BLOG: One perspective on trochleoplasty
Recent follow up studies and work on the surgical details of performing trochleoplasty for patients with patellofemoral instability have demonstrated it is an effective procedure, when properly done, for adding stability to the patellofemoral joint. Much credit is due to H. Brattström and more recently to David H. Dejour, MD, and his father, Prof. Henri Dejour, for their emphasis on defining trochlear morphology variations. Their classification, along with an appreciation of trochlear inclination and distal vs. proximal trochlear deficiency, has helped surgeons to understand trochlear deficiencies contributing to patella instability.
When to use trochleoplasty
Historically, it has been possible to stabilize patella tracking effectively in most patients by establishing lower extremity core stability and sometimes by surgically restoring medial support for the patella (medial imbrication), the medial patellofemoral complex, the medial patellofemoral ligament (MPFL) or by medial quadriceps tendon-femoral ligament reconstruction, and by optimizing the tracking relationship between the patella and trochlea by tibial tubercle transfer, when needed. Trochleoplasty has rarely, in the past, been needed to accomplish the goal of stable patella tracking, so one must ask: Why and when should we use trochleoplasty in patients?
John P. Fulkerson
Recent work on deepening trochleoplasty has offered an important new option for adding patellofemoral stability. Dejour, Phillip B. Schoettle, MD, PhD; Roland M. Biedert, MD; Jonathan D. Eldridge, MD, FRCS; Rene Verdonk, MD, PhD; Luca Amendola, MD; Elizabeth A. Arendt, MD; Manfred Nelitz, MD; Simon T. Donell, MD; Stéphanie Rouanet, DESS; Christopher M. LaPrade, BA; Philippe Beaufils, MD; Matthew Bollier, MD; Lars Blønd, MD, and many others have recently presented perspectives on trochleoplasty. From what I have read and heard, a well done trochleoplasty will add stability to the patellofemoral joint and likely prevent re-dislocation of the patella, particularly when an MPFL reconstruction is added. Arthritis and pain after trochleoplasty have been reported, but the greater concern is late arthritis as a result of increased subchondral bone stiffness related to cortication of the subchondral area with resulting diminished ability of the overlying cartilage to resist impact and stress in the long term. As MPFL reconstruction works so well, why and when do we really need to add trochleoplasty? Because we have better ways of doing trochleoplasty, should we use it more often? Have the indications for doing trochleoplasty changed? If the indications have changed, we must ask: Why and what are the associated risks vs. benefit?
Trochleoplasty only for extreme cases
Trochleoplasty is an important procedure for a select group of patients who cannot be managed sufficiently with stabilization/alignment surgery, particularly when a supratrochlear spur or “bump” can be removed without consequence to subchondral bone of the proximal trochlea. Ultimately, the best patellofemoral stabilization surgery will provide optimal stability and function, but also longevity of trochlea articular cartilage. I continue to reserve trochleoplasty for select patients who fail, or are likely to fail, MPFL reconstruction with or without tibial tubercle transfer alone. If alignment and medial stabilization surgery provide sufficient stability, why add trochleoplasty, except in extreme cases?
John P. Fulkerson, MD, is a clinical professor of orthopedic surgery at the University of Connecticut School of Medicine and practices at Orthopedic Associates of Hartford in Farmington, Conn. He is also president of The Patellofemoral Foundation.
Disclosure: Fulkerson reports he receives royalties from DJO Global and is a patent holder for DJO Global.