Medial Fractures of the Patella (= Patellar Dislocation) Scott D. Gillogly, MD

3 February 2016 Val d’Isère, France

•  Medial Patella Fractures are typically the “tip of the iceberg”

•  Treatment is often determined by underlying pathology and preexisting conditions

•  The fracture is seldom the factor that predicts or drives outcomes.

MedialPatellaFractures

Patella Avulsion Fracture

Lateral Medial

76%

24%

•  46/122 (38%) acute patellar dislocations (12-20 yrs old) have osteochondral patellar fractures.

•  Fractures occurred at the patella in 35 pts.(76%), LFC in 11 pts (24%).

•  In 21 patients (44%), MRI confirmed osteochondral injury despite the plain radiograph interpretation as negative for fracture

PatellaFractureAssociatedwithPatellarDisloca4on

Osteochondral injury after acute patellar dislocation in children and adolescents. Seeley MA; Knesek M; Vanderhave KL: J Pediatr Orthop Jul-Aug 2013, 33(5) p511-8

•  Medial marginal fracture of the patella was an avulsion fracture of the MPFL that occurred at the middle one-third of the patella

•  The bony fragments were continuous with the thick and taut MPFL in all cases

Medial marginal fracture of the patella following patellar dislocation.. Toritsuka Y; Horibe S; Hiro-Oka A; Mitsuoka T; Nakamura NKnee, Dec 2007, 14(6) p429-33

MedialPatellarFractureandMPFL

MPFL

Three Patterns of Injury medially with patellar dislocation: 1.  Avulsion of MPFL, all soft tissue 2.  Avulsion of MPFL with non-articular

bone fracture 3.  Avulsion of MPFL with bone fracture

involving articular surface

Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome. Sillanpaa PJ; Salonen E; Pihlajamaki H; Maenpaa HM:. Knee Surg Sports Traumatol Arthrosc, Oct 2014, 22(10) p2414-8

Opera4veTreatmentforPatellaAvulsionFractureandMPFLRepairAssociatedwith

PatellarDisloca4on

P0

P1

P2

P2

P1

•  44/56 patients with patellar detachment injury to the MPFL followed at average 4 yrs.

•  13 pts had undergone MPFL repair and osteochondral medial patellar fixation.

•  31 pts. with patellar MPFL injures had non-operative TX.

•  2/13 (15%) surgery pts had patellar instability and 17/31 (55%) of non-operative TX had patellar instability

Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome. Sillanpaa PJ; Salonen E; Pihlajamaki H; Maenpaa HM:. Knee Surg Sports Traumatol Arthrosc, Oct 2014, 22(10) p2414-8

Opera4veTreatmentforPatellaAvulsionFractureandMPFLRepairAssociatedwith

PatellarDisloca4on

•  38 complications in 29 knees (16.2%) from 179 MPFL reconstruction, 34 major and 4 minor. •  Recurrent lateral patellar instability (8 patients, 4.5%) •  Motion stiffness with flexion deficits (8 patients, 4.5%) •  Patellar fractures (6 patients, 3.4%) •  Patellofemoral arthrosis /pain (5 patients, 3%)

•  18/38 (47%) complications were considered technical errors. Female gender and bilateral MPFL reconstructions were risk factors

Complications of medial patellofemoral ligament reconstruction in young patients. Parikh SN; Nathan ST; Wall EJ; Eismann EA et al: Am J Sports Med, May 2013, 41(5) p1030-8

Complica4onswithMPFLReconstruc4on

•  Distance of the femoral tunnel from the anatomic position predicted clinical outcome (Kujala score, P = .043; Lysholm score, P = .028).

•  ≤10 mm of the anatomic position defined by Schottle

•  4/68 pts (6%) had patella fractures postoperatively

Does degree of trochlear dysplasia and position of femoral tunnel influence outcome after medial patellofemoral ligament reconstruction? Hopper GP; Leach WJ; Rooney BP; Walker CR; Blyth M: Am J Sports Med, Mar 2014, 42(3) p716-22

EffectofTrochleaDysplasiaandTunnelPosi4ononMPFLReconstruc4on

•  All pts with severe trochlear dysplasia (n = 7) failed with recurrent dislocations (57% satisfied) vs. only 9.3% of pts (n = 5) with mild trochlear dysplasia (83% satisfied) (P = .05)

•  Combina)onofTibialTubercledistaliza)onandtenodesisoftendontooriginaltuberclesitewithanchors,22pts.

•  Norecurrentdisloca)onat9.6yrfollow‐up,IKDCscorewas75.6•  Patellartendonlengthdecreasedfrom56.3mmto

44.3mm(P<.0001).

•  Caton‐Deschampsindexdecreasedfrom1.22to0.95(P<.0001)

•  Insall‐Salva4ra4odecreasedfrom1.42to0.91(P<.0001)

•  Patellartendontenodesisand)bialtubercledistaliza)onresultinnormaliza)onofpatellartendonlengthandastablepatellofemoraljoint

Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. Mayer C; Magnussen RA; Servien E; Demey G; Jacobi M; Neyret P; Lustig S: Am J Sports Med (United States), Feb 2012, 40(2) p346-51

PatellarTendonShorteningforPatellarDisloca4on

•  Recommendini)alnon‐opera)vemanagementofafirst‐)metrauma)cpatellardisloca)onexcept:

•  Osteochondralfracture•  Significantdisrup)onofthemedialpatellarstabilizers

•  Persistentlaterallysubluxedpatellawithnormalalignmentofthecontralateralknee

•  Seconddisloca)on•  Noimprovementwithappropriaterehabilita)on

First-time traumatic patellar dislocation: a systematic review. Stefancin JJ; Parker RD, Clin Orthop Relat Res, Feb 2007, 455 p93-101

1stEpisodePatellarDisloca4onSystema4cReviewRecommenda4ons

•  14adolescentptswithOCFfollowedave.30months

•  Lateralcondyle:9,Patella:5;injurymechanismwaspatellardisloca)on(n=9)oradirectimpact(n=4)

•  Alldetachedfragmentswerefixed:screwfixa)on(n=5),resorbablepins(n=5),orpull‐outsuture(n=4).Biologicalgluewasadded(6);Patellarstabiliza)onperformedin2cases

•  Allfracturesunited;IKDC88.6,Allsa)sfied•  3(21%)ptsunderwentsecondarypatellarstabiliza)on

Knee osteochondral fractures in skeletally immature patients: French multicenter study. Chotel F; Knorr G; Simian E; Dubrana F; Versier G: Orthop Traumatol Surg Res (France), Dec 2011, 97(8 Suppl) pS154-9

KneeOsteochondralFractures“FrenchArthroscopySocietyStudy”

•  16 year old American Football with recurrent Patellar Dislocation, Medial Fracture

•  6 months after (Outside Clinic) MPFL Reconstruction, Lateral Release, Removal of Loose bodies and Chondral Biopsy (concomitant articular cartilage injury)

CaseBasedDiscussionSecondaryIssuesofPatellarAvulsionFracture

andPatellarDisloca4on

•  TT-TG 23.9 mm •  IS pre op 1.45 - post op 1.2 •  CD pre op 1.51 – post op 1.18 •  Q angle 18

RecurrentInjuryImaging

Now What ?

• Risk Factors on evaluation: •  FT Chondral Defect • Valgus alignment • Increased Q-angle • Increased TT-TG • Patella alta • Hypermobility/Hyperlaxity

Temporary Treatment: •  Aspiration •  Pre-habilitation program •  Bracing while awaiting definitive

surgery

•  Biopsy already done so definitive surgery in 4 wks. (cells available quickly)

•  Recommended Treatment: •  Scope Loose Bodies •  Open ACI Patellar defect •  Trochleoplasty (grooveplasty) •  AMTT (Fulkerson) with

distalization •  Medial Imbrication/Reefing •  Lateral lengthening

CaseBasedDiscussionSecondaryIssuesofPatellarAvulsionFracture

andPatellarDisloca4on

1.  Arthroscopy: Removal of loose bodies,

CaseBasedDiscussionDefini4veTreatment(SingleStage)

2. Trochleoplasty (grooveplasty): create concave entrance to trochlear groove

CaseBasedDiscussionDefini4veTreatment(SingleStage)

3. AMTT (Fulkerson) with distalization 4. Medial Imbrication/Reefing of MPFL

CaseBasedDiscussionDefini4veTreatment(SingleStage)

AnteroMedialization of Tibial Tubercle

5. Autologous Chondrocyte Implantation Patella FTCD with Absorbable Collagen Membrane

CaseBasedDiscussionDefini4veTreatment(SingleStage)

Type I/III Collagen Membrane

•  Post-Operative Imaging

CaseBasedDiscussionDefini4veTreatment(SingleStage)

Autologous Chondrocyte Implantation (ACI) Articular Cartilage Defects of the Patellofemoral Joint

•  Treatment of both the articular cartilage defect and abnormal biomechanical loading and malalignment

•  articular cartilage defect with Autologous Chondrocyte Implantation concomitantly 2nd Look at 2 yrs

PatellaACIStudies

#Pts Follow‐up Defectsizecm2

ClinicalOutcome Comments

Bri^berg,Peterson,NEJM94

7Isolated 36.4mos. 3.5 Only28%G/Exc(2)3Fair2Poor

NoTTO

HendersonKnee2006

22isolated22w/TTO

29mos.26.2mos.

3.22.92

55%G/Excw/outTTO86%G/Excw/TTO,36.2IKDCincrease

Periostealpatchhypertrophy(9)

MacmullIntOrthop2012

25isolated 45mos. 4.73 40%GoodtoExc NoTTO

Pascual‐GarridoAJSM2009

11Isolated12AMZ

30mos.51.6mos.

4.33.9

54%GoodtoExc83%GoodtoExc

7.7%clinicalFailures

FarrCORR2007

21Isolated7Bipolar73%AMZ

37mos. 5.4 80%GoodtoExc ICRSArthroscopicassessment1.2yrs11/12

MinasICRS2013

3073%w/TTO

2‐10years 5.5 83%‐GoodtoExc.13%‐Fair4%‐Poor

Bestresultsseenwithgoodfillrateandsurfaceintegrity

GilloglyAJSM2014

27IsolatedAllhadAMTT

5‐11years,Mean7years

6.4 83%GoodtoExc.;IKDC42preopimprovedto75postop(p<.0001)

Resultsfordiffuselesionsnodifferentthanfacetlesions;91%sa)sfac)on

GomollMul)‐CenterAJSM2014

11069%AMZ27%Both

2‐4yrs 5.264.5cmTrochleaDef.

86%Improved74%(20pointinc.onIKDC);9%Failure

HighPa)entSa)sfac)on92%

Autologous Chondrocyte Implantation for Patellar Chondral Defects: Results

•  Suspect OCF in 1st time patellar dislocations; Radiographs unreliable so get MRI in acute setting

•  Evaluate patient for risk factors of recurrent dislocation

•  Osteochondralfracture(“)poftheiceberg”)•  Significantdisrup)onofthemedialpatellarstabilizers•  Persistentlaterallysubluxedpatellawithnormalalignmentoftheuninvolvedknee

•  Recurrence•  Incorporate patellar stabilization into OCF repair •  Address Predisposing Factors upfront, Counsel

patient and family

Medial Patella Fractures Summary

Merci Molte Grazie Danke Schön

Thank You