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Congenital and irreducible non-traumatic dislocation of the patella—a modified soft tissue procedure
The Knee 11 (2004) 117–120
Congenital and irreducible non-traumatic dislocation of the patella—a modified soft tissue procedure R.W. Paton, A.Y. Bonshahi*, W.Y. Kim Department of Orthopaedic and Trauma Surgery, Blackburn Royal Infirmary, Bolton Road, Blackburn, UK Received 24 January 2003; received in revised form 25 March 2003; accepted 13 May 2003
Abstract Many procedures have been described for the correction of congenital dislocation of the patella. Most operations entail extensive soft tissue releases through curved skin incisions. A modification of the Langenskiold and Ritsila procedure is described. The main alterations include a limited and straight anterior skin incision, a fashioning of a ‘buckle’ of the transferred distal-patellar tendon to a distally based flap and the transposition of an extensive medial rotation flap. This report describes the early results (means19 months) of the modified procedure in three cases of congenital lateral dislocation of the patella. 䊚 2003 Elsevier Science B.V. All rights reserved. Keywords: Congenital; Irreducible; Dislocation; Patella
1. Introduction An irreducible dislocated patella may be congenital or acquired. If congenital, the inheritance is usually autosomal dominant w1x. It may also be associated with other congenital conditions or syndromes such as Down’s syndrome, congenital vertical talus or cerebral palsy w2x. The pathological anatomy in congenital and acquired irreducible dislocation of the patella in infancy is similar w2,3x. The patella is hypoplastic, dislocated laterally and somewhat superiorly with reference to the trochlea. The trochlea itself is underdeveloped. The patellar tendon is inserted more laterally in the upper tibia. The iliotibial band is thickened and tubular, the quadriceps is short and malformed and the vastus lateralis is adherent to the iliotibial band and tensor fascia lata. The vastus medialis and medial structures are thinner and stretched w2,3x. This condition usually presents with a progressive valgus and fixed flexion deformity of the knee and delayed walking. The patella is small and difficult to palpate. The diagnosis is usually clinical and is con*Corresponding author. Present address: 20 Stablefold, Worsley, Manchester M28 2ED, UK. Tel.: q44-0161-2888659; fax: q33-388-41-40-99. E-mail address: [email protected] (A.Y. Bonshahi).
firmed by X-rays or CT scan. Radiographs are difficult to interpret as the normal patella ossifies between the ages of 3–5 years. In plain X-rays, the patella is not seen in the lateral view and is laterally dislocated in the skyline views. The treatment is surgical w4,5x. Numerous soft tissue corrective procedures have been described in the literature. There are three basic groups: 1. Extensive proximal release and transposition of the entire quadriceps mechanism anteriorly (Gordon and Shoenecker procedure) w6x. 2. Lateral release and distal partial transfer of the patellar tendon (Goldthwaite–Roux procedure). 3. Transposition medially to a more correct anatomical position of the laterally attached patellar tendon, with release of the distal attachment (Langenskiold and Ritsila procedure) w7x. We describe a modification of the Langenskiold and Ritsila operation: a procedure from the third group. 2. Patients and methods 2.1. Operative procedure A longitudinal midline incision is used from the tibial tuberosity to the suprapatellar pouch. The vastus medialis, quadriceps tendon, patella and patellar tendon are
0968-0160/04/$ - see front matter 䊚 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0968-0160Ž03.00074-7
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R.W. Paton et al. / The Knee 11 (2004) 117–120
by medial transposition. It is sutured securely to the surrounding ‘flap’. If knee flexion is restricted beyond 908 then a V–Y plasty or a reverse rectus snip of the quadriceps mechanism is undertaken. The redundant medial capsule, retinaculum and VMO are mobilised as a rotation flap, transposed anteriorly and laterally to the patella and are sutured to the lateral edge of the lateral release (Fig. 3). The medial defect is closed with sutures. The tracking of the patella is checked. The skin is closed with a subcuticular suture. A plaster cast is used for 6 weeks post operatively. This modified operative procedure has been undertaken on three cases: 1. An 11-year-old boy with generalised joint hyperlaxity and severe learning difficulties had undergone a Goldthwaite Roux procedure, which failed. At presentation to our unit, there was a fixed flexion deformity of 308 and a valgus deformity of 208 affecting his right knee joint. Pre-operative X-rays confirmed a lateral irreducible dislocation of the patella. Twentyfive months after undergoing this modified procedure the patella was located and tracked normally though there was still a fixed flexion deformity of 108. The
Fig. 1. Exposure of dislocated patella with appropriate flaps marked.
exposed. The iliotibial band is visualised and divided. An extensive lateral release is undertaken, starting at the level of the tibial tuberosity and extending to the level of the suprapatellar pouch between rectus femoris and vastus lateralis. A medial parapatellar release is undertaken from the level of the tibial tuberosity proximally. At the level of the inferior pole of the patella the release is extended horizontally and then distally to produce a medial and distally based rectangular flap of retinaculum, synovium and capsule (Fig. 1). The vastus medialis obliquus (VMO) is detached from its insertion. The stretched medial structures and VMO are fashioned into a large rotation flap. The extensor mechanism and patella are freed from the underlying structures. The pathological lateral insertion of the patellar tendon is released allowing the whole extensor mechanism (patellar tendon, patella quadriceps tendon and muscles) to be rotated through 908 medially (Fig. 2). The distal part of the patellar tendon is passed through a transverse buttonhole slit in the medially based ‘flap’ and turned down as a ‘buckle’ (Fig. 3). This corrects the abnormal anatomical insertion of the patella tendon
Fig. 2. Exposure with adequate release of soft tissue.
R.W. Paton et al. / The Knee 11 (2004) 117–120
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valgus to the knee. Incidentally, she also she had an ipsilateral vertical talus that had been successfully treated by a radical release at 11 months of age. 3. Discussion
Fig. 3. Reconstruction with buckle technique and medial rotation flap.
valgus deformity had corrected and the knee was stable. 2. A 6-year-old girl with trisomy 21 (Down’s syndrome) presented with a fixed flexion deformity of 208 and a valgus of 158 of her right knee joint. The patella was palpable laterally and X-rays confirmed the dislocation. Nineteen months post surgery there was no residual deformity and the patella tracked normally. The knee has a full range of flexion with a loss of 58 of hyperextension and the patella was not dislocatable. The child can run and twist without problems. 3. A 5-year-old girl with Mulibrey Nanism syndrome (growth failure, triangular faces, muscle hypotonia) presented with a fixed flexion and valgus deformity of the left knee of 158. The patella was difficult to palpate and a pre-operative CT scan confirmed a dislocated patella. At 13 months follow up after this procedure, she has active extension with a 58 fixed flexion deformity, 1108 further flexion and slight
Many skin incisions have been advocated for surgical correction of congenital patellar dislocation: the anterolateral (Eilert) w8x, curved lateral (Jones) w5x, U shaped (Zeier) w9x and extensive lateral to medial: just below greater trochanter to tibial tuberosity (Gordon and Shoenecker) w6x, (Ghanem) w4x and S-shaped incision (Langenskiold and Ritsila) w7x. The advantage of the mid-line incision described in this report is that it is a versatile incision that heals well and can be reused in adulthood. It is a relatively short incision when compared with other procedures and gives a more acceptable scar than S-shaped or more extensive curved incisions. Congenital irreducible dislocation of the patella is characterised by anterolateral rotation of the entire extensor mechanism around the long axis of the femur. In case 1 of our series, a lateral release and Goldthwaite– Roux transposition did not address this problem and led to a re-dislocation of the patella. Tachdijian suggested the Galleazzi–Dewar procedure: tenodesis of the semimembranosus tendon to the patellar tendon w10x. We do not feel that these procedures are extensive enough to correct the pathological anatomy, as derotation of the insertion of the patellar tendon is required and is not achieved by these operations. The release of the entire extensor mechanism to the greater trochanter corrects the problem of malrotation but is an extensive soft tissue procedure with the drawbacks of scarring and bleeding. We feel that correction can be achieved avoiding this extensive release. Transfer of the patellar tendon with the tibial tuberosity should be avoided in skeletally immature children as recurvatum of the knee joint may occur secondary to growth arrest of the tibial apophysis. Medial transfer of the tendon is usually safe as highlighted in Langenskiold’s long-term series where there were no cases of recurvatum of the knee postoperatively w7 x . Langenskiold and Ritsila released the distal patellar tendon attachment from the tibial tuberosity and transferred it medially. This transfer was held by routing the patellar tendon through a synovial pouch and attaching it with sutures through distally based drill holes through the upper tibia. Our modification with a medially based capsularyretinacular ‘flap’ gives a stronger and more secure hold than synovium alone. Drill holes to the upper tibia are unnecessary. This modification of the Langenskiold and Ritsila procedure requires less dissection and scarring than other operations, with no bony surgery and a cosmetic scar. The early results confirm that the patella remains located and tracks normally. The valgus and flexion deformities have significantly
120
R.W. Paton et al. / The Knee 11 (2004) 117–120
improved. The Langenskiold and Ritsila procedure has been successful w7x and we feel that this modification simplifies and improves on the original technique. Acknowledgments Ruth Eaves – Senior Medical Artist, Medical Illustration Department, Royal Bolton Hospital, UK. References w1x Robinson AHN, Aladin A, Green AJ, Dandy DJ. Congenital dislocation of the patella—the genetics and conservative management. Knee 1998;5:235 –237. w2x Ghanem I, Wattincourt L, Seringe R. Congenital dislocation of the patella. Part I: pathological anatomy. J Pediatr Orthop 2000;20:812 –816.
w3x Gao GX, Lee EH, Bose K. Surgical management of congenital and habitual dislocation of the patella. J Pediatr Orthop 1990;10:255 –260. w4x Ghanem I, Wattincourt L, Seringe R. Congenital dislocation of the patella. Part II: orthopaedic management. J Pediatr Orthop 2000;20:817 –822. w5x Jones RDS, Fisher RL, Curtis BH. Congenital dislocation of the patella. Clin Orthop 1976;19:177 –183. w6x Gordon JE, Shoenecker PL. Surgical treatment of congenital dislocation of the patella. J Pediatr Orthop 1999;19:260 –264. w7x Langenskiold A, Ritsila V. Congenital dislocation of the patella and its operative treatment. J Pediatr Orthop 1992;12:315 – 323. w8x Eilert RE. Congenital dislocation of the patella. Clin Orthop 2001;389:22 –29. w9x Zeier FG, Dissanayake C. Congenital dislocation of the patella. Clin Orthop 1980;148:140 –146. w10x Tachdjian MO. Pediatric orthopaedics, vol. 1, 2nd ed., 1990.
Congenital and irreducible non-traumatic dislocation of the patella—a modified soft tissue procedure R.W. Paton, A.Y. Bonshahi*, W.Y. Kim Department of Orthopaedic and Trauma Surgery, Blackburn Royal Infirmary, Bolton Road, Blackburn, UK Received 24 January 2003; received in revised form 25 March 2003; accepted 13 May 2003
Abstract Many procedures have been described for the correction of congenital dislocation of the patella. Most operations entail extensive soft tissue releases through curved skin incisions. A modification of the Langenskiold and Ritsila procedure is described. The main alterations include a limited and straight anterior skin incision, a fashioning of a ‘buckle’ of the transferred distal-patellar tendon to a distally based flap and the transposition of an extensive medial rotation flap. This report describes the early results (means19 months) of the modified procedure in three cases of congenital lateral dislocation of the patella. 䊚 2003 Elsevier Science B.V. All rights reserved. Keywords: Congenital; Irreducible; Dislocation; Patella
1. Introduction An irreducible dislocated patella may be congenital or acquired. If congenital, the inheritance is usually autosomal dominant w1x. It may also be associated with other congenital conditions or syndromes such as Down’s syndrome, congenital vertical talus or cerebral palsy w2x. The pathological anatomy in congenital and acquired irreducible dislocation of the patella in infancy is similar w2,3x. The patella is hypoplastic, dislocated laterally and somewhat superiorly with reference to the trochlea. The trochlea itself is underdeveloped. The patellar tendon is inserted more laterally in the upper tibia. The iliotibial band is thickened and tubular, the quadriceps is short and malformed and the vastus lateralis is adherent to the iliotibial band and tensor fascia lata. The vastus medialis and medial structures are thinner and stretched w2,3x. This condition usually presents with a progressive valgus and fixed flexion deformity of the knee and delayed walking. The patella is small and difficult to palpate. The diagnosis is usually clinical and is con*Corresponding author. Present address: 20 Stablefold, Worsley, Manchester M28 2ED, UK. Tel.: q44-0161-2888659; fax: q33-388-41-40-99. E-mail address: [email protected] (A.Y. Bonshahi).
firmed by X-rays or CT scan. Radiographs are difficult to interpret as the normal patella ossifies between the ages of 3–5 years. In plain X-rays, the patella is not seen in the lateral view and is laterally dislocated in the skyline views. The treatment is surgical w4,5x. Numerous soft tissue corrective procedures have been described in the literature. There are three basic groups: 1. Extensive proximal release and transposition of the entire quadriceps mechanism anteriorly (Gordon and Shoenecker procedure) w6x. 2. Lateral release and distal partial transfer of the patellar tendon (Goldthwaite–Roux procedure). 3. Transposition medially to a more correct anatomical position of the laterally attached patellar tendon, with release of the distal attachment (Langenskiold and Ritsila procedure) w7x. We describe a modification of the Langenskiold and Ritsila operation: a procedure from the third group. 2. Patients and methods 2.1. Operative procedure A longitudinal midline incision is used from the tibial tuberosity to the suprapatellar pouch. The vastus medialis, quadriceps tendon, patella and patellar tendon are
0968-0160/04/$ - see front matter 䊚 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0968-0160Ž03.00074-7
118
R.W. Paton et al. / The Knee 11 (2004) 117–120
by medial transposition. It is sutured securely to the surrounding ‘flap’. If knee flexion is restricted beyond 908 then a V–Y plasty or a reverse rectus snip of the quadriceps mechanism is undertaken. The redundant medial capsule, retinaculum and VMO are mobilised as a rotation flap, transposed anteriorly and laterally to the patella and are sutured to the lateral edge of the lateral release (Fig. 3). The medial defect is closed with sutures. The tracking of the patella is checked. The skin is closed with a subcuticular suture. A plaster cast is used for 6 weeks post operatively. This modified operative procedure has been undertaken on three cases: 1. An 11-year-old boy with generalised joint hyperlaxity and severe learning difficulties had undergone a Goldthwaite Roux procedure, which failed. At presentation to our unit, there was a fixed flexion deformity of 308 and a valgus deformity of 208 affecting his right knee joint. Pre-operative X-rays confirmed a lateral irreducible dislocation of the patella. Twentyfive months after undergoing this modified procedure the patella was located and tracked normally though there was still a fixed flexion deformity of 108. The
Fig. 1. Exposure of dislocated patella with appropriate flaps marked.
exposed. The iliotibial band is visualised and divided. An extensive lateral release is undertaken, starting at the level of the tibial tuberosity and extending to the level of the suprapatellar pouch between rectus femoris and vastus lateralis. A medial parapatellar release is undertaken from the level of the tibial tuberosity proximally. At the level of the inferior pole of the patella the release is extended horizontally and then distally to produce a medial and distally based rectangular flap of retinaculum, synovium and capsule (Fig. 1). The vastus medialis obliquus (VMO) is detached from its insertion. The stretched medial structures and VMO are fashioned into a large rotation flap. The extensor mechanism and patella are freed from the underlying structures. The pathological lateral insertion of the patellar tendon is released allowing the whole extensor mechanism (patellar tendon, patella quadriceps tendon and muscles) to be rotated through 908 medially (Fig. 2). The distal part of the patellar tendon is passed through a transverse buttonhole slit in the medially based ‘flap’ and turned down as a ‘buckle’ (Fig. 3). This corrects the abnormal anatomical insertion of the patella tendon
Fig. 2. Exposure with adequate release of soft tissue.
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valgus to the knee. Incidentally, she also she had an ipsilateral vertical talus that had been successfully treated by a radical release at 11 months of age. 3. Discussion
Fig. 3. Reconstruction with buckle technique and medial rotation flap.
valgus deformity had corrected and the knee was stable. 2. A 6-year-old girl with trisomy 21 (Down’s syndrome) presented with a fixed flexion deformity of 208 and a valgus of 158 of her right knee joint. The patella was palpable laterally and X-rays confirmed the dislocation. Nineteen months post surgery there was no residual deformity and the patella tracked normally. The knee has a full range of flexion with a loss of 58 of hyperextension and the patella was not dislocatable. The child can run and twist without problems. 3. A 5-year-old girl with Mulibrey Nanism syndrome (growth failure, triangular faces, muscle hypotonia) presented with a fixed flexion and valgus deformity of the left knee of 158. The patella was difficult to palpate and a pre-operative CT scan confirmed a dislocated patella. At 13 months follow up after this procedure, she has active extension with a 58 fixed flexion deformity, 1108 further flexion and slight
Many skin incisions have been advocated for surgical correction of congenital patellar dislocation: the anterolateral (Eilert) w8x, curved lateral (Jones) w5x, U shaped (Zeier) w9x and extensive lateral to medial: just below greater trochanter to tibial tuberosity (Gordon and Shoenecker) w6x, (Ghanem) w4x and S-shaped incision (Langenskiold and Ritsila) w7x. The advantage of the mid-line incision described in this report is that it is a versatile incision that heals well and can be reused in adulthood. It is a relatively short incision when compared with other procedures and gives a more acceptable scar than S-shaped or more extensive curved incisions. Congenital irreducible dislocation of the patella is characterised by anterolateral rotation of the entire extensor mechanism around the long axis of the femur. In case 1 of our series, a lateral release and Goldthwaite– Roux transposition did not address this problem and led to a re-dislocation of the patella. Tachdijian suggested the Galleazzi–Dewar procedure: tenodesis of the semimembranosus tendon to the patellar tendon w10x. We do not feel that these procedures are extensive enough to correct the pathological anatomy, as derotation of the insertion of the patellar tendon is required and is not achieved by these operations. The release of the entire extensor mechanism to the greater trochanter corrects the problem of malrotation but is an extensive soft tissue procedure with the drawbacks of scarring and bleeding. We feel that correction can be achieved avoiding this extensive release. Transfer of the patellar tendon with the tibial tuberosity should be avoided in skeletally immature children as recurvatum of the knee joint may occur secondary to growth arrest of the tibial apophysis. Medial transfer of the tendon is usually safe as highlighted in Langenskiold’s long-term series where there were no cases of recurvatum of the knee postoperatively w7 x . Langenskiold and Ritsila released the distal patellar tendon attachment from the tibial tuberosity and transferred it medially. This transfer was held by routing the patellar tendon through a synovial pouch and attaching it with sutures through distally based drill holes through the upper tibia. Our modification with a medially based capsularyretinacular ‘flap’ gives a stronger and more secure hold than synovium alone. Drill holes to the upper tibia are unnecessary. This modification of the Langenskiold and Ritsila procedure requires less dissection and scarring than other operations, with no bony surgery and a cosmetic scar. The early results confirm that the patella remains located and tracks normally. The valgus and flexion deformities have significantly
120
R.W. Paton et al. / The Knee 11 (2004) 117–120
improved. The Langenskiold and Ritsila procedure has been successful w7x and we feel that this modification simplifies and improves on the original technique. Acknowledgments Ruth Eaves – Senior Medical Artist, Medical Illustration Department, Royal Bolton Hospital, UK. References w1x Robinson AHN, Aladin A, Green AJ, Dandy DJ. Congenital dislocation of the patella—the genetics and conservative management. Knee 1998;5:235 –237. w2x Ghanem I, Wattincourt L, Seringe R. Congenital dislocation of the patella. Part I: pathological anatomy. J Pediatr Orthop 2000;20:812 –816.
w3x Gao GX, Lee EH, Bose K. Surgical management of congenital and habitual dislocation of the patella. J Pediatr Orthop 1990;10:255 –260. w4x Ghanem I, Wattincourt L, Seringe R. Congenital dislocation of the patella. Part II: orthopaedic management. J Pediatr Orthop 2000;20:817 –822. w5x Jones RDS, Fisher RL, Curtis BH. Congenital dislocation of the patella. Clin Orthop 1976;19:177 –183. w6x Gordon JE, Shoenecker PL. Surgical treatment of congenital dislocation of the patella. J Pediatr Orthop 1999;19:260 –264. w7x Langenskiold A, Ritsila V. Congenital dislocation of the patella and its operative treatment. J Pediatr Orthop 1992;12:315 – 323. w8x Eilert RE. Congenital dislocation of the patella. Clin Orthop 2001;389:22 –29. w9x Zeier FG, Dissanayake C. Congenital dislocation of the patella. Clin Orthop 1980;148:140 –146. w10x Tachdjian MO. Pediatric orthopaedics, vol. 1, 2nd ed., 1990.