Simplification of the Elmslie-Trillat procedure for patellofemoral malalignment. Is medial capsulorraphy necessary?

Incidence of Complications After Tibial Tubercle Osteotomy and Tibial Tubercle Osteotomy With Distalization

BACKGROUND

Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patellofemoral instability and pain. TTO with distalization (TTO-D) is indicated for patients with patellofemoral instability, patellar malalignment, and patella alta. The current literature demonstrates several complications that may be associated with TTO, with reportedly higher rates of complications associated with TTO-D.

PURPOSE

To analyze and compare complication rates after TTO without distalization (TTO-ND) and TTO-D and assess risk factors associated with complications.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All skeletally mature patients who underwent TTO with or without distalization by a single surgeon between September 2014 and May 2023 with a minimum of 6 months of clinical follow-up were retrospectively reviewed. Patient factors, surgical indications, perioperative data, and complications were collected via a retrospective review of electronic medical records. Concomitant procedures were categorized as intra-articular, extra-articular, and osteotomies.

RESULTS

A total of 251 TTOs (117 TTO-D, 134 TTO-ND) were included in the study group. Postoperative complications were observed in 15 operations (6%), with arthrofibrosis as the most common complication (10 operations [4%]). TTO-D and TTO-ND had similar rates of complication (5% vs 7%; P = .793). Clinical nonunion was observed in 3 operations (3%) in the TTO-D cohort and 1 operation (1%) in the TTO-ND cohort. In the TTO-D cohort, concomitant intra-articular procedures were significantly associated with an increased likelihood of complications in a univariate model. In the TTO-ND cohort, an increased tourniquet time was significantly associated with an increased likelihood of complications in a univariate model. For all TTOs as well as the TTO-D and TTO-ND cohorts, there were no significant associations between patient or surgical variables in a multivariate model.

CONCLUSION

TTO with and without distalization is a safe procedure with low rates of complication. TTO-D was not associated with a higher rate of complications compared with TTO-ND. There was no association between complications and surgical variables for TTO procedures.

MPFL Reconstruction Combined with a Modified Elmslie-Trillat Procedure for Recurrent Patellofemoral Instability

Several combined procedures have been reported for treating recurrent patellofemoral instability (RPI) with various types and severity of morphological abnormalities, but none have identified absolute threshold values as indications for surgery. We performed medial patellofemoral ligament (MPFL) reconstruction combined with a modified Elmslie-Trillat (ET) procedure on 24 knees (10 male and 11 female patients) to treat RPI with morphological abnormalities corresponding to elevated tibial tubercle-trochlear groove (TT-TG) distance, significant patella alta, and trochlear dysplasia. The inclusion criteria were RPI with morphological abnormalities corresponding to one or more of the following: sulcus angle > 160 degrees, trochlear dysplasia of Dejour classification C or D, Caton-Deschamps index > 1.5, lateral shift ratio > 50%, congruence angle > 15 degrees, or TT-TG distance > 20 mm, including habitual dislocation of the patella. Skeletally immature patients and those with congenital dislocation of the patella were excluded. The Kujala score, International Knee Documentation Committee subjective score, Knee Injury and Osteoarthritis Outcome score (KOOS), and each item of the KOOS improved significantly after surgery. Patellar apprehension sign was present preoperatively in all cases, but all disappeared postoperatively. No instance of postoperative redislocation was observed. On radiographic examination, the mean Q angle, tilting angle, lateral shift ratio, congruence angle, Caton-Deschamps index, Insall-Salvati index, and TT-TG distance improved significantly after surgery. There were no significant differences in sulcus angle after surgery. These results suggest MPFL reconstruction combined with a modified ET procedure provides satisfactory outcomes based on radiological and clinical evaluations for RPI with morphological abnormalities corresponding to elevated TT-TG distance, significant patella alta, and trochlear dysplasia.

Complications of a self-centering sliding tibial tubercle osteotomy for patellofemoral complaints; low incidence of non-union and fracture

BACKGROUND

A tibial tubercle osteotomy (TTO) is a commonly performed procedure in young and active patients with patellofemoral complaints. Previous small patient series demonstrated a relatively high risk of complications, which appear to be technique dependent. The purpose of this large case series is to quantify the risk of procedure specific postoperative complications related to a uniform self-centering TTO technique in a large cohort, performed by two different surgeons in one center.

HYPOTHESIS

We hypothesize that non-union or fracture occurs in less than 1% of the procedures.

PATIENTS AND METHODS

Five hundred and twenty-nine knees in four hundred and forty-seven patients who underwent a self-centering TTO with at least one year of follow-up were included. We performed a retrospective cohort review. Tibial fracture, osteotomy non-union, neurovascular complications, infection and wound complications that required surgical intervention were defined as major complications, miscellaneous complications were defined minor.

RESULTS

The major finding in this study is the low incidence of non-union (0.6%) and tibial fracture (0.4%). In total 9 (1.7%) major complications were reported. Minor complications included superficial wound infection in five patients, two patients had a venous thrombo-embolism (VTE).

CONCLUSION

A self-centering TTO is a relatively safe technique with a low number of non-union and fracture.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

The Incidence of Complications of Tibial Tubercle Osteotomy: A Systematic Review

PURPOSE

The goal of this review was to quantify the risk of perioperative and early postoperative complications of tibial tubercle osteotomy (TTO) with different techniques.

METHODS

A systematic review of multiple databases was performed to identify studies that reported complications of TTO. Complications were defined as any adverse outcome, including osteotomy site nonunion, fracture, infection, wound complications, neurovascular complications, deep vein thrombosis (DVT), and pulmonary embolism (PE). Major complications were defined as nonunion, fracture, infections/wound complications requiring return to the operating room, and DVT or PE. The risk of subsequent hardware removal was also quantified.

RESULTS

The 19 identified studies included a total of 787 TTOs: 472 direct medialization procedures (Elmslie-Trillat technique), 193 anteromedialization procedures (Fulkerson technique), and 102 procedures in which the tibial tubercle was completely detached for medialization or distalization, or a combination. The overall complication risk was 4.6%. The risk of complications was higher when the tibial tubercle was completely detached (10.7%) than with Elmslie-Trillat (3.3%) or Fulkerson (3.7%) procedures (P = .004). The overall risk of major complications was 3.0%. Hardware removal was performed in 36.7% of osteotomies and was less frequent with the Elmslie-Trillat technique (26.8%) than with the Fulkerson technique (49.0%) or complete tubercle detachment (48.3%) (P < .001).

CONCLUSIONS

Tibial tubercle osteotomy is a complex surgical procedure with a significant risk of complications. Osteotomies that involve complete detachment of the tubercle have an increased risk of complications compared with those in which a distal cortical hinge is maintained.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Evaluation of the modified Elmslie-Trillat procedure for patellofemoral dysfunction

The goal of this study was to evaluate the Elmslie-Trillat procedure for recurrent patellar dislocation, patellofemoral pain (with extensor mechanism malalignment), or a combination of both. Thirty-two patients underwent the modified Elmslie-Trillat procedure, consisting of a lateral retinacular release and medialization of the tibial tuberosity for recurrent patellar dislocation, patellofemoral pain, or both. Twenty-nine of 32 patients were available for follow-up. All patients were evaluated clinically and radiologically. Subjective scores were evaluated using the Cox grading system and objective scores using Fulkerson's functional knee score. Average patient age was 33 years. Mean follow-up was 45 months. Subjectively, using the Cox grading system, 10 patients (34%) had an excellent result, 8 (28%) had a good result, 8 (28%) had a fair result, and 3 (10%) had a poor result. All patients with patella dislocation had an excellent or good subjective result, while only 3 patients (34%) with the primary symptom of patellofemoral pain with extensor mechanism malalignment and 4 patients (44%) with a combination of both symptoms had a good or excellent result. Mean Fulkerson's functional knee score was excellent for patients with dislocation only, and fair for those with only pain or both pain and dislocation. The congruence angle was corrected in all patients with this technique. There were no further dislocations in our series. Two patients required hardware removal. The Elmslie-Trillat procedure is a good surgical option for treatment of recurrent patella instability following failed conservative therapy. However, the results are not as favorable for patients with patellofemoral pain without instability.

Functional outcome following modified Elmslie-Trillat procedure

The aim of this study was to evaluate the mid- and long-term outcome of the modified Elmslie-Trillat procedure, as well as to detect factors affecting it. Thirty-eight patients (44 procedures) with a mean age of 31 years were included in this study. The reason for operation was patellar instability in 10 cases, anterior knee pain with malalignment of the extensor mechanism in 15 cases and a combination of both in 19 cases. Patients were followed for an average of 40 months (range=18-130 months). The functional outcome was very satisfactory or satisfactory for 73% of patients. According to Cox's criteria it was excellent in 13 cases (30%), good in 18 (41%), fair in 7 (16%) and poor in the remaining 6 (13%). Patients scored an average of 3.5 (range=2-8) in their Tegner Activity Scale, while their score in Activities of Daily Living Scale of the Knee Outcome Survey ranged from 43 to 98 (average=76). Result analysis revealed a better functional outcome when the operation was performed for patellar instability, as well as in the absence of grade 3 or 4 chondral changes in the patellofemoral joint at the time of operation. Elmslie-Trillat procedure satisfactorily restores patellofemoral stability and offers a very good functional outcome, especially in the absence of significant chondral changes in the patellofemoral joint at the time of operation.

Measurement of patellar tracking: assessment and analysis of the literature

Patellar tracking is defined as the motion of the patella relative to the femur or femoral groove on knee flexion and extension. Abnormalities of tracking (maltracking) are thought to relate to many disorders of the patellofemoral joint and may be defined easily or may be extremely difficult to observe. Accurate measurement of patellar tracking, and definition of normal tracking, have not been achieved yet in experimental conditions or in clinical conditions. Such information would be valuable in the diagnosis and treatment of patellofemoral disorders. In the current report, the literature is reviewed critically with an emphasis on methodology and results. The reporting of patellar tracking is affected significantly by basic definitions of coordinate systems and reference points. The method of muscle loading, range, and direction of knee motion, use of static or dynamic measurement techniques, and tibial rotation also will affect the results obtained. The accuracy of the equipment used is important as differences in tracking may be small. Comparison between existing studies is difficult because of differences in methodology. There is general agreement that the patella translates medially in early knee flexion and then translates laterally. Regarding patellar tilt, results are less consistent, especially in vivo and the results for patellar rotation are highly variable.

Patellofemoral malalignment: looking beyond the viewbox

A clear understanding of the pathophysiology of anterior knee pain is inhibited by the use of imprecise, poorly defined, and often interchanged words, such as malalignment, patellar alignment, maltracking, subluxation, dislocation, and congruence. The literature is filled with articles regarding the diagnosis, "malalignment of the patella," most of which give no precise diagnosis. This article presents a definition of malalignment and a plea for rational descriptive and scientific analysis. Much of what is described is based on theory, not facts. These ideas are supported by clinical experience and logical analysis, but very little in the way of scientific data. Most of the data involve radiographic images, which present only one piece of the puzzle.

Functional evaluation of the modified Elmslie-Trillat procedure for patello-femoral dysfunction

A series of 28 knees in 27 patients were evaluated at an average of 36 months following surgical treatment for patella dislocation, patello-femoral pain, or a combination of both. All cases were treated by the modified Elmslie-Trillat procedure, which involves a lateral retinacular release and medialisation of the tibial tubercle on a distal pedicle. The evaluation included subjective, objective (Fulkerson and Kujala functional knee scores) and radiographic assessments. Subjectively, eight knees (28%) had excellent results, nine knees (33%) good results and seven knees (25%) fair results, accounting for an overall improvement of 86% over the preoperative status. All the knees in patients with a primary symptom of patella dislocation had an excellent or good subjective result, whilst only four knees (40%) in those patients with a primary symptom of pain and four knees (44%) in those with both pain and dislocation had a good or excellent result. The mean objective knee score was excellent for patients with dislocation only, and fair for those with only pain or both pain and dislocation. There have been no further episodes of dislocation in all patients. Six knees (21%) required later screw removal. The modified Elmslie-Trillat procedure produces a favourable outcome in patients with patella dislocation.