Medial Tibial Tubercle Transfer Research Articles

Quality of life following medial patellofemoral ligament reconstruction combined with medial tibial tubercle transfer in patients with recurrent patellar dislocation: a retrospective comparative study

BackgroundBecause the patients undergoing medial patellofemoral ligament reconstruction (MPFLr) combined with medial tibial tubercle transfer (TTT) procedure are usually young and active, the quality of life (QoL) is also an important prognostic factor for patients with recurrent patellar dislocation. Assessing QoL can provide more useful and accurate evidence for the effects of this procedure. This study aimed to evaluate QoL following MPFLr combined with TTT, compared with isolated MPFLr (iMPFLr).MethodsFifty-one patients who underwent iMPFLr + TTT and 48 patients who underwent iMPFLr were included. Clinical evaluation included QoL (EQ-5D-5L and EQ-5D VAS), functional outcomes (Kujala, Lysholm and Tegner activity scores), physical examinations (patellar apprehension test and range of motion) and redislocation rates. Radiological evaluation included patellar tilt angle and bisect offset. These preoperative and postoperative results were compared between groups at baseline and the final follow-up. The paired and independent t tests were used for the data following a normal distribution. Otherwise, the Wilcoxon and Mann–Whitney U tests were used to analyze the differences. Categorical variables were compared by chi-square or Fisher’s exact test.ResultsAll of the QoL (EQ-5D-5L and EQ-5D VAS), clinical results and radiological outcomes significantly improved in both groups at the final follow-up, with no significant differences between groups. There was no significant difference in five dimensions of EQ-5D at the final follow-up, although percentages of people with problems of mobility and pain/discomfort were higher in the MPFLr + TTT group. Female patients had lower EQ-5D index and EQ-5D VAS compared with male patients in both groups at the final follow-up, but there was only a significant difference in the EQ-5D VAS.ConclusionsBoth MPFLr + TTT and iMPFLr groups obtained similar and satisfactory improvements in the QoL, clinical results and radiological outcomes, indicating that MPFLr combined with TTT is a safe and effective procedure, which can significantly improve the QoL for patients with recurrent patellar dislocation in cases of pathologically lateralized TT. However, female patients obtained lower QoL than males.

Anatomical Components Associated With Increased Tibial Tuberosity-Trochlear Groove Distance.

Background:Increased tibial tuberosity–trochlear groove (TT-TG) distance is an important indicator of medial tibial tubercle transfer in the surgical management of lateral patellar dislocation (LPD). Changes to TT-TG distance are determined by a combination of several anatomical factors.Purpose:To (1) determine the anatomical components related to increased TT-TG distance and (2) quantify the contribution of each to identify the most prominent component.Study Design:Case-control study; Level of evidence, 3.Methods:Included were 80 patients with recurrent LPD and 80 age- and body mass index–matched controls. The 2 groups were compared in TT-TG distance and its related anatomical components: tibial tubercle lateralization (TTL), trochlear groove medialization, femoral anteversion, tibiofemoral rotation (TFR), tibial torsion, and mechanical axis deviation (MAD). The Pearson correlation coefficient (r) was calculated to evaluate the association between increased TT-TG distance and its anatomical parameters, and factors that met the inclusion criteria of P < .05 and r ≥ 0.30 were analyzed via stepwise multivariable linear regression analysis to predict TT-TG distance.Results:The LPD and control groups differed significantly in TT-TG distance, TTL, TFR, and MAD (P < .001 for all). Increased TT-TG distance was significantly positively correlated with TTL (r = 0.376; P < .001), femoral anteversion (r = 0.166; P = .036), TFR (r = 0.574; P < .001), and MAD (r = 0.415; P < .001), and it was signficantly negatively correlated with trochlear groove medialization (r = −0.178; P = .024). The stepwise multivariable analysis revealed that higher TTL, excessive knee external rotation, and excessive knee valgus were statistically significant predictors of greater TT-TG distance (P < .001 for all). The standardized estimates that were used for evaluating the predictive values were larger for TFR compared with those for TTL and MAD.Conclusion:TTL, TFR, and MAD were the main independent anatomical components associated with increased TT-TG distance, with the most prominent component being TFR. The association of TT-TG distance to each component analyzed in our study may help guide surgical planning.

Arthroscopic lateral retinacular release, medial retinacular plication and partial medial tibial tubercle transfer for recurrent patellar dislocation

ObjectiveTo assess the efficacy of a therapeutic protocol composed of arthroscopic lateral retinacular release, medial retinacular plication, and partial medial tibial tuberosity transfer for patients with recurrent patellar dislocation. Method71 patients, 11 males and 60 females and a total of 77 knees, with recurrent dislocation of the patella were enrolled between 1998 and 2012. The average age of the patients was 19.5 years and 67 of them had previous knee trauma history. Tibial tubercle avulsion fractures were all surgically treated without complications like dysplasia in the femoral trochlear groove or valgus deformity. The Q angle, sulcus angle, patella-femoral trochlear congruence angle and lateral patellofemoral angle were measured on X-ray, while tibial tubercle-trochlear groove (TT-TG) distance was measure on CT scans, before the arthroscopic operation. Result69 patients were followed-up for 2–16 years (average of 7.2 years), while 2 patients were lost during follow-up. Among the patients with follow-up, one patient had recurrent patella dislocation two months after the operation. Q angle decreased from 13.2° to 9.2° in male patients (P < 0.05) and from 21.0° to 15.4° in female patients (P < 0.05). On average, the patella-femoral trochlear congruence angle decreased from 24.2 ± 6.8° to −2.1 ± 5.8° (P < 0.05) and the lateral patellofemoral angle increased from −2.0 ± 5.2° to 10.9 ± 4.0° (P < 0.05). TT-TG distance decreased from 19.8 ± 2.1 mm to 13.6 ± 1.8 mm (P < 0.01). Mean Lysholm score increased from 45.6 ± 4.8 to 92.3 ± 10.8 (P < 0.05) and, IKDC score increased from 48.3 ± 6.8 to 94.3 ± 8.4 (P < 0.05). ConclusionAs evidenced by minimal trauma and markedly improved knee joint function, the proposed therapeutic protocol demonstrated clear benefits for patients with recurrent patella dislocation.

What Components Comprise the Measurement of the Tibial Tuberosity-Trochlear Groove Distance in a Patellar Dislocation Population?

The tibial tuberosity-trochlear groove distance is used as an indicator for medial tibial tubercle transfer; however, to our knowledge, no studies have verified whether this distance is strongly affected by tubercle lateralization at the proximal part of the tibia. We hypothesized that the tibial tuberosity-trochlear groove distance is mainly affected by tibial tubercle lateralization at the proximal part of the tibia. Forty-four patients with a history of patellar dislocation and forty-four age and sex-matched controls were analyzed with use of computed tomography. The tibial tuberosity-trochlear groove distance, tibial tubercle lateralization, trochlear groove medialization, and knee rotation were measured and were compared between the patellar dislocation group and the control group. The association between the tibial tuberosity-trochlear groove distance and three other parameters was calculated with use of the Pearson correlation coefficient and partial correlation analysis. There were significant differences in the tibial tuberosity-trochlear groove distance (p < 0.001) and knee rotation (p < 0.001), but there was no difference in the tibial tubercle lateralization (p = 0.13) and trochlear groove medialization (p = 0.08) between the patellar dislocation group and the control group. The tibial tuberosity-trochlear groove distance had no linear correlation with tubercle lateralization (r = 0.21) or groove medialization (r = -0.15); however, knee rotation had a good positive correlation in the patellar dislocation group (r = 0.62). After adjusting for the remaining parameters, knee rotation strongly correlated with the tibial tuberosity-trochlear groove distance (r = 0.69, p < 0.001), whereas tubercle lateralization showed moderate significant correlations in the patellar dislocation group (r = 0.42; p = 0.005). Because the tibial tuberosity-trochlear groove distance is affected more by knee rotation than by tubercle malposition, its use as an indicator for tibial tubercle transfer may not be appropriate. Surgical decisions of tibial tubercle transfer should be made after the careful analysis of several underlying factors of patellar dislocation.

Results of Isolated Lateral Retinacular Reconstruction for Iatrogenic Medial Patellar Instability

The aim of this study was to assess the outcomes of an isolated lateral retinaculum reconstruction for iatrogenic medial patellar instability (IMPI) in patients with continued pain after failed lateral retinacular release (LRR), including associated psychometric analysis. Pain was assessed using the visual analog scale (VAS) and disability was determined with the Lysholm scale. Psychological variables such as anxiety, depression, catastrophizing, and fear-of-movement beliefs were studied by using self-administered psychometric questionnaires. All 17 patients (13 women and 4 men) in this retrospective study had undergone LRR previously for anterior knee pain or lateral patellar instability. Four patients had undergone LRR plus proximal (Insall) realignment, and one had undergone LRR plus a medial tibial tubercle transfer. After their procedures, all had disabling symptoms. All patients underwent reconstructive surgery for IMPI. At a minimum follow-up of 2 years (range, 2 to 8 years), the mean preoperative VAS score was 7.6 (range, 5 to 9) and improved to 1.9 (range, 0 to 8) at the time of final follow-up (P < .001). The mean preoperative Lysholm score was 36.4 (range, 20 to 55), and the knee was described as bad (<65 points) in all cases. Postoperatively, it improved to 86.1 (range, 70 to 94) at final follow-up (P < .001). Before surgery, 4 patients (24%) had the clinical criteria for depression, 10 (59%) had anxiety, 7 (41%) had "catastrophizing" ideas concerning pain, and all (100%) had kinesiophobia (fear of movement). After surgery, none of the patients had depression or anxiety, none had catastrophizing ideation, and only 53% had kinesiophobia. Reconstruction of the deep transverse layer of the lateral retinaculum (LR) using a central strip of the iliotibial band for IMPI in patients with continued pain after failed LRR can successfully treat these severely disabled patients. Level IV, therapeutic case series.

Proximal realignment and medial tibial tubercle transfer

Patella realignment may be necessary for successful treatment of recurrent patella dislocation. Both proximal and distal realignment procedures have been used. Proximal realignment of the patella involves medial realignment of the quadriceps mechanism, restoring normal patellofemoral congruence. Medial tibial tubercle transfer realigns the tubercle sulcus angle, restoring normal patellofemoral tracking. Combined proximal distal procedures are sometimes required.

Fascia lata sling reconstruction for recurrent medial dislocation of the patella

Medial dislocation of the patella is a rare clinical problem. A mild variety of subluxation of the patella can be identified on arthoscopy but frank medial dislocation, idiopathic or traumatic, is very uncommon. The patella is known to medially dislocate repeatedly as a complication of medial tibial tubercle transfer surgery. We present four such cases in three patients and describe their treatment by creating a lateral patellar sling using a strip of fascia lata. We also illustrate the surgical technique.

Distal Realignment of the Patellar Tendon to Correct Abnormal Patellar Tracking

Between January 1980 and January 1994, 31 knees required distal realignment of the extensor mechanism to treat lateral patellar subluxation that could not be corrected with lateral patellar release and vastus medialis advancement during total knee arthroplasty. Fifteen had a preoperative valgus angle of more than 12 degrees, and 16 were undergoing revision total knee arthroplasty. Ten knees had a modified Roux-Goldthwait procedure, 18 had medial tibial tubercle transfer, and three had medial transfer of the medial 1/2 of the patellar tendon. The length of followup ranged from 2 to 16 years. No late patellar subluxations or dislocations have occurred in any of these cases. Three cases of medial tibial tubercle transfer had hematomas develop, with two requiring surgical evacuation; one of these developed a late infection. No fractures or displacements of the tubercle fragment have occurred. No significant patellar complications have occurred in those patients who underwent the modified Roux-Goldthwait procedure or the medial transfer of the medial 1/2 of the patellar tendon. One year after surgery, the mean knee flexion was 113 degrees, four knees had a flexion contracture of 5 degrees, and none had a quadriceps lag.

The Anteroposterior Axis for Femoral Rotational Alignment in Valgus Total Knee Arthroplasty

This study evaluated a technique using the anteroposterior axis of the distal femur, rather than the transepicondylar or posterior femoral condylar axis, to establish rotational alignment of the femoral component in valgus knees. The anteroposterior axis of the distal femur was defined by a line through the deepest part of the patellar groove anteriorly and the center of the intercondylar notch posteriorly. Total knee arthroplasty was done in 46 valgus knees between 1980 and 1986 using the posterior femoral condyles as landmarks for rotational alignment. From January 1986 through January 1992 total knee arthroplasty was done in 107 valgus knees using the anteroposterior axis for rotational alignment of the femoral component. In the group of knees using the posterior condylar axis, medial tibial tubercle transfer was needed intra-operatively in 8 knees to prevent lateral dislocation of the patella. In the first 2 postoperative years, 4 knees had recurrent patellar dislocation or subluxation that required surgical correction. In the group of knees using the anteroposterior axis, patellar tracking problems that required realignment were significantly reduced. One knee required medial tibial tubercle transfer to correct a Q angle > 20 degrees. In the remaining knees, the Q angle was < 10 degrees, and patellar tracking was acceptable. Two years after surgery, no knees had patellar instability.