techniques chirurgicales et indications thÉrapeutiques
TRANSCRIPT
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TECHNIQUES CHIRURGICALES ETINDICATIONS THÉRAPEUTIQUES
Pr E. ServienDIU chir genou 2018
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MPFL ANATOMY
Nomura E, Inoue M, Osada N (2005) Anatomical analysis of the medial patellofemoral ligament of the knee, especially the femoral atachment. Knee Surg Sports Traumatol Arthrosc;13:510-515.
Femoral inserton : 15.4 mm
• MCL – adductor tubercle
(Tuxoe et al., Conlan et al. )
• Anterior / MCL (Feller et al.)
• 9.5 mm proximal § 5 mm posterior (Nomura et al.)
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Quelle grefe?Gracilis
Reconstructon du MPFL
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PATELLA
- FixatonTunnel ou ancre, 1 or 2- Positon des tunnels
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PATELLA
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Positon du tunnel femoral
FEMUR
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Tension de la grefe
In vivo positoning analysis of Medial patellofemoral ligament reconstructon. Servien et al., Am J Sport Med, 2010 , Jan (1) : 134-9
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Gestes associés
Femoral tunnel enlargement after medial patellofemoral ligament reconstruction: prevalence, risk factors, and clinical effect.Am J Sports Med. 2014 Feb;42(2):297-301.
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Facteurs d’instabilité
1. Trochlear dysplasia
2. Patella alta
3. Tibial tubercle-trochlear groove distance (TT-GT) > 20mm
4. Patellar tilt > 20°Tibial Tubercule Transfer (TTT)Distal and/or Medial
Dejour H, Walch G, Nove-Josserand L, et al.: Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc. 2: 19-26, 1994
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IndicationDistalisation TTA
Patella alta
Caton-Deschamps index (AT/AP) > 1.2
P
A
Goal : Caton-Deschamps index = 0.8 - 1
T
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L’ index d’Insall-Salvati n’est pas affecté par un distal TTT
Distal TTT Pre opn = 135
Post op
n = 135
Caton-Deschamps 1.1(0.8-1.6)
0.90 (0.6-1.3)
Insall-Salvati 1.3(0.8 – 1.8)
1.2(0.9 – 1.8)
E. Servien, T Ait Si Selmi, Ph Neyret : Subjective evaluation of surgical treatment for patellar instabilityRev Chir Orthop, 2004, 90, 137-142
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IndicationMedialisation TTA
TA-GT (CT-Scan) > 20 mm
But = 10-12 mm
Trochlear groove coronal view (Bernageau et Goutallier)
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Indication osteotomie « mixte »
Patella alta
+
TA-GT excessive
Combinaison
Distalisation + Medialisation
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Technique chirurgicale Distalisation
6 cm
Voie antéromédiale
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Technique chirurgicale Distalisation
Préparaton de la fxaton mèchage à 4.5mm
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Technique chirurgicale Distalisation
6-8 cm
Servien E, Verdonk P, Neyret P: Tibial tuberosity transfer for episodic patellar dislocation. Sports Med Arthrosc. 15: 61-7, 2007
TTA : 6-8cm de long
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Technique chirurgicale Distalisation
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Technique chirurgicale Distalisation
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Technique chirurgicale Distalisation
4.5mm screws Perpendiculaires au tbia
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Technique chirurgicale Médialisation
Ostéotomie d’Elmslie-Trillat
Osteotomie pédiculée
Une vis corticale 4.5mm , légèrement ascendante
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Complications
1. « OVERMEDIALIZATION » » »
TAGT -12mm
Overmedialization: risque d’arthrose FP médiale
20y FU
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Complications
2. Fracture du tibia
3. Pseudarthrose de TTA
4. Patella infera
5. Sepsis…
COMPLICATIONS
8 mois postop
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trochleoplaste
Creusement Albee
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Indicaton?
• Cas par cas
• Course anormale de la rotule
• Dysplasie de trochlée (stage D)
• Luxaton habituelle
• Subluxaton en fexion
à 30°
• Echec ?
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Technique chirurgicale
Ancillaire spécial pour preserver le cartlage
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Préparaton
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Technique chirurgicale
Fixaton par des bandeletes de suture, vis ou 2 agrafes enfouies
Secton du cartlage en milieu de
trochlée
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Conclusion 1
Pathoanatomical factors not constant
Henri Dejour « menu à la carte »
Transfer of ATT for patella alta
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PF Laxity at 0º, 30º;Strict Lateral xray
Laxity, crossing sign, bump>4mm
No PF Laxity, No Dysplasia, Normal radiographs
No CT Required
MR Arthrogram
cartlage fap tear or chondrosis
MR neg
Consider EUA, scope Conservatve Rx, consider further w/u
CT Scan
TT-GT Patella alta Patella Tilt
20mm
MedializeTT
Index >1.2
Distalize TT
>20°
Balance Ligaments MPFL reconstucton
Episodic Patellar Dislocation
Episodic PF pain with knee instabilityFithian , Servien, Neyret
Tech Knee Surg 2007
Surgical Treatment
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D. Fithian 2005
Patellar tlt is a consequence, not a factor :MPFL rupture
In vivo positoning analysis of Medial patellofemoral ligament reconstructon. Servien et al., Am J Sport Med, 2010 , Jan (1) : 134-9
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Conclusion
MPFL + ? (cas par cas = menu à la carte!)