Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3388-4
KNEE
Tibial tubercle osteotomy for patello-femoral joint disorders Matthew J. Hall · Vipul I. Mandalia
Received: 23 April 2014 / Accepted: 10 October 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Tibial tubercle osteotomy has a long history in the management of patella instability and patello-femoral arthritis. This review aims to provide a comprehensive review of the literature describing the biomechanics of the patello-femoral joint and the rationale behind the use of the tibial tubercle osteotomy in modern day practice. Several different tibial tubercle osteotomies are available and we aim to detail the concepts behind their use and the subsequent clinical results. With continued developments of chondrocyte implantation techniques, the potential to fill defects on the chondral surface of either the patella or trochlea in conjunction with a tibial tubercle osteotomy may well become more commonplace in a group that is commonly young and difficult to manage. Level of evidence III. Keywords Patello-femoral joint · Tibial tubercle osteotomy · Anterior knee pain · Patella dislocation
which control the patella; if there are deficiencies in either of these areas, the chondral surface of the patella is at high risk of excessive damage. The role of the patella is to increase the lever arm of the quadriceps mechanism thus providing a mechanical advantage with very high stresses placed upon the chondral surface during activities such as stair climbing or squatting. The exact morphology of the articular surface of the patella varies hugely between individuals, with two main facets, medial and lateral remaining constant; however, the exact size and orientation may differ [25]. Patello-femoral disorders fall into two main categories: patello-femoral arthritis and patella instability. Tibial tubercle (TT) osteotomy can accordingly be utilised either to unload the chondral surface of the patella or to improve stability and to alter tracking. In this review, we will not discuss tibial tubercle osteotomy in the setting of revision knee arthroplasty. Biomechanics
Introduction Anterior knee pain is a frequent presentation to orthopaedic clinics and remains a diagnostic and therapeutic challenge throughout all age groups. The relationship between the patella and trochlea is a complex relationship that is reliant upon the architecture of the trochlea and the soft tissues M. J. Hall (*) Yeovil District Hospital, Higher Kingston, Yeovil BA21 4AT, Somerset, UK e-mail: [email protected] V. I. Mandalia Royal Devon and Exeter Hospital, Devon, UK
When the knee is in full extension, the patella rests proximal and lateral to the trochlea groove. In this position, the patella has no bony stability, only soft tissue restraints which accounts for the majority of patella dislocations occurring with the knee in full extension. At 20–30° of knee flexion, the patella engages in the trochlear groove and it is the larger lateral trochlea facet that acts as the main restraint to lateral subluxation. At this point, only the distal pole of the patella contacts the trochlea groove that captures the patella with the overall lateral distorting force being resisted by the medial soft tissue structures. As knee flexion increases, the main contact area on the patella surface moves superiorly and from the lateral facet to the medial facet. Past
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90° of flexion, the patella exits the trochlear and articulates with the intercondylar notch [25]. Forces across the patella chondral surface are estimated to be 385N on walking, 2400N on stair ascent/descent, and 6000N on landing from a jump [18]. It is the action of the strong quadriceps muscle to displace the patella laterally when the knee is extended. Significant valgus or varus malalignment of the tibial femoral joint along with rotational deformities of either the tibia of femur will affect patella tracking or subsequently contact stress areas on the patella [2]. Patella maltracking occurs due to the net lateral deforming force which results from the lateral displacement of the TT in relation to the TG. Medialisation of the tibial tubercle acts to reduce the Q angle, but studies show that this does not decrease the peak patello-femoral pressures, but it only acts to shift them onto the medial facet of the patella [18]. Normal blood supply The blood supply around the knee is derived from a rich anastomosis of the geniculate arteries, namely the superior, middle and inferior both medial and lateral. The blood supply to the upper tibial epiphysis is from the inferior medial and lateral geniculate arteries with the tibial tubercle supply emanating from this system as well. The supply enters from ventral surface near to the attachment of the ligamentum patellae [32]. Imaging There are a number of indices used to describe the height, but the most common used include Insall–Salvati ratio where the length of the patella-to-patella tendon is measured as a ratio; Blackburne–Peel ratio where the length of the patella articular surface to the distance from the distal end of the articular surface to the line of tibial plateau is compared as a ratio; and the Labelle–Laurin method where the position of the proximal pole of the patella is compared to a line down the anterior cortex of the femur with the knee in 90° of flexion. Caton–Deschamps ratio is another method where the length of the articular surface is compared to the distance from the distal aspect of the articular surface and the most antero-superior point on the tibia. Anagnostakos compared all these methods in the same subjects and found that the ratios that used the articular surface, i.e. Insall–Salvati, Caton–Deschamps and Blackburne–Peel, showed the most reliability when in comparison [17]. Dejour [12] described a method to assess the distance between the TT and TG that involved axial sections of a CT scan being superimposed on one another to define a
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specific measurement. The sections were through the intercondylar notch to profile the TG, and the second section is through the proximal TT. The normal TTTG distance is 10 ± 1 mm [45] although there is a recognised large variation possible with Dejour’s original work recording a series of patients with patella instability with a mean TTTG distance of 19.8 ± 1.6 mm. However, if the TTTG distance is >15 mm, then this is considered pathological according to Dejour’s criteria [12]. A recent study has proposed the concept that TTTG distance is relative to the joint size and a single figure should not be used to decide operative treatment [28]. The depth of the trochlea is assessed on a true lateral radiograph with the knee flexed to 30° and the condyles superimposed. In a normal trochlea, the base can be identified, whereas in a shallow trochlea, the line of the floor of the trochlea crosses the lateral lip of the condyle; this is termed the crossover or crossing sign [12]. There is now increasing availability to MRI scanning which has the advantage of low radiation exposure in what is predominantly a young age group. Several series have been published demonstrating good correlation between CT and MRI scans for TTTG distance [17, 52]. MRI scanning has the advantage in that it can assess the extent of cartilage loss throughout the knee as well as provide images from which all relevant information described above can be established. Phillips et al. [46] in a review article concluded that although numerous methods exist to assess patella height, none can be applied universally as there is no strong evidence to support any one particular method. Types of tibial tubercle transfer Roux [50] in the late nineteenth century carried out the first recorded operation for patella instability that involved medialisation of the tubercle. Subsequently, various techniques have been described including the Hauser procedure involving the medial and posterior displacement of the tibial tubercle [26], Elmslie in England and Trillat in France popularised the concept of a pure medial shift to the tubercle in order to reduce patello-femoral contact pressures [57]. Fulkerson [19] in 1983 combined the apparent advantages of both of these procedures with an anterior and medial shift of the tubercle by using an oblique osteotomy and is commonly used to address both instability as well as an offloading procedure in osteoarthritis. Techniques have evolved such that a combination of planar correction is achieved as part of the transfer [16]. The most popular osteotomy involves shifting the tibial tubercle either anteriorly, medially or a combination of the two, anterio-medialisation dependant on the surgical objectives.
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Direction of tubercle transfer • Medial and posterior The Hauser procedure involves moving the tibial tubercle in a medial and posterior direction with the aim of offloading the patello-femoral joint and improving patella stability. Barbari et al. reported on 63 knees having undergone a Hauser procedure with an average follow-up of 8 years. The operation was considered a success in 84 % of patients; however, 58 % experienced pain and discomfort following the procedure [3]. Juliusson et al. [30] carried out a long-term followup study of patients who had undergone this procedure and found that 66 % of patients had some degree of osteoarthritis and pain at follow-up. Other long-term studies have shown that approximately 70 % of patients have evidence of progression of osteoarthritis at an average follow-up of 7–18 years [47]. As a result of the high incidence of late osteoarthritis resulting from increased patello-femoral pressure, the procedure should be avoided in modern day practice. • Anterior Maquet first described anteriorisation of the tubercle in 1963 [38] as a method to potentially overcome the problem of the degenerative patello-femoral joint. By increasing the lever arm of the patella tendon by anteriorisation of the tibial tubercle, the patella contact pressures decrease. ShiraziAdl et al. carried out a 3D modelling study looking at the effects of anteriorisation of the tibial tubercle on patellofemoral contact pressures. This group concluded that the tibio-femoral biomechanics are significantly affected by tibial tubercle elevation and accordingly needs to be considered in planning any surgery [54]. Several studies report favourable outcomes with this procedure ranging from 60, 62 to 80 % [29, 42, 53] with follow-up ranging from 6 to 11 years. Naranja et al. recommended the procedure be restricted to young patients with no osteoarthritis and only patella instability as these were found to have better outcomes. This study also found that 44 % of patients required screw removal from the osteotomy site [42]. Pan et al. found that the length of the tibial shingle has an effect on the contact pressures of the patella. In a cadaveric study, a short length of anterior tibial osteotomy (7 cm) resulted in tipping of the patella onto the superior pole with resultant increase in contact pressures compared with a longer (20 cm) tibial osteotomy [44]. Initially, this procedure was popular with early success although longterm follow-up studies report deterioration of initially good results [27, 36]. The procedure is associated with complications became apparent such as fracture, non-union and skin necrosis and as a result Maquet’s osteotomy has largely fallen out of favour currently [51]. Perhaps, the most
significant was skin necrosis with several authors reporting wound complication rates between 10 and 37 % [31]. The extent of the anteriorisation results in significant tissue tension over the osteotomy site and Maquet described closing this primarily releasing the skin posteriorly and covering this defect with a skin graft [38]. • Medial Medial displacement of the tibial tubercle aims to improve alignment by reducing the TTTG and subsequently reduce patello-femoral contact area and stresses [58]. Marcacci et al. published a series of 16 patients with bilateral recurrent patella dislocation with a 30-year follow–up. They found that on the operated side, three had excellent results and three worse compared with on the non-operated side six excellent and one worse. The conclusions were that the Roux technique provides an excellent solution to patella dislocation; however, there was no evidence to demonstrate reliable and effective modification of the degenerative process [39]. Several studies report excellent and good scores, 60 [42], 64 [41] and 62.5 % [43] from the medialisation procedure with long-term follow-up. However, Nakagawa et al. [41] found that there was deterioration with time with good function, falling from 64 to 53 % at ten years. Naveed et al. [43] found that 54 % developed early signs of osteoarthritis in the patello-femoral joint, and of this group, 58 % were found to have early signs of degenerative changes in the tibio-femoral joint. Wang et al. [59] demonstrated that with an incremental increase in medial displacement of the tubercle, the contact pressure within the patello-femoral joint increased by as much as 18 %, decreased the patello-femoral contact area by 16 % and increased the medial–lateral ratio of patellofemoral stresses by 36 %. Kuroda et al. [34] demonstrated similar findings; in that, after medialisation, there was an increase in patello-femoral contact pressures and increased medial tibio-femoral compartment contact pressure. Pritsch et al. published a study with a tailored approach to the degree of medial correction of the tibial tubercle. The technique describes a combination of intra-operative passive and active assessment of patella tracking in conjunction with assessment of the condition of the patella chondral surface in deciding the degree of tubercle shift. The results of the study at 2-year follow-up showed that 72.5 % of operated knees had good-to-excellent clinical scores with supporting physical findings [49]. • Anterio-medialisation In 1983, Fulkerson [19] described an alternative to pure medialisation, involving a combination of medialisation
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and anteriorisation of the tibial tubercle. Typically, a 1.5 cm shift medially and anteriorly is recommended [21], with the obliquity of the osteotomy allowing flexibility in the bi-planar correction. The advantage of the Fulkerson combined shift is that it addresses the increased patellofemoral forces with the anteriorisation component and then addresses the mechanical alignment issues and efficiency of the patello-femoral mechanism with the medialisation component. The osteotomy also has the advantage that there is no requirement for bone grafting and fewer complications arise due to the maintenance of a viable soft tissue envelope [16]. Carofino et al. looked at a cohort of patients over 50 who underwent antero-medialisation osteotomy and at average follow-up of 77 months and showed that 63 % had an excellent or good result and only 5 % having a poor result. These authors suggest that the anteromedial tubercle osteotomy is a good option for isolated patello-femoral arthritis in the active older patient [7]. Fulkerson [21] published results of this osteotomy with 93 % showing excellent or good result at 5-year followup, 75 % of these patients having advanced osteoarthritis of the patello-femoral joint. Karamehmetoglu et al. [33] found similar results to this study with 85.7 % excellent or good outcome and only 4.8 % poor at average follow-up of 28 months. • Proximalisation Proximalisation of the tibial tubercle is usually a component of extensive salvage surgery to treat patella infera, typically resulting from arthrofibrosis. This direction of osteotomy can be a viable alternative to patella lengthening; however, it should be noted that this is only one strategy to help manage a complex condition [16]. There are no long-term results published for proximalisation of the tibial tubercle. • Distalisation Tibial tubercle distalisation is infrequently carried out in isolation, but more commonly in conjunction with procedures to correct a patella alta, usually associated with congenital abnormalities and patella instability. The instability resulting from the high riding patella is due to failure of engagement within the constraints of the trochlea during progressive knee flexion. Al-Sayyad looked at a group of patients with patella alta but no symptoms of subluxation having undergone a distalisation procedure with an average follow-up of 2.4 years. These results showed significant improvement in patello-femoral scores in the post-operative group with the conclusion that this procedure is beneficial in isolated patella alta with no instability [1].
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Fixation techniques Very little literature has been published looking at techniques of fixation in relation to failure strengths. One study by Davis et al. [11] compared static strength between two cortical screws and three cerclage wires with either a bevelcut or stepcut osteotomy and in both situations the screw fixation provided significantly greater strength and hence more reliable fixation. Davis et al. examined the fixation strength with loading the osteotomy parallel to the tibial axis; Caldwell et al. examined the strength of the osteotomy in a more dynamic manner so as to replicate the rehabilitation environment. This study showed that in terms of both displacement of the osteotomy and load to failure at 0° and 25° of flexion, screw fixation was superior to wire fixation [6]. These authors also found trends in their data of increased failure in patients with raised BMI and low bone mineral density. Complications Each of the tubercle osteotomies carries its own specific complications, but one thing all have in common is that even with correctly performed surgery an unhappy patient can often result. Biomechanically it can provide good unloading characteristics; however, if the transfer is too much, then this can act to increase chondral loading through the medial facet and clearly hasten degenerative changes on the patella as well as in the tibio-femoral joint [14]. Cosgarea [9] reported a case of non-union following Fulkerson’s osteotomy and concluded that inadequate fixation technique and a too aggressive rehabilitation technique was likely to have influenced this. Luhmann et al. [35] published a series where they reported an overall bony complication rate of 5.9 %; however, when an intact periosteum was left around the distal portion of the osteotomy, then this figure fell to 0 %. Wang et al. [60] published a similar series with a reported non-union rate of 3 %. Fracture of the proximal tibia is a significant complication and has been reported by several authors [4, 56], with Bellemans and Stetson reporting fractures no later than 13 weeks in their series. Eager has subsequently reported on five patients with this complication where the average time for fracture was 25 weeks. The recommendation from all of these studies was to initiate a progressive rehabilitation regime to protect the osteotomy site that in all these cases was antero-medialisation [13, 20]. The reported fracture rates of the proximal tibia range from 2.6 [56] to 8 % [4]; however, with the above recommendations for rehabilitation, these figures have fallen. Godde reported on two fractures of the proximal tibia 6 months following Fulkerson’s osteotomy where the patients had shown radiographic
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evidence of bony union, and accordingly recommended restriction on sporting activities for up to 9 months following surgery [24]. As described in the relevant section, the Maquet procedure has significantly high complication rates mainly relating to the extent of the anteriorisation and resultant soft tissue tension leading to wound breakdown, with reported rates as high as 8.2 % [48]. Bessette et al. [5] found from a study on Maquet procedures that generally the results were less satisfactory when internal fixation was used and recommended this. Rehabilitation The key to a successful rehabilitation from either a surgical intervention or non-operative management is initiating a focused rehabilitation programme and again there appears little consensus on treatment guidelines [40]. Much of the initial physiotherapy regimes are based around standard patello-femoral rehabilitation of restoration of range of movement and quadriceps strengthening. Early studies suggested non-weight bearing for the first 6–8 weeks; however, modern studies suggest a more aggressive regime of partial weight bearing or even full weight bearing immediately post-operatively [8, 60]. However, there is increasing recognition now that the key issue from a rehabilitation programme is the development of kinematic control of the whole extremity as a functionally linked kinematic chain. Studies now focus upon looking at the hip and foot kinematics and the impact this may have upon the knee and more specifically the patellofemoral joint. Souza et al. looked at the effect of abnormal hip kinematic control and the impact this has on the control of the patella. Using data collected from EMG studies and strength analysis, the results showed that individuals in the patello-femoral group demonstrated increased internal hip rotation, decreased hip muscle strength and differences in muscle recruitment around the hip compared with a control group [55]. Based on these findings, patient education in undertaking daily tasks such as sitting are essential as an imbalanced hip and knee can result in overloading the patellofemoral joint. Escamilla et al. looked at patello-femoral force in squatting and found that less compressive force was noted in small degrees of flexion when carrying out squatting manoeuvre. Thus, recommending patients to use more hip flexion and forward trunk lean when sitting so as to minimise these potentially excessive forces [15]. Future technology The technological advances in tissue engineering and chondral replacement surgery means there is potential for
combination surgery in the form of articular cartilage restoration to the defects in the patello-femoral joint with distance realignment of the tibial tubercle in order to offload the deficient zone. One study by Mandelbaum [37] looking at results of autologous chondrocyte implantation (ACI) specifically to the trochlear found that despite a reoperation rate of 28, 90 % of patients showed improvement in symptoms at an average of 5 years. Gobbi et al. published a series of 34 patients at 5-year follow-up who underwent a combined treatment of ACI and realignment surgery. All knee scores showed a statistically significant improvement at both 2-year and 5-year follow-up [23]. It would therefore appear that the combination of realignment surgery with chondrocyte transplantation is yielding outcomes superior to either techniques in isolation.
Discussion Patello-femoral pain and instability provides a complex multi-faceted problem that is most common in the younger age groups. The mantra of ‘first do no harm’ is particularly pertinent in this population of patients where all avenues of potential non-operative treatments should be explored before consideration of realignment surgery is undertaken. Many patients suffer from patella maltracking and subsequent instability although a relatively small percentage of this group requires corrective surgery. A large proportion of patients do benefit from conservative treatment in the form of physiotherapy. Once non-operative measures have been exhausted and proven not to be successful, appropriate imaging and arthroscopic assessment should be carried out to ascertain whether realignment surgery is likely to benefit the patient. Numerous osteotomies are available to the surgeon; hence, selecting the correct procedure for the patients’ symptoms and pathology is important in order to maximise the opportunity for a successful outcome. Early studies showed varied success of tibial tubercle osteotomy at both medium and long-term follow-up as the complexity of the patello-femoral joint was discovered. As a result of this increased understanding, the potential benefits of the osteotomy were appreciated with the ability to correct instability and also alter the contact pressures in the patella chondral surface. One of the difficulties with TTT studies is comparing clinical outcomes between the different series, as often the patient population is different and the methods of evaluation are different. Additionally, it is most common that these series are all retrospective in evaluation. Pidoriano categorised location of chondral defects in the patella with success of tibial tubercle transfer. This group found that the location of the lesion rather than the depth
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and extent of the lesion correlated better to the overall outcome. They concluded that caution should be taken when carrying out tubercle transfer when diffuse chondral damage exists on the retro-patella surface [46]. The future is now concentrated on cartilage regeneration procedures to fill defects within the patello-femoral joint and to combine this with a realignment procedure to reduce patello-femoral joint contact stresses. Results from such procedures are now showing good functional outcomes at 5 years [22, 23, 37, 47]. Cosgarea et al. demonstrated on biomechanical testing that a flat osteotomy (medialisation) failed at higher mean peak loads and higher energy than the oblique osteotomies (anteromedialisation). This group recommended using the flat osteotomy in the subset of patients without significant patella or trochlea chondral degeneration and the oblique osteotomy in the subset of patients who have degeneration of the patello-femoral joint and would benefit from the unloading benefits of anteriorisation [10]. There is increased awareness of the patello-femoral joint symptoms, and the potential to influence improvement in symptoms through a surgical procedure is greater. However, even with these advances, it still remains a clinical conundrum to identify clearly the precise pathology precipitating anterior knee pain in the younger patient. Currently, there are many surgical procedures available to help soft tissue balancing of the patella in order to maintain constraint within the trochlea along with osteotomies which can either improve constraint and/or offload chondral surfaces. Tibial tubercle osteotomy should be the final visit along a treatment pathway where all options of non-operative treatments have failed and imaging has revealed an identifiable cause for the patients’ symptoms. Patients need to be fully informed that there is a likelihood of on-going symptoms with commonly only partial relief of symptoms and subsequently the individual may need to modify their lifestyle accordingly.
Conclusion When planning a tibial tubercle osteotomy it is important to have a clear concept of whether the aim of surgery is to improve alignment and tracking, off load the chondral surface or a combination of the two. What has been established in the literature is that with clear clinical signs of patella maltracking or anterior knee pain in conjunction with CT evidence of lateral positioning of the tibial tubercle, shifting the tibial tubercle will provide good symptom relief in a large proportion of patients. With clear criteria on patient selection, the tibial tubercle osteotomy is a very viable treatment option for this group of patients.
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43. Naveed MA, Ackroyd CE, Porteous AJ (2013) Long-term (ten to 15 year) outcome of the arthroscopically assisted Elmslie-Trillat tibial tubercle osteotomy. Bone Joint J 95-B(4):478–485 44. Pan HQ, Kish V, Boyd RD (1993) The Maquet procedure: effect of tibial shingle length on patellofemoral pressures. J Orthop Res 11(2):199–204 45. Pandit S, Frampton C, Stoddart J et al (2011) Magnetic resonance imaging assessment of tibial tuberosity-trochlear groove distance: normal values for males and females. Int Orthop 35:1799–1803 46. Phillips CL, Silver DA, Schranz PJ, Mandalia V (2010) The measurement of patellar height: a review of the methods of imaging. J Bone Joint Surg Br 92(8):1045–1053 47. Pidoriana AJ, Weinstein RN, Buuck DA et al (1997) Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer. Am J Sports Med 25(4):533–537 48. Post WR, Fulkerson JP (1992) Distal realignment of the patellofemoral joint indications, effects, results and recommendations. Orthop Clin North Am 23(4):631–643 49. Priitsch T, Haim A, Snir N et al (2007) Tailored tibial tubercle transfer for patellofemoral malalignment: analysis of clinical outcomes. Knee Surg Sports Traumatol Arthrosc 15:994–1002 50. Roux C (1979) The classic: recurrent dislocation of the patella: operative treatment. Clin Orthop Relat Res 144:4–8 51. Rue JP, Colton A, Zare SM et al (2008) Trochlear contact pressures after straight anteriorization of the tibial tuberosity. Am J Sports Med 36(10):1953–1959 52. Schoettle PB, Zanetti M, Seifert B (2006) The tibial tuberosity– trochlear groove distance; a comparison study between CT and MRI scanning. Knee 13(1):26–31 53. Schmid F (1993) The Maquet procedure in the treatment of patellofemoral osteoarthrosis: long-term results. Clin Orthop Relat Res 294:254–258 54. Shirazi-Adl A, Mesfar W (2007) Effect of tibial tubercle elevation on biomechanics of the entire knee joint under muscle loads. Clin Biomech (Bristol, Avon) 22(3):344–351 55. Souza RB, Draper CE, Fredericson M et al (2010) Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. J Orthop Sports Phys Ther 40(5):277–285 56. Stetson WB, Friedman MJ, Fulkerson JP et al (1997) Fracture of the proximal tibia with immediate weight bearing after a Fulkerson osteotomy. Am J Sports Med 25:570–574 57. Trillat A, Dejour H, Coutte A (1964) Diagnosis and treatment of recurrent dislocations of the patella. Rev Chir Orthop Reparatrice Appar Mot 50:813–824 58. Wang CJ (2001) Management of patellofemoral arthrosis in middle-aged patients. Chang Gung Med J 24(11):672–679 59. Wang CJ, Chen LM, Chen HS (1999) Patellofemoral disorders treated by distal realignment. J Orthop Surg ROC 16:61–68 60. Wang CJ, Wong T, Ko JY et al (2012) Triple positioning of tibial tubercle osteotomy for patellofemoral disorders. Knee 21(1):133–137
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Tibial tubercle osteotomy for patello-femoral joint disorders Matthew J. Hall · Vipul I. Mandalia
Received: 23 April 2014 / Accepted: 10 October 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Tibial tubercle osteotomy has a long history in the management of patella instability and patello-femoral arthritis. This review aims to provide a comprehensive review of the literature describing the biomechanics of the patello-femoral joint and the rationale behind the use of the tibial tubercle osteotomy in modern day practice. Several different tibial tubercle osteotomies are available and we aim to detail the concepts behind their use and the subsequent clinical results. With continued developments of chondrocyte implantation techniques, the potential to fill defects on the chondral surface of either the patella or trochlea in conjunction with a tibial tubercle osteotomy may well become more commonplace in a group that is commonly young and difficult to manage. Level of evidence III. Keywords Patello-femoral joint · Tibial tubercle osteotomy · Anterior knee pain · Patella dislocation
which control the patella; if there are deficiencies in either of these areas, the chondral surface of the patella is at high risk of excessive damage. The role of the patella is to increase the lever arm of the quadriceps mechanism thus providing a mechanical advantage with very high stresses placed upon the chondral surface during activities such as stair climbing or squatting. The exact morphology of the articular surface of the patella varies hugely between individuals, with two main facets, medial and lateral remaining constant; however, the exact size and orientation may differ [25]. Patello-femoral disorders fall into two main categories: patello-femoral arthritis and patella instability. Tibial tubercle (TT) osteotomy can accordingly be utilised either to unload the chondral surface of the patella or to improve stability and to alter tracking. In this review, we will not discuss tibial tubercle osteotomy in the setting of revision knee arthroplasty. Biomechanics
Introduction Anterior knee pain is a frequent presentation to orthopaedic clinics and remains a diagnostic and therapeutic challenge throughout all age groups. The relationship between the patella and trochlea is a complex relationship that is reliant upon the architecture of the trochlea and the soft tissues M. J. Hall (*) Yeovil District Hospital, Higher Kingston, Yeovil BA21 4AT, Somerset, UK e-mail: [email protected] V. I. Mandalia Royal Devon and Exeter Hospital, Devon, UK
When the knee is in full extension, the patella rests proximal and lateral to the trochlea groove. In this position, the patella has no bony stability, only soft tissue restraints which accounts for the majority of patella dislocations occurring with the knee in full extension. At 20–30° of knee flexion, the patella engages in the trochlear groove and it is the larger lateral trochlea facet that acts as the main restraint to lateral subluxation. At this point, only the distal pole of the patella contacts the trochlea groove that captures the patella with the overall lateral distorting force being resisted by the medial soft tissue structures. As knee flexion increases, the main contact area on the patella surface moves superiorly and from the lateral facet to the medial facet. Past
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90° of flexion, the patella exits the trochlear and articulates with the intercondylar notch [25]. Forces across the patella chondral surface are estimated to be 385N on walking, 2400N on stair ascent/descent, and 6000N on landing from a jump [18]. It is the action of the strong quadriceps muscle to displace the patella laterally when the knee is extended. Significant valgus or varus malalignment of the tibial femoral joint along with rotational deformities of either the tibia of femur will affect patella tracking or subsequently contact stress areas on the patella [2]. Patella maltracking occurs due to the net lateral deforming force which results from the lateral displacement of the TT in relation to the TG. Medialisation of the tibial tubercle acts to reduce the Q angle, but studies show that this does not decrease the peak patello-femoral pressures, but it only acts to shift them onto the medial facet of the patella [18]. Normal blood supply The blood supply around the knee is derived from a rich anastomosis of the geniculate arteries, namely the superior, middle and inferior both medial and lateral. The blood supply to the upper tibial epiphysis is from the inferior medial and lateral geniculate arteries with the tibial tubercle supply emanating from this system as well. The supply enters from ventral surface near to the attachment of the ligamentum patellae [32]. Imaging There are a number of indices used to describe the height, but the most common used include Insall–Salvati ratio where the length of the patella-to-patella tendon is measured as a ratio; Blackburne–Peel ratio where the length of the patella articular surface to the distance from the distal end of the articular surface to the line of tibial plateau is compared as a ratio; and the Labelle–Laurin method where the position of the proximal pole of the patella is compared to a line down the anterior cortex of the femur with the knee in 90° of flexion. Caton–Deschamps ratio is another method where the length of the articular surface is compared to the distance from the distal aspect of the articular surface and the most antero-superior point on the tibia. Anagnostakos compared all these methods in the same subjects and found that the ratios that used the articular surface, i.e. Insall–Salvati, Caton–Deschamps and Blackburne–Peel, showed the most reliability when in comparison [17]. Dejour [12] described a method to assess the distance between the TT and TG that involved axial sections of a CT scan being superimposed on one another to define a
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specific measurement. The sections were through the intercondylar notch to profile the TG, and the second section is through the proximal TT. The normal TTTG distance is 10 ± 1 mm [45] although there is a recognised large variation possible with Dejour’s original work recording a series of patients with patella instability with a mean TTTG distance of 19.8 ± 1.6 mm. However, if the TTTG distance is >15 mm, then this is considered pathological according to Dejour’s criteria [12]. A recent study has proposed the concept that TTTG distance is relative to the joint size and a single figure should not be used to decide operative treatment [28]. The depth of the trochlea is assessed on a true lateral radiograph with the knee flexed to 30° and the condyles superimposed. In a normal trochlea, the base can be identified, whereas in a shallow trochlea, the line of the floor of the trochlea crosses the lateral lip of the condyle; this is termed the crossover or crossing sign [12]. There is now increasing availability to MRI scanning which has the advantage of low radiation exposure in what is predominantly a young age group. Several series have been published demonstrating good correlation between CT and MRI scans for TTTG distance [17, 52]. MRI scanning has the advantage in that it can assess the extent of cartilage loss throughout the knee as well as provide images from which all relevant information described above can be established. Phillips et al. [46] in a review article concluded that although numerous methods exist to assess patella height, none can be applied universally as there is no strong evidence to support any one particular method. Types of tibial tubercle transfer Roux [50] in the late nineteenth century carried out the first recorded operation for patella instability that involved medialisation of the tubercle. Subsequently, various techniques have been described including the Hauser procedure involving the medial and posterior displacement of the tibial tubercle [26], Elmslie in England and Trillat in France popularised the concept of a pure medial shift to the tubercle in order to reduce patello-femoral contact pressures [57]. Fulkerson [19] in 1983 combined the apparent advantages of both of these procedures with an anterior and medial shift of the tubercle by using an oblique osteotomy and is commonly used to address both instability as well as an offloading procedure in osteoarthritis. Techniques have evolved such that a combination of planar correction is achieved as part of the transfer [16]. The most popular osteotomy involves shifting the tibial tubercle either anteriorly, medially or a combination of the two, anterio-medialisation dependant on the surgical objectives.
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Direction of tubercle transfer • Medial and posterior The Hauser procedure involves moving the tibial tubercle in a medial and posterior direction with the aim of offloading the patello-femoral joint and improving patella stability. Barbari et al. reported on 63 knees having undergone a Hauser procedure with an average follow-up of 8 years. The operation was considered a success in 84 % of patients; however, 58 % experienced pain and discomfort following the procedure [3]. Juliusson et al. [30] carried out a long-term followup study of patients who had undergone this procedure and found that 66 % of patients had some degree of osteoarthritis and pain at follow-up. Other long-term studies have shown that approximately 70 % of patients have evidence of progression of osteoarthritis at an average follow-up of 7–18 years [47]. As a result of the high incidence of late osteoarthritis resulting from increased patello-femoral pressure, the procedure should be avoided in modern day practice. • Anterior Maquet first described anteriorisation of the tubercle in 1963 [38] as a method to potentially overcome the problem of the degenerative patello-femoral joint. By increasing the lever arm of the patella tendon by anteriorisation of the tibial tubercle, the patella contact pressures decrease. ShiraziAdl et al. carried out a 3D modelling study looking at the effects of anteriorisation of the tibial tubercle on patellofemoral contact pressures. This group concluded that the tibio-femoral biomechanics are significantly affected by tibial tubercle elevation and accordingly needs to be considered in planning any surgery [54]. Several studies report favourable outcomes with this procedure ranging from 60, 62 to 80 % [29, 42, 53] with follow-up ranging from 6 to 11 years. Naranja et al. recommended the procedure be restricted to young patients with no osteoarthritis and only patella instability as these were found to have better outcomes. This study also found that 44 % of patients required screw removal from the osteotomy site [42]. Pan et al. found that the length of the tibial shingle has an effect on the contact pressures of the patella. In a cadaveric study, a short length of anterior tibial osteotomy (7 cm) resulted in tipping of the patella onto the superior pole with resultant increase in contact pressures compared with a longer (20 cm) tibial osteotomy [44]. Initially, this procedure was popular with early success although longterm follow-up studies report deterioration of initially good results [27, 36]. The procedure is associated with complications became apparent such as fracture, non-union and skin necrosis and as a result Maquet’s osteotomy has largely fallen out of favour currently [51]. Perhaps, the most
significant was skin necrosis with several authors reporting wound complication rates between 10 and 37 % [31]. The extent of the anteriorisation results in significant tissue tension over the osteotomy site and Maquet described closing this primarily releasing the skin posteriorly and covering this defect with a skin graft [38]. • Medial Medial displacement of the tibial tubercle aims to improve alignment by reducing the TTTG and subsequently reduce patello-femoral contact area and stresses [58]. Marcacci et al. published a series of 16 patients with bilateral recurrent patella dislocation with a 30-year follow–up. They found that on the operated side, three had excellent results and three worse compared with on the non-operated side six excellent and one worse. The conclusions were that the Roux technique provides an excellent solution to patella dislocation; however, there was no evidence to demonstrate reliable and effective modification of the degenerative process [39]. Several studies report excellent and good scores, 60 [42], 64 [41] and 62.5 % [43] from the medialisation procedure with long-term follow-up. However, Nakagawa et al. [41] found that there was deterioration with time with good function, falling from 64 to 53 % at ten years. Naveed et al. [43] found that 54 % developed early signs of osteoarthritis in the patello-femoral joint, and of this group, 58 % were found to have early signs of degenerative changes in the tibio-femoral joint. Wang et al. [59] demonstrated that with an incremental increase in medial displacement of the tubercle, the contact pressure within the patello-femoral joint increased by as much as 18 %, decreased the patello-femoral contact area by 16 % and increased the medial–lateral ratio of patellofemoral stresses by 36 %. Kuroda et al. [34] demonstrated similar findings; in that, after medialisation, there was an increase in patello-femoral contact pressures and increased medial tibio-femoral compartment contact pressure. Pritsch et al. published a study with a tailored approach to the degree of medial correction of the tibial tubercle. The technique describes a combination of intra-operative passive and active assessment of patella tracking in conjunction with assessment of the condition of the patella chondral surface in deciding the degree of tubercle shift. The results of the study at 2-year follow-up showed that 72.5 % of operated knees had good-to-excellent clinical scores with supporting physical findings [49]. • Anterio-medialisation In 1983, Fulkerson [19] described an alternative to pure medialisation, involving a combination of medialisation
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and anteriorisation of the tibial tubercle. Typically, a 1.5 cm shift medially and anteriorly is recommended [21], with the obliquity of the osteotomy allowing flexibility in the bi-planar correction. The advantage of the Fulkerson combined shift is that it addresses the increased patellofemoral forces with the anteriorisation component and then addresses the mechanical alignment issues and efficiency of the patello-femoral mechanism with the medialisation component. The osteotomy also has the advantage that there is no requirement for bone grafting and fewer complications arise due to the maintenance of a viable soft tissue envelope [16]. Carofino et al. looked at a cohort of patients over 50 who underwent antero-medialisation osteotomy and at average follow-up of 77 months and showed that 63 % had an excellent or good result and only 5 % having a poor result. These authors suggest that the anteromedial tubercle osteotomy is a good option for isolated patello-femoral arthritis in the active older patient [7]. Fulkerson [21] published results of this osteotomy with 93 % showing excellent or good result at 5-year followup, 75 % of these patients having advanced osteoarthritis of the patello-femoral joint. Karamehmetoglu et al. [33] found similar results to this study with 85.7 % excellent or good outcome and only 4.8 % poor at average follow-up of 28 months. • Proximalisation Proximalisation of the tibial tubercle is usually a component of extensive salvage surgery to treat patella infera, typically resulting from arthrofibrosis. This direction of osteotomy can be a viable alternative to patella lengthening; however, it should be noted that this is only one strategy to help manage a complex condition [16]. There are no long-term results published for proximalisation of the tibial tubercle. • Distalisation Tibial tubercle distalisation is infrequently carried out in isolation, but more commonly in conjunction with procedures to correct a patella alta, usually associated with congenital abnormalities and patella instability. The instability resulting from the high riding patella is due to failure of engagement within the constraints of the trochlea during progressive knee flexion. Al-Sayyad looked at a group of patients with patella alta but no symptoms of subluxation having undergone a distalisation procedure with an average follow-up of 2.4 years. These results showed significant improvement in patello-femoral scores in the post-operative group with the conclusion that this procedure is beneficial in isolated patella alta with no instability [1].
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Fixation techniques Very little literature has been published looking at techniques of fixation in relation to failure strengths. One study by Davis et al. [11] compared static strength between two cortical screws and three cerclage wires with either a bevelcut or stepcut osteotomy and in both situations the screw fixation provided significantly greater strength and hence more reliable fixation. Davis et al. examined the fixation strength with loading the osteotomy parallel to the tibial axis; Caldwell et al. examined the strength of the osteotomy in a more dynamic manner so as to replicate the rehabilitation environment. This study showed that in terms of both displacement of the osteotomy and load to failure at 0° and 25° of flexion, screw fixation was superior to wire fixation [6]. These authors also found trends in their data of increased failure in patients with raised BMI and low bone mineral density. Complications Each of the tubercle osteotomies carries its own specific complications, but one thing all have in common is that even with correctly performed surgery an unhappy patient can often result. Biomechanically it can provide good unloading characteristics; however, if the transfer is too much, then this can act to increase chondral loading through the medial facet and clearly hasten degenerative changes on the patella as well as in the tibio-femoral joint [14]. Cosgarea [9] reported a case of non-union following Fulkerson’s osteotomy and concluded that inadequate fixation technique and a too aggressive rehabilitation technique was likely to have influenced this. Luhmann et al. [35] published a series where they reported an overall bony complication rate of 5.9 %; however, when an intact periosteum was left around the distal portion of the osteotomy, then this figure fell to 0 %. Wang et al. [60] published a similar series with a reported non-union rate of 3 %. Fracture of the proximal tibia is a significant complication and has been reported by several authors [4, 56], with Bellemans and Stetson reporting fractures no later than 13 weeks in their series. Eager has subsequently reported on five patients with this complication where the average time for fracture was 25 weeks. The recommendation from all of these studies was to initiate a progressive rehabilitation regime to protect the osteotomy site that in all these cases was antero-medialisation [13, 20]. The reported fracture rates of the proximal tibia range from 2.6 [56] to 8 % [4]; however, with the above recommendations for rehabilitation, these figures have fallen. Godde reported on two fractures of the proximal tibia 6 months following Fulkerson’s osteotomy where the patients had shown radiographic
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evidence of bony union, and accordingly recommended restriction on sporting activities for up to 9 months following surgery [24]. As described in the relevant section, the Maquet procedure has significantly high complication rates mainly relating to the extent of the anteriorisation and resultant soft tissue tension leading to wound breakdown, with reported rates as high as 8.2 % [48]. Bessette et al. [5] found from a study on Maquet procedures that generally the results were less satisfactory when internal fixation was used and recommended this. Rehabilitation The key to a successful rehabilitation from either a surgical intervention or non-operative management is initiating a focused rehabilitation programme and again there appears little consensus on treatment guidelines [40]. Much of the initial physiotherapy regimes are based around standard patello-femoral rehabilitation of restoration of range of movement and quadriceps strengthening. Early studies suggested non-weight bearing for the first 6–8 weeks; however, modern studies suggest a more aggressive regime of partial weight bearing or even full weight bearing immediately post-operatively [8, 60]. However, there is increasing recognition now that the key issue from a rehabilitation programme is the development of kinematic control of the whole extremity as a functionally linked kinematic chain. Studies now focus upon looking at the hip and foot kinematics and the impact this may have upon the knee and more specifically the patellofemoral joint. Souza et al. looked at the effect of abnormal hip kinematic control and the impact this has on the control of the patella. Using data collected from EMG studies and strength analysis, the results showed that individuals in the patello-femoral group demonstrated increased internal hip rotation, decreased hip muscle strength and differences in muscle recruitment around the hip compared with a control group [55]. Based on these findings, patient education in undertaking daily tasks such as sitting are essential as an imbalanced hip and knee can result in overloading the patellofemoral joint. Escamilla et al. looked at patello-femoral force in squatting and found that less compressive force was noted in small degrees of flexion when carrying out squatting manoeuvre. Thus, recommending patients to use more hip flexion and forward trunk lean when sitting so as to minimise these potentially excessive forces [15]. Future technology The technological advances in tissue engineering and chondral replacement surgery means there is potential for
combination surgery in the form of articular cartilage restoration to the defects in the patello-femoral joint with distance realignment of the tibial tubercle in order to offload the deficient zone. One study by Mandelbaum [37] looking at results of autologous chondrocyte implantation (ACI) specifically to the trochlear found that despite a reoperation rate of 28, 90 % of patients showed improvement in symptoms at an average of 5 years. Gobbi et al. published a series of 34 patients at 5-year follow-up who underwent a combined treatment of ACI and realignment surgery. All knee scores showed a statistically significant improvement at both 2-year and 5-year follow-up [23]. It would therefore appear that the combination of realignment surgery with chondrocyte transplantation is yielding outcomes superior to either techniques in isolation.
Discussion Patello-femoral pain and instability provides a complex multi-faceted problem that is most common in the younger age groups. The mantra of ‘first do no harm’ is particularly pertinent in this population of patients where all avenues of potential non-operative treatments should be explored before consideration of realignment surgery is undertaken. Many patients suffer from patella maltracking and subsequent instability although a relatively small percentage of this group requires corrective surgery. A large proportion of patients do benefit from conservative treatment in the form of physiotherapy. Once non-operative measures have been exhausted and proven not to be successful, appropriate imaging and arthroscopic assessment should be carried out to ascertain whether realignment surgery is likely to benefit the patient. Numerous osteotomies are available to the surgeon; hence, selecting the correct procedure for the patients’ symptoms and pathology is important in order to maximise the opportunity for a successful outcome. Early studies showed varied success of tibial tubercle osteotomy at both medium and long-term follow-up as the complexity of the patello-femoral joint was discovered. As a result of this increased understanding, the potential benefits of the osteotomy were appreciated with the ability to correct instability and also alter the contact pressures in the patella chondral surface. One of the difficulties with TTT studies is comparing clinical outcomes between the different series, as often the patient population is different and the methods of evaluation are different. Additionally, it is most common that these series are all retrospective in evaluation. Pidoriano categorised location of chondral defects in the patella with success of tibial tubercle transfer. This group found that the location of the lesion rather than the depth
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and extent of the lesion correlated better to the overall outcome. They concluded that caution should be taken when carrying out tubercle transfer when diffuse chondral damage exists on the retro-patella surface [46]. The future is now concentrated on cartilage regeneration procedures to fill defects within the patello-femoral joint and to combine this with a realignment procedure to reduce patello-femoral joint contact stresses. Results from such procedures are now showing good functional outcomes at 5 years [22, 23, 37, 47]. Cosgarea et al. demonstrated on biomechanical testing that a flat osteotomy (medialisation) failed at higher mean peak loads and higher energy than the oblique osteotomies (anteromedialisation). This group recommended using the flat osteotomy in the subset of patients without significant patella or trochlea chondral degeneration and the oblique osteotomy in the subset of patients who have degeneration of the patello-femoral joint and would benefit from the unloading benefits of anteriorisation [10]. There is increased awareness of the patello-femoral joint symptoms, and the potential to influence improvement in symptoms through a surgical procedure is greater. However, even with these advances, it still remains a clinical conundrum to identify clearly the precise pathology precipitating anterior knee pain in the younger patient. Currently, there are many surgical procedures available to help soft tissue balancing of the patella in order to maintain constraint within the trochlea along with osteotomies which can either improve constraint and/or offload chondral surfaces. Tibial tubercle osteotomy should be the final visit along a treatment pathway where all options of non-operative treatments have failed and imaging has revealed an identifiable cause for the patients’ symptoms. Patients need to be fully informed that there is a likelihood of on-going symptoms with commonly only partial relief of symptoms and subsequently the individual may need to modify their lifestyle accordingly.
Conclusion When planning a tibial tubercle osteotomy it is important to have a clear concept of whether the aim of surgery is to improve alignment and tracking, off load the chondral surface or a combination of the two. What has been established in the literature is that with clear clinical signs of patella maltracking or anterior knee pain in conjunction with CT evidence of lateral positioning of the tibial tubercle, shifting the tibial tubercle will provide good symptom relief in a large proportion of patients. With clear criteria on patient selection, the tibial tubercle osteotomy is a very viable treatment option for this group of patients.
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