Article

Success of torsional correction surgery after failed surgeries for patellofemoral pain and instability

Strategies in Trauma and Limb Reconstruction 12/2013; 9(1). DOI: 10.1007/s11751-013-0181-8
Source: PubMed

ABSTRACT

Torsional deformities of the femur and/or tibia often go unrecognized in adolescents and adults who present with anterior knee pain, and patellar maltracking or instability. While open and arthroscopic surgical techniques have evolved to address these problems, unrecognized torsion may compromise the outcomes of these procedures. We collected a group of 16 consecutive patients (23 knees), with mean age of 17, who had undergone knee surgery before torsion was recognized and subsequently treated by means of rotational osteotomy of the tibia and/or femur. By follow-up questionnaire, we sought to determine the role of rotational correction at mean 59-month follow-up. We reasoned that, by correcting torsional alignment, we might be able to optimize long-term outcomes and avert repeated knee surgery. Knee pain was significantly improved after torsional treatment (mean 8.6 pre-op vs. 3.3 post-op, p < 0.001), while 70 % of patients did have some continued knee pain postoperatively. Only 43 % of patients had continued patellar instability, and 57 % could trust their knee after surgery. Activity level remained the same or increased in 78 % of patients after torsional treatment. Excluding planned rod removal, subsequent knee surgery for continued anterior knee pain was undertaken on only 3 knees in 2 patients. We believe that malrotation of the lower limb not only raises the propensity for anterior knee symptoms, but is also a under-recognized etiology in the failure of surgeries for anterior knee pain and patellar instability. Addressing rotational abnormalities in the index surgery yields better clinical outcomes than osteotomies performed after other prior knee surgeries.

Full-text

Available from: Jeremy M Gililland, Mar 05, 2014
ORIGINAL ARTICLE
Success of torsional correction surgery after failed surgeries
for patellofemoral pain and instability
Peter M. Stevens
Jeremy M. Gililland
Lucas A. Anderson
Jennifer B. Mickelson
Jenifer Nielson
Joshua W. Klatt
Received: 23 February 2013 / Accepted: 29 November 2013
Ó The Author(s) 2013. This article is published with open access at Springerlink.com
Abstract Torsional deformities of the femur and/or tibia
often go unrecognized in adolescents and adults who
present with anterior knee pain, and patellar maltracking or
instability. While open and arthroscopic surgical tech-
niques have evolved to address these problems, unrecog-
nized torsion may compromise the outcomes of these
procedures. We collected a group of 16 consecutive
patients (23 knees), with mean age of 17, who had
undergone knee surgery before torsion was recognized and
subsequently treated by means of rotational osteotomy of
the tibia and/or femur. By follow-up questionnaire, we
sought to determine the role of rotational correction at
mean 59-month follow-up. We reasoned that, by correcting
torsional alignment, we might be able to optimize long-
term outcomes and avert repeated knee surgery. Knee pain
was significantly improved after torsional treatment (mean
8.6 pre-op vs. 3.3 post-op, p \ 0.001), while 70 % of
patients did have some continued knee pain postopera-
tively. Only 43 % of patients had continued patellar
instability, and 57 % could trust their knee after surgery.
Activity level remained the same or increased in 78 % of
patients after torsional treatment. Excluding planned rod
removal, subsequent knee surgery for continued anterior
knee pain was undertaken on only 3 knees in 2 patients. We
believe that malrotation of the lower limb not only raises
the propensity for anterior knee symptoms, but is also a
under-recognized etiology in the failure of surgeries for
anterior knee pain and patellar instability. Addressing
rotational abnormalities in the index surgery yields better
clinical outcomes than osteotomies performed after other
prior knee surgeries.
Keywords Pan genu torsion Miserable malalignment
Tibial torsion Femoral anteversion Osteotomy
Introduction
Anterior knee pain and patellofemoral instability are common
causes of knee problems in both adolescents and adults.
Theories as to the etiology of the above have included
quadriceps muscle imbalance, retinacular/soft-tissue tight-
ness, elevated ‘‘Q-angles,’’ pathomorphology of the trochlea,
and abnormal extensor complex (patella alta/baja) [13].
However, torsional deformities of the femur and/or tibia often
go unrecognized in both adolescents and adults who present
with anterior knee pain, and patellar maltracking and/or
instability. While arthroscopic [4] and open [5, 6] surgical
techniques have evolved to address the latter problems, the
results may be compromised by underlying torsion. Failure to
recognize and address the transverse plane deformities may
prove disappointing to the patient and surgeon alike.
We hypothesized that there would be a satisfactory
clinical improvement after rotational osteotomies of the
tibia and/or femur in knees with unrecognized torsional
abnormalities and ongoing knee problems after prior knee
surgery for anterior knee pain or patellofemoral instability.
Materials and methods
This study was a retrospective review on a group of 18
patients who all had developed anterior knee pain and/or
P. M. Stevens (&) J. M. Gililland L. A. Anderson
J. B. Mickelson J. Nielson J. W. Klatt
Department of Orthopaedic, Primary Children’s Hospital,
University of Utah School of Medicine, 100 Mario Capecchi
Drive Suite 4550, Salt Lake City, UT 84113, USA
e-mail: peter.stevens@hsc.utah.edu; peter.stevens@mac.com
123
Strat Traum Limb Recon
DOI 10.1007/s11751-013-0181-8
Page 1
instability before skeletal maturity and had all undergone
one or more prior knee surgeries before presenting to our
clinic where torsional abnormalities were recognized
(Fig. 1). Torsional deformities were treated by a single
surgeon in our institution (PMS) by means of rotational
osteotomy of the tibia and/or femur between May 1998 and
November 2010.
We contacted these patients with a custom outcome
questionnaire and 17 of 18 returned the questionnaire
(Fig. 2). One of the 17 returned questionnaires contained
incomplete data and was excluded. We therefore reviewed
the records of 16 participating patients with 23 operated
knees with mean 59-month follow-up (range
11–145 months). This group consisted of 13 females and 3
males. The mean age at the time of index rotational oste-
otomy was 17, with a range of 9–30 years of age. The
average number of prior knee surgeries per patient was 2
with a range of 1–4 (Table 1). A patient case example is
included in Fig. 3.
Prior to osteotomy, each patient had a ‘gunsight’
rotational CT scan or MRI to document the degree of
excessive torsion and determine whether to cut the femur,
Fig. 1 Torsion outcomes
questionnaire
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123
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tibia, or both [2, 7, 8] (Fig. 3). Surgical interventions
included femoral rotational osteotomy to correct antever-
sion, tibial rotational osteotomies to address outward tibial
torsion, and simultaneous ipsilateral tibial and femoral
osteotomies to address pan genu torsion (Tables 1 and 2).
Surgical correction of the contralateral extremity was
undertaken within 3 months in seven patients with bilateral
symptoms.
The femoral osteotomies were performed percutane-
ously, at the mid-shaft level and stabilized with an ante-
grade, locked, intramedullary rod, using a trans-
trochanteric (not piriformis) entry point [9]. In skeletally
mature patients, all tibial osteotomies were mid-shaft,
leaving the fibula intact, and secured with an intramedul-
lary rod [10]. If the patellar retinaculum was tight, as
judged by a negative patellar inversion angle, then a lateral
retinacular release was undertaken at the same sitting. The
intramedullary rods were removed approximately 1 year
after the osteotomies.
For the patients who were skeletally immature, the open
proximal physis precluded the safe use of an intramedul-
lary rod in the tibia. Instead, a supra-malleolar osteotomy
of the tibia was performed and stabilized with two smooth,
crossed Steinman pins, leaving the fibula undisturbed for
stability and support [11]. Following 4 weeks in a below-
the-knee cast, the pins were removed in the clinic and the
patients permitted weight bearing in a walking boot for an
additional month.
Clinical outcomes were evaluated by a custom ques-
tionnaire (Fig. 1). This questionnaire asked about preop-
erative and postoperative pain levels, recurrent patellar
instability, ability to ‘trust’ the knee, postoperative
activity levels, and any subsequent knee surgeries after the
rotational osteotomy and hardware removal.
Data were analyzed by an independent statistician using
commercially available software (STATA Version 11,
College Station, TX). Student’s t test was used for com-
paring the continuous variables of preoperative and post-
operative pain.
Results
Knee pain on a scale of 1–10 was significantly improved
after torsional treatment (mean 8.6 pre-op vs. 3.3 post-op,
p \ 0.001), while 70 % of patients did have some contin-
ued knee pain postoperatively (Table 3). Ten of 23 knees
had continued patellar instability after torsional treatment,
and 13 of 23 knees were ‘trusted’ by the patient of after
surgery. Activity level was improved after 15 of 23 of these
cases, remained the same after in 3 knees, and was
decreased after in 5 knees.
Our complication rate in this series was 8.7 % with 2
complications encountered. The first complication was a
femoral nonunion treated successfully with exchange
reamed nailing. The second complication was a peroneal
nerve irritation by a loose proximal tibial interlocking
screw. This was treated successfully with hardware
removal and peroneal neurolysis. Excluding planned rod
removal, subsequent knee surgery for continued anterior
knee pain was undertaken on three knees in two patients.
One patient underwent bilateral guided growth to address
Fig. 2 Bar graph illustrating
types and number of prior failed
surgeries before rotational
malalignment addressed
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123
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Table 1 Patient demographics and procedures
Patient Side Gender Age
a
Follow-
up (months)
Prior knee surgeries Femoral
torsional
correction (°)
Tibial
torsional
correction (°)
Lateral release at
time of
osteotomy
Complications Subsequent surgeries
1 R F 19 17 Tibial tubercle transfer 20 30 No Nonunion Exchange nailing for femoral
nonunion
2 L F 17 18 Arthroscopic debridement 9 220 30 No
3 R M 9 113 Arthroscopic debridement 20 20 Yes Distal femoral hemiepiphysiodesis,
knee arthroscopy, MPFL
reconstruction
3 L M 9 110 Arthroscopic debridement 20 20 No Distal femoral hemiepiphysiodesis
4 R F 16 18 Tibial tubercle transfer,
Arthroscopic debridement
20 30 Yes
5 R F 10 42 MPFL Reconstruction 30 No Tibial tubercle transfer and lateral
release
6 L M 22 41 Tibial tubercle transfer, medial
reefing
30 30 No
7 L F 24 61 Arthroscopic lateral release 30 40 No
7 R F 24 63 Arthroscopic lateral release 35 35 Yes
8 R F 15 117 Tibial tubercle transfer 25 No
8 L F 15 114 Tibial tubercle transfer 40 No
9 R F 17 36 Tibial tubercle transfer 30 Yes
9 L F 17 35 Tibial tubercle transfer 30 No
10 R F 17 86 Tibial tubercle transfer,
Arthroscopic lateral release
30 No
10 L F 17 82 Arthroscopic lateral release 25 No
11 R F 16 14 Arthroscopic debridement 25 Yes
11 L F 16 13 Arthroscopic debridement 30 Yes
12 L F 18 26 Tibial tubercle transfer,
Arthroscopic debridement,
Medial reefing
25 No Loose interlock
with nerve
irritation
Advancement left distal interlock
screw, decompression peroneal
nerve
12 R F 18 11 Tibial tubercle transfer 25 No
13 R F 18 64 Tibial tubercle transfer 25 Yes
14 L F 30 145 Tibial tubercle transfer,
Arthroscopic debridement,
Micro fracture
25 No Arthroscopic microfracture of
patella
15 R M 16 113 Arthroscopic debridement 30 Yes
16 R F 21 22 Arthroscopic debridement,
Arthroscopic lateral release
30 No
MPFL medial patellofemoral ligament
a
Age is age at time of osteotomy in years
Strat Traum Limb Recon
123
Page 4
genu valgum, bilateral patellar realignment, and MPFL
reconstruction. The second patient required a knee scope
debridement and microfracture (Table 1).
Discussion
Persistent torsional deformities of the femur and/or tibia
often go unrecognized in patients with anterior knee pain
and/or patellofemoral instability. As the associated acute
and chronic symptoms are most often at the knee, there is a
tendency for the orthopedic surgeon to focus on that level,
without screening for rotational abnormalities of the femur
and/or tibia. There is a lingering belief that the physiologic
torsional deformities, observed during childhood, are uni-
formly benign and self-limiting [12]. This belief may result
in a failure to appreciate the consequences of persistent and
pathological torsion; even Staheli states that ‘persistent
problems are often genetically determined and may only be
corrected by osteotomy.’ Unfortunately, failing to screen
for torsional deformities can lead to the detriment of some
Fig. 3 a A 12-year-old girl was ‘tackled’ playing soccer and
suffered a traumatic dislocation of her left patella. The arrow depicts
the osteochondral fracture. b Three years (and four knee operations)
later, she continues to have left patellar instability. She is now
developing knee symptoms on the right. c Her torsional profile
demonstrated 30° of excessive outward tibial torsion bilaterally. Her
‘gunsight’ CT scan corroborates the excessive bilateral tibial
outward torsion, in the presence of normal femoral version. d At
the time of her 30° rotational tibial osteotomy, the tubercle screws
were removed, leaving the transferred tubercle in situ. Two months
later, she underwent a rotational osteotomy of her right tibia. At latest
follow-up, she has stable patellae and is asymptomatic
Table 2 Operative details (n = 23 rotational surgeries)
Operative detail Number
a
Amount of correction
b
Femoral osteotomy 9 (39 %) 25 (20–35)
Tibial osteotomy 22 (96 %) 29 (20–40)
Both femoral and tibial 8 (35 %) 54 (40–70)
c
Lateral release 8 (35 %)
a
Data presented as mean with percentage of total cases in
parentheses
b
Data presented as mean with range in parentheses
c
Data presented as mean total combined correction of tibial and
femoral osteotomies with range in parentheses
Strat Traum Limb Recon
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Page 5
reconstructive endeavors of the orthopedic sports medicine
and adult reconstruction specialists [5, 1315] (Fig. 4).
Femoral anteversion and/or outward tibial torsion
have a dramatic effect upon the kinematics of the knee,
most notably of which may be seen at the patellofe-
moral join [11]. Eckhoff stated that ‘the patella is a
passive component of the extensor mechanism, where
the static and dynamic relationships of the underlying
tibia and femur determine the patellar tracking pattern’
[2]. Turner and Smillie in their measurements of tibial
torsion in over 800 patients found that patients with
patellofemoral instability had a significant increase in
outward tibial torsion [16]. Increased femoral antever-
sion, external tibial torsion, pan genu torsion, and knee
version (external rotation of the tibia with respect to the
femur) have all been shown to be associated with
anterior knee pain in various studies. Therefore, while
patellar instability and/or persistent patellofemoral pain
may require prompt and sometimes aggressive
management, the possibility that there is a proximate
cause of the problem should be kept in mind [1, 2, 8,
16]. In fact, Flandry and Hughston [15] showed a high
failure rate for extensor mechanism realignment when
the underlying cause of patellofemoral pain was exces-
sive femoral anteversion, external tibial torsion, or both.
A careful clinical assessment is most revealing and is
paramount to successful clinical management. When the
patient stands with their feet parallel, the patella should be
facing forward. The ‘foot progression angle’ should be
neutral when walking [12, 17]. When presenting individ-
ually, femoral anteversion is manifest by in-toeing and
outward tibial torsion by out-toeing. However, if there is
concomitant femoral anteversion and outward tibial tor-
sion, also known as pan genu torsion or ‘miserable mala-
lignment’ [7], the footprint will be neutral and this
combined long bone deformity may be concealed to the
unwary observer [7]. It is therefore important to have the
patient appropriately unclad and note the knee progression
angle as well [7, 10, 11].
Malrotation is readily documented by means of assess-
ing the torsional profile in the prone position. Tibial torsion
can be documented by measuring the thigh-foot axis
(normal = neutral to 15° outward) [16]. Femoral antever-
sion may be recognized by identifying, in the prone posi-
tion, how much inward rotation there is at each hip in
extension, compared to outward rotation (normally equal
inward and outward rotation ±30°)[5, 7]. The findings are
not always symmetrical; anecdotally, it is often noted that
the affected knee is the one that has more torsion. While
plain radiographs do not accurately identify torsion, they
are nevertheless helpful. A long-standing anteroposterior
radiograph of the legs, with the patellae neutral, will
identify any concurrent limb length discrepancy and/or
angular deformities. The apparent increase in the femoral
neck-shaft angle may be due to increased femoral ante-
version. One can observe the presence (or closure) of the
physes and measure the limb lengths and mechanical axis.
A lateral view of each knee and Merchant [18] or Laurin
views [19] of the patella may demonstrate patellar
Table 3 Clinical outcome
measures (n = 23 knees with
mean follow-up of 59 months)
a
Data presented as means with
95 % confidence intervals in
parentheses
Pain Preoperative Postoperative p value
Pain on scale of 1–10
a
8.6 (7.9–9.4) 3.3 (2.0–4.6) <0.001
Outcomes questionnaire item Postoperative response
Do you continue to have knee pain/problems? 70 % Yes
Have you had any patellar instability since surgery? 43 % Yes
Do you ‘trust’ your knee? 57 % Yes
Have you changed your lifestyle/activities? 65 % Increased
13 % Same
22 % Decreased
Have you had knee surgery since your osteotomy/hardware removal? 22 % Yes
Fig. 4 There is a prevalence of torsional anomalies (femoral
anteversion and/or outward tibial torsion) in females, and this is
often familial. This mother and daughter, both with excessive
outward tibial torsion, have undergone a variety of patellar stabiliza-
tion surgery, but remain symptomatic
Strat Traum Limb Recon
123
Page 6
malorientation or fragmentation, perhaps as a consequence
of long bone torsion.
Significant abnormalities documented on the clinical
examination, correlated with the history, may be an indi-
cation for advanced imaging. The standard is the ‘gun-
sight’ CT scan or MRI, employing accepted bony
landmarks to define and quantify the degree of malrotation
of the femur and/or tibia. While not mandatory, this
imaging may help to refine the plans for rotational cor-
rective osteotomies [2, 79, 11]. Lee et al showed through
a cadaver knee study that a 20° inward rotational deformity
of the femur resulted in increased lateral patellofemoral
contact pressures, and a drastic increase in lateral patel-
lofemoral contact pressure resulted when 30° or more
inward rotational deformity was seen [20]. We therefore
employ the femoral osteotomies for patients who have
greater than 20° of inward rotational deformity indicated
by the preoperative hip range of motion and CT scan.
Turner studied rotational profiles in over 1,200 patients and
showed consistently that patients with patellofemoral pain
and instability had increased tibial outward torsion mea-
suring an average of 24.5° [16]. We employ inward tibial
osteotomies for patients who have greater than 20° of
excess outward rotational deformity [11]. As can be seen in
the results from this study, our typical corrective rotations
are 25° in the femur and 30° in the tibia.
The level and specific technique/fixation of rotational
osteotomies remain up to the discretion of the surgeon,
which is typically a reflection of training and experience.
With the exception of the immature tibia, we believe
that intramedullary fixation offers several advantages [10,
21]. The surgical exposure is minimal, and the compara-
tively strong load-sharing implants are well tolerated.
Immediate mobilization of the joints without cast protec-
tion is also appealing to the patient and surgeon alike. In
the setting of the skeletally immature tibia, our preferred
method of derotation is a distal tibia osteotomy secured
with crossing Kirschner wires. We feel that distal tibial
osteotomies are simpler, well tolerated, and we have shown
that they work well in terms of correcting knee alignment
and frontal plane knee moments [11]. In 1994, two separate
studies showed improved outcomes for tibial rotational
osteotomies when the fibula was left intact [22, 23]. Fibular
osteotomy is rarely used in our practice and is reserved for
limbs where we cannot easily achieve the desired rotation.
In our experience, patients with anterior knee pain and
underlying torsional abnormalities respond very well to
derotational corrective osteotomies. In previous work, we
evaluated a group of 14 patients with anterior knee pain in
27 limbs with underlying pan genu torsion. These patients
all had excellent outcomes with derotational osteotomies of
their femurs and tibias [7]. However, none of these patients
had prior surgical interventions for their anterior knee pain.
The excellent outcomes seen in our 2004 study provide a
stark contrast to the results of the present study comprised
entirely of patients who had prior surgeries for their ante-
rior knee symptoms. About 70 % of the current study
patients had some continued knee pain, 43 % of these
knees had continued patellar instability, and activity level
was decreased in 22 % of these patients.
The history of prior failed knee surgery is not a con-
traindication to corrective osteotomy. In our experience, if
a lateral retinacular release has already been undertaken,
this may not need to be repeated. If the patellar tendon has
been transferred, it may be left in situ, removing the
retained screws if an intramedullary device is to be utilized.
If the patella remains unstable, revision of patellar align-
ment should be postponed pending the results of the rota-
tional correction; this may be undertaken at the time of rod
removal. Likewise, such draconian measures such as pat-
ellectomy or patellofemoral arthroplasty should be post-
poned unless or until the femoral and/or tibial malrotation
have been corrected [14, 24].
There are several limitations to this study. The retro-
spective nature yields itself to several biases, including
selection and recall bias. However, we did attempt to fol-
low these patients prospectively through the use of our
outcomes questionnaire. Our outcome measures are
inherently limited in that we are not using a validated
outcome measure such as the Lysholm knee score [25]. The
follow-up on this study was also relatively short-term,
limiting conclusions regarding prevention of arthritis,
lasting symptom relief, and need for further interventions.
A final limitation is that this is a relatively small and het-
erogeneous group of patients. While we have a prior study
of pan genu torsion patients without prior surgery, we feel
that this study of patients who had prior failed nontorsional
correcting surgery is a useful addition to the literature and a
caveat to the knee surgeon.
Conclusion
In conclusion, we believe that malrotation of the lower limb
not only raises the propensity for knee injuries and condi-
tions, but is also a under-recognized etiology in the failure of
surgeries for anterior knee pain and/or patellar instability.
Further examination of our two series demonstrates that
addressing rotational abnormalities in the index surgery
yields better clinical outcomes than osteotomies performed
after extensor complex transfers or soft-tissue procedures.
There are advantages to considering rotational osteotomy
early in patients with prominent rotational abnormalities.
Conflict of interest The authors declare that they have no conflict
of interest.
Strat Traum Limb Recon
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Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use, dis-
tribution, and reproduction in any medium, provided the original
author(s) and the source are credited.
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