KNEE

ORTHOPEDICS July 2011;34(7):524.

Arthroscopic Medial Retinacular Imbrication for the Treatment of Recurrent Patellar Instability: A Simple and All-Inside Technique

by Hu Xu, MD; Chunli Zhang, MD; Guoxian Pei, MD; Qinsheng Zhu, MD; Yisheng Han, MD

Abstract

Proximal soft tissue realignment is the main surgical intervention for recurrent patellar instability. In recent years, all-inside arthroscopic procedures or mini-open surgeries have replaced traditional surgeries, which have more associated morbidity and poor cosmetic results. This article describes a simple and all-inside arthroscopic technique for the operative treatment of recurrent patellar instability. Using 2 epidural needles in several steps and no accessory portals required, the medial patellar retinaculum is imbricated to the desired tension. The combination of lateral release and medial retinacular placation obviously improves the patellar tracking compared with preoperatively.

Drs Xu, Zhang, Pei, Zhu, and Han are from the Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, People’s Republic of China.

Drs Xu, Zhang, Pei, Zhu, and Han have no relevant financial relationships to disclose.

Correspondence should be addressed to: Hu Xu, MD, Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, 710032, People’s Republic of China (xuhutiger1997@yahoo.com.cn).

Although >100 different surgical methods have been described for the treatment of recurrent patellar instability, the best choice remains controversial. Since various procedures in a number of studies have been proved effective, no gold standard surgery has been defined yet. Most surgeries typically involve 2 basic techniques: proximal soft tissue realignment and distal bony realignment. Proximal realignment generally is addressed by a combination of lateral retinacular release and imbrications of medial retinaculum. Traditional open surgical management ordinarily leads to poor cosmetic results; therefore, total arthroscopic techniques and arthroscopy-assisted mini-open medial reefing for the medial soft tissue realignment have been reported in recent years. ^1,2 However, most arthroscopic methods for medial retinacular plication either require special instruments or have relatively complicated procedures.

Almazán et al ³ introduced an arthroscopic technique for the repair of the shoulder rotator interval. Using 2 spinal cannular needles with several steps, the defect of the rotator cuff interval lesion could be repaired without accessory portals. Combining Almazán et al’s ³ method with previously reported knee arthroscopic techniques, we developed a simple and all-inside procedure for the treatment of recurrent patellar instability.

Surgical Technique

Surgery is performed with the patient under general or spinal anesthesia. The patient is positioned supine on the operating table with an inflated tourniquet applied to the operative extremity. The leg is sterilely prepped and draped in routine fashion. Using the standard inferolateral and inferomedial portals, routine diagnostic arthroscopy is performed to observe the lesion of menisci and cartilage, traumatic loose bodies (chondral or osteochondral fragments), and rupture of the anterior and posterior cruciate ligaments. Corresponding treatments including partial meniscectomy, chondroplasty, and removal of loose bodies are performed.

Particular attention should be paid to check the relationship of the patellar ridge with the femoral trochlear groove through range of motion of the knee and assessing patellar tracking from both inferolateral and inferomedial portals. Lateral tilt and overhang of the lateral patellar facet can be observed. The extent of laxity of the medial patellar capsuloligmentous complex and tightness of the lateral patellar retinaculum can be evaluated.

Two spinal needles (17F Weiss or Tuohy) are used for reefing the patellar medial retinaculum. A suture retriever is prepared by a needle and a suture loop with 1 end passed through the cannula of the needle (Figures ). A spinal needle is inserted into knee joint at the medial patellar edge, and under arthroscope the needle is retreated for 1 or 2 cm to make a proper suture loop for another needle passing (Figures ). At a medial 2 or 3 cm from the first needle on the skin, another needle is pierced into the joint posteromedially to make the inner exit as far away the medial edge of patella as possible. Within the joint, under arthroscopic view, 2 suture retriever loops are crossed (Figures ) and 1 end of the suture loop is pulled by a forceps to open the loop into a free suture (Figures ). After removal of 2 needles from the joint and leaving 2 sutures, the suture loop is pulled to deliver 1 end of the free suture out of joint to complete 1 stitch (Figures ). This procedure is repeated 3 or 4 times so that the stitches evenly spread from the superior pole to the inferior pole of the patella (Figure ). Using a giant needle subcutaneously passing through the 2 eyelets of 1 stitch on the skin, the end of suture at patella edge is brought to the far medial eyelet (Figures ).

Figure 1:. Two spinal needles, each with a suture loop, were inserted into the joint on the medial side of the patella (A). Under arthroscopic control, 2 suture retriever loops were crossed (B) and 1 suture end was pulled (C, arrow) to open the loop to a free suture (D). After removal of the needles, pulling 2 ends of a suture loop (E, arrow) brought another suture out of the joint (E, F) to complete a stitch. Bold arrow: bruise of medial patellofemoral ligament. The procedure was repeated several times so that the stitches (arrowheads) evenly spread from the superior to the inferior pole of the patella (G). Abbreviations: FC, femoral condyle; P, patella.

Figure 2:. A giant needle passing through the inlet and outlet of the stitch subcutaneously (A, arrow) led the suture end at medial patellar edge out from the far medial eyelet (A, B). Abbreviations: IM, inferomedial portal; P, patella.

The camera is switched from the inferolateral portal to the inferomedial portal to get a better view of the lateral retinaculum. In most patients with recurrent patellar instability, after debridement of the lateral synovium of the patella by a 4.5-mm Linvatec soft tissue shaver (Largo, Florida), a radiofrequency device is inserted in the joint through the inferolateral portal to perform lateral retinaculum release. A full-thickness retinaculum cut is made from the superior pole of the patella to the inferior pole at 1 cm lateral to the patella.

The assistant manually tightens the sutures at medial side of the patella, and patellar tracking is evaluated again from full extension to 90° of flexion under arthroscope. After medial plication and lateral release, the new relationship of the patellar ridge with the femoral sulcus can be observed. Furthermore, it is found that lateral tilt and overhang of lateral patellar facet are vanished or improved. At the same time, it also can be found that the patella is pulled medially from apparent view. Based on re-evaluation of patellar congruency in the trochlea and tracking, we regulate the tension of medial retinaculum imbrication to avoid internal tilt in case of excessive medialization of the patella.

Then the fluid of the joint is drained and the sutures tightened and knotted 1 by 1 when the assistant pushes the patella medially and maintains the tension according to the reevaluation under arthroscope (Figure ). After this procedure, we check the joint under arthroscope again to make sure patellar tracking is satisfied, and then bury the knots subcutaneously (Figure ).

Figure 3:. After re-evaluation of patellar tracking, the sutures were tightened and knotted with the knots buried subcutaneously (A, arrowheads). The medial reefing (arrowhead) was checked again under arthroscope (B). Bold arrow: bruise of medial patellofemoral ligament. Abbreviations: FC, femoral condyle; IL, inferolateral portal; IM, inferomedial portal; P, patella.

Postoperatively, as a part of standard rehabilitation program, quadriceps contractions and straight-leg raises are encouraged immediately after anesthesia fades. After 2 weeks, the patient is allowed to partially bear weight with crutch support and brace protection. Full weight bearing is allowed at 4 weeks. The brace is unlocked to enable patients to begin range of motion exercises not beyond 60° and 90° every 2 weeks. At 4 weeks, the patient is allowed to increase knee flexion as tolerated.

Results

To date, 17 patients with recurrent patellar instability have been treated by this all-inside arthroscopic technique. Traumatic chondral or osteochondral fragments were found in 4 cases, and 3 of them underwent chondroplasty. In 2 cases, lesion of the menisci was found and corresponding partial meniscectomy was performed. No anterior and posterior cruciate ligament rapture was found. No operational complications such as intra-articular infection or iatrogenic injury were observed. Mean operative time was 48.4±6.7 minutes (range, 39–61 minutes), whereas average time for medial imbrication was 23.2±4.9 minutes (range, 17–35 minutes). Furthermore, in the latest 5 cases performed in the past 12 months, medial reefing was performed in <20 minutes.

Postoperatively, 3 patients have been followed for >2 years, 7 patients for 1 year, and 5 patients for <1 year. Two patients were lost to follow-up. No recurrence of patellar subluxation or luxation has been found. On physical examination, all patients had a normal patella tracking and good stability in response to manual translation of the patella. One patient who failed to follow standard rehabilitation program had significant loss of range of motion (from 5° to 95°) 7 months postoperatively.

Discussion

For the treatment of patellar dislocation, many open procedures, including soft tissue realignment and bony procedures such as Elmslie-Trillat, ⁴ Roux-Goldthwait, ⁴ Hauser, ⁵ Insall proximal realignment, ⁶and combined realignment procedures, ⁷ have been popularized in the past. Although these traditional operations have proven to result in successful clinical outcomes to a varying extent, they generally accompany apparent morbidity and poor cosmetic results. Nevertheless, the recent progress of knee arthroscopy provides the possibility of minimally invasive procedures for proximal realignment of the patella.

Our technique does not require special instruments, complicated surgical skills, or accessory portals. The procedure is simple and easy for surgeons to perform. Halbrecht ⁸ reported an all-inside technique for proximal patella realignment under arthroscopy. Using 1 epidural needle toward 2 different directions subcutaneously, the medial retinaculum and capsule were penetrated twice so that the suture was introduced to create a loop for knotting. Compared to our technique, the disadvantages of Halbrecht’s ⁸method are: (1) it requires an accessory superolateral portal; (2) the second stab through the retinaculum by epidural needle subcutaneously is difficult to precisely control the position of the outlet and the span of a stitch; and (3) it takes more time and more complicated skills to knot 4 or 5 times in the joint under arthroscope rather than freehand knotting outside the joint.

In 2002, Haspl et al ⁹ developed another all-inside method with some instruments including a working cannula and Transporter Suture Retriever (Acufex, Mansfield, Massachusetts). In their method, an accessory superomedial portal was needed, and 4 or 5 arthroscopic knots were formed and slid down through the extra-articular cannula. Compared to our technique, their procedure is relatively complicated, and the span of the stitch is limited since the inlet and the outlet are perforated from a cannula through the same superomedial portal.

In 2007, Ali and Bhatti ¹ reported a technique to reef the medial retinaculum with a long and prebent 16-gauge Tuohy needle, meniscal suture needle, and artery forceps, which created a subcutaneous plane to retrieve sutures. Their method is not simpler than Haspl et al’s ⁹ since 4 portals (inferolateral, inferomedial, superolateral, and midmedial parapatellar) are needed. According to Ali and Bhatti, ¹ the inlets of the stitches are not close to the medial edge of the patella, mainly as a result of the difficulty of bending a metal 16-gauge Tuohy needle precisely for perforating the capsule twice in aimed positions.

In 2006, Schöttle et al ¹⁰ reported a similar technique, with 2 differences compared to our method: (1) the first needle is pierced through the periosteum of the medial patellar facet, which may lead to avulsion of the insertion on the periosteum as a result of the high tension of knotting in medial imbrication; and (2) an eyelet is advanced through the subcutaneous tissue and is pressed against the skin, where a second epidural needle is inserted through the eyelet into the joint. It may be not easy for a needle to pass through the subcutaneous eyelet precisely.

Although some studies show the clinical success of isolated lateral retinacular release for the treatment of recurrent patellar dislocation, ¹¹ a recent systematic review combining the results of 14 studies concludes that compared with lateral release and medial soft tissue realignment, lateral release alone yields significantly inferior long-term results with respect to symptoms of recurrent lateral patellar instability. ¹² In our technique, we performed both lateral release and medial retinacular imbrication for patients, and no recurrence of patellar subluxation or luxation has been found. After full-thickness lateral release, the patella could be pushed medially by an assistant and medial plication performed. In 2010, Dodson et al ¹³ performed plication first and then released the lateral retinaculum. However, based on clinical experience, we believe that the initial lateral release would provide suitable conditions to further medial plication and knotting the sutures with desired tension. Furthermore, it is incorrect to knot the sutures as tightly as possible in medial reefing. An in vitro study has implied that proximal soft tissue realignment may result in significantly medialized and internally tilted patellar movement. ¹⁴ We suggest that the knotting should be adjusted to appropriate tension according the re-evaluation of patellar tracking under arthroscope.

Our technique is performed in patients with recurrent patellar instability combined with acute injury of the medial patellofemoral ligament body (Figures , , ), since imbrication provides a tension-free condition for ligament healing.

Indications for our technique include recurrent patellar instability resulting from laxity of the medial retinaculum, injury of the medial patellofemoral ligament body, and cases without serious trochlear dysplasia, patella alta, and a considerably high Q angle. However, for the treatment of most severe osseous abnormalities, such as significantly high Q angle, serious patella alta, or trochlear dysplasia, distal bony realignment procedures should be initially considered rather than our technique. Moreover, theoretically our technique is unsuitable for some special types of patellar instability even with a normal Q angle. For example, in cases of avulsion of the medial patellofemoral ligament from the patellar side, ligament reattachment on the medial patellar facet or the reconstruction of the medial patellofemoral ligament is a better choice. ^13,15 In another unpublished study by our medical group, we used anchors for the treatment of patellar instability combined with avulsion of the medial patellofemoral ligament.

Conclusion

The advantages of our technique include simple steps, no special instruments, no accessory portals, and ease of manipulation for arthroscopists. The pitfalls include the limitation that it cannot be performed when the medial patellofemoral ligament has been avulsed off the femoral or patellar side, and that the sharp tip of the spinal needles may cut off the sutures when they pierce into the joint.

For further information: http://www.orthosupersite.com/view.aspx?rid=85222

KNEE

Posted on the ORTHOSuperSite July 8, 2011

Study pinpoints risk factors for TKA following knee arthroscopy

SAN DIEGO — Older age and lower surgeon volume are key risk factors for patients ofknee arthroscopy to undergo total knee arthroplasty within a year of the procedure, according to a recently presented study.

“If a patient undergoes knee arthroscopy shortly before [total knee arthroplasty] TKA, arthroscopy may have been an accessory,” Hassan Ghomrawi, PhD, said during his presentation at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons.

He noted that previous research suggests that 5% to 10% of patients who had a knee arthroscopy undergo TKA within a year of the procedure. “Although we know surgeons have a major role in the decision making when doing an arthroscopy, these epidemiologic studies did not evaluate the effect of surgeon characteristics or volume on outcome.”

Ghomrawi’s team used a New York database to identify 188,575 patients older than 40 years of age who underwent knee arthroscopy between 1999 and 2005. The team traced patient identifiers to locate those who underwent TKA within a year of their arthroscopy. The odds ratio model used for the study took into account gender, insurance type, comorbidities, diagnosis, type of arthroscopy and the yearly arthroscopy volume of the surgeon.

Ghomrawi and colleagues found that 42,833 patients in the study were diagnosed with arthritis. Overall 4,536 patients (2.4%) went on to receive TKA within a year of their arthroscopy.

Patients who were 70 years or older, female, had arthritis, were insured by Medicare or Medicaid and those who underwent arthroscopy with a surgeon whose workload was less than 12 arthroscopies per year were found to be more likely to undergo a subsequent TKA.

The risk of undergoing a TKA decreased with ACL reconstruction and meniscectomy.

“Our results highlight the significance of volume-outcome relationships, and call for further investigation in this area,” Ghomrawi concluded.

For further information: http://www.orthosupersite.com/view.aspx?rid=85511

FOOT AND ANKLE

ORTHOPEDICS July 2011;34(7):530.

Achilles Tendon Rupture and Subsequent Repair

by Keith L. Wapner, MD

Dr Wapner is from the University of Pennsylvania, Philadelphia, Pennsylvania.

Dr Wapner has no relevant financial relationships to disclose.

Correspondence should be addressed to: Keith L. Wapner, MD, 230 W Washington Sq, 5th Floor, Philadelphia, PA 19106.

What are the leading causes of Achilles tendon rupture?

Achilles tendon injuries are deceleration injuries. They occur when the gastrocsoleus muscle forcibly retracts, such as when you land after going up for a rebound in basketball, causing a sudden unexpected dorsiflexion to the ankle. They can occur while pushing off with the knee extended, as in tennis while lunging for a shot. They can also occur with sudden violent dorsiflexion force on a plantar flexed foot. These traumatic ruptures occur because the force exerted on the suddenly rapidly loaded tendon exceeds the tendon’s tensile strength.

What is your technique for an Achilles tendon repair?

I generally do an open repair of the Achilles tendon using a nonabsorbable suture. I use a medial approach just anterior to the Achilles tendon to avoid a posterior scar and to avoid the sural nerve laterally. Dissection is always done deep to the paratenon to avoid injury to the blood supply to the skin. The goal is to debride any devitalized tissue and then anastamose the ends of the tendon back to restore the normal resting length of the muscle, to avoid overlengthening and subsequent weakness. I use a modified Bunnell-type stitch but generally place 2 to 3 passes depending on the degree of mop-handle tearing. Postoperatively, I begin active range of motion and protected weight bearing at 4 weeks and strengthening at 8 weeks.

What is your cut-off for a primary repair, and how do you treat one if it is past your cut-off?

I do not have a cut-off for primary repair of the tendon, but if the rupture is older than 3 months, if the tendon ends are devitalized, or if I have any difficulty getting the ends of the tendon opposed, I will add a flexor hallucis longus tendon transfer to reinforce the repair and give better strength to the tendon.

How do you treat chronic Achilles tendinosis? When do you operate?

I will initially try nonoperative treatment. If the tendinosis is severe, I first immobilize the patient in a molded ankle-foot orthosis until the tenderness is diminished. I start range of motion exercises, then advance to theraband strengthening and eccentric exercises. I wean the patient out of the orthosis and continue with these exercises. If the tendinosis is not severe, I start with the therapy first. If this is not successful in resolving the patient’s pain, or if the patient does not wish to try nonoperative treatment, I give them the option of surgery with debridement of the tendon and flexor hallucis longus transfer. I will harvest the flexor hallucis longus from a separate midfoot incision and pass it through a hole in the posterior calcaneus, then weave the flexor hallucis longus up through the Achilles.

Which patients benefit from nonoperative treatment of an Achilles tendon rupture?

In the acute setting, patients who are not operative candidates because of concomitant medical problems benefit from nonoperative treatment. Some studies show that closed treatment will give satisfactory results, but most of these rely on serial ultrasound studies to assure that the tendon ends are opposed to prevent healing with an overlengthened tendon.

In the setting of chronic tendinosis, patients who do not wish to significantly limit their activity or undergo surgery can be managed with molded ankle-foot orthosis bracing.

What should the physical examination entail for an acute Achilles tendon rupture?

The classic test for an Achilles rupture is the Thompson test. The examiner lays the patient prone with the foot extending past the end of the examination table, then squeezes the calf muscle. If the patient’s foot does not plantar flex, this indicates that the tendon is ruptured. This can also be done prone with the patient’s knee flexed. At times, a palpable gap may be present in the tendon, but this is less reliable. Plantar flexion against resistance is also unreliable, as the patient may be able to generate significant plantar flexion force with the flexor hallucis longus and flexor digitorum longus muscles.

What is the role of imaging in diagnosing acute Achilles tendon ruptures?

Generally, imaging other than radiographs to rule out concomitant fractures is not required. If the diagnosis is not clear on physical examination, it can be confirmed by sonogram or magnetic resonance imaging.

Does immediate mobilization following Achilles tendon rupture surgery lead to a quicker recovery?

Immediate mobilization should be delayed until there is either surgical repair of the tendon or sonogram evidence of healing of the tendon ends if nonoperative treatment is used. Early mobilization has been shown to improve functional long-term results and is widely accepted.

What does the future hold for the treatment of Achilles tendon rupture?

The use of biologics may lead to earlier and enhanced healing of the Achilles tendon. This is an area where further research and ongoing studies may provide us with better treatment options.

In this issue of ORTHOPEDICS, Dr Keith L. Wapner discusses his technique for Achilles tendon repair and which patients may benefit from nonoperative treatment.

For further information:

http://www.orthosupersite.com/view.aspx?rid=85223

KNEE

ORTHOPEDICS July 2011;34(7):524.

Arthroscopic Medial Retinacular Imbrication for the Treatment of Recurrent Patellar Instability: A Simple and All-Inside Technique

by Hu Xu, MD; Chunli Zhang, MD; Guoxian Pei, MD; Qinsheng Zhu, MD; Yisheng Han, MD

Abstract

Proximal soft tissue realignment is the main surgical intervention for recurrent patellar instability. In recent years, all-inside arthroscopic procedures or mini-open surgeries have replaced traditional surgeries, which have more associated morbidity and poor cosmetic results. This article describes a simple and all-inside arthroscopic technique for the operative treatment of recurrent patellar instability. Using 2 epidural needles in several steps and no accessory portals required, the medial patellar retinaculum is imbricated to the desired tension. The combination of lateral release and medial retinacular placation obviously improves the patellar tracking compared with preoperatively.

Drs Xu, Zhang, Pei, Zhu, and Han are from the Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, People’s Republic of China.

Drs Xu, Zhang, Pei, Zhu, and Han have no relevant financial relationships to disclose.

Correspondence should be addressed to: Hu Xu, MD, Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, 710032, People’s Republic of China (xuhutiger1997@yahoo.com.cn).

Although >100 different surgical methods have been described for the treatment of recurrent patellar instability, the best choice remains controversial. Since various procedures in a number of studies have been proved effective, no gold standard surgery has been defined yet. Most surgeries typically involve 2 basic techniques: proximal soft tissue realignment and distal bony realignment. Proximal realignment generally is addressed by a combination of lateral retinacular release and imbrications of medial retinaculum. Traditional open surgical management ordinarily leads to poor cosmetic results; therefore, total arthroscopic techniques and arthroscopy-assisted mini-open medial reefing for the medial soft tissue realignment have been reported in recent years. ^1,2 However, most arthroscopic methods for medial retinacular plication either require special instruments or have relatively complicated procedures.

Almazán et al ³ introduced an arthroscopic technique for the repair of the shoulder rotator interval. Using 2 spinal cannular needles with several steps, the defect of the rotator cuff interval lesion could be repaired without accessory portals. Combining Almazán et al’s ³ method with previously reported knee arthroscopic techniques, we developed a simple and all-inside procedure for the treatment of recurrent patellar instability.

Surgical Technique

Surgery is performed with the patient under general or spinal anesthesia. The patient is positioned supine on the operating table with an inflated tourniquet applied to the operative extremity. The leg is sterilely prepped and draped in routine fashion. Using the standard inferolateral and inferomedial portals, routine diagnostic arthroscopy is performed to observe the lesion of menisci and cartilage, traumatic loose bodies (chondral or osteochondral fragments), and rupture of the anterior and posterior cruciate ligaments. Corresponding treatments including partial meniscectomy, chondroplasty, and removal of loose bodies are performed.

Particular attention should be paid to check the relationship of the patellar ridge with the femoral trochlear groove through range of motion of the knee and assessing patellar tracking from both inferolateral and inferomedial portals. Lateral tilt and overhang of the lateral patellar facet can be observed. The extent of laxity of the medial patellar capsuloligmentous complex and tightness of the lateral patellar retinaculum can be evaluated.

Two spinal needles (17F Weiss or Tuohy) are used for reefing the patellar medial retinaculum. A suture retriever is prepared by a needle and a suture loop with 1 end passed through the cannula of the needle (Figures ). A spinal needle is inserted into knee joint at the medial patellar edge, and under arthroscope the needle is retreated for 1 or 2 cm to make a proper suture loop for another needle passing (Figures ). At a medial 2 or 3 cm from the first needle on the skin, another needle is pierced into the joint posteromedially to make the inner exit as far away the medial edge of patella as possible. Within the joint, under arthroscopic view, 2 suture retriever loops are crossed (Figures ) and 1 end of the suture loop is pulled by a forceps to open the loop into a free suture (Figures ). After removal of 2 needles from the joint and leaving 2 sutures, the suture loop is pulled to deliver 1 end of the free suture out of joint to complete 1 stitch (Figures ). This procedure is repeated 3 or 4 times so that the stitches evenly spread from the superior pole to the inferior pole of the patella (Figure ). Using a giant needle subcutaneously passing through the 2 eyelets of 1 stitch on the skin, the end of suture at patella edge is brought to the far medial eyelet (Figures ).

Figure 1:. Two spinal needles, each with a suture loop, were inserted into the joint on the medial side of the patella (A). Under arthroscopic control, 2 suture retriever loops were crossed (B) and 1 suture end was pulled (C, arrow) to open the loop to a free suture (D). After removal of the needles, pulling 2 ends of a suture loop (E, arrow) brought another suture out of the joint (E, F) to complete a stitch. Bold arrow: bruise of medial patellofemoral ligament. The procedure was repeated several times so that the stitches (arrowheads) evenly spread from the superior to the inferior pole of the patella (G). Abbreviations: FC, femoral condyle; P, patella.

Figure 2:. A giant needle passing through the inlet and outlet of the stitch subcutaneously (A, arrow) led the suture end at medial patellar edge out from the far medial eyelet (A, B). Abbreviations: IM, inferomedial portal; P, patella.

The camera is switched from the inferolateral portal to the inferomedial portal to get a better view of the lateral retinaculum. In most patients with recurrent patellar instability, after debridement of the lateral synovium of the patella by a 4.5-mm Linvatec soft tissue shaver (Largo, Florida), a radiofrequency device is inserted in the joint through the inferolateral portal to perform lateral retinaculum release. A full-thickness retinaculum cut is made from the superior pole of the patella to the inferior pole at 1 cm lateral to the patella.

The assistant manually tightens the sutures at medial side of the patella, and patellar tracking is evaluated again from full extension to 90° of flexion under arthroscope. After medial plication and lateral release, the new relationship of the patellar ridge with the femoral sulcus can be observed. Furthermore, it is found that lateral tilt and overhang of lateral patellar facet are vanished or improved. At the same time, it also can be found that the patella is pulled medially from apparent view. Based on re-evaluation of patellar congruency in the trochlea and tracking, we regulate the tension of medial retinaculum imbrication to avoid internal tilt in case of excessive medialization of the patella.

Then the fluid of the joint is drained and the sutures tightened and knotted 1 by 1 when the assistant pushes the patella medially and maintains the tension according to the reevaluation under arthroscope (Figure ). After this procedure, we check the joint under arthroscope again to make sure patellar tracking is satisfied, and then bury the knots subcutaneously (Figure ).

Figure 3:. After re-evaluation of patellar tracking, the sutures were tightened and knotted with the knots buried subcutaneously (A, arrowheads). The medial reefing (arrowhead) was checked again under arthroscope (B). Bold arrow: bruise of medial patellofemoral ligament. Abbreviations: FC, femoral condyle; IL, inferolateral portal; IM, inferomedial portal; P, patella.

Postoperatively, as a part of standard rehabilitation program, quadriceps contractions and straight-leg raises are encouraged immediately after anesthesia fades. After 2 weeks, the patient is allowed to partially bear weight with crutch support and brace protection. Full weight bearing is allowed at 4 weeks. The brace is unlocked to enable patients to begin range of motion exercises not beyond 60° and 90° every 2 weeks. At 4 weeks, the patient is allowed to increase knee flexion as tolerated.

Results

To date, 17 patients with recurrent patellar instability have been treated by this all-inside arthroscopic technique. Traumatic chondral or osteochondral fragments were found in 4 cases, and 3 of them underwent chondroplasty. In 2 cases, lesion of the menisci was found and corresponding partial meniscectomy was performed. No anterior and posterior cruciate ligament rapture was found. No operational complications such as intra-articular infection or iatrogenic injury were observed. Mean operative time was 48.4±6.7 minutes (range, 39–61 minutes), whereas average time for medial imbrication was 23.2±4.9 minutes (range, 17–35 minutes). Furthermore, in the latest 5 cases performed in the past 12 months, medial reefing was performed in <20 minutes.

Postoperatively, 3 patients have been followed for >2 years, 7 patients for 1 year, and 5 patients for <1 year. Two patients were lost to follow-up. No recurrence of patellar subluxation or luxation has been found. On physical examination, all patients had a normal patella tracking and good stability in response to manual translation of the patella. One patient who failed to follow standard rehabilitation program had significant loss of range of motion (from 5° to 95°) 7 months postoperatively.

Discussion

For the treatment of patellar dislocation, many open procedures, including soft tissue realignment and bony procedures such as Elmslie-Trillat, ⁴ Roux-Goldthwait, ⁴ Hauser, ⁵ Insall proximal realignment, ⁶and combined realignment procedures, ⁷ have been popularized in the past. Although these traditional operations have proven to result in successful clinical outcomes to a varying extent, they generally accompany apparent morbidity and poor cosmetic results. Nevertheless, the recent progress of knee arthroscopy provides the possibility of minimally invasive procedures for proximal realignment of the patella.

Our technique does not require special instruments, complicated surgical skills, or accessory portals. The procedure is simple and easy for surgeons to perform. Halbrecht ⁸ reported an all-inside technique for proximal patella realignment under arthroscopy. Using 1 epidural needle toward 2 different directions subcutaneously, the medial retinaculum and capsule were penetrated twice so that the suture was introduced to create a loop for knotting. Compared to our technique, the disadvantages of Halbrecht’s ⁸method are: (1) it requires an accessory superolateral portal; (2) the second stab through the retinaculum by epidural needle subcutaneously is difficult to precisely control the position of the outlet and the span of a stitch; and (3) it takes more time and more complicated skills to knot 4 or 5 times in the joint under arthroscope rather than freehand knotting outside the joint.

In 2002, Haspl et al ⁹ developed another all-inside method with some instruments including a working cannula and Transporter Suture Retriever (Acufex, Mansfield, Massachusetts). In their method, an accessory superomedial portal was needed, and 4 or 5 arthroscopic knots were formed and slid down through the extra-articular cannula. Compared to our technique, their procedure is relatively complicated, and the span of the stitch is limited since the inlet and the outlet are perforated from a cannula through the same superomedial portal.

In 2007, Ali and Bhatti ¹ reported a technique to reef the medial retinaculum with a long and prebent 16-gauge Tuohy needle, meniscal suture needle, and artery forceps, which created a subcutaneous plane to retrieve sutures. Their method is not simpler than Haspl et al’s ⁹ since 4 portals (inferolateral, inferomedial, superolateral, and midmedial parapatellar) are needed. According to Ali and Bhatti, ¹ the inlets of the stitches are not close to the medial edge of the patella, mainly as a result of the difficulty of bending a metal 16-gauge Tuohy needle precisely for perforating the capsule twice in aimed positions.

In 2006, Schöttle et al ¹⁰ reported a similar technique, with 2 differences compared to our method: (1) the first needle is pierced through the periosteum of the medial patellar facet, which may lead to avulsion of the insertion on the periosteum as a result of the high tension of knotting in medial imbrication; and (2) an eyelet is advanced through the subcutaneous tissue and is pressed against the skin, where a second epidural needle is inserted through the eyelet into the joint. It may be not easy for a needle to pass through the subcutaneous eyelet precisely.

Although some studies show the clinical success of isolated lateral retinacular release for the treatment of recurrent patellar dislocation, ¹¹ a recent systematic review combining the results of 14 studies concludes that compared with lateral release and medial soft tissue realignment, lateral release alone yields significantly inferior long-term results with respect to symptoms of recurrent lateral patellar instability. ¹² In our technique, we performed both lateral release and medial retinacular imbrication for patients, and no recurrence of patellar subluxation or luxation has been found. After full-thickness lateral release, the patella could be pushed medially by an assistant and medial plication performed. In 2010, Dodson et al ¹³ performed plication first and then released the lateral retinaculum. However, based on clinical experience, we believe that the initial lateral release would provide suitable conditions to further medial plication and knotting the sutures with desired tension. Furthermore, it is incorrect to knot the sutures as tightly as possible in medial reefing. An in vitro study has implied that proximal soft tissue realignment may result in significantly medialized and internally tilted patellar movement. ¹⁴ We suggest that the knotting should be adjusted to appropriate tension according the re-evaluation of patellar tracking under arthroscope.

Our technique is performed in patients with recurrent patellar instability combined with acute injury of the medial patellofemoral ligament body (Figures , , ), since imbrication provides a tension-free condition for ligament healing.

Indications for our technique include recurrent patellar instability resulting from laxity of the medial retinaculum, injury of the medial patellofemoral ligament body, and cases without serious trochlear dysplasia, patella alta, and a considerably high Q angle. However, for the treatment of most severe osseous abnormalities, such as significantly high Q angle, serious patella alta, or trochlear dysplasia, distal bony realignment procedures should be initially considered rather than our technique. Moreover, theoretically our technique is unsuitable for some special types of patellar instability even with a normal Q angle. For example, in cases of avulsion of the medial patellofemoral ligament from the patellar side, ligament reattachment on the medial patellar facet or the reconstruction of the medial patellofemoral ligament is a better choice. ^13,15 In another unpublished study by our medical group, we used anchors for the treatment of patellar instability combined with avulsion of the medial patellofemoral ligament.

Conclusion

The advantages of our technique include simple steps, no special instruments, no accessory portals, and ease of manipulation for arthroscopists. The pitfalls include the limitation that it cannot be performed when the medial patellofemoral ligament has been avulsed off the femoral or patellar side, and that the sharp tip of the spinal needles may cut off the sutures when they pierce into the joint.

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KNEE

ORTHOPEDICS July 2011;34(7):251.

Do Microfractures Improve High Tibial Osteotomy Outcome?

by Walter Pascale, MD; Simone Luraghi, MD; Laura Perico, MD; Valerio Pascale, MD

Abstract

The aim of this study was to determine if microfractures improve the outcome of high tibial osteotomy in patients with medial compartmental osteoarthritis in genu varum. Forty patients presenting with Outerbridge grade III and IV chondropathies on the femoral and/or the tibial joint surface underwent high tibial osteotomy with Puddu plates (Arthrex, Inc, Naples, Florida) for primary medial compartment osteoarthritis in genu varum at our institution. Patients were randomly assigned to either the high tibial osteotomy plus microfractures group (A; n=20) or the high tibial osteotomy alone group (B; n=20). Final assessment was conducted 5 years postoperatively, including clinical response measured by the International Knee Documentation Committee (IKDC), Lysholm score, and patient satisfaction score. All patients were blinded to the treatment received and followed the same rehabilitation protocol. A statistically significant improvement between pre- and postoperative values was observed for Lysholm and IKDC scores in both groups, without any statistically significant difference between them. Regarding the satisfaction score, there were no differences between the 2 groups in terms of preoperative self-assessment ( P>.05), whereas postoperative subjective satisfaction at 5-year follow-up was significantly higher in group A than in group B ( P=.0036).

Our study results provide further evidence that medial tibial osteotomy is an effective surgical option for treating a varus knee associated with medial degenerative arthritis in patients wishing to continue accustomed levels of physical activity. In particular, patient satisfaction was higher among those who underwent the combined treatment involving high tibial osteotomy to correct femorotibial angle and microfractures.

Drs Pascale (Walter), Luraghi, Perico, and Pascale (Valerio) are from IRCCS Galeazzi Orthopaedic Institute, and Dr Pascale (Valerio) is also from Clinica Ortopedica e Traumatologica, Università degli Studi di Milano, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy.

Drs Pascale (Walter), Luraghi, Perico, and Pascale (Valerio) have no relevant financial relationships to disclose.

Correspondence should be addressed to: Walter Pascale, MD, IRCCS Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161 Milano, Italy (pascalew@tiscali.it).

Posted Online: July 07, 2011

Treatment of unicompartmental knee osteoarthritis continues to raise discussion. As initially described by Jackson et al, ¹ the causes of knee joint cartilage degeneration have been primarily attributed to medial deviation of the functional axis of the knee, tibial and femoral bone deformities, and malalignment and disorientation due to primary laxity of the collateral ligaments. ² High tibial osteotomy is a treatment of choice, particularly in patients wishing to continue to practice high levels of physical activity. Unicompartmental prosthesis is a more definitive treatment than high tibial osteotomy and is indicated in patients affected by wider cartilage degeneration or in older patients. ³

First described by Jackson and Waugh ⁴ in 1982, high tibial osteotomy attracted attention following publication of long-term results in a study by Coventry et al. ⁵ Debeyre and Artigou ⁶ outlined the technique of open wedge medial tibial osteotomy. With the introduction of the Puddu plate (Arthrex, Inc, Naples, Florida) into clinical practice in the late 1990s, which simplified the technique, high tibial osteotomy has reached wider acceptance. However, controversy exists about the use of high tibial osteotomy in association with microfractures to stimulate cartilage regeneration. ^7,8

Johnson ⁹ reported that microfracture is a suitable treatment for knee cartilage lesions, providing repair of the lesions by the formation of fibrocartilage. Although favorable results have been reported in patients with slight deviation of the functional axis, the long-term outcome remains unclear. ^10,11 In their studies, Bergenudd et al ¹² and Odenbring et al ¹³ found that high tibial osteotomy can lead to long-term clinical improvement in cases of knee cartilage lesions.

The aim of this study was to assess patient satisfaction and functional outcome after high tibial osteotomy in combination with microfractures in patients with medial osteoarthritis in genu varum.

Materials and Methods

The study population comprised 40 patients who underwent high tibial osteotomy with Puddu plates for primary medial compartment osteoarthritis in genu varum at our institution between 2002 and 2003. Inclusion criteria were chondropathies present on the femoral and/or the tibial joint surface, multiple Outerbridge grade III and IV lesions, femorotibial deviation between 7° and 10°, age between 40 and 70 years, body mass index (BMI) <32 kg/m ². The work was approved by our institution’s ethical committee. All patients gave their consent to be included in the study.

Group A patients were treated with high tibial osteotomy plus microfractures (20 knees in 20 patients), while group B patients received high tibial osteotomy alone (20 knees in 20 patients). All 40 patients were randomly assigned to either group by an external researcher not involved in the study using a randomization block. All procedures were performed by the same surgeon (W.P.), and the patients were blinded to treatment received. Imaging studies, including anteroposterior (AP), lateral, and tangential knee and long-leg radiographs and magnetic resonance imaging (MRI) were performed for each patient (Figure ). The radiologist also was blinded to the study conditions. The patients received a 30-day course of prophylactic deep venous thrombosis treatment and a short-term course of prophylactic antibiotic therapy.

Figure 1:. AP radiograph of a high tibial osteotomy procedure.

Knee joint cartilage was evaluated arthroscopically by the same surgeon preoperatively according to Outerbridge’s criteria: grade 0=normal; grade I=softening and slight fibrillation of the surface; grade II=generally smooth joint surface but with unevenness, fragmentation, fissuring, and fibrillation over an area <1.5 cm; grade III=white fibrous tissue, fragmentation, fissuring, and fibrillation over an area >1.5 cm; grade IV=subchondral bone exposure and eburnation over almost all the joint surface. ¹⁴

Symptoms were evaluated by the International Knee Documentation Committee (IKDC) and Lysholm scales preoperatively and at 6 months, 1 year, 2 years, and 5 years postoperatively. This study presents the 5-year follow-up data. Lysholm scores were considered: >64=not sufficient; 65–83=sufficient; 84–94=good; 95–100=excellent. Patient satisfaction was measured according to a satisfaction scale (score 1–10).

Surgical Technique

High tibial osteotomy was performed by wedge interlocking osteotomy and fixation with a Puddu plate. Prior to osteotomy, the degree of joint degeneration was measured arthroscopically. In group A, abrasion arthroplasty was performed using a steel abrader to a depth of approximately 1 mm; microfractures were created by drilling holes in the perimeter and the central area of the damaged cartilage to a depth of approximately 1 mm until bleeding of the subchondral bone occurred. This procedure was performed on the tibial plateau and femoral condyle in all patients except for 3 patients in group A who did not present with chondropathy of the tibial plateau and who received microfractures of the femoral condyle only. Group B patients underwent high tibial osteotomy only.

Starting from postoperative day 2, the physiotherapy regimen comprised physiotherapist-assisted continuous passive motion exercises, approximately 4 hours daily for 2 weeks, as well as isometric gymnastic and passive and active kinesis for approximately 2 hours daily for 2 weeks (Figure ). ^15,16 The work load was adjusted at 6 to 8 weeks, before full weight bearing was permitted.

Figure 2:. After 2 weeks of the rehabilitation program, patients were able to actively reach 90° of flexion.

Analysis of variance (ANOVA) was performed on continuous data; the chi-square test was used to analyze the categorical scores. Statistical significance was set at P<.05.

Using an alpha value of 0.05 and a power of 80%, the power calculations were derived from an estimated difference of 8 points in postoperative Lysholm score between the 2 groups. The sample size resulted in 20 patients for each group.

Results

The clinical characteristics of the patients are summarized in Table . Group A comprised 13 men and 7 women, and group B comprised 15 men and 5 women. Average patient age at surgery was 50±4.6 years (range, 44–64 years) in group A and 49.7±5.8 years (range, 43–67 years) in group B ( P<.05).

Table 1. Patient Clinical Characteristics

Eleven patients in group A and 13 patients in group B were affected by Outer-bridge grade III lesions, whereas all other patients, 9 in group A and 7 in group B, presented with grade IV cartilage lesions. All patients presented with femoral and tibial eburnation, with the exception of 3 patients in group A and 2 patients in group B who did not have tibial eburnation. Three patients in group A and 2 in group B had received arthroscopic debridement; the remaining patients, 17 in group A and 18 in group B, had undergone conservative treatment for 1 year. All patients were affected by multiple lesions, differing in size and in Outerbridge grade, but no cases involved the entire tibial plateau or condyle. A significant difference between pre- and postoperative values in terms of femorotibial angle correction was present in each group (178.5±1.5 and 184.5±0.9 for group A, respectively; 178.2±1.6 and184.6±0.9 for group B, respectively; all P<.05), but no statistically significant differences between the 2 groups were observed (P<.05).

The same trend was observed for the Lysholm and IKDC scores preoperatively and 5 years postoperatively: analysis showed a statistically significant improvement in postoperative Lysholm scores in both groups compared to the preoperative scores ( P<.05), but there was no statistically significant difference in pre- and postoperative scores between the 2 groups ( P>.05) (Table ). Preoperative IKDC score was D in 70% and 75% of patients in group A and B, respectively ( P>.05). Postoperative IKDC score significantly increased in both groups: 16 patients in the combined treatment group (80%) and 17 patients treated with high tibial osteotomy alone (85%) scored A, whereas the others scored B, with no significant differences between the 2 groups ( P>.05).

Table 2. Mean Pre- and Postoperative Lysholm and Satisfaction Scores

Regarding the satisfaction score, there were no differences between the 2 groups in terms of preoperative self-assessment ( P>.05), whereas postoperative subjective satisfaction at 5-year follow-up was significantly higher in group A than in group B ( P=.0036). The inverse correlation between BMI and postoperative Lysholm score ( r=-0.049; P=.001) was statistically significant only in group B patients. Furthermore, a negative correlation emerged between age and lesion grade according to Outerbridge’s criteria in group B patients: with increasing age, the lesion grade decreased (grades III and IV at an average age of 51.8 and 46.9 years, respectively; P=.014).

Postoperative Lysholm score was sufficient in 65% and good in 35% of group A patients, whereas in group B it was insufficient in 5%, sufficient in 60%, and good in 35% of patients. The patients who scored highest on the Lysholm scale were those with the highest preoperative lesion grade.

Magnetic resonance imaging assessment 5 years postoperatively disclosed regeneration of cartilage tissue on the femoral and tibial bones. In 3 cases of residual pain and articular stiffness in the operated knee, an arthroscopic second look of the joint observed good formation of a covering tissue (Figure ).

Figure 3:. Arthroscopic second look after 1 year with microfracture treatment of a medial femoral condyle.

At 1-year follow-up, 1 patient was excluded from the study because of failure to return for examination. At 5-year follow-up, 2 patients (5%) were noted to have 3° undercorrection in genu varum that produced arthroscopically and clinically insufficient healing. For this reason and because of persistent pain, both received total knee arthroplasty (TKA). Deep venous thrombosis in 1 patient (2.5%) resolved with medical and compression therapy and did not affect the final analysis of the results.

Discussion

Our study results provide further evidence that medial tibial osteotomy is an effective surgical option for treating a varus knee associated with medial degenerative arthritis in patients wishing to continue accustomed levels of physical activity. In particular, patient satisfaction was higher among those who underwent the combined treatment involving high tibial osteotomy to correct femorotibial angle and microfractures. Furthermore, an inverse correlation emerged between BMI values, Lysholm and IKDC scores, patient age, and degree of correction.

In this study population, a second intervention was necessary in only 2 cases where correction of the mechanical axis failed to restore normal valgus and serious pain persisted at 5-year follow-up. The 2 patients subsequently underwent TKA.

Published data suggest that abrasion-microfractures fail to completely resolve knee joint damage in patients with medial compartment arthritis associated with severe genu varum. ^17–19 Indeed, symptoms may later return, even after initial good results at 1-year postoperatively. For this reason, as described by Shaw and Moulton, ²⁰ high tibial osteotomy associated with microfractures is a valid attempt to correct the primary cause of arthritis. As demonstrated in a study by Puddu et al, ²¹ medial tibial osteotomy is able to produce a clear improvement in clinical and subjective symptoms. Given the subjective nature of pain symptoms, our results show that the combined treatment achieved greater postoperative patient satisfaction, although the clinical results in the 2 treatment groups were objectively definitely comparable. This was probably due to the fibrocartilage formation that abrasion and microfracture are able to promote by stimulating the incoming of subchondral bone marrow blood to the surgical site. Fibrocartilage formation leads to enhanced restoration of physiological knee joint equilibrium, thus reducing pain and increasing patient satisfaction.

Six years postoperatively, we performed arthroscopic reintervention for a medial meniscal lesion in 3 patients. In these patients we were able to observe the new regenerated cartilaginous tissue on the area treated by microfractures. In 2 of these patients, the new formed tissue completely covered the chondral lesion, both approximately 1 cm ², at femoral condyle level in 1 case and on the tibial plateau in the other. In the third patient, where the lesion size was approximately 3 cm ², the new regenerated cartilaginous tissue just partially covered the tibial area. However, despite the results obtained by the second look arthroscopy in 3 of our patients showing no differences between condyles and tibial plateau, our surgical experience allowed us to observe that normally the use of microfractures in combination with osteotomy yields better subjective results in the femoral condyle than in the tibial plateau.

Even if it is known that chondral lesions microfractures could not result in exhaustive and durable results, in particular in lesions >1 cm ², this technique is still the most used treatment for isolated cartilage lesions. When patients present an axial deviation, the outcome could ameliorate combining microfractures with high tibial osteotomy. However, when high tibial osteotomy is not practical, as in normal morphotype patients, alternative treatments could be used for larger cartilage lesions according to patient age, activity level, and general joint conditions. ²² This evidence induced us to use microfractures in patients with focal chondral lesions, whereas for larger lesions, and in cases of correct indications, we performed high tibial osteotomy or a uniprosthesis.

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