The challenge of knowing when not to operate can be a difficult lesson to learn. As an orthopedic surgeon dealing with pediatric patella instability, it can be heartbreaking to see children severely incapacitated by the condition. They are unable to participate in sporting activities, daily activities and in many cases, are ostracized by their classmates because they have no obvious manifestation of the pathology.
The open physis prevents many surgical techniques that are traditionally used to intervene in patellar instability and as a recipient of 2017 Patellofemoral Travelling Fellowship, it was my desire to see what approaches were being used at an international level to manage the condition in both adults and children with high-grade dysplasia and associated bony malalignment. The fellowship led us to Minneapolis; Baltimore; Banff, Alberta, Canada; New York and Kobe, although our budget and time constraints saw us regrettably miss out on several centers that would have been valuable learning opportunities.
Our hosts in Minneapolis were
, and . We observed trochleoplasty and PFJ replacement surgery, along with several stabilizations. The opportunity to discuss the role of distalization in cases of instability with alta was particularly relevant to my adolescent practice.
We moved on to Baltimore where a cadaver lab with anteromedialization and medial patellofemoral ligament reconstruction. Miho J. Tanaka, MD, demonstrated some interesting research on factors contributing to the J sign and its classification. It was becoming apparent that the biomechanics of the patellofemoral joint (PFJ) are far from well understood and do not lend themselves to a simple operative algorithm. An individualized approach to assessment and management of these cases seems to be mandatory.
showed us his technique of
MD, PhD, FRCSC, organized a beautiful snowscape to greet us in Banff. This was in addition to an impressive day of surgeries along with two PFJ clinics and a trip to Lake Louise. analytical approach to the amalgamation of clinical and radiological signs was great to observe. We saw cases of the Bereiter thin flap trochleoplasty (bump recession) and MPFL reconstruction, which again, are relevant to the adolescent skeletally mature population.
Our final stop was at Hospital for Special Surgery where
demonstrated some complex cases involving malalignment, pain, instability and chondral injury. The management of chondral injury in young patients is a concerning problem in my practice. De novo chondral augmentation and OATS procedures were used for chondral restoration with correction of bony malalignment to offload the affected areas. The opportunity to observe some pediatric stabilization cases by Green was a particular treat.
We cannot reiterate our thanks enough to the incredibly hospitable and talented surgeons who hosted us. Not only were they incredibly generous with their time, but their willingness to teach and express to us their perceptions of the biomechanical balancing act that underpins patellofemoral stability was an honor to experience.
While I am not necessarily able to say that I understand the patellofemoral joint, I am able to better appreciate the complexity of its biomechanics. I hope that when I treat my patients, I am therefore better able to tailor the surgery to their pathology and produce better outcomes for them. -