Management of recurrent dislocation of patella by reconstructing2
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Transcript of Management of recurrent dislocation of patella by reconstructing2
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Management of Recurrent Dislocation of Patella by Reconstruction of Medial Patellofemoral Ligament – A Noval Approach
JITESH JAINSAURABH AGARWAL
MANAGEMENT OF RECURRENT DISLOCATION OF PATELLA BY RECONSTRUCTIONING MEDIAL PATELLOFEMORAL LIGAMENT – A NOVAL APPROACH.
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PATTERNS OF DISLOCATION
Recurrent dislocation –• repeated, occasional dislocation (commonest form).• The dislocations may occur at intervals of weeks or months.
Recurrent subluxation. •This implies a less drastic event than a dislocation but the distinction between the two is often unclear.• Patients with lax joints.
Habitual dislocation.• patella which dislocates every time the knee flexes.• in these cases it cannot be held in the reduced position throughout the full range of flexion.
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IntroductionInstability of the patella is a common problem. The medial patellofemoral ligament (MPFL) has been demonstrated to be the major soft tissue stabilizer to prevent abnormal lateral displacement of the patella.
Desio SM et al Soft Tissue Restraints to Lateral Patellar Translation in the HumanKnee, Am J Sports Med
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Anatomy
It extends between the superomedial pole of
the patella to the anterior aspect of the medial
epicondyle
The vertical distance from the superior pole of
the patella to the top of the medial
patellofemoral ligament averages about 6.1
mm.
The distal border of the VMO muscle attaches
along the majority of the proximal medial
edge of the MPFL
Steensen RN et al, Am J Sports Med. 2004;32:1509-1513.
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Anatomy-Design fault?The patellofemoral joint is intrinsically unstable joint? Tibial tubercle lies lateral to the long axis of the femur and the quadriceps muscle, and the patella is therefore subject to a laterally directed force.
This apparent ‘design fault’ is
minimised by the resistance of the
lateral lip of trochlea to lateral movement of the patella during
flexion.
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Biomechanics
Biomechanically, the medial patello-femoral
ligament is considered the primary passive restraint
to patellar lateral displacement, with a mean tensile
strength of 208 N
Amis AA et al, Knee. 2003;10:215-220.
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Biomechanics From 0° to 30° of flexion- the median ridge of the patella lies lateral to the centre of the trochlea. 30° and 60° of flexion-it moves medially to become centred in the trochlear groove.As flexion proceeds the patella is more deeply engaged in the trochlea and is held firmly by soft-tissue tension. Beyond 90°-It tilts so that its medial facet articulates with the medial femoral condyle.
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Biomechanics
Lateral patellar displacement tests in vitro showed
that the patella subluxed most easily at 20 degrees
knee flexion.
The contribution of the MPFL to resisting patellar
lateral subluxation was greatest in the extended knee
Amis AA et al, Knee. 2003,Anatomy and biomechanics of the medial patello-femoral ligament.
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Factors Leading To Patellar Instability
Poor engagement abnormally high patella, patellar dysplasia or a poorly developed trochlea.
Failure to stay in the trochlea•Defective lateral trochlear margin •unusually shallow trochlear groove.•Greater laterally directed force -excessive valgus.• excessively tight lateral structures -fibrosis of the vastus lateralis or•deficient medial structures -injury to the medial retinaculum,• stretching of medial structures after repeated dislocations, •severe wasting of the vastus medialis.
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Management-Options are more than 100 lateral release, medial imbrication, medial patellofemoral ligament repair, and a number of distal realignment
procedures.
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Management Recently, medial patellofemoral ligament
reconstruction has gained popularity as a treatment modality for recurrent patellar instability.
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Why MPFL?
Deie M et al noted that after Reconstruction of the medial patellofemoral ligament no recurrence of patellar instability was found with normalization of the congruence angle, tilt angle, and lateral shift ratio in all of their patients.Deie M, et al. J Bone Joint Surg Br2003.
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Why MPFL?Drez D et alNoted in their series of 15 patients a 93% good to excellent results of medial patello-femoral ligament reconstruction in the treatment of patellar dislocation.
Autogenous hamstring or fascia lata for reconstruction Mean follow-up was 31.5 months, Drez D et al, Arthroscopy. 2001.
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Why MPFL? Ellera Gomes JL et al showed in their series of 16 knees with Medial patello-femoral ligament reconstruction with semitendinosus autograft for chronic patellar instability 94% of patient outcomes were rated good or excellent according to the Crosby-Insall criteria.88% of the patients were satisfied with their surgery 15 knees showed a negative apprehension test at follow-up.
Arthroscopy. 2004
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Why MPFL MPFL is injured in most cases with acute patellar dsilocation and MPFL insufficiency is present in all cases with recurrent patellar dislocation.
…Now, the role of the MPFL has been almost established in the Management of Dislocations of patella.
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Material and methods 14 Patients with patellar instability were enrolled in this study from 2008-2012
5 habitual dislocation 9 Recurrent dislocation
Medial patellofemoral ligament pathology was confirmed by both clinical and radiological examination. Apprension test was positive in 12 patientsAverage Q angle..
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The MPFL is attenuated without a discrete tear noted with a laterally dislocated patella
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There is complete avulsion of the MPFL at the femoral attachment and a tear at the patellar attachment
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Material and methods
Technique• Arthroscopic reconstruction of the medial
patellofemoral ligament was done using hamstring graft looped around the patella and anchored to the medial epicondyle of femur with either bone staples or Interference Screws.
• Postoperatively above knee brace support was given for 3 weeks with intermittent physiotherapy and gradual mobilization.
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Material and methods
Non-anatomic reconstruction of the MPFL can lead to non-physiologic patello-femoral loads and kinematics.So the goal of surgical intervention must be an anatomic reconstruction.
Amis AA et al Anatomy and Biomechanics of the Medial Patellofemoral Ligament, Knee 2003.
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Technique – Graft Harvesting
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Technique – Graft Preparation
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Technique – Patellar Preperation
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Graft Loop Through Patella
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Graft was passed through a Soft Tissue Tunnel between Medial Retinaculum and Joint Capsule
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Graft Fixed to the Medial Epicondyle of Femur
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Results
13 out of 14 patients returned to their daily work and sport activities within 6 weeks to 3 months.
1 patient had stiffness around knee post surgery with ROM 10-1000. 100 flexion deformity was gradually corrected with supervised physiotherapy over next 3 months.
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Results
Complications: Anterior knee pain-3 Patients. Numbness -5 patients experience mild
numbness on the shin, close to the surgical scar.
No case of graft rupture and infection was noted
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Case-1
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Case -1; 2 Years Post-Up
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Case – II , Pre-op
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Case – II, Post-op
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Case III, 35 years Male6 Years Follow-Up
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3 Years Follow-Up
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Case-IV
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Conclusion The principal advantage of this procedure is
the ability to definitively reconstruct the medial patellofemoral ligament on the femur.
Allowing reasonable MPFL isometry throughout the arc of knee motion.
A minimal invasive surgery. With this procedure early rehabilitation can
be started and is a good technique for sport persons with MPFL injuries.
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