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Klasan A, Compagnoni R, Grassi A, Menetrey J. Promising results following derotational femoral osteotomy in patellofemoral instability with increased femoral anteversion: A systematic review on current indications, outcomes and complication rate. J Exp Orthop 2024; 11:e12032. [PMID: 38774579 PMCID: PMC11106799 DOI: 10.1002/jeo2.12032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 05/24/2024] Open
Abstract
Purpose Patellofemoral joint instability (PFJI) can surgically be treated with a multitude of approaches, depending on the underlying pathology. In the presence of increased femoral anteversion, some authors have reported good results with a derotational distal femoral osteotomy (DeDFO). The purpose of the study was to investigate the indications, outcomes and complication rate of DeDFO for PFJI. Methods A systematic review was performed according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) by searching Medline, Embase, Web of Science and Cochrane Library databases through 1 December 2023. Included were levels 1-4 clinical studies of skeletally mature patients undergoing a DeDFO for PFJI irrespective of concomitant procedures. Study characteristics, indications, radiological and clinical outcomes, surgical technique and concomitant procedures, re-dislocation and complication rate were all analysed, as was methodological quality. Results A total of 12 studies including 310 patients (325 knees) were included. Three studies were cohort studies, all others were case series. The mean patient age across the studies was 22 years, and the mean follow-up was 29.4 months. Femoral anteversion cut-off was between 20° and 30°. Every study included at least one concurrent soft tissue, bony or combined procedure. Across all studies, one case of re-dislocation was reported (0.3%) and four implant or osteotomy-related complications (1.2%) were reported. All studies reported a statistically significant increase in clinical scores. Conclusion This systematic review of DeDFO for patellofemoral instability in the presence of increased femoral anteversion demonstrates promising clinical results and an extremely low dislocation and complication rate. The heterogeneity of the cut-off in anteversion and concomitant procedures, especially tibial tubercle osteotomy with seemingly identical results, indicates the need for high-quality evidence for treating patellofemoral instability. Based upon this systematic review, we strongly recommend that DeDFO be added to the 'menu à la carte' of PFJI. Level of Evidence Level III Systematic Review.
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Affiliation(s)
- Antonio Klasan
- AUVA UKH SteiermarkGrazAustria
- Johannes Kepler University LinzLinzAustria
| | - Riccardo Compagnoni
- 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini‐CTOMilanItaly
- Department of Biomedical, Surgical and Dental SciencesUniversità degli Studi di MilanoMilanItaly
| | - Alberto Grassi
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico RizzoliBolognaItaly
| | - Jacques Menetrey
- Swiss Olympic Medical Center, Hirslanden Clinique La CollineGenevaSwitzerland
- Orthopaedic Surgery ServiceUniversity Hospital of GenevaGenevaSwitzerland
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Yang J, Zhong J, Li H, Du Y, Liu X, Li Z, Liu Y. Medial patellar ligament reconstruction in combination with derotational distal femoral osteotomy for treating recurrent patellar dislocation in the presence of increased femoral anteversion: a systematic review. J Orthop Surg Res 2024; 19:228. [PMID: 38582853 PMCID: PMC10998303 DOI: 10.1186/s13018-024-04709-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Medial patellar ligament reconstruction (MPFL-R) in combination with derotational distal femoral osteotomy (DDFO) for treating recurrent patellar dislocation (RPD) in the presence of increased femoral anteversion is one of the most commonly used surgical techniques in the current clinical practice. However, there are limited studies on the clinical outcomes of MPFL-R in combination with DDFO to treat RPD in the presence of increased femoral anteversion. PURPOSE To study the role of MPFL-R in combination with DDFO in the treatment of RPD in the presence of increased femoral anteversion. METHODS A systematic review was performed according to the PRISMA guidelines by searching the Medline, Embase, Web of Science, and Cochrane Library databases through June 1, 2023. Studies of patients who received MPFL-R in combination with DDFO after presenting with RPD and increased femoral anteversion were included. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. Each study's basic characteristics, including characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications, were recorded and analyzed. RESULTS A total of 6 studies with 231 patients (236 knees) were included. Sample sizes ranged from 12 to 162 patients, and the majority of the patients were female (range, 67-100%). The mean age and follow-up ranges were 18 to 24 years and 16 to 49 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting preoperative and postoperative outcomes, significant improvements were found in the Lysholm score, Kujala score, International Knee Documentation Committee score, and visual analog scale for pain. Postoperative complications were reported in all studies, with an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period. CONCLUSION For RPD with increased femoral anteversion, MPFL-R in combination with DDFO leads to a good clinical outcome and a low redislocation rate. However, there was no consensus among researchers on the indications for MPFL-R combined with DDFO in the treatment of RPD.
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Affiliation(s)
- Jinghong Yang
- Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Lu Zhou, 646000, China
| | - Jun Zhong
- Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Lu Zhou, 646000, China
| | - Han Li
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, 25 TAIPING Street, Luzhou City, 646000, Sichuan Province, China
| | - Yimin Du
- Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Lu Zhou, 646000, China
| | - Xu Liu
- Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Lu Zhou, 646000, China
| | - Zhong Li
- Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Lu Zhou, 646000, China.
| | - Yanshi Liu
- Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Lu Zhou, 646000, China.
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Ribeiro R, Gomes E, Ferreira B, Figueiredo I, Valente C, Delgado D, Sánchez M, Andrade R, Espregueira-Mendes J. Derotational distal femoral osteotomy corrects excessive femoral anteversion in patients with patellofemoral instability: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024; 32:713-724. [PMID: 38385776 DOI: 10.1002/ksa.12097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/25/2024] [Accepted: 02/04/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Patellofemoral instability (PFI) is a common condition that can be caused from multiple factors, including lower limb rotational malalignments. Determining precise criteria for performing corrective torsional osteotomy can be a daunting task due to the lack of consensus on normal and excessive values and the limited evidence-based data in the postoperative results. The purpose was to assess the clinical, functional and imaging outcomes following derotational distal femoral osteotomy (DDFO) in patients with PFI and/or anterior knee pain (AKP) associated with lower limb rotational malalignments. METHODS Searches were conducted on PubMed, EMBASE and Web of Science databases up to October 2023. Studies reporting outcomes after DDFO in patients with PFI and/or AKP were eligible for the systematic review. The primary outcome was imaging metrics, especially femoral anteversion. Secondary outcomes included the patient-reported outcome measures (PROMs) (clinical and functional). Quantitative synthesis involved the use of weighted averages to calculate pre- to postoperative mean differences (MD) and compare them against the minimal clinically important difference (MCID). RESULTS Ten studies (309 knees) were included with a mean follow-up of 36.1 ± 11.7 months. Imaging outcomes consistently indicated the correction of femoral anteversion (MD = -19.4 degrees, 95% confidence interval: -20.1 to -18.7) following DDFO. PROMs showed significant improvements in most studies, exceeding the MCID. Patient satisfaction with the DDFO was high (93.3%). CONCLUSIONS The DDFO was an effective treatment option for correcting excessive femoral anteversion in patients with PFI associated with clinically relevant functional and clinical improvement and a high satisfaction rate. LEVEL OF EVIDENCE Level IV, systematic review of level II-IV studies.
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Affiliation(s)
| | - Eluana Gomes
- Clínica Espregueira-FIFA Medical Centre of Excellence, Porto, Portugal
| | | | | | - Cristina Valente
- Clínica Espregueira-FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
| | - Diego Delgado
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
| | - Mikel Sánchez
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
| | - Renato Andrade
- Clínica Espregueira-FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- Porto Biomechanics Laboratory (LABIOMEP), Faculty of Sports, University of Porto, Porto, Portugal
| | - João Espregueira-Mendes
- School of Medicine, Minho University, Braga, Portugal
- Clínica Espregueira-FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
- 3B's Research Group-Biomaterials, Biodegradables and Biomimetics, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, University of Minho, Braga, Portugal
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Wang D, Zheng T, Cao Y, Zhang Z, Di M, Fu Q, Sun J, Zhang H. Derotational distal femoral osteotomy improves subjective function and patellar tracking after medial patellofemoral ligament reconstruction in recurrent patellar dislocation patients with increased femoral anteversion: A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2024; 32:151-166. [PMID: 38226710 DOI: 10.1002/ksa.12021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE The purpose of this study is to systematically review and quantitatively analyse the clinical outcomes of combined derotational distal femoral osteotomy (D-DFO) and medial patellofemoral ligament reconstruction (MPFL-R) in the treatment of recurrent patellar dislocation (RPD) with increased femoral anteversion angle (FAA). METHODS This study was performed in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality Of Systematic Reviews) Guidelines. PubMed, Embase, Web of Science and Cochrane Library databases were searched to identify studies reporting clinical outcomes of combined D-DFO and MPFL-R in RPD patients with increased FAA. Data on patient-reported outcome measures, radiological parameters, patellar tracking as revealed by J-sign and complications were extracted based on the inclusion criteria. The Methodological Index for Non-Randomized Study score was used for quality assessment. Review Manager and R statistical software were used to perform the statistical analysis. RESULTS Eleven studies with a total of 569 knees in 553 patients were included. Patients were predominantly female (79%). The weighted mean of FAA decreased from 33.6° to 13.0° (weighted mean difference = 20.59; p < 0.00001) after the combined procedure. Significant improvements (p < 0.00001) were identified in the Lysholm score (weighted mean: 55.5 vs. 80.4), International Knee Documentation Committee (IKDC) score (weighted mean: 52.8 vs. 78.6) and Kujala score (weighted mean: 54.5 vs. 80.6). The incidence of residual J-sign ranged from 14.3% to 38.3% with an overall pooled rate of 28.2% (95% confidence interval = 22.8%-33.6%). The overall redislocation rate was 1.1%. No patients experienced surgical site infection or bone nonunion. Two studies compared the clinical outcomes of MPFL-R with and without D-DFO. Compared with isolated MPFL-R, the combined procedure yielded a better Lysholm score (weighted mean: 84.9 vs. 79.3, p < 0.0001), IKDC score (weighted mean: 84.1 vs. 79.9, p = 0.001), Kujala score (weighted mean: 84.3 vs. 79.4, p < 0.0001) and a lower residual J-sign rate (26/97 [26.8%] vs. 44/105 [41.9%], p = 0.02), respectively. CONCLUSION The combination of D-DFO and MPFL-R led to improved clinical outcomes and a low redislocation rate in patients with RPD and increased FAA. Additional D-DFO can achieve more favourable results in subjective function and patellar tracking than isolated MPFL-R in the setting of excessive FAA. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Daofeng Wang
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Tong Zheng
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Yanwei Cao
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Zhijun Zhang
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Menglinqian Di
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Qizhen Fu
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Jianzhong Sun
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Hui Zhang
- Department of Sports Medicine, Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
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Ferner F, Klinder A, Woerner M, Morris P, Harrer J, Dickschas J, Lutter C. Intraoperative control by Schanz-screws is inaccurate to achieve the exact amount of correction in de-rotational osteotomies. Knee Surg Sports Traumatol Arthrosc 2023; 31:4319-4326. [PMID: 37329368 DOI: 10.1007/s00167-023-07485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/06/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE The accuracy of intraoperative control of correction commonly is achieved by K-wires or Schanz-screws in combination with goniometer in de-rotational osteotomies. The purpose of this study is to investigate the accuracy of intraoperative torsional control in de-rotational femoral and tibial osteotomies. It is hypothesized, that intraoperative control by Schanz-screws and goniometer in de-rotational osteotomies around the knee is a safe and well predictable method to control the surgical torsional correction intraoperatively. METHODS 55 consecutive osteotomies around the knee joint were registered, 28 femoral and 27 tibial. The indication for osteotomy was femoral or tibial torsional deformity with the clinical occurrence of patellofemoral maltracking or PFI. Pre- and postoperative torsions were measured according to the method of Waidelich on computed tomography (CT) scan. The scheduled value of torsional correction was defined by the surgeon preoperatively. Intraoperative control of torsional correction was achieved by 5 mm-Schanz-screws and goniometer. The measured values of torsional CT scan were compared to the preoperative defined and intended values and deviation was calculated separately for femoral and tibial osteotomies. RESULTS The surgeon's intraoperative measured mean value of correction in all osteotomies was 15.2° (SD 4.6; range 10-27), whereas the postoperatively measured mean value on CT scan was 15.6 (6.8; 5.0-28.5). Intraoperatively the femoral mean value measured 17.9° (4.9; 10-27) and 12.4° (1.9; 10-15) for the tibia. Postoperatively the mean value for femoral correction was 19.8 (5.5; 9.0-28.5) and 11.3 (5.0; 5.0-26.0) for tibial correction. When considering a deviation of plus or minus 3° to be acceptable femorally 15 osteotomies (53.6%) and tibially 14 osteotomies (51.9%) fell within these limits. Nine femoral cases (32.1.%) were overcorrected, four cases undercorrected (14.3%). Four tibial cases of overcorrection (14.8%) and 9 tibial cases of undercorrection (33.3%) were observed. However, the observed difference between femur and tibia regarding the distribution of cases between the three groups did not reach significance. Moreover, there was no correlation between the extent of correction and the deviation from the intended result. CONCLUSION The use of Schanz-screws and goniometer in de-rotational osteotomies as an intraoperative control of correction is an inaccurate method. Every surgeon performing derotational osteotomies must consider this and include postoperative torsional measurement in his postoperative algorithm until new tools or devices are available to guarantee a better intraoperative accuracy of torsional correction. STUDY DESIGN Observational study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Felix Ferner
- Klinik für Orthopädie, Unfallchirurgie, Handchirurgie, Regiomed Klinik Lichtenfels, Prof. Arneth Str. 2B, 96125, Lichtenfels, Germany.
- Orthopädische Klinik und Poliklinik, Universität Rostock, Rostock, Germany.
- Osteotomie Komitee, Deutsche Kniegesellschaft, Lichtenfels, Germany.
| | - Annett Klinder
- Orthopädische Klinik und Poliklinik, Universität Rostock, Rostock, Germany
| | - Michael Woerner
- Klinik für Orthopädie und Unfallchirurgie, Sozialstiftung Bamberg, Bamberg, Germany
| | - Patrick Morris
- Klinik für Orthopädie und Unfallchirurgie, Sozialstiftung Bamberg, Bamberg, Germany
| | - Joerg Harrer
- Klinik für Orthopädie, Unfallchirurgie, Handchirurgie, Regiomed Klinik Lichtenfels, Prof. Arneth Str. 2B, 96125, Lichtenfels, Germany
- Osteotomie Komitee, Deutsche Kniegesellschaft, Lichtenfels, Germany
| | - Joerg Dickschas
- Klinik für Orthopädie und Unfallchirurgie, Sozialstiftung Bamberg, Bamberg, Germany
| | - Christoph Lutter
- Orthopädische Klinik und Poliklinik, Universität Rostock, Rostock, Germany
- Osteotomie Komitee, Deutsche Kniegesellschaft, Lichtenfels, Germany
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Zhou K, Sun Z, Feng A, Guo H, Sun R, Niu Y, Liu L, Wang X. Derotational distal femur osteotomy combined with medial patellofemoral ligament reconstruction yields satisfactory results in recurrent patellar dislocation with excessive femoral anteversion angle and trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc 2023; 31:4347-4354. [PMID: 37340219 DOI: 10.1007/s00167-023-07476-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical outcomes of medial patellofemoral ligament (MPFL) reconstruction combined with derotational distal femur osteotomy in patients with recurrent patellar dislocation who had excessive femoral anteversion angle and trochlear dysplasia. METHODS Between 2015 and 2020, 64 patients (64 knees) with recurrent patellar dislocation, who had excessive femoral anteversion angle (≥ 25°) and trochlear dysplasia and were surgically treated using derotational distal femur osteotomy and MPFL reconstruction, were eligible for this retrospective study. These patients were assigned to two groups according to the grade of trochlear dysplasia. Group A (type A trochlear dysplasia, n = 33) and Group B (type B, C, D trochlear dysplasia, n = 31). Preoperative and postoperative patellar tilt angle (PTA), Caton-Deschamps index (CD-I), tibial tubercle-trochlear groove (TT-TG) distance and femoral anteversion angle were evaluated. Patient outcomes were assessed using the preoperative and postoperative International Knee Documentation Committee (IKDC) score, Kujala score, Lysholm score, Tegner score, and visual analog scale (VAS) score. RESULTS A total of 64 patients (64 knees) were evaluated in this study, with a mean follow-up period of 28.4 ± 3.6 months. There were no cases of wound infection, osteotomy site fractures, deep venous thrombosis of the lower extremities, or re-dislocation in the two groups during the postoperative follow-up period. All patients returned to full extension and flexion. The postoperative Tegner score, Lysholm score, Kujala score, IKDC score, VAS score, PTA, CD-I, TT-TG distance, and femoral anteversion angle were significantly improved compared with the preoperative status (P < 0.05). There was no significant difference between the two groups (n.s.). CONCLUSION MPFL reconstruction combined with derotational distal femur osteotomy showed satisfactory clinical outcomes during follow-up in patients with recurrent patellar dislocation who had excessive femoral anteversion angle and trochlear dysplasia. Even patients with high-grade trochlear dysplasia showed satisfactory results. For those patients, additional surgery is not necessary. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kezhen Zhou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Zhiwen Sun
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Ao Feng
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Hailong Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Ran Sun
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Yingzhen Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Lei Liu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Xiaofeng Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China.
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Gür V, Yapici F, Subaşi İÖ, Gökgöz MB, Tanoğlu O, Koçkara N, Tandoğan NR. TT-TG distance decreases after open wedge distal femoral varization osteotomy in patients with genu valgum & patellar instability. A pilot 3D computed tomography simulation study. BMC Musculoskelet Disord 2023; 24:753. [PMID: 37749570 PMCID: PMC10519055 DOI: 10.1186/s12891-023-06832-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/25/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Genu valgum is considered to be a risk factor for patellar instability. Correction of valgus alone or combined with a tibial tuberosity medialization has been described. However, changes occurring in the tibial tuberosity-trochlear groove (TT-TG) distance after a lateral distal femoral opening wedge osteotomy (LDF-OWO) are not known. PURPOSE This study aimed to define changes in TT-TG distance with increasing amounts of valgus correction after LDF-OWO. METHODS Three-Dimensional Computed Tomography (3D-CT) scans of six patients (two females and four males) aged between 19 and 35 years with genu valgum and patellar instability were analyzed. 3D models of femoral, tibial, and patellar bones were created with the advanced segment option of Mimics 21® software. An oblique lateral opening wedge osteotomy of the distal femur was simulated in 2-degree increments up to 12 degrees of varus opening. Change in TT-TG distance was measured in mm on 3D models of the knee. RESULTS Compared to baseline without osteotomy, the TT-TG distance decreased significantly (p < 0.05) for all corrections from 2 to 12 degrees in 2° steps. The TT-TG distance decreased by an average of 1.7 mm for every 2 degrees of varus opening. CONCLUSION Lateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance. The surgeon should be aware of the magnitude of this change (1.7 mm decrease for every 2° increment of valgus opening).
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Affiliation(s)
- Volkan Gür
- Department of Orthopedics, Erzincan Faculty of Medicine, Erzincan, Turkey
| | - Furkan Yapici
- Department of Orthopedics, Erzincan Faculty of Medicine, Erzincan, Turkey
| | - İzzet Özay Subaşi
- Department of Orthopedics, Erzincan Faculty of Medicine, Erzincan, Turkey
| | | | - Oğuzhan Tanoğlu
- Department of Orthopedics, Buca Seyfi Demirsoy Training and Research Hospital, İzmir, Turkey
| | - Nizamettin Koçkara
- Department of Orthopedics, Erzincan Faculty of Medicine, Erzincan, Turkey.
| | - Nevzat Reha Tandoğan
- Department of Orthopedics, Haliç University Faculty of Medicine, İstanbul, Turkey
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Chen J, Ma J, Wang Y, Bai H, Lu B, Zhao X, Wu Y, Dai J, Ma X. Computer-aided design combined with 3D-printed osteotomy guide-assisted derotational distal femoral osteotomy for treating recurrent patellar dislocation with increased femoral anteversion angle: a retrospective study. INTERNATIONAL ORTHOPAEDICS 2023; 47:2197-2205. [PMID: 37067550 DOI: 10.1007/s00264-023-05798-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/26/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE Derotational distal femoral osteotomy (DDFO) has good clinical outcomes for the treatment of the recurrent patellar dislocation combined with increased femoral anteversion angle (FAA). Currently, there is no uniform surgical technique. The purpose of this study was to evaluate the safety and efficacy of computer-aided design (CAD) combined 3D-printed osteotomy guide-assisted DDFO for treating these patients. METHODS In a retrospective study of 36 patients with recurrent patellar dislocation (RPD) from December 2017 to December 2020, all patients had increased FAA and underwent DDFO assisted by CAD combined with a 3D-printed osteotomy guide. Patients' radiological parameters were used to assess the correction of increased femoral torsion and preoperative and postoperative subjective scores were recorded to evaluate the knee function. Complications were recorded to determine the safety of the surgery. RESULT A total of 36 knees were included in this study, with a mean follow-up time of 32.6 ± 8.1 months. The mean age of the patients was 24.9±4.4 years and all patients experienced patellar dislocation preoperatively with a mean of 5.7±3.2 times. The patients' femoral anteversion angle decreased from 35.03±3.05° preoperatively to 14.80±0.87°, and the TT-TG distance decreased from 20.03±1.27 mm preoperatively to 19.22±1.22 mm. The hip-knee-ankle (HKA) angle and Insall-Salvatti index were not significantly different postoperatively compared to preoperatively. The knee function scores and visual analogue scale at the last follow-up were significantly improved compared to the preoperative scores. No major complications such as redislocation, nonunion, fixation or graft failure, or infection were observed in any patients. CONCLUSION Computer-aided design combined with 3D-printed osteotomy guide-assisted derotational distal femoral osteotomy could correct the increased anterior femoral torsion and demonstrate good results. There were no patients experienced re-dislocation during follow-up period and the overall complication rate is low.
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Affiliation(s)
- Jiahui Chen
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, 300070, People's Republic of China
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
| | - Jianxiong Ma
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
- Tianjin Key Laboratory of Orthopaedic Biomechanics and Medical Engineering, Tianjin, 300050, People's Republic of China
| | - Ying Wang
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
- Tianjin Key Laboratory of Orthopaedic Biomechanics and Medical Engineering, Tianjin, 300050, People's Republic of China
| | - Haohao Bai
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
- Tianjin Key Laboratory of Orthopaedic Biomechanics and Medical Engineering, Tianjin, 300050, People's Republic of China
| | - Bin Lu
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
- Tianjin Key Laboratory of Orthopaedic Biomechanics and Medical Engineering, Tianjin, 300050, People's Republic of China
| | - Xingwen Zhao
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, 300070, People's Republic of China
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
| | - Yanfei Wu
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, 300070, People's Republic of China
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
| | - Jing Dai
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, 300070, People's Republic of China
- Tianjin Hospital, Tianjin, 300211, People's Republic of China
| | - Xinlong Ma
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, 300070, People's Republic of China.
- Tianjin Hospital, Tianjin, 300211, People's Republic of China.
- Tianjin Key Laboratory of Orthopaedic Biomechanics and Medical Engineering, Tianjin, 300050, People's Republic of China.
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9
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Hao K, Niu Y, Feng A, Wang F. Outcomes After Derotational Distal Femoral Osteotomy for Recurrent Patellar Dislocations With Increased Femoral Anteversion: A Systematic Review and Meta-analysis. Orthop J Sports Med 2023; 11:23259671231181601. [PMID: 37465210 PMCID: PMC10350774 DOI: 10.1177/23259671231181601] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/31/2023] [Indexed: 07/20/2023] Open
Abstract
Background An increased femoral anteversion angle (FAA) is a predisposing factor for recurrent patellar dislocations (RPDs), and combined procedures including derotational distal femoral osteotomy (DDFO) have been shown to be good options. Purpose To investigate the safety and effectiveness of combined DDFO on clinical and radiological outcomes to treat RPDs with an increased FAA. Study Design Systematic review; Level of evidence, 4. Methods This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. We searched 7 databases for articles from inception to March 10, 2023, that reported outcomes after combined DDFO in patients with an RPD and increased FAA. Two reviewers independently extracted data and assessed study quality. Outcomes evaluated were functional scores, redislocation rates, complications, satisfaction, and radiological parameters. A meta-analysis was performed to pool functional scores, with data reported as mean differences (MDs) and 95% confidence intervals (CIs). Results Included were 8 studies of 189 knees from 183 patients, with a mean patient age of 22.4 years and a mean follow-up of 33.4 months. The mean preoperative FAA ranged from 31° to 42.70°, and the mean postoperative FAA ranged from 10° to 19.08°. Significant improvements were found in the Kujala score (MD, 26.96 [95% CI, 23.54 to 30.37]), Lysholm score (MD, 26.17 [95% CI, 22.13 to 30.22]), visual analog scale score for pain (MD, -2.61 [95% CI, -3.12 to -2.10]), and Tegner activity score (MD, 1.33 [95% CI, 0.86 to 1.79]). No subluxation or redislocation occurred. The overall complication rate was 10.6%, and most of the complications were pain (60%) and limited knee activity (20%). The overall satisfaction rate was 83.3%. The patellar tilt angle significantly decreased from 40.7° ± 11.9° to 20.5° ± 8.7° and from 26.35° ± 6.86° to 11.65° ± 2.85° in 2 studies. Conclusion Combined DDFO was found to be safe and effective for the treatment of RPDs and an increased FAA by addressing both patellar dislocations and torsional malalignment. However, because of the lack of comparisons, it remains to be investigated when DDFO should be combined in such patients.
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Affiliation(s)
- Kuo Hao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yingzhen Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ao Feng
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Fei Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
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10
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Wheatley BB, Chaclas NA, Seeley MA. Patellofemoral joint load and knee abduction/adduction moment are sensitive to variations in femoral version and individual muscle forces. J Orthop Res 2023; 41:570-582. [PMID: 35689506 PMCID: PMC9741666 DOI: 10.1002/jor.25396] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/18/2022] [Accepted: 06/08/2022] [Indexed: 02/04/2023]
Abstract
Torsional profiles of the lower limbs, such as femoral anteversion, can dictate gait and mobility, joint biomechanics and pain, and functional impairment. It currently remains unclear how the interactions between femoral anteversion, kinematics, and muscle activity patterns contribute to joint biomechanics and thus conditions such as knee pain. This study presents a computational modeling approach to investigating the interactions between femoral anteversion, muscle forces, and knee joint loads. We employed an optimal control approach to produce actuator and muscle-driven simulations of the stance phase of gait for femoral anteversion angles ranging from -8° (retroversion) to 52° (anteversion) with a typically developing baseline of 12° of anteversion and implemented a Monte Carlo analysis for variations in lower limb muscle forces. While total patellofemoral joint load decreased with increasing femoral anteversion, patellofemoral joint load alignment worsened, and knee abduction/adduction magnitude increased with both positive and negative changes in femoral anteversion (p < 0.001). The rectus femoris muscle was found to greatly influence patellofemoral joint loads across all femoral anteversion alignments (R > 0.8, p < 0.001), and the medial gastrocnemius was found to greatly influence knee abduction/adduction moments for the extreme version cases (R > 0.74, p < 0.001). Along with the vastus lateralis, which decreased with increasing femoral anteversion (R = 0.89, p < 0.001), these muscles are prime candidates for future experimental and clinical efforts to address joint pain in individuals with extreme femoral version. These findings, along with future modeling efforts, could help clinicians better design treatment strategies for knee joint pain in populations with extreme femoral anteversion or retroversion.
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Affiliation(s)
- Benjamin B Wheatley
- Department of Mechanical Engineering, Bucknell University, Lewisburg, PA
- Geisinger Commonwealth School of Medicine, Scranton, PA
| | | | - Mark A Seeley
- Geisinger Commonwealth School of Medicine, Scranton, PA
- Orthopaedic Surgery, Geisinger Medical Center, Danville, PA
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11
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Tibial Derotational Osteotomy for Patellofemoral Instability: A Systematic Review. Adv Orthop 2022; 2022:8672113. [PMID: 36620474 PMCID: PMC9812606 DOI: 10.1155/2022/8672113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/15/2022] [Accepted: 12/14/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction The etiology of patellofemoral (PF) instability is multifactorial. Excessive external tibial torsion has been associated with recurrent patellar subluxation and persistent anterior knee pain. Several surgical techniques have been historically used to correct this, including medial patellofemoral ligament reconstruction, tibial tuberosity transfer (TTT), trochleoplasty, and tibial derotation osteotomy (TDO). The purpose of this systematic review is to investigate the safety and efficacy of TDO for PF instability and pain. Methods A thorough search of the literature was conducted on July 15, 2022. Seven studies met the inclusion criteria for this systematic review. Results Among the included studies, there were 179 total subjects and 204 operative knees. Mean follow-up time was 66.31 months (range 11-192). Complication rate was low (12.8%) in studies that reported complications. Average degree of anatomical correction in the transverse plane was 19.9 degrees with TDO. This increased to 34 degrees when combined with TTT. All PROMs assessed were significantly increased postoperatively (p < 0.05). Age greater than 25 years and advanced PF chondromalacia may negatively affect postoperative outcomes. Conclusion The primary findings of this review were as follows: (1) TDO results in significantly improved pain and PROM ratings in patients with PF pain and/or instability, (2) the likelihood of complication, including recurrent patella subluxation after TDO, is low but may be increased by aging, and (3) the successful anatomical correction of TDO may be augmented by concurrent TTT in some cases.
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12
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Derotational distal femoral osteotomy for patients with recurrent patellar instability and increased femoral antetorsion improves knee function and adequately treats both torsional and valgus malalignment. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07150-9. [PMID: 36109379 DOI: 10.1007/s00167-022-07150-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The aim of the study was to evaluate the functional and radiological outcome following derotational distal femoral osteotomy (D-DFO) in patients with high-grade patellofemoral instability (PFI) and an associated increased femoral antetorsion (FA). It was hypothesized that D-DFO would lead to a good functional and radiological outcome, and that both torsional and coronal malalignment could be normalized. METHODS Patients that underwent D-DFO between 06/2011 and 12/2018 for high-grade PFI with an increased FA (> 20°) were included. Patient-reported outcome measures (Visual Analog Scale [VAS] for pain, Kujala score, Lysholm score, International Knee Documentation Committee subjective knee form [IKDC], and Tegner Activity Scale [TAS]) were evaluated pre- and minimum 24 months postoperatively. Magnetic resonance imaging of the lower extremity and weight-bearing whole-leg anteroposterior radiographs were conducted pre- and postoperatively. The change in FA, coronal limb alignment, and PROMs were tested for statistical significance. RESULTS In total, 27 patients (30 knees) were included. The D-DFO aimed to only correct FA (Group 1) or to additionally perform a varization (Group 2) in 14 cases each. In the remaining two cases, double-level osteotomies were performed to correct additional tibial deformities. In 25 cases (83.3%), concomitant procedures also addressing patellofemoral instability were performed. At follow-up (38.0 months [25-75% interquartile range 31.8-52.5 months]), a significant reduction in pain (VAS for pain: 2.0 [1.0-5.0] vs. 0 [0-1.0], p < 0.05), significant improvement in knee function (Kujala Score: 55.6 ± SD 13.6 vs. 80.3 ± 16.7, p < 0.05; Lysholm Score: 58.6 ± 17.4 vs. 79.5 ± 16.6, p < 0.05; IKDC: 54.6 ± 18.7 vs. 74.1 ± 15.0, p < 0.05), and an increase in sporting activity (TAS: 3.0 [3.0-4.0] vs. 4.0 [3.0-5.0], p = n.s.) were reported. Femoral antetorsion was significantly reduced (28.2 ± 6.4° vs. 13.6 ± 5.2°, p < 0.05). A significant varization was observed in Group 2 (2.4 ± 1.2° valgus vs. 0.3 ± 2.4° valgus; p < 0.05). In one case, patellar redislocation occurred 70 months postoperatively. CONCLUSION In patients with PFI and an associated increased FA, D-DFO achieved a significant reduction in pain, an improvement of subjective knee function, as well as an adequate correction of torsional and coronal alignment. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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13
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Chen J, Yin B, Yao J, Zhou Y, Zhang H, Zhang J, Zhou A. Femoral anteversion measured by the surgical transepicondylar axis is a reliable parameter for evaluating femoral rotational deformities in patients with patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07016-0. [PMID: 35666305 DOI: 10.1007/s00167-022-07016-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/15/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To verify whether femoral anteversion measured by the surgical transepicondylar axis (S-FA) is a reliable parameter for evaluating femoral rotational deformities and to provide an indication for derotational distal femoral osteotomy (DDFO) in patients with patellar dislocation. METHODS Ninety patients with recurrent patellar dislocation and 90 healthy individuals were enrolled. The S-FA, the femoral anteversion measured by posterior condylar reference line (P-FA), the length of posterior femoral condyles, and the posterior condylar angle (PCA) were assessed by CT images. The unpaired t test and Pearson correlation analysis were conducted. Receiver operating characteristic curves and the area under the curve (AUC) were used to evaluate the diagnostic capacity of the parameters. The pathological value of the measurements was determined, and a binary regression model was established. RESULTS The S-FA and P-FA were greater in the study group (14.2 ± 7.7° and 19.7 ± 7.3°, respectively) than in the control group (7.2 ± 8.0° and 12.2 ± 8.2°, respectively) (P < 0.001). The lateral/posterior condyle was shorter in patients with patellar dislocation (21.2 ± 2.5 mm) than in healthy individuals (23.5 ± 2.7 mm) (P = 0.001). The P-FA was correlated with PCA in the study group (P < 0.001). The S-FA and P-FA had AUCs of 0.734 and 0.767 for patellar dislocation, respectively. The pathological values of the S-FA and P-FA were 20.4° and 25.8°, respectively. The S-FA revealed a significant OR of 10.47 (P = 0.014) for patellar dislocation. CONCLUSION The S-FA is a reliable parameter for identifying femoral rotational deformities in patients with patellar dislocation. DDFO is recommended when a pathological S-FA (> 20.4°) is presented. LEVEL OF EVIDENCE Retrospective cohort study (diagnostic), level II.
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Affiliation(s)
- Jiaxing Chen
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Baoshan Yin
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Jinjiang Yao
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Yunlong Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Hua Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Jian Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China
| | - Aiguo Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China. .,Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, China.
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