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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!