Rev. bras. ortop. vol.51 número5

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Total

knee

arthroplasty

with

subvastus

approach

in

patient

with

chronic

post-traumatic

patellar

dislocation

夽

Jader

Joel

Machado

Junqueira

_,

_Camilo

_Partezani

_Helito,

_Marcelo

_Batista

_Bonadio,

Jose

Ricardo

Pécora,

Marco

Kawamura

Demange

InstituteofOrthopaedicsandTraumatology,FacultyofMedicine,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil

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Articlehistory:

Received30September2015 Accepted6November2015 Availableonlinexxx

Keywords: Osteoarthritis Knee Arthroplasty Patellardislocation

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Chroniclateraldislocationofthepatellaisarareconditionandacquiredcausesareusually secondarytokneetrauma.Theneglectedchronicdislocationleadstoprogressivegenu val-gumandexternaltibialtorsiondeformitieswithsubsequentgonarthrosis,whichbecomes painfulanddebilitating.Thereisnoconsensusregardingtreatmentofthesepatients,but totalkneearthroplasty(TKA)isausefultherapyincasesofpainfulsymptomatic gonarthro-sis.Fewreportshaveshownthatsubvastusapproachandlateralreleasemaybeavalid optionforTKA,sinceitallowsthecorrectionofvalgusdeformityandpatellartracking with-outinterruptingvascularbloodsupplyofpatella.ThisarticlereportsacaseofTKAand extensormechanismrealignmentwithoutpatellarresurfacinginapatientwithgenu val-gumandchronicpost-traumaticpatellardislocationwithsatisfactoryresultsaftertwoyears offollow-up.

©2016PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Artroplastia

total

de

joelho

por

via

subvasto

em

paciente

com

luxac¸ão

crônica

pós-traumática

de

patela

Palavras-chave: Osteoartrose Joelho Artroplastia Luxac¸ãodepatela

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e

s

u

m

o

A luxac¸ão crônica da patela é uma patologia rara e o trauma sua principal causa adquirida.Quandonegligenciada,levaaogenovalgoprogressivo,torc¸ãoexternadatíbia esubsequenteartrosedebilitante.Nãoexisteconsensonaliteraturacomrelac¸ãoao trata-mento desses pacientes, porém a artroplastia total de joelho (ATJ) tem se mostrado um procedimentoeficaz em casos de gonartrose sintomática dolorosa. Poucos relatos mostraramqueaviasubvastoassociadaàliberac¸ãolateraléumaopc¸ãoválidaparaATJ,já

夽_{WorkdevelopedintheKneeGroup,InstituteofOrthopedicsandTraumatology,HospitaldasClínicas,FacultyofMedicine,Universidade}

deSãoPaulo,SãoPaulo,SP,Brazil.

∗_{Correspondingauthor.}

E-mail:[email protected](J.J.Junqueira).

http://dx.doi.org/10.1016/j.rbo.2015.11.002

0102-3616/©2016PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopediaeTraumatologia.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

2255-4971

http://dx.doi.org/10.1016/j.rboe.2016.06.005

Universidade de São Paulo, Faculdade de Medicina, Instituto de Ortopedia e Traumatologia,

que permite a correc¸ão de deformidades em valgo e da boa excursão patelar, sem interrupc¸ãodosuprimentosanguíneo.Relatamosumcasodeumapacientecomgenovalgo eluxac¸ãocrônicapós-traumáticadepatelasubmetidaaATJassociadaaorealinhamentodo mecanismoextensor,comresultadossatisfatóriospersistentesapósseguimentodedois anos.

©2016PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Chroniclateraldislocationofthepatellaisararecondition that is usuallycongenital or acquired inorigin.1 _Acquired

causesareusuallysecondarytorecurrenttraumaaboutthe knee,inpatientswhohavepredispositionforpatellar disloca-tion.Femoralortibialshaftfracturewithvalgusorexternal rotation malunion will exaggerate the valgus vector and increasethispredispositionfordislocation.2

Theneglectedchronicpatellardislocationleadsto progres-sivegenuvalgumandexternaltibialtorciondeformitieswith subsequentgonarthrosis,whichbecomespainfuland debili-tating.Valgusmalalignmentofthelowerextremity,alaterally dislocatedpatella,andaweakactivekneeextensionarethe typicalphysicalfindings.3

There is no consensus regarding treatment of these patients,buttotalkneearthroplasty(TKA)isausefultherapy incasesofpainfulsymptomaticgonarthrosis.4_Surgical recon-structioncanbetechnicallydemandingandrequiresattention torestoringtheextensormechanismrealignment,softtissue balancing,goodpatellartracking,aswellascorrectionofthe bonydeformitiespresentintheseverevalgusknee.2,5_Another

concernisaboutthepotentialforosteonecrosisofthepatella duetodisruptionofitsbloodsupplyduringmedial parapatel-larapproachandwhenperformingextensivelateralreleaseof theextensormechanism.1,3,6

Onlyonereportshowedthatsubvastusapproachand lat-eralreleasemaybeavalidoptionforTKAinpatientswith chronicpost-traumaticpatellardislocationsinceitallowsthe correctionofvalgusdeformityandpatellartrackingwithout interruptingvascularbloodsupplyofpatella.1

WereportacaseofTKAandextensormechanism realign-ment without patellar resurfacing in a patient with genu valgumandchronicpost-traumaticpatellardislocation.

Case

report

A59-year-oldwomanwithsevereleftkneepain,whichshe hadexperiencedfor10years,wasreferredtoourHospital. Painhasgraduallyworsenedoverthelast3yearsbecauseofa traumaticdislocationofpatella.Ambulationandstair climb-ingweredifficultforherbutshecouldwalkwithoutsupport. Shehasnorelevantfamilyhistoryorcongenitaldisease. Con-servativetreatmentwithanalgesics,anti-inflammatoriesand physiotherapyformusclestrengtheningwasnoteffective.

Onexamination,therewasslightquadricepsatrophyinthe leftknee,partiallyreduciblevalgusdeformity,passiverange

Fig.1–Preoperativeclinicalphotographyshowinga completelydislocatedpatella.

ofmotionfrom0◦_to100◦_{withpainfulcrepitusoflateral} com-partmentandextensionlagof10◦_{.Thepatellawasdislocated} laterallyanditcouldnotbereducedatfullextension(Fig.1). Minimalpatellarmobilityduringflexionandextensionwas observed.Noeffusionwaspalpableandnosignsofinstability orligamentousdeficiencywereobserved.

Astandinganteroposteriorradiographofthekneeshowed valgusdeformityandosteoarthriticchangesinall compart-mentswithalmostcomplete lossofthe lateraljointspace; lateral radiograph revealed thatthe patella was notinthe anteriorportionoftheknee;skylineviewradiographshowed acompletelydislocatedpatellaanditsdirectcontactwiththe outerborderofthelateralfemoralcondyle(Fig.2).

Surgicaltechnique

SheunderwentaTKAontheleftknee(MedialPivot,Wright MedicalTechnology, Inc.).Amidline longitudinalskin inci-sionwasmadeoverthepatellainasubvastusapproachwith theobjectivetoprotectpatellarcirculation.Thepatellawas locatedinthelateralgutterofthekneeandthelateralfemoral condylewashypoplastic.

Fig.2–Preoperativeanteroposterior,lateralandskylineradiographsoftheleftknee.

Fig.3–Intraoperativephotographyshowingthepatella centrallyplacedinthegrooveofthefemoralcomponent.

An extensive lateral release was performed beginning proximally invastus lateralisand extendingdistally tothe tibialtuberosityobtainingapatellartrackingcenteredinthe femoralgroove(Fig.3).Iliotibialbandwasalsolengthenedwith theuseofpie-crustingtechnique.Distalrealignmentbytibial tubercletransferwasnotnecessary.Totalsurgicaltimewas 95minutes.

The patient was allowed immediate weight bearing on first postoperative day. Rehabilitation program included quadriceps strengthening exercises and gradually increas-ingkneemotionfromfullextensionto120◦ _{flexionwithno} extensorlag.

At 2 years postoperatively follow up, the patient was satisfiedwiththe surgeryand painfreeduringactiveknee motion and weightbearing activities (Fig. 4). The patient’s

KneeSocietyscore(KSS)7_{improvedfrompreoperativevalues} of49to93postoperatively.

ATechnetium-99mmethylenediphosphatebonescanwas donetoassessthepatellarviabilityandshowed hypercapta-tionontheleft patellawithpreservedvascularizationafter 2yearspostoperatively(Fig.5).

Discussion

Considerablefunctionaldisabilityisassociatedwithchronic post-traumatic patellar dislocation. There is no consensus regardingtreatmentofneglectedpatientsandthereareonly very few reports in literature, but TKA is a useful ther-apy in patients that have developed painful symptomatic gonarthritis.4 _{TKA inthis groupofpatients requires major} problems tobe addressed: dislocated extensormechanism andvalgusdeformity.2

Many techniques of proximal (V-Y quadricepsplasty, Z-plasty,Vulpiustechnique)anddistalrealignmenthavebeen describedandareusuallyrequiredtorelocatethepatellaand realigntheextensormechanism.3–5 _Someauthors8 _reported

total knee arthroplastywithout an attemptto relocatethe extensormechanismasasurgicaloption,buttheeffectsof neglectingpatellarstabilityoncomponentsurvivaland func-tionalresultsatlong-termfollow-upareunknown.Inourcase isolatedlateralreleasewasperformedfromthemusclefibers ofthevastuslateralistothetibialtuberositywithasatisfactory patellartracking.

Fig.4–Radiographsofthelastfollow-upevaluation:anteroposteriorandlateralviewsoftheleftknee.

subvastusapproach,whichpermitspreservationofthe des-cendinggeniculateartery,similarthatpreviouslydescribedby Inetal.,1_{associatedwithacontrolledlateralrelease,achieving} anadequatepatellartracking.Onealternativethatcouldalso improvetrackingwouldberesurfacingthepatella,butdueto itssmallthicknessitwasleftintact.

Eventhoughourcasehastwo-yearfollowupitmightbe notenoughtimetoaddressallpossiblepatello-femoral com-plications.NoorpuriandMaqsood6_{foundapatellarnecrosis} sevenyearsafteraTKAandHelitoetal.9_{reportedamigrated} patellanineyearsafterTKA,thatiswhysurgeonsmustdoa periodicradiographiccontrolofthesepatients.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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254–9.

2. BullekDD,ScuderiGR,InsallJN.Managementofthechronic irreduciblepatellardislocationintotalkneearthroplasty.J Arthroplasty.1996;11:339–45.

3. DaoQ,ChenDB,ScottRD.Proximalpatellarquadricepsplasty realignmentduringtotalkneearthroplastyforirreducible congenitaldislocationofthepatella.JBoneJointSurgAm. 2010;92:2457–61.

4.YamanakaH,KawamotoT,TamaiH,SuzukiM,KobayashiT, EguchiY,etal.Totalkneearthroplastyinapatientwith bilateralcongenitaldislocationofthepatellatreatedwitha differentmethodineachknee.CaseRepOrthop.

2015;2015:890315.

5.MatsushitaT,KurodaR,KuboS,MizunoK,MatsumotoT, KurosakaM.Totalkneearthroplastycombinedwithmedial patellofemoralligamentreconstructionforosteoarthriticknee withpreoperativevalgusdeformityandchronicpatellar dislocation.JArthroplasty.2011;26:505.e17–20.

6.NoorpuriBS,MaqsoodM.Osteonecrosisofthepatellaand prostheticextrusionaftertotalkneearthroplasty.J Arthroplasty.2002;17(5):662–3.

7.InsallJN,DorrLD,ScottRD,ScottWN.RationaleoftheKnee Societyclinicalratingsystem.ClinOrthopRelatRes.1989:13–4.

8.PradhanRL,WatanabeW,ItoiE,YamadaS,ShimadaY,SatoK. Totalkneearthroplastyinbilateralcongenitaldislocationof thepatella–acasereport.ActaOrthopScand.2001;72:422–4.

9.HelitoCP,GobbiRG,TiricoLEP,PecoraJR,CamanhoGL. Looseningofthepatellarcomponentandextra-articularand transcutaneousmigrationafterTKA.Orthopedics.