Chronic patellofemoral instability and pain treated effectively by anteromedial tibial tubercle transfer (Fulkerson osteotomy) with or without medial patellofemoral ligament reconstruction
DOI:
https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20213163Keywords:
Fulkerson osteotomy, Medial patellofemoral ligament, Patellofemoral painAbstract
Background-Chronic patellar instability (subluxation and dislocation) and pain is a debilitating knee condition that frequently involves young, active patients. Bony malalignment and soft tissue injury (torn or stretched MPFL) is considered as a surgical indication for distal realignment in the form of Anteromedial tibial tubercle transfer(Fulkerson osteotomy) with or without MPFL reconstruction that effectively prevents the patella from tracking laterally and thus unloads the lateral patella while making the patellofemoral joint more congruous , stable and pain free.
Materials and method - It is a prospective study of 22 patients of chronic patellar instability and pain. Follow up ranged from 24 to 36(average 30) months. Preoperative assessment included clinical examination, Lysholm, IKDC score and Radiological examination (X-ray, CT scan and MRI). 18 patients with history of dislocation and pain having bony malalignment and torn MPFL were treated with Fulkerson osteotomy and MPFL reconstruction and 4 patients with history of subluxation and pain having bony malalignment only were treated with Fulkerson osteotomy alone. Patients were followed up with the help of X-rays at regular interval and the clinical outcome was measured using scoring system.
Results-There was a significant improvement in postoperative assessment with regards to scoring system (Lysholm and IKDC) and knee pain. Union at osteotomy site for all patients was seen. None of the patients had further episode of dislocation or subluxation. Pain at femoral site of MPFL reconstruction in 2 cases persisted for 3 months followed by resolution of their symptoms. One of our patients had profuse swelling at the site of operation postoperatively which was treated with Rest, Ice Pack, Compression and Limb elevation. Out of 22 patients undertaken infection at osteotomy site was seen in 1 patient for which implant removal was done from osteotomy site after union.
Conclusion-Anteromedial Tibial tuberosity osteotomy and MPFL reconstruction is a successful procedure to treat patellofemoral pain and instability.
References
Fulkerson JP. Anteromedialization of the tibial tuberosity for Patellofemoral malalignment. Clin Orthop Relat Res. 1983;176-81.
McConnell J. The physical therapist’s approach to patellofemoral disorders. Clin Sports Med. 2002;21:363-87.
Larson RL. Subluxation-dislocation of the patella. In: Kennedy JC, ed.
The injured adolescent knee. Baltimore: Williams & Wilkins. 1979;161-204.
Stephen JM, Dodds AL, Lumpaopong P, Kader D, Williams A, Amis AA.
The ability of medial patellofemoral ligament reconstruction to correct patellar kinematics and contact mechanics in the presence of a lateralized tibial tubercle. Am J Sports Med. 2015;43:2198-207.
Rue LJ-PH, Colton A, Zare SM. Trochlear contact pressures after straight anteriorization of the tibial tuberosity. Am J Sports Med. 2008;36:1953-9.
Ramappa AJ, Apreleva M, Harrold FR, Fitzgibbons PG, Wilson DR, Gill TJ. The effects of medialization and anteromedialization of the tibial tubercle on patellofemoral mechanics and kinematics. Am J Sports Med. 2006;34:749-56.
Beck PR, Thomas AL, Farr J, Lewis PB, Cole BJ. Trochlear contact pressures after anteromedialization of the tibial tubercle. Am J Sports Med. 2005;33:1710-5.
Stephen JM, Lumpaopong P, Dodds AL, Williams A, Amis AA. The effect of tibial tuberosity medialization and lateralization on patellofemoral joint kinematics, contact mechanics, and stability. Am J Sports Med. 2015;43:186-94.
Mulliez A, Lambrecht D, Verbruggen D, Van Der Straeten C, Verdonk P, Victor J. Clinical outcome in MPFL reconstruction with and without tuberosity transposition. Knee Surg Sports Traumatol Arthrosc. 2015.
Hauser EDW. Total tendon transplant for slipping patella: A new operation for recurrent dislocation of the patella. Surg Gynec Obstet. 1938;66:199-214.
Maquet P. A biomechanical treatment of femoro-patellar arthrosis: Advancement of the patellar tendon. Rev Rhum Mal Osteoartic. 1963;30:779-83.
Cox JS. Evaluation of the Roux-Elmslie-Trillat procedure for knee extensor realignment. Am J Sports Med. 1982;10:303-10.
Cox JS. An evaluation of the Elmslie-Trillat procedure for management of patellar dislocations and subluxations: A preliminary report. Am J Sports Med. 1976;4:72-7.
Fulkerson JP. Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop. 1983;177:176-81.
