on bone PF arthris

« Young » patient

Arthritis post-dysplasia

Post-traumatic arthritis

Avoid bad Indications

Infl. disease

Patella baja

Medial OA = > PFJ + ZUK

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1. Indication

2. Implant

3. Technique

4. Results

PFA First generation: resurfacing

Rasp and curette

Bring the patella on the femur

Not longer used !

Anatomy

Ancillary

Anterior cut: Bring the femur below

the patella

PFA: A3

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Anterior cut Lateral arthritis => 5 to 10 ° of External rotation

Central => 3 ° of External rotation

Normal knee

= > Patella

= > Trochlea

Lateral Medial

Phil Chapman-Sheath

and Versailles

Concept

Lateral arthritisPatella

Trochlea

Lateral Medial

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Solution with PFJ

And trochlear

dysplasia

Patella

Trochlea

Lateral Medial

Lateral arthritis => 5 to 10 ° of External rotation

LatMed

Patella

Trochlea

Lateral Medial

Solution with

Central Arthtritis

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Central => 3 ° of External rotation

MedLat


1. Indication

2. Implant

3. Technique

4. Results

No tourniquet

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MIS

Subvastus

Approach

Witheside line

Anterior cut

Rotation/thickness

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Femoral reaming

Patella : Always

Cement

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Post-op X-ray

When medial OA is associated

PFJ + ZUK


1. Indication

2. Implant

3. Technique

4. Results

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1. Primary Arthritis with no F-Tdeformity

2. P-F Instability with aligned extensor

mechanism

3. Post-traumatic: good mobility, no patella baja

Long term Results of PFA

• Blazina, CORR 1979

• Arciero, CORR 1988

• Witvoet, Ch Ens Sofcot 1994

• Argenson, CORR 1995

• Krajca-Raddiffe, CORR 1996

• Mertl, RCO 1996

• De Cloedt, Acta Orthop 1999

•Tauro, JBJS Br 2001

• Kooijman, JBJS Br 2003

• Lonner, CORR 2004

• Cartier, CORR 2005

• Merchant, CORR 2005

• Lotke, J Arthroplasty

2005

• Ackroyd, CORR 2005

• Argenson, CORR 2005

• Cossey, J Arthroplasty

2006

• Sisto, JBJS Am 2006

• Ackroyd, JBJS Br 2007

Survival 85 % at 10 years and

70% at 15 years

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Mid term Results of PFA

• Van Jonbergen, J Arthroplasty 2010

• Dahm, Am J Orthop 2010

• Odumenya, JBJS Br 2010

• Dy, KSSTA 2011

• Mont, J Arthroplasty 2012

• Walker, JBJS Am 2012

• Lonner, Orthop Clin Am 2013

Survival 95 % at 5 years

Results

7 years experience:

New generation

Isolated or combined with the ZUK

But no

OA progression

No patellar maltracking

No loosening

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Easy conversion to TKA

• Lonner JH, Jasko JG, Booth RE JBJSAm 2006

• Parratte S, Lunebourg A, Ollivier M, Abdel MP, Argenson JN.

Are revisions of patellofemoral arthroplasties more like

primary or revision TKAs. Clin Orthop Relat Res. 2015

Conclusion and Key points

message

Indications: learn

PFJ : A3 : anatomy/ ancillary/ anterior cut

Technique : rotation+++

PFJ: reproducible solution for PFA

Good mid-term results new generation

presented by august 25th, 2015 proximal realignment · pdf filepatellar tendon tenodesis ......

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