Lowering of the patella secondary to anterior advancement of the tibial tubercle for the patellofemoral pain syndrome

From a series of 72 patients treated with anterior advancement of the tibial tubercle for patellofemoral pain syndrome, secondary lowering of the patella was noted in eight. In all eight patients the results were poor following surgery, with severe disabling retro- and peripatellar pain and atrophy of the quadriceps muscle. We describe this complication and illustrate and discuss the biomechanical consequences. The shortening of the patellar ligament and lever arm of the ligament were determined from radiographs of the knee joints before and after surgery. A theoretical analysis was made of the compressive force in the patellofemoral joint in one of these patients. The Insall-Salvati index decreased from 0.88-1.25 (mean 1.07) preoperatively to 0.54-0.78 (mean 0.70) at follow-up, 1.0-2.5 years post-operatively. The lowering of the patella was correlated to a reduction of the lever arm of the patellar ligament in seven patients. The mechanism behind the lowering of the patella is obscure, but the reduced lever arm of the patellar ligament will increase the compressive force in the patellofemoral joint, and this might be one explanation of the poor results. Impaired congruity of the patellofemoral joint, increased tension in the patellar ligament, and increased pressure against the quadriceps tendon are other possible explanations.     

Bad results after anterior advancement of the tibial tubercle for patello-femoral pain syndrome

Summary Seventy-one patients with patello-femoral pain syndrome were re-examined an average of 10 (range 8–12) years after anterior advancement of the tibial tuberosity. The clinical results were excellent in 8 (11%), good in 20 (28%), fair in 16 (23%), and poor in 27 (38%). Twenty patients had had a second operation. The results were worse in patients with Outerbridge grade III–IV cartilage damange. Since the clinical results deteriorated with time, this surgical procedure should no longer be used to treat patients with patello-femoral pain syndrome.     

Anterior advancement of the tibial tuberosity in the treatment of the patellofemoral pain syndrome

Summary Seventy-two patients with disabling patellofemoral pain were treated with anterior advancement of the tibial tuberosity. In a follow-up examination 1–5 years (mean 2.5) postoperatively, 57% of the patients had improved, 19% were unchanged, and 24% were worse. The high failure rate is disturbing, and we warn against too frequent use of the anterior tuberosity advancement procedure. Patients with patellofemoral pain should be approached by establishing a specific diagnosis and applying a specific treatment. In this study we concluded that the only patients who might benefit from the operation were those with grade I-11 changes of the patellar cartilage.

---

Zusammenfassung Bei 72 Patienten mit krankmachenden Schmerzen im Femoropatellargelenk wurde eine operative Ventralverlagerung der Tuberositas tibiae vorgenommen. Bei einer Nachuntersuchung 1–5 Jahre (durchschnittlich 2,5 Jahre) nach der Operation war bei 57% der Patienten eine Besserung zu verzeichnen. Bei 19% war keine Änderung and bei 24% eine Verschlimmerung eingetreten. Die hohe Rate der Mißerfolge hat zu einer Verunsicherung geführt, and als Schlußfolgerung daraus wird vor einer allzu häufigen Anwendung dieser Operation gewarnt. Patienten mit femoropatellaren Schmerzen sollten einer spezifischen Diagnostik and Therapie zugeführt werden. Die einzigen Patienten in dieser Studie, die möglicherweise von dieser Operation einen Nutzen gehabt haben, waren jene mit einem Knorpelschaden Grad I–II an der Kniescheibe.

     

Anterior advancement of the tibial tuberosity in the treatment of the patellofemoral pain syndrome

Seventy-two patients with disabling patellofemoral pain were treated with anterior advancement of the tibial tuberosity. In a follow-up examination 1-5 years (mean 2.5) postoperatively, 57% of the patients had improved, 19% were unchanged, and 24% were worse. The high failure rate is disturbing, and we warn against too frequent use of the anterior tuberosity advancement procedure. Patients with patellofemoral pain should be approached by establishing a specific diagnosis and applying a specific treatment. In this study we concluded that the only patients who might benefit from the operation were those with grade I-II changes of the patellar cartilage.     

Reduction of patellofemoral contact forces following anterior displacement of the tibial tubercle

Retropatellar pain often accompanies malalignment syndromes and frequently is attributed to excessive patellofemoral contact stresses. Elevation (anterior displacement) of the tibial tubercle has been recommended to relieve these conditions. The degree to which patellar contact forces are decreased and the extent to which elevation alters medial-lateral forces have not been studied directly. We performed anterior translation of the tibial tubercle in knees from cadavers and measured the effect on the magnitude of the three-dimensional patellofemoral contact force with use of a specially designed 6-degrees-of-freedom force transducer, with the natural patellar articular surface in place. Measurements were made in nine knees (average age 67 years, range 46–92 years). The resultant contact force decreased linearly with increasing tubercle elevations of as much as 2.5 cm. The average reduction per centimeter of elevation was 17% of the force measured with no elevation. Elevation of the tubercle had an inconsistent effect on the medial-lateral component of the contact force. As the elevation was increased, six knees exhibited an increase in the medial-lateral component of the contact force acting medially on the knee and three knees exhibited a decrease in this force component. The results of this study show that, while elevation of the tubercle without medialization reduced the total contact force on the patella, the medial-lateral component of this force was altered it an unpredictable way.     

Osteotomy of the patella in the patellofemoral pain syndrome

Summary In 40 patients with patellofemoral pain, intra-osseous pressure measurements were recorded under anaesthesia with the knee first in extension and then in flexion prior to performing a longitudinal osteotomy of the patella. There was a statistically significant increase of pressure in painful knees compared with normal knees (29 mm Hg. vs 15 mm Hg.), and a marked increase when compared during sustained flexion (97 mm Hg. vs 60 mm Hg.). However wide variability of individual results made the diagnostic value of a single pressure measurement unreliable.A clinical test, based on reproduction of the characteristic pain by sustained knee flexion, proved to be reliable in predicting a good response to operation.The effect of the operation was encouraging, with significant relief of pain as measured by a visual analogue scale.

---

Résumé Chez 40 malades présentant un syndrome douloureux rotulien, on a pratiqué sous anesthésie une mesure de la pression intra-osseuse sur le genou en extension, puis en flexion; ceci avant de réaliser une ostéotomie longitudinale de la rotule. On a trouvé une augmentation significative de la pression au niveau des genoux douloureux comparativement aux genoux normaux (29 mm Hg contre 15 mm Hg) et une augmentation notable lorsqu'on la compare après une flexion prolongée (97 mm Hg contre 60 mm Hg). Cependant l'existence d'importantes variantions individuelles ne permet pas d'accorder une valeur diagnostique à une measure de pression isolée.A l'inverse, un test clinique, basé sur le déclenchement de la douleur caractéristique par la flexion prolongée du genou, permet de prédire avec certitude le bon résultat de l'opération.Ces résultats sont encourageants puisqu'ils comportent une importante amélioration des douleurs que l'on peut mesurer grâce à une abaque.

     

Anteromedial displacement of the tibial tubercle for patellofemoral arthralgia

Anterior and medial repositioning of the tibial tubercle (anteromedialization) reduces patellofemoral pressure and corrects patellar malalignment. Over the last 6 years this simple procedure was carried out on 53 knees in patients who had no athletic inclinations. The average age was 40.4 years. Follow-up was at least 1 year. A rating system was developed and overall the results were 65.9% excellent, 15.9% good, 11.4% fair and 6.8% poor. In the over-45 age group, the results were 57.1% excellent, 28.6% good, 14.3% fair and none poor. The complication rate was relatively low (18.7%). This procedure appears to be satisfactory for patellofemoral arthralgia when malalignment is present, particularly in the elderly.     

Relief of patellofemoral contact stress by anterior displacement of the tibial tubercle.

Elevation of the patellar tendon by means of displacement of the tibial tubercle has been advocated by Maquet, Ficat and Hungerford, and Murray as an alternative to patellectomy for the treatment of patellofemoral arthralgias. Although tubercle elevation certainly reduces the over-all patellofemoral contact force, its effects on the complex local patterns of contact stress are of more direct significance. In a laboratory series using fresh amputation material, arrays of six miniature contact stress sensors were embedded in the retropatellar cartilage of knees subjected to isometric quadriceps-extension forces. The experimental data revealed that elevation of the patellar tendon generally afforded relief of local contact stress regardless of the joint configuration (zero degrees, 45 degrees, or 90 degrees of flexion), but that its effects were most pronounced at 90 degrees of flexion. Progressive increase in the tendon elevation caused progressive reduction in the contact stress. Most of the contact stress relief was achieved, however, with the first one-half inch of tendon elevation; further elevations to one and one and one-half inches were only marginally useful. In view of the increased superior patellar pole contact associated with distal pole flotation, the results indicate that under most circumstances the optimum amount of elevation of the tibial tubercle is about one-half inch.     

Modified technique for tibial tubercle elevation with realignment for patellofemoral pain. A preliminary report

Malalignment of the quadriceps mechanism was corrected and the tibial tuberosity elevated in 17 knees in 16 patients without the use of a free bone graft. The indications for operation were patellofemoral pain unresponsive to conservative treatment, recurrent subluxation or dislocation of the patella, and patients who had had a previous patellectomy with subsequent lateral subluxation of the patella tendon associated with pain. A bone block including the attachment of the patellar tendon is transposed medially to correct the quadriceps angle (Q-angle), elevate the tibial tuberosity, and thereby decrease patellofemoral pressure. A prerequisite for this procedure is a Q-angle of 20 degrees or more. The average age of the patients was 29 years. The follow-up period was one to four years. Eighty-five percent of the patients had an excellent or good result. The only complication was a stress fracture, which developed in one bone block.     

The treatment of patellofemoral pain by combined rotation and elevation of the tibial tubercle

An operation designed to achieve simultaneous decompression and realignment of the patella has been used by the senior one of us (B. J. M.) for the treatment of selected patients with patellofemoral pain since 1978. The procedure isolates the tibial tubercle as a pedicle and simultaneously rotates it medially and anteriorly. Patellar tracking is then checked intraoperatively, and no bone graft is required. This paper reports the results of the procedure in thirty-eight knees in twenty-nine patients. The minimum length of follow-up was 2.5 years. Twenty-one knees were graded as excellent; twelve, as good; and five were considered to be failures. Of the twenty-five knees that were followed for four years or more, twenty-one were rated as excellent or good and four were failures.     

Tibial tubercle advancement for anterior knee pain. A temporary or permanent solution

In a prospective study of 29 consecutive cases of tibial tubercle advancement, the patients were assessed on the Larson knee chart preoperatively, three years postoperatively, and again after a minimum of six years (range, six to eight years; mean, 7.2 years). Only one patient was lost to follow-up evaluation. The overall results show that at three years, 65.5% of the knees were excellent or good, 13.8% were fair, and 20.7% were poor. By six years a significant change occurred in five knees. Four knees deteriorated, while one improved. The remainder maintained their three-year postoperative grade. The patients provide clinical evidence to support the biomechanical and morphological observations that form the basis of the Maquet principle. Two considerations influence the final result: surgical complications (three out of four cases with complications had a poor result) and the preoperative status (in patellofemoral osteoarthritis a preoperative Larson score of over 60 is necessary for a satisfactory outcome).     

Ventralization of the tibial tubercle for patellar pain

Summary In this study patellar pain in 37 knees was treated by ventralization of the tibial tubercle. No primary arthrotomy was performed. Seventy-three percent of the knees improved in the opinions of the patients, 11% remained unchanged, and 16% grew worse. Extension did not deteriorate in any knee. No serious complications were encountered. Seven patients had to undergo reoperation. It is suggested that patellar pain should be subdivided into that due to excess pressure, that due to instability, and that due to excess intraosseous venous pressure, in order to find a treatment appropriate to the cause in each case.     

Functional outcome after tibial tubercle transfer for the painful patella alta

Twenty-five patients with painful patella alta without symptomatic subluxation were identified in a prospective database. All patients had a distal tibial tubercle transfer and preoperative knee arthroscopy. The mean postoperative followup was 2.4 years. These patients were matched with healthy volunteers. Patellofemoral scores using the scoring systems of Kujala et al and Lysholm and Gillquist were collected prospectively. The Short Form-36 health survey and the Western Ontario and McMaster Universities Osteoarthritis Index were used postoperatively. Significant improvement in the patellofemoral scores was documented postoperatively; however, the healthy volunteers had significantly higher patellofemoral scores when compared with the patients who were treated surgically. For the three Short Form-36 survey parameters based on physical health (physical functioning, role physical, and bodily pain), there were no statistically significant differences between the patients and the United States age-matched norms; data are available in the Short Form-36 survey manual. Patients with Grade 2 chondromalacia (fissuring and fragmentation less than 1.25 cm) had significantly better scores in pain and function domains of the Western Ontario and McMaster Universities Osteoarthritis Index compared with patients with Grade 3 (fissuring and fragmentation greater than 1.25 cm) and Grade 4 (erosion down to bone) changes. Distal tibial tubercle transfer is a beneficial procedure for treating patients with painful patella alta.     

Ventralization of the tibial tubercle for patellar pain

In this study patellar pain in 37 knees was treated by ventralization of the tibial tubercle. No primary arthrotomy was performed. Seventy-three percent of the knees improved in the opinions of the patients, 11% remained unchanged, and 16% grew worse. Extension did not deteriorate in any knee. No serious complications were encountered. Seven patients had to undergo reoperation. It is suggested that patellar pain should be subdivided into that due to excess pressure, that due to instability, and that due to excess intraosseous venous pressure, in order to find a treatment appropriate to the cause in each case.     

Anteromedialization of the tibial tubercle for patellofemoral arthritis in patients > 50 years

This is a retrospective study of one surgeon's experience performing anteromedialization of the tibial tubercle for the treatment of isolated patellofemoral arthritis in active older patients. Patients were included if they were > 50 years at the time of the surgery and had a minimum follow-up of 2 years. Outerbridge classifications were documented by arthroscopy, and patellofemoral alignment was evaluated clinically and radiographically. Lysholm and Fern pain scores were obtained via mailed questionnaire or phone survey. A total of 22 anteromedialization procedures were performed on 17 patients who met the inclusion criteria; 82% of patients completed the followup survey. Mean age was 55 years. Mean follow-up was 77 months. Mean postoperative Lysholm score was 83. Based on Lysholm scores, there were 12 good to excellent, 6 fair, and 1 poor outcomes. Anteromedialization of the tibial tubercle is a definitive treatment option for isolated patellofemoral arthritis in active older patients.     

Late results of transfer of the tibial tubercle for recurrent dislocation of the patella.

The authors wished to determine the late results of the Hauser operation, with special reference to the development of osteoarthritis. Predisposing factors associated with recurrent dislocation of the patella were also investigated. Thirty-five patients with forty-four surgically treated knees attended for review, ten to twenty-five (average sixteen) years after operation. Two patients had subsequently undergone excision of the patella. Ten patients gave a family history of recurrent dislocation of the patella and seven patients showed generalised joint laxity. Pain was present in eight knees before operation and was present in thirty-three knees (75 per cent) at the time of review. Patella crepitus was present in thirty-seven out of forty-two knees (88 per cent) at review. Osteoarthritis was present in thirty out of forty-two knees (70 per cent). The incidence increases with time since operation and the present age of the patient. It is concluded that the Hauser operation prevents further dislocation but does not prevent the development of osteoarthritis. It is possible that a simple soft-tissue operation which effectively prevents dislocation might achieve the same results.     

内侧髌股韧带重建联合胫骨结节移位和关节镜下外侧支持带松解术治疗持久性髌骨脱位

目的观察内侧髌股韧带重建联合胫骨结节移位和关节镜下外侧支持带松解术治疗持久性髌骨脱位的效果。方法对6例持久性髌骨脱位患者的10个膝关节行内侧髌股韧带重建联合胫骨结节移位和关节镜下髌骨外侧支持带松解术。手术前后采用Lysholm膝关节功能评价表和Kujala评分表进行评估,并通过CT观测手术前后髌骨外移度。结果 6例均获随访,时间24～36(29±7.21)个月。Lysholm评分术前为47.10分±10.31分,术后24个月为83.11分±5.21分,差异有统计学意义(P<0.05);Kujala评分术前为41.26分±13.36分,术后24个月为82.33分±5.31分,差异有统计学意义(P<0.05)。患膝运动能力均较术前明显改善。髌骨外移度术前为35.61 mm±5.37 mm,术后为4.30mm±1.13mm,差异有统计学意义(P<0.05)。结论内侧髌股韧带重建联合胫骨结节移位和关节镜下髌骨外侧支持带松解术能够有效纠正持久性髌骨外侧脱位,缓解症状,恢复膝关节功能。     

High tibial osteotomy combined with anterior displacement of the tibial tubercle for osteoarthritis of the knee

Summary Eighty-nine knees with medial tibiofemoral and patellofemoral osteoarthritis were treated by high tibial osteotomy between 1972 and 1978, and 71 were followed up for at least 5 years, the average being 6 years and 9 months. There was no significant loss of motion as recorded before and after operation. In most patients pain decreased or disappeared, and walking ability was regained. Evaluation using the Japanese rating system showed that there were Good and Fair results in 86% of the cases. The average tibio-femoral angle in the Good group was 169±5°. The angles in the Poor group varied over a wide range. There were serious complications such as nonunion, malunion and infection in a few cases. In Group 1 (30 knees) high tibial osteotomy alone was performed. In Group 2 (41 knees) there were associated osteoarthritic changes in the patellofemoral joint and a high tibial osteotomy was combined with anterior displacement of the tibial tubercle (ventralisation). In comparison, Group 2 had better results with regard to both clinical and radiological evaluation.Read at the 16th Congress of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie, London, England, 5th October, 1984     

Pathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active young

Although it is universally accepted that patellofemoral malalignment is the main cause of anterior knee pain and functional patellar instability in the active young, the question remains to be answered: what is the mechanism whereby patellofemoral malalignment produces pain and instability? Currently, there are two theories to explain the origin of pain and instability in patients with patellofemoral malalignment: the neural theory and the mechanical theory. Both theories are not exclusive, but complementary. We believe it is the neural factor that precipitates the symptoms in patients with certain mechanical anomalies who also subject the knee to overuse.