http://upload.orthobullets.com/topic/3021/images/merchants min tilt_moved.jpg
Introduction
  • Improper tracking of patella in trochlear groove 
  • Caused by tight lateral retinaculum
    • leads to excessive lateral tilt without excessive patellar mobility
  • Miserable Triad
    • is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. They include:
      • femoral anteversion
      • genu valgum
      • external tibial torsion / pronated feet
Presentation
  • Presentation
    • pain with stair climbing
    • theatre sign (pain with sitting for long periods of time)
  • Physical exam
    • pain with compression of patella and moderate lateral facet tenderness
    • inability to evert the lateral edge of the patella
Imaging
  • Radiographs
    • patellar tilt in lateral direction
Treatment
  • Nonoperative
    • NSAIDS, activity modification, and therapy
      • indications
        • mainstay of treatment and should be done for extensive period of time
      • technique
        • therapy should emphasize vastus medialis strengthening and closed chain short arc quadriceps exercises 
  • Operative
    • arthroscopic lateral release 
      • indications
        • objective evidence of lateral tilting (neutral or negative tilt)   
        • pain refractory to extensive rehabilitation
        • inability to evert the lateral edge of the patella
        • ideal candidate has no symptoms of instability
        • medial patellar glide of less than one quadrant
        • lateral patellar glide of less than three quadrants
    • patellar realignment surgery 
      • Maquet (tubercle anteriorization)
        • indicated only for distal pole lesions
        • only elevate 1 cm or else risk of skin necrosis
      • Elmslie-Trillat (medialization)
        • indicated only for instability with lateral translation (not isolated lateral tilt)
        • avoid if medial patellar facet arthrosis
      • Fulkerson alignment surgery (tubercle anteriorization and medialization) 
        • indications (controversial)
          • lateral and distal pole lesions 
          • increased Q angle
        • contraindications
          • superior medial arthrosis (scope before you perform the surgery)
          • skeletal immaturity
Techniques
  • Arthroscopic lateral release 
    • technique
      • viewing through superior portal will show medial facet does not articulate with trochlea at 40 degrees of knee flexion
      • be sure adequate hemostasis is obtained
      • postoperatively the patella should be able to be passively tilted 80°
    • complications
      • persistent or worsened pain
      • patellar instability with medial translation
 

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Questions (2)

(OBQ11.34) An 18-year-old female has 9 months of anterior knee pain recalcitrant to physical therapy that includes VMO strengthening, NSAIDS, and lifestyle modification. On physical examination she has no effusion in the knee and her Q angle is measured at 15 degrees. She has less than one quadrant of medial patella translation and less than two quadrants of lateral patella translation. The lateral edge of the patella is unable to be everted. A merchant view radiograph is shown in Figure A. The tibia tubercle-trochlear groove distance is measured as 14mm on a CT scan. Which of the following procedures is MOST appropriate? Review Topic

QID:3457
FIGURES:
1

Lateral retinacular release

78%

(1242/1596)

2

Anterolateral tibial tubercle osteotomy

5%

(77/1596)

3

Anterior tibial tubercle osteotomy (Maquet)

5%

(78/1596)

4

Medial tibial tubercle osteotomy (Elmslie-Trillat)

8%

(132/1596)

5

Medial plica resection

4%

(56/1596)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The patient's radiograph and clinical presentation are consistent with lateral patellar tilt and lateral facet compression syndrome, respectively. Of the options available, lateral retinacular release is the most appropriate treatment. The surgical treatment for this condition is rare and used only in cases that are recalcitrant to conservative measures.

Calpur et al present level 4 evidence of 169 lateral retinacular release cases. They divided this cohort into patients less than and older than 40 years of age. They found that both groups had a statistically significant improvement in Lysholm scores and there were only 3 patients with complications (fibrosis at the site of lateral release).

Video V shows a technique for arthroscopic lateral retinacular release. Arthroscopic viewing through the superior portal in lateral facet compression syndrome would demonstrate that the patella does not articulate medially with the trochlea when the knee is at 40 degrees of knee flexion.

Illustration A demonstrates how the tibia tubercle-trochlear groove (TT-TG) distance is measured by (A) first drawing a line from the trough of the trochlea perpendicular to the line connecting the posterior condyles. These lines are superimposed onto an image through the tibial tubercle (B), and the TT-TG distance is measured as that between the above-described line and the tibial tubercle (distance AB). A TT-TG distance greater than 20mm is an indicator that a medializing tibia tubercle osteotomy is needed.

Incorrect Responses:
2. An lateral tibial tubercle transfer would lead to an elevated TT-TG and malalignment.
3. An anterior transfer would further tension the lateral retinaculum and increase the negative tilt.
4. A medial transfer is not indicated for a normal TT-TG.
5. The clinical scenario does not support a symptomatic plica.

ILLUSTRATIONS:

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Question COMMENTS (12)

(OBQ05.184) A 21-year-old female presents with left knee pain for six months. The symptoms are worse climbing stairs and sitting for long periods of time. On physical exam she has a stable knee with no effusion and pain with compression of the patella. Her Q angle is 21 degrees. What is the first step in management? Review Topic

QID:1070
1

arthroscopic lateral retinacular release

1%

(7/950)

2

tubercle elevation and medialization

1%

(8/950)

3

strict immobilization and non-weight bearing for four weeks

1%

(7/950)

4

open chain exercises and a focus on seated leg extensions

9%

(88/950)

5

closed chain exercises with focus on quadriceps and hamstring strengthening

88%

(839/950)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

This patient has anterior knee pain with an increased Q angle (normal is 17 degrees in a female). The first line of treatment is physical therapy. Rehab should focus on isometrics and closed chain exercises.

Hungerford et al investigated the patellofemoral joint reaction force (PFJR) during closed chain exercises versus and open chain exercise. They found an increase in the PFJR during open chain exercises and with seated leg extensions that can cause further wear and irritation of the patellofemoral joint.

Incorrect Answers:
Answer 1 & 2: Surgery would not be indicated as the first line of treatment.
Answer 3: Immobilization would lead to deconditioning and stiffness and is not indicated.
Answer 4: Open chain exercises and with seated leg extensions that can cause further wear and irritation of the patellofemoral joint.


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Question COMMENTS (6)
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