The Operative Management of Patella Malalignment

Abstract

Management of patellofemoral joint pathology is challenging as a result of the unique and complex organization of static forces and dynamic factors contributing to its functional capacity. Anterior knee pain is a common musculoskeletal complaint seen daily in the practices of primary care physicians, rheumatologists, and orthopedic surgeons. The key to successful treatment lies not only in the correct diagnosis of a chondral defect, but more importantly, in the accurate identification of associated pathomechanical factors. Appreciating the pathoanatomic basis of the disease and addressing imbalances and anatomical abnormalities should guide treatment.Despite the complexity of the interplay of various components it is essential to attempt to describe patellar malalignement as a clinical entity in order to proceed with appropriate surgical management and successful outcomes. The goals of patellofemoral re- alignment surgery should be to create both a stable environment for optimal extensor mechanism performance and an appropriate load transmission for optimal cartilage wear and joint loading. In the context of this article we will review the operative management of patellofemoral malalignment; the indications for surgery, the different techniques available and the evidence regarding their effectiveness.A large number of procedures have been employed and they have all undergone various modifications over the course of the years. The majority of publications are retrospective series in poorly defined population groups. There are significant methodological inconsistencies and as a result there is lack of strong evidence base for the majority of these procedures.

Torsional osteotomies of the femur

“…Thus, in patients who underwent concomitant surgical procedures, the results obtained at the followup examination could not be assigned to the femoral torsional osteotomy alone. For example the treatment of patellofemoral instability with an isolated lateral release has been reported to yield poor long-term results in several studies; [21][22][23] combinations of lateral release and reconstruction of the medial retinaculum have provided better results. 21,[24][25][26] Modern procedures with autologous tendon graft were superior to an isolated suture, (arthroscopic or open) of the MPFL, which was performed in this study.…”

Patella Dislocation in Children and Adolescents

“…Der hochsignifikant höhere Grad der Patella-und Gleitlagerdysplasie mit vergrößertem Sulcuswinkel im Vergleich zur Kontrollgruppe spricht für deren Stellenwert als prädisponierender Faktor. Die Klassifikation der Trochlea nach Dejour [10,24,[26][27][28][29] Fast alle Patienten wiesen einen Patellahochstand auf (signifikant häufiger als KG), was den disponierenden Stellenwert des Patellahochstands bestätigt [35]. Nach aktuellen CT-Untersuchungen an einem großen Patientenkollektiv besitzen Patella-Tilt und Patelladeviation den höchsten prädiktiven Wert hinsichtlich des Auftretens einer PL [36].…”

“…94 % [57] und 98 % [59]. Die MPFL-R ist dabei rekonstruktiven Verfahren mit Vastus-medialis-Plastik oder Einsatz autologer Sehnentransplantate unterlegen [18][19][20][21][22][23][24][25].…”

“…In den letzten Jahren hat man sich vermehrt der Frage gewidmet, welchen Stellenwert dabei die unterschiedlichen Faktoren besitzen, inwieweit dies die Therapie zur Vermeidung von Rezidiven beeinflusst und welche operativen Verfahren am effektivsten sind [2,6,[14][15][16][17][18][19][20][21][22][23][24][25].…”

A Combined Closing Wedge Distal Femoral Osteotomy and Medial Reefing Procedure for Recurrent Patellar Dislocation with Genu Valgum

“…Furthermore, biplanar closing-wedge DFO (CWDFO) provides better stability and promotes bone healing, due to increased cancellous bone surface area at the osteotomy site 9101415. For these reasons, CWDFO could be a valuable procedure in a chronic patellar instability patient with excessive Q-angle stemming from significant genu valgum, Additional medial reefing with lateral release could be helpful when instability would be potentially intractable in the patient 1011121316…”