BLOG: Balanced, stable tracking should be the end goal
The desired end result of treatment following recurrent patella dislocations is pain-free, stable patella tracking and return to normal activities. In recent years, the alternatives for achieving this goal have increased with particular focus on “metrics” or objective measurements that may be used to guide an orthopedic surgeon in accurate restoration of patella stability. Objective measurements are indeed important in the assessment of the underlying reasons for patella instability, but “normalizing” them surgically often means extensive surgery.
Art, experience and judgment needed
While metrics are important, I wholeheartedly believe, based on 35 years of doing patellofemoral surgery, that art, experience and judgment should be important factors in the decision-making process once one has viewed and studied the objective measurements (metrics). For instance, a 16-year-old girl may have some excessive femoral anteversion that causes too much internal rotation at the hip with some secondary trochlear dysplasia.
One surgeon might justify derotation of the femur and trochleoplasty as the most appropriate surgical treatment. However, another surgeon might very well say such a patient will do well with core strengthening and, if the core strengthening alone is insufficient, a medial patellofemoral ligament (MPFL) or medial quadriceps tendon-femoral ligament (MQTFL) reconstruction. Few surgeons would derotate this young person’s femur or do a trochleoplasty, except in extreme circumstances.
John P. Fulkerson
In the majority of cases, achieving stability of patella tracking is predominantly a matter of achieving balance of the extensor mechanism, but not necessarily by normalizing the metrics. If one has lateral patella tracking, then recurrent patella dislocations and metrics demonstrating excessive tibial external rotation as well as excessive internal femoral rotation and some secondary flattening of the trochlea, should the surgeon derotate the tibia and femur, do a trochleoplasty and then a medial reconstruction (MPFL or MQTFL)? I believe the best approach for the majority of patients, is time-tested and more appropriate. Align the patella with the trochlea by compensatory medial or anteromedial tibial tubercle transfer when appropriate and stabilize the medial side as needed by MPFL or MQTFL reconstruction. This is far less surgery, yields the desired end result of stable patella tracking and both patient and surgeon are happy.
When I think about these matters, “primum non nocere” comes to mind.
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.