The Knee 12 (2005) 323 328 www.elsevier.

com/locate/knee

Treatment outcome of extensor realignment for patellofemoral dysfunction

Ian Henderson*, Ramces Francisco
Orthopaedic Research Department, St. Vincents and Mercy Private Hospital, 166 Gipps Street, East Melbourne, Victoria 3002, Australia Received 29 September 2004; accepted 17 November 2004

Abstract Patellofemoral pain remains one of the most common musculoskeletal disorders encountered in orthopaedic practice. In this retrospective clinical study, 108 knees in 98 patients with patellofemoral pain due to malalignment were treated using a combined proximal and distal realignment technique. The results were evaluated at an average of 29.2 (19.2 years) months postoperatively. At final evaluation using the modified Trillat grading scale, good or excellent results were obtained in 88 (81.4%) of the knees treated. Second-look arthroscopy performed in 65 (60.2%) knees demonstrated good patellar tracking and Grade II articular changes were noted in 16 (14.8%) of the patellofemoral joints examined. Complications noted included anterior compartment syndrome with foot drop in one case and arthrofibrosis in another. We conclude that extensor realignment surgery with a combined proximal and distal realignment procedure is a reliable technique for patellofemoral pain secondary to malalignment. D 2004 Elsevier B.V. All rights reserved.
Keywords: Patellar malalignment; Extensor realignment; Patellofemoral pain

1. Introduction Patellofemoral pain still remains a challenging disorder. For many years, conditions such as chondromalacia patellae and patellofemoral arthritis have been cited as the pathologies most commonly involved in producing anterior knee pain [13] However, recent literature suggests that multiple factors and other aetiologies such as osteochondritis dissecans, synovitis, plicae, Osgood Schlatter disease, and bipartite patella may be involved [4,5]. A detailed history and clinical examination is essential to facilitate accurate diagnosis. Previous episodes of patellar dislocation/subluxation and its correlation with clinical findings of an increased quadriceps angle, patellar instability, or presence of rotation in the lower extremity may suggest the presence of malalignment [2]. To obtain additional information, radiographic evaluation is carried

* Corresponding author. Tel.: +61 3 94158000; fax: +61 3 94158100. E-mail address: ijphenderson@hotmail.com (I. Henderson). 0968-0160/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2004.11.003

out with a standard tangential (axial) view of the patella [6,7]. Computed tomography of the patellofemoral joint with the knee at 158, 308, and 458 of flexion provides objective data regarding the presence of any abnormalities in patellar alignment. In selected cases, magnetic resonance and nuclear imaging can be used [2,4,8,9]. In instances where equivocal clinical and radiological data are obtained, knee arthroscopy can be carried out to evaluate both the retropatellar articular surface and patellar tracking in detail [2,10,11]. For most cases, nonoperative treatment for patellofemoral pain is usually successful. This consists of a structured programme of rehabilitation that includes stretching and strengthening of the peripatellar soft tissues combined with the use of orthotic devices and antiinflammatory medications [1,2,4]. Occasionally, surgical intervention is necessary to address the underlying pathology. Options for repair include soft tissue release, tubercle transfer, or both. In this retrospective study, the treatment outcome of extensor realignment procedures carried out in 108 knees (98 patients), using a combined proximal and distal realignment technique, was evaluated.

324

I. Henderson, R. Francisco / The Knee 12 (2005) 323328

2. Materials and methods 2.1. Patient data From April 1977 to October 2002, 124 patellar realignments using a combined proximal and distal realignment technique in 114 patients were performed. Included in this review were patients: (1) who remained symptomatic despite completing at least 6 months of nonoperative treatment tailored to the specific clinical diagnosis, and (2) those who had a minimum follow-up of 12 months after the realignment procedure. Sixteen patients were excluded from this review as they were not able to complete at least 12 months of follow-up. A total of 108 knees in 98 patients were included. Patients were evaluated preoperatively and at regular intervals postoperatively with a mean duration of 29.2 months (range, 19.2 years). The mean age of patients at the time of surgery was 25.4 years, ranging from 14 to 71 years, with 39 (39.8%) between the ages of 18 and 25 years. There were 36 males and 62 females involved in this study. Ten (10.2%) patients had bilateral knee involvement, 50 (51%) with their right knee affected and 38 (38.8%) with the left knee involved. Seventy (64.8%) of the involved knees had surgery prior to the realignment procedure, including lateral release, partial meniscectomy, ACL reconstruction, and chondroplasty. 2.2. Clinical, radiographic, and arthroscopic evaluation Clinical findings augmented by X-ray examination formed the basis of diagnosis for the patients reviewed. Fifty-seven (58.2%) presented with a history of recurrent patellar dislocation or subluxation (Table 1). Twenty-six (26.5%) patients had some form of trauma (sports, vehicular, or fall-related) that precipitated their symptoms, 10 (10.2%) patients had long-standing problems with their knee, while five (5.1%) patients had insidious onset of knee symptoms. The most common preoperative complaint was knee pain followed by retropatellar crepitus which were both prominent on bent knee activities. The sensation of giving way and knee discomfort was only evident in a few of the patients seen. Clinical examination for instability was demonstrated with a positive apprehension test in 42 (38.9%) of the cases reviewed.
Table 1 Mechanism and nature of knee injury Previous knee injuries Patients Number Dislocation/subluxation Trauma Sports-related Vehicular Fall Minor Chronic knee problems Other causes 57 8 5 4 9 10 5 % 58.1 8.2 5.1 4.1 9.2 10.2 5.1

Patellofemoral radiographic evaluation demonstrated lateral subluxation in 10 (22.2%) patients while seven (15.6%) had flattening of the trochlea. In cases where the clinical and radiologic examination suggested the presence of other knee pathologies, preliminary arthroscopy was performed to evaluate the patellofemoral joint as well as the remainder of the knee. A superolateral portal was utilised to assess patellar tracking and determine the presence of any articular cartilage lesion. In this review, initial arthroscopic evaluation was carried out in 46 (42.6%) knees. 2.3. Surgical treatment The technique used in this series to achieve patella realignment was a combined proximal and distal realignment procedure. Patients treated presented with patellofemoral pain associated with a pathologically hypermobile patella, a positive apprehension sign for lateral patellar instability and an increased Q-angle. A lateral retinacular release was carried out by dividing the longitudinal fibres of the lateral capsule and the vastus lateralis in a proximal direction to adequately release the thick tendon of the vastus lateralis. The lateral synovium was then incised, followed by another incision through the medial capsule and synovium. Inspection for other intraarticular pathologies followed. The anterior tibial tuberosity was then identified and an osteotome was placed at its proximal end behind the patellar tendon from the lateral side. Wedge thickness of approximately 0.5 cm and length of 46 cm were observed. In carrying out the osteotomy, a thin piece of tibial tuberosity was left attached to the tibia by a distal periosteal pedicle. The patellar tendon and the associated tibial tuberosity were then elevated and rotated medially with the foot in external rotation to realign the quadriceps mechanism, placing the patella in a position that allows the best in-line tracking with the trochlea. The desired medial displacement of the tuberosity was 7 mm. A longer rather than shorter portion of the tuberosity was included to minimise the risk of splintering the bone and losing fixation. Two AO cancellous screws were then used to fix the tuberosity in this position. Finally, sufficient medial capsular plication and VMO advancement were carried out, making sure that no patellar tilting occurred throughout the full range of knee motion. A drain was then placed prior to wound closure. 2.4. Postoperative rehabilitation Postoperatively, patients were maintained in an extension splint. Immediate ankle and quadriceps locking exercises were encouraged. The drain was removed the day following the operation. Patients were then sent home on crutches for approximately 4 weeks while continuing with the static quadriceps and active hamstring programme. Sutures were removed after 2 weeks. Cycling and swimming exercises were allowed to commence at approximately 3 weeks after the operation. Patients were then weaned from the crutches

I. Henderson, R. Francisco / The Knee 12 (2005) 323328 Table 2 Modified Trillat grading system Excellent Asymptomatic Unrestricted activities Full range of motion No crepitus No tenderness No muscle atrophy Slight symptoms with activity Full range of motion Occasional crepitus Occasional tenderness No effusion Improvement in symptoms but pain with activity Limited range of motion Occasional painful crepitus Occasional joint effusion Chronic pain Marked limitation of activity Recurrence of subluxation

325

Good

In this system, results are graded as excellent if the patient is asymptomatic and able to engage in unrestricted activities. Good results were ascribed to those who had only slight symptoms with activity, full range of movement, but occasional tenderness and crepitus. Patients were categorised as having fair results when there was improvement in symptoms but pain with activity and occasional painful crepitus. Lastly, poor results were obtained when there was chronic pain and marked limitation of activity.

Fair

3. Results 3.1. Clinical All patients had a minimum postoperative follow-up of 12 months. Data were obtained from their clinical records, and findings were translated using the modified Trillat scoring system as used in a similar study by Morshuis et al. To facilitate analysis of outcome, patients were grouped according to the nature of the knee injury sustained. Prior to the realignment procedure, 64 (59.2%) knees were rated as fair or poor among the group of patients with previous dislocation or subluxation. Patients who had some form of trauma prior to the onset of knee symptoms demonstrated 27 (25%) knees with a fair or poor rating, while patients with chronic knee pain (N6 weeks) demonstrated 11 (10.2%) knees with fair or poor rating. For the group with knee symptoms secondary to other pathologies, six (5.6%) were rated as fair or poor. Following the extensor realignment procedure, in the group with previous dislocations/subluxations, 11 (10.2%) were rated as excellent, 45 (41.7%) were good, and 8 (7.4%) remained fair or poor. In the group with previous trauma, 3 (2.8%) were rated as excellent, 17 (15.7%) as good, and 7 (6.5%) remained fair or poor. Patients with chronic patellofemoral pain demonstrated two (1.9%) excellent, five (4.6%) good, and four (3.7%) fair or poor results after surgery, while the group with other pathologies presented one (0.9%) excellent, four (3.7%) good, and one (0.9%) fair knee (Table 3a). Overall results in the 108 knees treated revealed 17 (15.7%) knees with excellent results, 71 (65.7%) with good, 13 (12%) with fair, and 7 (6.5%) with poor outcome (Table 3b). All of the patients whose knees were rated as excellent showed no residual symptoms postoperatively. In this group,

Poor

and then from the splint as good quadriceps control and flexion range were gained. At this point, normal walking was allowed but bent knee activities and, in particular, resisted extension exercises were avoided. Rehabilitation was continued until about 3 months after the operation. In instances where patients had difficulty carrying out the prescribed rehabilitation program, referral to a physiotherapy centre was facilitated. 2.5. Second-look arthroscopy When the tibial tuberosity had healed radiologically, removal of the internal fixation was scheduled. At the same time, second-look arthroscopy was performed to assess patellar tracking of the involved knee. In this study, 65 (60.2%) knees had second-look arthroscopy and removal of screws. This was carried out at a mean of 13.3 months (range, 485 months) postoperatively. During the arthroscopy, patellar tracking and the condition of the retropatellar articular surface were evaluated using a superolateral portal. The knee joint was also inspected for other pathologies and suitable arthroscopic treatment was carried out. 2.6. Grading system All patients were evaluated using the grading system first described by Trillat et al. and later modified by Cox (Table 2).
Table 3a Pre and post-operative knee scores according to type of injury sustained Modified Trillat knee rating Aetiology Dislocation Pre Excellent Good Fair Poor 0 0 52 12 Post 11 45 6 2 Trauma (sports) Pre 0 0 8 0 Post 2 5 1 0

Trauma (VA) Pre 0 0 3 3 Post 1 2 1 2

Trauma (fall) Pre 0 0 4 0 Post 0 4 0 0

Trauma (minor) Pre 0 0 8 1 Post 0 6 3 0

Chronic Pre 0 0 8 3 Post 2 5 1 3

Other Pre 0 0 5 1 Post 1 4 1 0

326

I. Henderson, R. Francisco / The Knee 12 (2005) 323328 Table 4 Findings at second-look arthroscopy (n =65) Findings Retropatellar articular surface Normala Grade I II III IV (ACI repair assessment) Grade II Patellar tracking Stable Unstable Other findings Meniscal tear Synovitis Arthrofibrosis Flattened trochlea Convex trochlea
a

patients were able to return to sporting activities without any problems at a mean of 22.9 months postoperatively. Patients classified as having good results demonstrated no difficulties in carrying out activities of daily living but would occasionally have discomfort when engaging in recreational activities. Of the seven cases with poor outcome, four developed progressive retropatellar deterioration and recurrence of patellofemoral symptoms that eventually led to patellectomy. Two had subsequent episodes of dislocation while one case required further extensor realignment. In this group, the initial postoperative course was satisfactory prior to recurrence of symptoms. 3.2. Complications None of the patients treated had infection from the surgical procedure. However, one patient developed a footdrop, indicating the presence of a possible anterior compartment syndrome. This, however, was temporary and resolution of symptoms was documented 4 months after the realignment surgery. Another patient had limited range of movement postoperatively, which on arthroscopy revealed arthrofibrosis. Arthroscopic scar resection was then performed, which enabled the patient to gain improvement in knee motion. 3.3. Second-look arthroscopy Data obtained from second-look arthroscopies revealed normal tracking of the patella over the intertrochlear groove when compared to findings at initial arthroscopy, which demonstrated subluxed/malaligned patella (Table 4). Upon inspection of the retropatellar articular surface using the Modified Outerbridge classification scheme, Grade II articular changes were evident in 16 of the knees inspected. In these cases, arthroscopic debridement/chondroplasty was carried out at the same time. Three cases had subsequent autologous chondrocyte implantation (ACI) at a mean duration of 1 month after undergoing the realignment surgery. This group of patients was documented as having Grade IIIIV articular pathologies on initial arthroscopy where the biopsies for implantation were also obtained. Second-look arthroscopic findings in two of these patients revealed good patellar tracking and nearly normal (Grade II) International Cartilage Repair Society (ICRS) visual scores,

Number (%) 21 6 34 2 0 1 (32.3) (9.2) (52.3) (3.1) (0) (3.1)

65 (100) 0 (0)

2 1 1 5 1

Modified Outerbridge classification.

with the grafted area demonstrating excellent fill and good marginal integration. Morphologically, flattening of the trochlea that was initially observed in seven preoperative radiographs was arthroscopically visualised during arthroscopy performed prior to the realignment procedure. Six of these seven knees had second-look arthroscopy. Convex trochlea was also documented in one knee. Other findings included minor synovitis in one knee and arthrofibrosis in another where arthroscopic scar resection was carried out.

4. Discussion Traumatic episodes of patellar dislocation are usually compounded by the associated underlying problems found in the knee. Osteochondral fractures have been shown to have an incidence approaching 4050%. However, Dainer et al. demonstrated that even a bsignificant-sizedQ osteochondral fragment can be missed on preoperative X-rays, as shown in 40% of the 29 cases they reviewed. This has led some authors to recommend arthroscopy in all cases of acute patellar dislocation [12]. Other pathologies, like meniscal tears, ligament ruptures (ACL and/or MCL), and even tears at the VMO insertion have also been demonstrated. Therefore, a detailed clinical examination of the knee, together with appropriate radiographs, is necessary to obtain an accurate diagnosis. Hughston, Insall et al., Kettelkamp, and Rillman et al. have proven in their studies that clinical determination of patellar malalignment can be difficult [1316]. Moreover, radiographic evaluation of the patellofemoral joint is prone to inconsistencies. In these instances, direct visualisation of the patellofemoral joint is necessary through arthroscopy in order to obtain a more detailed examination. Grana et al. and Sojbjerg et al.

Table 3b Treatment outcome Grade Knees treated Number Excellent Good Fair Poor 17 71 13 7 % 15.7 65.7 12 6.5

I. Henderson, R. Francisco / The Knee 12 (2005) 323328

327

demonstrated the advantage of performing arthroscopic evaluation of the patellofemoral joint by accurately defining patellar malalignment with this technique [10,11]. When performing arthroscopy of the patellofemoral joint, assessment of patellar tracking is primarily determined. Grana et al. and Rillman et al. have defined malalignment in their arthroscopic studies as the failure of the midpatellar ridge to seat in the femoral groove during the first 458 of knee flexion [10,16]. In our series, 46 (42.6%) knees had arthroscopic evaluation prior to having the realignment surgery done. Part of this arthroscopic evaluation is the assessment of the retropatellar articular surface to determine the size, depth, and location of any lesions and the exclusion of other internal derangements of the knee. Any pathologies identified that are amenable to arthroscopic management were addressed immediately while lesions requiring a more extensive treatment (e.g., ACI) were documented and planned for. Through the years, various techniques have been used to correct patellar malalignment and subsequently unload the stresses on the retropatellar surface. From the Macquet procedure, which is now rarely used, to the anteromedialisation of the tibial tuberosity popularised by Fulkerson [1 3,17], various results have been obtained. Some authors believe that when proximal realignment is performed, distal realignment is unnecessary [1820]. However, there are those who advocate that the inability to medialise the tibial tubercle sufficiently with a high Q-angle is correlated with unsatisfactory results. In a similar study conducted by Cox [21] in 1982, it has been demonstrated that an excellent outcome was obtained in 22 (19.2%) of 114 extensor realignment cases carried out using the ElmslieTrillat technique. Good results were evident in 55 (47.4%) cases, fair results in 27 (23.3%), and poor results in 12 (10.3%) knees. In this review, the results obtained demonstrated that 88 (81.4%) of the 108 knees treated had either good or excellent results. Only 13 (12%) cases had a fair outcome, while seven (6.5%) were documented as poor. This clinical outcome parallels the findings at second-look arthroscopy where good patellar tracking was documented and significant retropatellar articular surface degeneration evident in some of the cases was treated. In these cases, the patellar articular surface had significant degeneration to begin with. Most cases included in this review had a history of patellar dislocation or subluxation. While literature shows that inconsistent results are achieved with the various surgical techniques available in managing dislocations, in this series, we were able to attain good or excellent results in 56/64 (87.5%) knees treated while 2/64 (3.1%) had poor results. One of these cases had another episode of dislocation with patellar fracture 1 year postoperatively, which required fixation and removal of loose bodies. The other case continued to have persistent retropatellar pain. Second-look arthroscopy conducted at a mean of 13.3 months postoperatively also demonstrated satisfactory outcome of repair with this technique.

Documented postoperative complications with extensor realignment surgeries can include infections, reflex sympathetic dystrophy (RSD), thrombophlebitis, loss of flexion, nonunion, and anterior compartment syndrome [14,18, 21,22]. One case in this series developed signs of anterior compartment syndrome when the patient presented with footdrop postoperatively. However, this was only temporary as complete resolution of symptoms was documented 4 months after surgery. Preventive measures that should be routinely practiced include the use of evacuation drainage, leg elevation, and postoperative patient monitoring. Deviation from the standard postoperative course should be noted and appropriate investigations carried out to identify the cause. In cases where postoperative improvement is slow, the presence of other associated knee pathologies could prolong the rehabilitation of the affected knees. Concurrent injuries that may occur during the rehabilitative phase of treatment can be minimised by strict compliance with the structured postoperative program. The difficulty associated with the management of patellofemoral malalignment is reflected in the evolution of its diagnosis and treatment. Numerous surgical procedures have been used and modified to correct the varying pathologies involved. In this review, we have demonstrated that good results can be obtained with a combined proximal and distal realignment procedure when indications for its use are satisfied.

References
[1] Fulkerson J, Schutzer SF. After failure of conservative treatment for painful patellofemoral malalignment: lateral release or realignment? Orthop Clin North Am 1986 (April);17(2):283 8. [2] Fulkerson JP, Shea K. Disorders of patellofemoral alignment. J Bone Joint Surg 1990 (Oct.);72-A(9):1424 9. [3] Morshuis WJ, Pavlov PW, De Rooy KP. Anteromedialization of the tibial tuberosity in the treatment of patellofemoral pain and malalignment. Clin Orthop 1990 (June);255:242 50. [4] Grelsamer RP. Patellar malalignment. J Bone Joint Surg 2000 (Nov.);82-A:1639 45. [5] Thomee R, Augustsson J, Karlsson J. Patellofemoral pain syndrome: a review of current issues. Sports Med 1999 (Oct.);28(4):245 62. [6] Davies AP, Costa ML, Donell ST, Glasgow MM, Shepstone L. The sulcus angle and malalignment of the extensor mechanism of the knee. J Bone Joint Surg 2000 (Nov.);82-B(8):1162 6. [7] Murray T, Dupont JY, Fulkerson JP. Axial and lateral radiographs in evaluating patellofemoral malalignment. Am J Sports Med 1999 (SeptOct);27(5):580 4. [8] Bellemans J, Cauwenberghs F, Witvrouw E, Brys P, Victor J. Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment. Am J Sports Med 1997;25(3):375 81. [9] Dong Q, Zheng Z. CT scanning and arthroscopic evaluation of patellofemoral malalignment. Abstract. Chin Med J 2000 (Feb.); 113(2):133 5. [10] Grana WA, Hinkley B, Hollingsworth S. Arthroscopic evaluation and treatment of patellar malalignment. Clin Orthop 1984 (June);186: 122 8. [11] Sojbjerg JO, Lauritzen J, Hvid I, Boe S. Arthroscopic determination of patellofemoral malalignment. Clin Orthop 1987 (Feb.);215:243 8.

328

I. Henderson, R. Francisco / The Knee 12 (2005) 323328 [18] Crosby EB, Insall J. Recurrent dislocation of the patella. J Bone Joint Surg 1976 (Jan.);58-A(1):9 13. [19] Garth WP, DiChristina DG, Holt G. Delayed proximal repair and distal realignment after patellar dislocation. Clin Orthop 2000 (Aug.);377:132 44. [20] McCall RE, Ratts V. Soft tissue realignment for adolescent patellar instability. Abstract. J Pediatr Orthop 1999 (JulAug);19(4): 549 52. [21] Cox JS. Evaluation of the RouxElmslieTrillat procedure for knee extensor realignment. Am J Sports Med 1982;10(5):303 10. [22] Shelbourne KD, Porter DA, Rozzi W. Use of a modified Elmslie Trillat procedure to improve abnormal patellar congruence angle. Am J Sports Med 1994;22(3):318 23.

[12] Dainer RD, Barrack RL, Buckley SL, Alexander AH. Arthroscopic treatment of acute patella dislocation. Arthroscopy 1988;4:267. [13] Hughston JC. Subluxation of the patella. J Bone Joint Surg 1968;50A:1003 26. [14] Insall J, Falvo K, Wise D. Chondromalacia patellae. J Bone Joint Surg 1976 (Jan.);58-A(1):1 8. [15] Kettelkamp DB. Management of patellar malalignment. J Bone Joint Surg 1981;63-A:1344. [16] Rillman P, Oswald A, Holzach P. Fulkersons modified ElmslieTrillat procedure for objective patellar instability and patellofemoral pain syndrome. Abstract. Swiss Surg 2000;6(6):328 34. [17] Kuroda R, Kambic H, Valdevit A, Andrish J. Articular cartilage contact pressure after tibial tuberosity transfer. A cadaveric study. Am J Sports Med 2001 (JulAug);29(4):403 9.