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The three-in-one proximal and distal soft tissue patellar realignment procedure: Results, and its place in the management of patellofemoral instability

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  • Perth Orthopaedics &Sportsmed centre

Abstract and Figures

The three-in-one procedure for extensor mechanism realignment of the knee combines lateral release, vastus medialis obliquus muscle advancement, and transfer of the medial one-third of the patellar tendon to the tibial collateral ligament. We observed 37 patients (42 knees) receiving this treatment at a minimum 25-month follow-up (range, 25 to 85 months; mean, 44). Thirty-two of 42 knees (76%) with recurrent patellar dislocation had good or excellent results after surgery. Redislocation occurred in four knees (9.5%). Skeletal immaturity, chondral damage, and generalized ligament laxity did not seem to affect outcome. Thirty patients (37 knees) were studied 2 years earlier as well (mean follow-up, 29 months). When comparing the results 2 years later, there was a significant deterioration in outcome over time. These results are comparable with the published results for other techniques of patellar stabilization. We describe the place of the three-in-one operation in our surgical protocol for patellofemoral instability, which is based on the principle that a procedure should be selected to address the underlying pathologic features in an individual case rather than always using one operation for all cases.
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The Three-In-One Proximal and Distal Soft
Tissue Patellar Realignment Procedure
Results, and Its Place in the Management of
Patellofemoral Instability*
Peter Myers, FRACS, Andrew Williams,† FRCS(Orth), Richard Dodds, OBE FRCS, and
Jens Bu¨low, MD
From The Brisbane Orthopaedic and Sports Medicine Centre,
Brisbane, Queensland, Australia
ABSTRACT
The three-in-one procedure for extensor mechanism
realignment of the knee combines lateral release, vas-
tus medialis obliquus muscle advancement, and trans-
fer of the medial one-third of the patellar tendon to the
tibial collateral ligament. We observed 37 patients (42
knees) receiving this treatment at a minimum 25-month
follow-up (range, 25 to 85 months; mean, 44). Thirty-
two of 42 knees (76%) with recurrent patellar disloca-
tion had good or excellent results after surgery. Redis-
location occurred in four knees (9.5%). Skeletal
immaturity, chondral damage, and generalized liga-
ment laxity did not seem to affect outcome. Thirty
patients (37 knees) were studied 2 years earlier as well
(mean follow-up, 29 months). When comparing the
results 2 years later, there was a significant deteriora-
tion in outcome over time. These results are compara-
ble with the published results for other techniques of
patellar stabilization. We describe the place of the
three-in-one operation in our surgical protocol for patel-
lofemoral instability, which is based on the principle
that a procedure should be selected to address the
underlying pathologic features in an individual case
rather than always using one operation for all cases.
Patellar instability and its surgical treatment (after a
period of rehabilitation has failed) remains controversial.
We present the results of a technique used by the senior
author (PM) and discuss its place in our current protocol
for surgical treatment of patellar instability. Preexisting
patellofemoral chondral damage
8,13
and generalized liga-
ment laxity
10,16
have been reported to be adverse factors
in extensor mechanism realignment surgery. Further-
more, a deterioration of results with time has been re-
ported for some techniques.
8,10
We assessed these obser-
vations in the context of our series.
PATIENTS AND METHODS
The senior author (PM) performed a combined proximal
and distal soft tissue patellar realignment procedure (the
three-in-one procedure
24
) for 48 knees with recurrent lat-
eral dislocation of the patella. All patients had undergone
a rehabilitation program and, in some cases, lateral re-
lease surgery. In skeletally mature patients, only those
with a Q angle
3
less than 25° underwent the three-in-one
procedure. A modified Elmslie-Trillat tibial tuberosity
transfer was preferred for knees having larger Q angles
(see “Discussion” section). In the skeletally immature pa-
tient, because of the risk of premature epiphyseal closure,
only soft tissue surgery was offered and therefore any
magnitude of Q angle was accepted for the three-in-one
procedure. The Q angle was measured with the patient
supine and the knee flexed 30° over a wedge support to
engage the patella in the trochlear groove. To reduce er-
rors in measurement due to rotation, the medial border of
the foot was kept vertical. A specially adapted goniometer
with a hinge to conform to the limb and a long arm to
reach to the anterosuperior iliac spine was employed. An
assessment for evidence of generalized joint laxity was
made using the criteria of Carter and Wilkinson.
5
Clinical records were reviewed and patients completed
postal questionnaires that incorporated the Hughston
* Presented in part at the annual meeting of the Australian Orthopaedic
Association, Hobart, Tasmania, September 1993.
Address correspondence and reprint requests to Andrew Williams,
FRCS(Orth), The Institute of Orthopaedics, Royal National Orthopaedic Hos-
pital Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom.
No author or related institution has received any financial benefit from
research in this study.
0363-5465/99/2727-0575$02.00/0
THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 27, No. 5
© 1999 American Orthopaedic Society for Sports Medicine
575
Knee Disorders Subjective History Visual Analog Score
(Hughston VAS), which has previously been validated.
12
Adopting the practice of the Hughston Clinic (Colum-
bus, Georgia), we equated a score of 90 to 100 with an
excellent result, one of 75 to 89 with a good result, one of
50 to 74 with a fair result, and one less than 50 with a poor
result (G. C. Terry, personal communication, 1994). Any
patient suffering a recurrent patellar dislocation after sur-
gery was reported as having a poor result, regardless of
his or her questionnaire score.
Thirty patients (37 knees) included in this study were
the subjects of a similar study made using the same cri-
teria for assessing outcome 2 years earlier.
24
The period of
follow-up then was a mean of 29 months (range, 10 to 70).
Comparison of outcome data from that study with the data
collected here, 2 years later, allowed assessment of any
changes in the result with time.
Operative Technique
An initial arthroscopic examination of the knee was per-
formed. In particular, any lesions that could be responsi-
ble for symptoms, such as plica or fat pad abnormalities,
were sought. Any unstable flaps of the patellar articular
cartilage were trimmed, but no shaving or drilling was
performed. Once arthroscopic examination was complete,
a skin incision was made starting over the midpoint of the
patella and continuing inferiorly to the medial side of the
tibial tuberosity. The incision was usually about 8 to 10
cm long. The incision was deepened through the subcuta-
neous fat to the fascia, from which the fat layer was
elevated to allow visualization of the lateral and medial
retinacula, patellar tendon, and superomedial patella
where the vastus medialis obliquus tendon inserts.
Division of the lateral retinaculum was performed with
an electric needle, taking care to leave the synovium in-
tact and not to extend the division proximal to the supe-
rior pole of the patella nor into the muscle fibers of the
vastus lateralis muscle.
The medial retinaculum was divided to release the vas-
tus medialis obliquus insertion and to reveal the medial
patellar tendon. The incision started adjacent to the su-
peromedial corner of the patella and passed inferiorly
about 5 mm from the edge of the medial patella, then ran
down the medial border of the patellar tendon to the tibial
tuberosity. Only the retinaculum was opened; the joint
was not breached. The sheath of the patellar tendon was
opened medially. The retinaculum was elevated medially
from the tibia to expose the anterior edge of the tibial
collateral ligament superior to the pes anserinus. The
medial one-third of the patellar tendon was detached from
its tibial insertion by sharp dissection and split from the
remaining tendon, leaving it attached proximally to the
patella. This portion of the patellar tendon was then
transferred medially and sutured to the tibial collateral
ligament so that the transferred portion made an angle of
40° to 45° with the intact patellar tendon (Fig. 1). The
knee was flexed approximately 30° during the insertion of
sutures to prevent overtightening of the transferred por-
tion of the patellar tendon relative to the intact
two-thirds.
The vastus medialis obliquus tendon insertion was ad-
vanced 5 to 10 mm distally and laterally by means of
stout, interrupted plicating sutures. Usually three or four
sutures were required. Then a continuous suture was used
to close the retinaculum (Fig. 2).
The tourniquet used during the procedure was deflated
and hemostasis was achieved before the wound was closed
in layers over a suction drain. Local anesthetic was infil-
trated into the wounds, the lateral release site, and the
knee joint. Dressings and a brace (to maintain 20° of
flexion) were applied. The postoperative regimen was 2
weeks of nonweightbearing followed by a transition from
partial to full weightbearing over the next 2 weeks, during
which time the patient was “weaned” off the brace to begin
limited movement. At 6 weeks after surgery, a program of
strengthening and restoration of range of movement was
commenced. At 12 weeks after surgery, a period of sport-
specific rehabilitation was started.
Figure 1. Lateral release and transfer of the medial one-
third of the patellar tendon to the tibial collateral ligament in a
right knee.
576 Myers et al. American Journal of Sports Medicine
RESULTS
Data were available on 42 (88%) knees from the 48 oper-
ated on. The minimum period of follow-up was over 2
years (range, 25 to 85 months; mean, 44). The mean pa-
tient age was 21.1 years (range, 13 to 56). There were 12
male and 25 female patients and 11 patients had gener-
alized ligament laxity. Prior surgical interventions are
summarized in Table 1.
There were 76.2% good (17 knees) or excellent (15
knees) results. Of the five knees with poor results, three
had overall scores on the Hughston VAS of less than 50,
and two of these had recurrent patellar dislocations. The
other two knees with poor results also had recurrent dis-
locations but had better Hughston VAS scores. One of
these patients was back to full sporting activity, and the
other was rated fair according to the Hughston VAS score.
Overall, the redislocation rate was 9.5% (four knees). Two
of those patients with redislocations have undergone sub-
sequent Elmslie-Trillat patellar realignment procedures
with satisfactory outcomes.
No significant difference was found in the rate of good or
excellent results for skeletally immature compared with
skeletally mature patients by application of the chi-square
test with Yates correction (P.0.1). The grades of patellar
articular surface damage (according to Outerbridge
26
) and
subsequent surgical outcome scores are summarized in
Table 2. Applying the statistical analysis described ear-
lier, no significant relationship of patellar chondral dam-
age and outcome was found (P.0.1).
Overall outcome scores for the 30 patients (37 knees)
who were assessed in the preliminary study were com-
pared with the outcome scores for the current study. In the
earlier report, at a mean 29 months’ follow-up, there were
87.5% good or excellent results (32 of 37 knees) compared
with 76.2% (32 of 42) 2 years later using the same criteria
for assessing outcome. Applying the signed Wilcoxon rank
sum test revealed that the deterioration in functional
outcome was statistically significant (P,0.05).
Complications after surgery were seen in two patients.
One developed a deep vein thrombosis that was treated
with warfarin. Another patient required open arthrolysis.
Many of the patients’ scars spread, but none were hyper-
trophic. Despite this, there were no complaints of scar
sensitivity.
DISCUSSION
The technique described here is a modification of the pro-
cedures described by Goldthwait,
15
Slocum et al.,
30
and
Mansat.
21
The effect of the medial soft tissue surgery is to
reinforce the medial patellofemoral and patellotibial liga-
ments in “fascial layer 2”
31
and the medial patellomenis-
cal ligament in “fascial layer 3.”
31
These ligaments com-
bine to provide more than 75% of the passive resistance to
lateral patellar displacement.
7
They are usually attenu-
ated in cases of recurrent patellar instability. In addition,
the medial surgery combined with the lateral release
counters the laterally directed force on the patella during
knee motion. Medial transfer of the medial one-third of
the patellar tendon rather than the lateral one-third, as in
the Roux-Goldthwait procedure, avoids problems of induc-
ing lateral patellar tilt.
Figure 2. Technique for advancement of the vastus medialis
obliquus tendon insertion and closure of the medial
retinaculum.
TABLE 1
Prior Surgeries Undergone by Patients in this Study
Previous surgery Number
Diagnostic arthroscopy 7
Lateral release 4
Removal of loose bodies 1
Unknown operation 1
TABLE 2
The Relationship Between the Outerbridge Grade of Patellar
Chondral Damage and Postoperative Outcome Grade
Patellar chondral
damage (Outerbridge
grade)
Outcome
Good/Excellent Fair/Poor
0–2 28 6
3–4 4 4
Vol. 27, No. 5, 1999 Proximal and Distal Soft Tissue Patellar Realignment 577
We believe our patient-assessment method by means of
the Hughston VAS is appropriate. It is a valid clinical
outcome measure. The Hughston VAS allows objective
assessment of subjective symptomatic and functional sta-
tus. Furthermore, it has been compared favorably
12
with
the Larson,
19
Lysholm,
20
and Noyes
25
knee scores.
Over 100 surgical procedures have been described for
the treatment of patellofemoral instability. Although each
has its merits and disadvantages, none is ideal for all
cases. The major problems in comparing published results
of surgical treatment of patellofemoral instability are that
the indications for surgery and the patient groups are
dissimilar, and the methods of patient assessment vary
greatly among studies.
Some surgeons advocate lateral release alone, even for
recurrent patellar dislocation.
11,23
Good results have been
reported for proximal soft tissue procedures.
17,28
The
Roux-Goldthwait soft tissue realignment procedure has
been well documented.
6,13
Bonnard et al.
2
reported results similar to ours using a
technique different from the one we describe, but they
included medial transfer of the medial patellar tendon to
the tibial collateral ligament in children. The Elmslie-
Trillat procedure (involving tibial tuberosity transfer) has
had satisfactory results reported.
4,8, 27,32
The results we
present for the three-in-one operation are comparable
with those published for other procedures. Compared with
the published literature, our series is significant in size
and length of follow-up.
Our 9.5% rate of recurrent dislocation compares well
with the rates reported by other authors. Scuderi et al.
28
recognized redislocation as a “common complication” after
a patellar realignment procedure. In their review of pub-
lications they found redislocation rates varied from 5% to
25%. A problem in interpreting the literature is that it is
not always possible to be sure whether recurrent instabil-
ity refers to dislocation or subluxation or both. Unfortu-
nately, unlike the report by Shelbourne et al.,
29
most
studies do not clearly differentiate recurrent subluxation
from recurrent dislocation.
Several authors have been able to correlate chondral
damage of increasing severity on the patella with a poor
outcome after patellar realignment surgery.
8,13
However,
like other authors
17,28
we did not find this relationship.
Similarly, we did not find an association between the
presence of generalized ligament laxity and a poor out-
come, although this has been previously reported.
10,16
Dandy and Desai
10
noted a deterioration in the results
according to the system of Crosby and Insall
9
from 50%
graded excellent at 4 years after lateral release in cases of
frank recurrent lateral dislocation of patella to 37% at 8
years. We, too, noticed a deterioration in functional out-
come for the patients evaluated in our earlier study.
24
Presumably, this is due to a degree of stretching of the soft
tissues, declines in patients’ compliance with rehabilita-
tion exercises, occurrence of new knee abnormalities, and
possibly a decline in activity levels with age.
The management of anterior knee pain is controversial.
A problem is that there is a range of disorders that can
have similar clinical findings. Merchant
22
has proposed a
classification system for patellofemoral disorders. In keep-
ing with this type of approach, most orthopaedic surgeons
now appreciate the importance of careful patient evalua-
tion to allow identification of an underlying cause for the
patients’ symptoms, rather than simply assigning a diag-
nosis such as the previously overused chondromalacia pa-
tellae.
14
Some cases are due to occult patellofemoral in-
stability. Furthermore, if rehabilitation treatment fails to
provide symptomatic relief, then patellar realignment
may be considered. However, our experience with the
three-in-one procedure for patients with anterior knee
pain has been disappointing. Twenty-two knees with an-
terior knee pain but no overt dislocations or subluxations
that were believed to have clinical signs suggestive of a
predisposition to patellofemoral instability underwent the
procedure. Only 12 (54.5%) of these knees had good or
excellent results (assessed by the same means as in the
current study). We do not recommend the three-in-one
operation in these cases and no longer use it for them.
In patellofemoral instability, identification of an under-
lying abnormality should allow selection of the surgery,
when appropriate, designed to specifically address the
underlying cause. This is the basis for our current ratio-
nale for surgical treatment of patellofemoral instability
once a rehabilitation program has been unsuccessful.
If clinical evaluation reveals a positive lateral patellar
glide test,
18
then pathologically tight lateral parapatellar
soft tissues are likely to be responsible for symptoms. This
test is performed with the thigh relaxed and the knee
flexed to 20° to 30°. A positive result is judged when
passive lateral displacement of the patella is possible to
two patellar quadrants or more combined with less than
one quadrant of medial displacement. In the uncommon
situation that this is the only abnormality found, we will
perform an isolated arthroscopic lateral release, if reha-
bilitation treatment has failed.
Those patients with bone abnormalities (as evidenced
by features such as increased tibiofemoral valgus or per-
sistent lower limb torsional abnormalities) who require
surgery are treated by the modified Elmslie-Trillat proce-
dure (medial tibial tuberosity transfer and lateral reti-
nacular release) to address the bone malalignment. If
patella alta is present, the patella is also moved distally to
a normal height by moving the tibial tuberosity inferiorly
as well as medially. Before definitive fixation of the dis-
placed tibial tuberosity, temporary fixation with a stout
Kirschner wire is undertaken and “dynamic” stability of
the patella, with the knee flexed at 30°, is tested by intra-
operative femoral nerve stimulation. The optimal position
for the transferred tibial tuberosity is found where neither
net lateral nor medial displacement of the patella occurs
when the quadriceps muscle is activated by means of
stimulation of the femoral nerve in the groin. If patellar
stability is still poor after patella alta has been addressed,
the usual cause is an excessively shallow trochlear groove.
In this situation we have occasionally deepened the groove
by means of the Albee procedure,
1
whereby the lateral
femoral condyle is elevated by inserting a wedge of bone
graft.
578 Myers et al. American Journal of Sports Medicine
In skeletally mature patients we now reserve the three-
in-one procedure for those who have presumed failure of
their medial parapatellar soft tissue restraints, usually
after significant trauma, and lack the bone abnormalities
described previously. The surgery here is to restore nor-
mal soft tissue balance. The poor results of the three-in-
one procedure we obtained when used for patients with
anterior knee pain may reflect the fact that many of these
patients, although having clinical evidence of patellofemo-
ral instability, also had features of abnormal bone config-
uration and the three-in-one procedure did not address
these.
In view of the risk of physeal arrest, the modified
Elmslie-Trillat procedure cannot be offered to the patient
who is not skeletally mature. In this situation, if surgery
is absolutely necessary, the three-in-one procedure is an
option (although it cannot address bone malalignment). If
the postsurgical stabilization achieved deteriorates with
time, the modified Elmslie-Trillat procedure can be per-
formed when skeletal maturity is reached. In our experi-
ence, of the few cases requiring this sequence of operations
there is no particular technical difficulty in performing the
second procedure and the results have been gratifying.
We believe that the results of the three-in-one procedure
when used in appropriate patients are comparable with
those of other satisfactory operations. According to the
protocol we have described for surgical management of
patients with patellofemoral instability, this procedure is
especially useful for the skeletally mature patient with
recurrent patellar instability and normal bone configura-
tion, and occasionally in those who are skeletally imma-
ture even if a bone abnormality is present.
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Vol. 27, No. 5, 1999 Proximal and Distal Soft Tissue Patellar Realignment 579
... Baseline characteristics of the overall group and the groups before and after 2010 are reported in Table 1. The mean overall follow-up was 10.4 ± 4.8 years (range [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. The group that was operated before 2010 had a significant longer mean follow-up period compared with the group that was operated after 2010 (14.1 vs 6.6 years, p = 0.02). ...
... Other widely used procedures are the 3-in-1 technique and the Roux-Goldthwait procedure. The SST-procedure differs from the 3-in-1 technique [13,15] by reinforcing the MPFL by a medial retinaculum strip instead of advancing the vastus medialis muscle. Also, after 2010 the lateral quarter of the PT is used, whereas the 3-in-1 technique uses the medial half of the PT. ...
... After a mean follow-up of 10.4 ± 4.8 years (range [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19], an overall redislocation rate of 23.5% and subluxation rate of 38.2% was observed after the SST-procedure. However, the incidence decreased significantly after 2010 (5.9%), after the slight change of the surgical technique. ...
Article
Full-text available
Purpose The ‘Spaarne soft tissue procedure’, is a 4-in-1 soft tissue procedure that treats recurrent patellar dislocations in the young and active population. The procedure has not yet described elsewhere. The purpose of this study is to analyse the redislocation rate and to evaluate the postoperative knee function and patient satisfaction. Methods Twenty-seven patients (34 knees) underwent the four-in-one SST-procedure. The 4-step technique required a minor change in 2010, including the use of a smaller strip of the patellar tendon for transposition. After a median follow-up of 10.4 years, the redislocation rate was evaluated as the primary outcome measure. Secondary outcome measures were functional outcome (IKDC, Kujala, Lysholm and Tegner activity scale) and Numeric Rating Scales for satisfaction and pain. Results Redislocation occurred in 8 cases (23.5%) and subluxation occurred in 13 cases (38.2%) post-surgery. A significant higher number of redislocations and subluxations were seen before 2010 ( p = 0.04, p = 0.03). The median postoperative IKDC, Lysholm and Kujala scores for the total group were 54, 76 and 81 respectively. Pre- and postoperative Tegner activity scale were both level 3. Median NRS scores during rest, walking and sports were 1, 3 and 5 respectively. Satisfaction with the procedure was reported as ‘excellent’ or ‘good’ by 79% of the patients. Conclusion Despite the high overall redislocation rate and increased pain scores, the SST-procedure shows to be a safe procedure in patients with recurrent patellar dislocations based on the cases after 2010. Mid- and long-term results show moderate to good functional outcomes and satisfaction. Level of evidence Therapeutic retrospective cohort study, LEVEL III
... Without bone plug 13,42,43,57 : requires soft tissue fixation techniques such as anchors. ...
... (2) No need for anchors or bone tunnels, avoiding complications from hardware usage; and (3) Patellar insertion of the patellar tendon is an anatomic position of the MPTL. 13,34,35,41,43,57 Disadvantages: (1) Tibial insertion of the hamstrings, ST or G is a nonanatomic position for the MPTL tibial attachment. 11,12,14,29,30,33,55,56 The hamstring insertion (41 ± 6.6 mm distal from the joint line and 6.88 ± 1 mm medial to the patellar tendon 58 ) is more distal and more midline than the MPTL insertion ≈13 mm distal to joint line and ≈12 mm medial to patellar tendon 17,59 ; (2) Distal to proximal tibial growth plate. ...
... 8,61 CLINICAL OUTCOMES Insight into the role of the distal patellar restraints is derived from articles discussing patella motion parameters associated with injury site, 25 clinical improvement after repair of MPML, 25 and successful patellar stabilization after reconstruction of the MPTL ligaments. [9][10][11][12][13][14]29,32,35,40,43,55 In a systematic review on MPTL reconstructions 19 articles were included detailing the clinical outcomes of 403 knees. 16 The surgical procedures described included hamstrings tenodesis with or without other major procedures, medial transfer of the medial patellar tendon with or without other major procedures, and the reconstruction of the MPTL in association with MPFL reconstruction. ...
Article
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The important medial patellar ligamentous restraints to lateral dislocation are the proximal group (the medial quadriceps tendon femoral ligament and the medial patellofemoral ligament) and the distal group [medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML)]. The MPTL patellar insertion is at inferomedial border of patella and tibial insertion is in the anteromedial tibia. The MPML originates in the inferomedial patella, right proximal to the MPTL, inserting in the medial meniscus. On the basis of anatomy and biomechanical studies, the MPTL and MPML are more important in 2 moments during knee range of motion: terminal extension, when it directly counteracts quadriceps contraction. In a systematic review on MPTL reconstructions 19 articles were included detailing the clinical outcomes of 403 knees. All were case series. Overall, good and excellent outcomes were achieved in >75% of cohorts in most studies and redislocations were <10%, with or without the association of the medial patellofemoral ligament. The MPTL is a relevant additional tool to proximal restraint reconstruction in select patient profiles; however, more definitive clinical studies are necessary to better define surgical indications.
... Clinical correlation for MPTL is derived from articles discussing patella motion parameters associated with injury site [11], imaging correlation with injury [37], and reconstruction of the MPTL ligaments [1,5,8,9,12,13,15,17,22,28,34,38]. ...
... Both techniques were analogous to MPTL reconstruction. Myers et al. [28] perform MPTL reconstruction in skeletally mature patients with Q < 25° or skel- [27] showed MPTL reconstruction to be a good option in case of objective habitual patella dislocation or chronic lateral instability; Zaffagnini et al. [38] (2014) used the same technique in case of dislocation, traumatic or atraumatic, with no resolution of symptoms after at least 3 months of conservative treatment. These reported clinical series were without a MPFL reconstruction. ...
Chapter
To better understand the patellofemoral joint’s complex anatomy, and perhaps improve surgical outcomes, focus on the distal medial patellar restraints (medial patellotibial ligament (MPTL) and patellomeniscal ligament (MPML)) has been recently scrutinized for their (potential) role in injury and surgery [3, 9, 11–13, 19, 24, 25, 32, 33, 35, 37]. The anatomy of the medial patellar restraints has been previously detailed [24, 34], and described in a companion chapter in this publication. Therefore, it is not included in this chapter.
... Management of recurrent patellofemoral instability remains a complex pathological process, with a wide range of treatment options and a lack of standardized surgical protocols. 2,9,11,17,22,34 Hawkins et al 23 reported on its natural history, with persistent instability and anterior knee pain manifesting in 30% to 50% of patients treated nonoperatively. Surgical stabilization of the patella has been shown to improve outcomes in selected patients; however, the interpretation of results may be limited given the wide range of treatment modalities available. ...
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Background Few studies have reported the long-term outcomes of patellar stabilization surgery in an active duty military cohort. Purpose To evaluate the long-term results of a combined open and arthroscopic patellar stabilization technique for the treatment of recurrent lateral patellar instability in members of a military population. Study Design Case series; Level of evidence, 4. Methods We performed a retrospective review of a consecutive series of 63 patients who underwent operative management for patellar instability at a tertiary military medical center between 2003 and 2017. All cases were performed by a single sports medicine fellowship–trained orthopaedic surgeon. Patients with recurrent lateral patellar instability whose nonoperative management failed were included. All patients underwent arthroscopic imbrication of the medial patellar retinaculum, an open lateral retinacular release, and an Elmslie-Trillat tibial tubercle osteotomy. Outcome measures at final follow-up included recurrent instability, need for surgical revision, subjective assessments, and military-specific metrics. We also analyzed anatomic risk factors for failure: patella alta, coronal plane alignment, trochlear dysplasia, and tibial tubercle–trochlear groove distance. Results A total of 51 patients were included (34 men, 17 women; mean ± SD age at surgery, 27.2 ± 5.8 years; mean follow-up, 5.3 years). The mean postoperative SANE score (Single Assessment Numeric Evaluation) was 75.0 ± 17.7, and the mean visual analog scale pain score was 2.5 ± 2.1. Four patients (7.8%) reported redislocation events, and 4 underwent revision surgery. Twenty-five patients (49.0%) reported a decrease in activity level as compared with preinjury, while 10 (19.6%) cited restrictions in activities of daily living. Of the 21 patients remaining on active duty, 6 (28.6%) required an activity-limiting medical profile. Of the 48 active duty patients, 12 (25.0%) underwent evaluation by a medical board for separation from the military. Differences in the Caton-Deschamps Index and tibial tubercle–trochlear groove distance between surgical success and failure were not statistically significant. Conclusion Surgical management of patellar instability utilizing a multifaceted technique resulted in low recurrence rates and may be independent of predisposing anatomic risk factors for instability. At 5-year follow-up, most patients retained their active duty status, although nearly half experienced a decrease in activity level.
Chapter
Patellar instability with recurrent dislocation prevents most patients from returning to regular physical and sports activities. For acute pattelar dislocation, conservative treatment is mainly the first choice of treatment. However, the redislocation rate is high. Anatomical and biomechanical studies show that the medial patellofemoral ligament (MPFL) is the primary restraint to lateral patellar translation between 0 and 30° of knee flexion. Patellar stabilization with MPFL reconstruction is a successful treatment option for patellar instability. It is a mini-invasive surgical procedure associated with low postoperative complications.
Chapter
The posterior cruciate ligament (PCL) is the primary posterior stabilizer in the knee. Recent anatomical and biomechanical studies have provided a better understanding of PCL function. PCL injuries are typically associated with other ligament, meniscus, and chondral injuries. Stress radiography is very important in surgical decision making and postoperative evaluation. While isolated grade I or II PCL injuries can usually be treated without surgery, surgical treatment is indicated when acute grade III PCL ruptures occur in conjunction with other ligament injuries and/or repairable meniscus tears. Surgical options for PCL reconstruction are transtibial and tibial inlay reconstruction techniques with single- or double-bundle reconstruction. These techniques can be performed both arthroscopically and open. However, it is not clear which is the best method for PCL reconstruction.
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The purpose of this study was to present a medial plication using an arthroscopic all-inside technique for the treatment of patellar instability in adolescents. From July 2009 to June 2012, 19 patients with acute patellar dislocation were operated by this technique. Of these patients, follow-up was available in 17 patients at an average of 3 years (range: 1.5-4 years). At the follow-up, we evaluated the patients with physical examinations, radiographs, computed tomography scan, as well as the Lysholm and Kujala scoring scales. No recurrence of patellar instability has been found. The recovery of knee mobilization resulted to be good. We think this could be a valid technique to treat patellar instability in adolescents with less associated morbidity and good cosmetic results.
Article
Purpose The purpose of this study was to investigate the isolated and combined effects of MPFL and MPTL deficiency and reconstruction on patellofemoral kinematics. Methods Sixteen matched-paired female cadaveric knee specimens with a mean age of 53.5 years (range, 26-65) were tested in five conditions; 1) intact, 2) MPFL or MPTL cut, 3) MPFL and MPTL combined cut, 4) MPFL or MPTL reconstruction, and 5) MPFL and MPTL combined reconstruction. Dynamic testing allowed continuous analysis of kinematics from 0° to 90° of knee flexion. Knees were also tested statically using a lateral load of 45 N at 0°, 30°, 60°, and 90° of flexion. In both dynamic and static loading tests, a motion capture system detected patellar position for each testing state to distinguish changes in patellar kinematics. Random-intercepts linear mixed-effects models were used to compare patellar kinematics. Results The MPFL is the primary restraint to lateral translation of the patella at all knee flexion angles. MPTL deficiency alone did not create significant patella instability, but further increased instability when the MPFL was deficient. Isolated MPFL and combined reconstruction provided improved stability. Through full range of motion native patella tracking was best recreated with combined ligament reconstruction. Conclusion The MPFL plays the greatest role in medial patellar stability, but the MPTL appears to have an influence on patella tracking. This study provides further understanding to the impact of the MPFL and MPTL on patellofemoral motion with implications for reconstruction to improve stability and optimize patellofemoral tracking.
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A questionnaire using a system of visual analog scales was developed for analyzing subjective knee com plaints. This system was tested on 117 consecutive patients who had undergone knee surgery and 65 patients at their initial office evaluation of a knee disor der. The validity of and patient affinity for this type of questionnaire was compared with that of three other established subjective evaluation methods. The visual analog scale system was shown to be valid and comparable to other methods while offering several advantages. It brought greater sensitivity and greater statistical power to data collection and analysis by allowing a broader range of responses than did traditional categorical responses. It removed bias that was introduced by examiner questioning, and it allowed graphic temporal comparisons. Most importantly, pa tient affinity was higher for this type of subjective evaluation than for other methods.
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This study describes the results of treating selected patients suffering from recurrent dislocation of the patella, with closed lateral retinacular release. Thirty-nine patients were reviewed after a mean follow-up time of 28 months. Thirty patients were substantially improved by the procedure, two patients had sustained a further dislocation. The major complication — haemarthrosis — occurred in four patients. These results compare favourably with those achieved by major realignment procedures. So lateral retinacular release is an effective treatment for selected patients with recurrent patella dislocation, and it offers distinct advantages over other procedures.
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In 26 knees treated by semitendinosus tenodesis, there was no recurrence of dislocation, but fair and poor results totaled 38% due to persistent pain because of chondromalacia of the patella. Poor results are also more common in the patients with generalized ligamentous laxity. Postoperative complications in wound healing suggest that the medial parapatellar skin incision is less than adequate. Semitendinosus tenodesis with or without modifications is a useful procedure to prevent recurrent dislocations and subluxation during the growth period.
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In a prospective study extending from 1966 to 1974, the results of the Hauser procedure were compared with the Roux-Goldthwait procedure for the correction of recurrent dislocations of the patella. In 87 knees in 75 patients, repaired consecutively and in a random manner with one procedure or the other, 100% retrieval was achieved. The average follow-up period was 7.7 years. Significant complications, though not necessarily of long term, occurred in 24 of 47 knees receiving Hauser repairs as compared with 6 of 40 knees in the Roux-Goldthwait group. Satisfactory long-term results were obtained in 72% with the Hauser technique and 93% with the Roux-Goldthwait technique.
Article
The goal of this study was to delineate the consistent anatomical structures in the medial side of the knee and to determine their relationship to one another. One hundred and fifty-four fresh human knee joints were dissected. A three-layered pattern was found in which ligaments could be consistently placed. We have made suggestions regarding the nomenclature of these structures. The limits of of the so-called capsule and its significance as a stabilizer of the knee joint were examined. Only minor variations in the over-all anatomical pattern were found.
Article
Eighty-one knees surgically treated and twenty-six conservatively treated for recurrent dislocation of the patella in seventy-eight patients were studied. The average follow-up on the surgically treated knees was eight years and on the conservatively treated knees, sixteen years. In the non-surgical group dislocations tended to become less frequent with advancing age and there was very little evidence of osteoarthritis. After the sixty-nine tibial tubercle transfers there was a 20 per cent recurrence rate; further procedures were often needed, and the incidence of late osteoarthritis was disturbingly high. After the twelve soft-tissue corrections without movement of the tibial tubercle, dislocation recurred in three, but late osteoarthritis was not seen.
Article
Before bony maturity, the treatment of the recurrent dislocation of the patella is based on tendinous transfers. These distal procedures were often combined with proximal procedures on the medial or lateral patellar retinaculum and vastus medialis muscle. For the purpose of analysing efficacity of the medial third tendon transfer to the distal and deep part of the medial collateral ligament before the bony maturity, 24 children have been reviewed with a post operative follow up of 14 months to 6 and half years. There were 4 boys and 20 girls between 7 to 15 years old at the time of surgery. The troubles duration before the operation was from a few days to 4 years and the pathology was very often bilateral (40 knees). The recurrent dislocation of the patella was present 6 times, an instability 25 times and a traumatic dislocation 9 times. The technical procedure was every time a stabilisation with the transfer of medial third of the patellar tendon, associated except in 6 cases with a correction of the patellar motion by patellar retinaculum plasties. The functional result has been evaluated according to the sport activity and the ordinary life, with very hard criteria according to patient's age. Twenty-four times the result was excellent (60 per cent), 8 times good (20 per cent) and fair 8 times. Two complications have been observed. The improvement of the trochlea angle, and the trochlea deepness have been significant. Sixteen patients (27 knees) have been reviewed after the bony maturity and no growth disturbance of the tibial tuberosity has been observed.(ABSTRACT TRUNCATED AT 250 WORDS)