Distal Femoral Osteotomy to Treat Patellar Instability with Valgus ...llrs.org/LLRS 2016 PDFS/Distal...

DistalFemoralOsteotomytoTreatPatellarInstabilitywithValgusLowerExtremity

AlignmentinAdolescents

SheenaR.Black,MD,HenryB.Ellis,MD,PhilipL.Wilson,MD,DavidA.Podeszwa,MD

LLRSAnnualMeetingJuly22,2016Charleston,S.C.

Disclosures

TheauthorshavenosigniKicantdisclosures

Introduction

Genuvalgumisariskfactorforrecurrentpatellarinstability

Introduction

•  Avarusproducingdistalfemoralosteotomy(DFO)maybeutilizedforthetreatmentofsymptomaticpatellarinstabilityintheskeletallymatureadolescent.

•  >3yrclinicalandradiographicresultsandincidenceofrecurrentdislocationarereported

Methods

•  Retrospectivelyreview,IRBapproved

•  ConsecutivepatientswhounderwentanISOLATEDopeningwedgeDFOforrecurrentpatellarinstability

•  Patients:•  <18yearsold•  Skeletallymature•  >3ormorepatellardislocationepisodes•  Moderatetoseveregenuvalgum

(≥ZoneIImechanicalaxisorlateraldistalfemoralangle<81°)

•  Failednon-operativetreatment

Methods

•  Exclusioncriteria:•  <3yearsfollow-up•  Anypriorsurgicaltreatment•  Congenitalpatellarinstability•  Bi-planarosteotomies(includingrotational)

•  Allosteotomieswereperformedbyaseniorauthor(DAP)usinganopeningwedgetechnique.

Methods

•  DataAnalysis:•  Demographic•  Clinical•  Radiographicdatameasures

•  Outcomesmeasures:•  Kujala•  TegnerActivity

•  FailuresDeKined:•  Documentedrecurrentpatellardislocation•  Symptomsofpatellarinstability

Results

•  11patientswithIsolatedDFOforPFI

•  10withminimumof3yearfollowup•  Avgage=16years(range14-18yrs)

•  3Males/7Females

•  Avgfollow-upof4.25years(range3.2-6.0yrs)

Results

•  Allpatientsinitiallypresentedwithposttraumaticpatellarinstability•  9fromsportsrelatedinjuries.•  Avg#DislocationPre-op:6.8(2-30)

•  BMI•  Avg=31.3(range19.7-46.8)•  Allbut1withBMI>25•  5/10(50%)withBMI>30

•  AvgHipIR:27.5°(20-45°)

Results

Pre-operative

•  AvgSulcusAngle:134°(119–156°)

•  AvgTTTG:21mm (18-23.5mm)

•  Trochleardysplasia(Dejourgrading)•  gradeAn=1•  gradeB4•  gradeC1•  gradeD2

Results

Pre-op Post-op SigniKicance Pre–oppatellaalta

Insall-Salvati 1.33(0.89–1.6)

1.16(0.70–1.66)

p=0.169 7(64%)

Caton-Deschamps

1.46(1.07-1.75)

1.08(0.86–1.3)

p<0.005 9(82%)

PatellarHeight

Results

•  ValgusCorrection:

•  Avgpre-oplateraldistalfemoralanglewas75.7°

•  Avgcorrection=10.4°(range7-12degrees)

Results

•  ValgusCorrection:

•  Avgpre-opLDFA75.7°(72-79°)•  Avgpost-opLDFA88.8°(86-91°)

•  Avgcorrection=10.4°(7-12°)

Results

Outcomes•  8/10(80%)

•  Nofurtherepisodesofinstabilityorsubluxation.

•  Post-operativeKujalascore-Avg83.6•  Post-operativeTegnerscore-Avg5.5

•  Allreportiitnessactivity•  6/10reportjoggingorrunning

Results-Failures

•  2/10(20%)•  RecurrentPatello-femoralsubluxationsymptoms•  OneunderwentaTTTosteotomywithaMPFLreconstruction

•  Oneelectedfornofurthersurgery

•  Non-PFIRe-Operations:•  3patients

•  2HWRforsymptomaticImplant•  1lateralfemoralOCAllografttoaddressindexchondralinjury

Discussion

•  Genuvalgum

•  Riskfactorforrecurrentpatellarinstability•  ProducesanincreasedQangleandanincreasedlateralforceplacedonthepatella

DejourD,LeCoultreB.Osteotomiesinpatello-femoralinstabilities.Sportsmedicineandarthroscopy review.2007;15:39-46.PostWR,TeitgeR,AmisA.Patellofemoralmalalignment:lookingbeyondtheviewbox.Clinicsinsports medicine.2002;21:521-546

•  CorrectionofValgus•  improvepatellartracking,allowsforreductionintheQangle•  relativemedializationofthetibialtubercle

PudduG,CipollaM,CerulloG,etal.Whichosteotomyforavalgusknee?Internationalorthopaedics.2010;34:239-247.

Discussion

•  Reportonthesuccessfuluseofselectiveisolatedhemi-epiphyseodesisforchildrenthatpresentwithpatello-femoralinstabilityinthepresenceofgenuvalgumKearneySP,MoscaVS.Selectivehemiepiphyseodesisforpatellarinstabilitywithassociatedgenuvalgum.JournalofOrthopaedics.2015;12:17-22

Summary

•  8/10inourcohortofpatientshadresolutionoftheirpatellofemoralinstabilitysymptomsaftersurgery

•  Onlyonepatienthadtoundergoarecurrentoperationtoaddresstheirongoingpatellofemoralinstabilitysymptoms

Discussion

Cohortexhibited•  ModeratetoSevereValgus•  LowerActivityDemands•  HighincidenceofoverweightandObesity

•  DFOmayprovideutilityinaspeciKic,butnotuncommon,populationwithvalgusandloweractivitydemands

•  Co-existingValgusandBMI•  Alignmentcorrectiondesirableforlateralcompartmentreducedarthrosis

•  Improvedpatellartracking

Discussion

•  Limitations•  retrospectivenature•  smallnumberofpatients

Conclusion

•  IsolatedDFOformoderatetoseverefemoralvalgusinthesettingofpatellofemoralinstabilitymayresolvepatellarinstability

•  DFOseemstoprovidesatisfactoryfunctionaloutcomesinaspeciiiccohortofskeletallymatureadolescents

ThankYou!

ThankYou!