Journal of the Korean Orthopaedic Association (대한정형외과학회지)

Korean Orthopaedic Association (대한정형외과학회)
권호 표지
DOI QR코드

DOI QR Code

Results of Surgical Treatment of Patella Dislocation

슬개골 탈구의 수술적 치료 결과

  • Kim, Hui Taek (Department of Orthopedic Surgery, Pusan National University Hospital) ;
  • Cho, Yoon Jae (Department of Orthopedic Surgery, Pusan National University Hospital)
  • Received : 2020.03.25
  • Accepted : 2020.06.08
  • Published : 2021.04.30
⟨ Previous Next ⟩

Abstract

Purpose: Patellar dislocations have a range of causes. This study examined the results of treatment aimed at balancing soft tissues around the patella. Materials and Methods: Thirty-two patellar dislocations in 28 patients (21 females and seven males) were examined. The mean patient age at the time of surgery was 11.5 years, and the mean follow-up period was 4.6 years. Dislocations were 19 chronic, six habitual, six congenital, and one acute. Soft tissue balancing surgery included lateral capsular release, medial capsular plication, and inferolateral transfer of the vastus medialis obliquus. Medial transfer of the patellar tendon, partial strip of the rectus femoris and patella tendon, and distal femoral osteotomy were also performed selectively. The preoperative Q angle, femoral anteversion angle, tibial external rotation angle, tibial tubercle-trochlear groove distance (TT-TG distance), mechanical femoral-tibial angle, and femoral trochlear dysplasia according to Dejour were measured, and the pre- and postoperative Lysholm-Tegner scores were used to analyze the clinical results. Results: The mean preoperative Q angle, TT-TG distance, femoral anteversion angle, tibial external rotation angle, mechanical femoraltibia angle, and Lysholm-Tegner score were 9.3°, 15.5 mm, 25.6°, 30.4°, 3.0°, and 75.8, respectively. Eleven patients had systemic ligament laxity with a Beighton score of five or more. Twenty-two patients had femoral trochlear dysplasia: four type A (3 patients), 16 type B (15 patients), one type C (1 patient), and four type D (3 patients). Of the 32 cases, 28 were corrected successfully by the first operation. Of four cases of postoperative subluxation, three were corrected by the second operation, and one of them was corrected after a third operation. The last patient is currently being followed-up. The mean Lysholm-Tegner score improved to 85.6 after the operation. Conclusion: Correcting all the causes of patella dislocation simultaneously is difficult. Nevertheless, satisfactory outcomes were obtained with soft tissue balancing surgery around the patella and a corrective osteotomy for an abnormal mechanical axis of the femur-tibia and torsion.

목적: 슬개골 탈구는 다양한 원인을 가지고 있다. 슬개골 주위 연부조직 균형을 일차 목표로 한 치료 결과를 분석하였다. 대상 및 방법: 28명의 환자(여자 21명, 남자 7명)에서 발생한 32예의 슬개골 탈구를 대상으로 하였다. 환자군의 평균 연령은 11.5세였으며 수술 후 평균 4.6년을 추시하였다. 탈구의 종류는 만성 19예, 습관성 6예, 선천성 6예, 급성이 1예였다. 연부조직 균형 수술은 관절 외측 유리술, 내측 주름술, 내측 대퇴광근의 외측하부 이전술을 기본으로 하였고, 슬개건 전체 혹은 슬개건과 대퇴직건의 내측 일부의 내측 이동술, 원위 대퇴 교정 절골술 등을 선별적으로 시행하였다. 수술 전 Q각과, 대퇴 전염각, 경골 외회전각, TT-TG 거리(tibial tubercle-trochlear groove distance), 기계적 대퇴-경골각, Dejour 분류에 따른 대퇴 과간 절흔 이형성 등을 측정하였고 수술 전후 Lysholm-Tegner 점수를 이용하여 임상 결과를 분석하였다. 결과: 수술 전 평균 Q각은 9.3°±5.8°, TT-TG 거리는 15.5±6.2 mm, 대퇴 전염각은 25.6°±12.3°, 경골 외회전각은 30.4°±9.6°, 기계적 대퇴-경골각은 3.0°±6.4°, Lysholm-Tegner 점수는 75.8±9.6점이었다. Beighton score 5점 이상의 전신인대 이완성을 보인 환아는 11명이었다. 대퇴 과간 절흔의 이형성을 가진 환자는 22명이었고, Dejour 등의 분류에 따라 A형이 3명(4예), B형이 15명(16예), C형이 1명(1예), D형이 3명(4예)였다. 32예 중 28예에서 1차 수술로 정복을 얻었고, 아탈구를 보인 4예 중 3예에서 2차 수술, 그 중 1예에서 3차 수술 이후 정복을 얻었고, 1예는 경과 관찰 중이다. Lysholm-Tegner 점수는 수술 후 최종 85.6±11.6점으로 향상되었다. 결론: 슬개골 탈구의 다양한 원인을 동시에 모두 교정하기는 어렵다. 연부조직 균형 수술과 함께 대퇴골-경골 기계적 축과 염전 이상 교정 절골술 등 적절한 술식을 조합해야 만족스러운 결과를 얻을 수 있다.

Keywords

References

  1. Lee JW, Lee Y, Park KB. Surgical treatment of patellar instability in children and adolescents. J Korean Orthop Assoc. 2018;53:201-9. https://doi.org/10.4055/jkoa.2018.53.3.201
  2. Colvin AC, West RV. Patellar instability. J Bone Joint Surg Am. 2008;90:2751-62. https://doi.org/10.2106/JBJS.H.00211
  3. Weber AE, Nathani A, Dines JS, et al. An algorithmic approach to the management of recurrent lateral patellar dislocation. J Bone Joint Surg Am. 2016;98:417-27. https://doi.org/10.2106/JBJS.O.00354
  4. Sanders TL, Pareek A, Hewett TE, Stuart MJ, Dahm DL, Krych AJ. Incidence of first-time lateral patellar dislocation: a 21-year population-based study. Sports Health. 2018;10:146-51. https://doi.org/10.1177/1941738117725055
  5. Fithian DC, Paxton EW, Stone ML, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114-21. https://doi.org/10.1177/0363546503260788
  6. Baksi DP. Restoration of dynamic stability of the patella by pes anserinus transposition. A new approach. J Bone Joint Surg Br. 1981;63:399-403. https://doi.org/10.1302/0301-620X.63B3.7263754
  7. Sabnis SG, Antonovych TT, Argy WP, Rakowski TA, Gandy DR, Salcedo JR. Nail-patella syndrome. Clin Nephrol. 1980;14:148-53.
  8. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413-8. https://doi.org/10.1136/ard.32.5.413
  9. Merchant AC, Mercer RL, Jacobsen RH, Cool CR. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am. 1974;56:1391-6. https://doi.org/10.2106/00004623-197456070-00007
  10. Remy F, Chantelot C, Fontaine C, Demondion X, Migaud H, Gougeon F. Inter- and intraobserver reproducibility in radiographic diagnosis and classification of femoral trochlear dysplasia. Surg Radiol Anat. 1998;20:285-9. https://doi.org/10.1007/BF01628492
  11. Dejour D, Le Coultre B. Osteotomies in patello-femoral instabilities. Sports Med Arthrosc Rev. 2007;15:39-46. https://doi.org/10.1097/JSA.0b013e31803035ae
  12. Lysholm J, Tegner Y. Knee injury rating scales. Acta Orthop. 2007;78:445-53. https://doi.org/10.1080/17453670710014068
  13. Rudert M, Edlich P, Wirth CJ. Insall proximal realignment of the patella for recurrent dislocation or subluxation. Orthop Traumatol. 2001;9:254-62. https://doi.org/10.1007/s00065-001-1027-3
  14. Marsh JS, Daigneault JP, Sethi P, Polzhofer GK. Treatment of recurrent patellar instability with a modification of the Roux-Goldthwait technique. J Pediatr Orthop. 2006;26:461-5. https://doi.org/10.1097/01.bpo.0000217711.34492.48
  15. Brown DE, Alexander AH, Lichtman DM. The Elmslie-Trillat procedure: evaluation in patellar dislocation and subluxation. Am J Sports Med. 1984;12:104-9. https://doi.org/10.1177/036354658401200203
  16. Chen H, Zhao D, Xie J, et al. The outcomes of the modified Fulkerson osteotomy procedure to treat habitual patellar dislocation associated with high-grade trochlear dysplasia. BMC Musculoskelet Disord. 2017;18:73. https://doi.org/10.1186/s12891-017-1417-4
  17. Chen SC, Ramanathan EB. The treatment of patellar instability by lateral release. J Bone Joint Surg Br. 1984;66:344-8. https://doi.org/10.1302/0301-620X.66B3.6725343
  18. Aulisa AG, Falciglia F, Giordano M, Savignoni P, Guzzanti V. Galeazzi's modified technique for recurrent patella dislocation in skeletally immature patients. J Orthop Sci. 2012;17:148-55. https://doi.org/10.1007/s00776-011-0189-1
  19. Crosby EB, Insall J. Recurrent dislocation of the patella. Relation of treatment to osteoarthritis. J Bone Joint Surg Am. 1976;58:9-13. https://doi.org/10.2106/00004623-197658010-00002
  20. Liu JN, Brady JM, Kalbian IL, et al. Clinical outcomes after isolated medial patellofemoral ligament reconstruction for patellar instability among patients with trochlear dysplasia. Am J Sports Med. 2018;46:883-9. https://doi.org/10.1177/0363546517745625
  21. Csintalan RP, Latt LD, Fornalski S, Raiszadeh K, Inacio MC, Fithian DC. Medial patellofemoral ligament (MPFL) reconstruction for the treatment of patellofemoral instability. J Knee Surg. 2014;27:139-46. https://doi.org/10.1055/s-0033-1360652
  22. Sillanpaa P, Mattila VM, Visuri T, Maenpaa H, Pihlajamaki H. Ligament reconstruction versus distal realignment for patellar dislocation. Clin Orthop Relat Res. 2008;466:1475-84. https://doi.org/10.1007/s11999-008-0207-6
  23. Nelitz M, Dreyhaupt J, Reichel H, Woelfle J, Lippacher S. Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents with open growth plates: surgical technique and clinical outcome. Am J Sports Med. 2013;41:58-63. https://doi.org/10.1177/0363546512463683
  24. Hasler CC, Studer D. Patella instability in children and adolescents. EFORT Open Rev. 2017;1:160-6. https://doi.org/10.1302/2058-5241.1.000018
  25. Dickens AJ, Morrell NT, Doering A, Tandberg D, Treme G. Tibial tubercle-trochlear groove distance: defining normal in a pediatric population. J Bone Joint Surg Am. 2014;96:318-24. https://doi.org/10.2106/JBJS.M.00688
  26. Joo SY, Park KB, Kim BR, Park HW, Kim HW. The 'fourin-one' procedure for habitual dislocation of the patella in children: early results in patients with severe generalised ligamentous laxity and aplasis of the trochlear groove. J Bone Joint Surg Br. 2007;89:1645-9.