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VID1-01352-EN | A | Trochleoplasty for Patellar Instability Due to Trochlea Dysplasia

J. Lee Pace

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Trochleoplasty for Patellar Instability Due to Trochlea Dysplasia

So this is a 20 year old female. As you can see, she's had prior mpfl repair surgery. She's had ongoing instability for years. Never a trauma. Her kneecap just started dislocating rather traumatically. Here she is in full extension. And I can completely dislocate her off to the side there. You can see her pop back in right there. Now, if I flex her up about 30 degrees, I can hold her off. And you can see that I can keep her kneecap. Just stays dislocated right there. And then it kind of violently pops back in. And now I have her up here probably about 45 degrees. And same thing. I can just slide it right off to the side and this will just stay out. So I kind of have to gently put this back in here. So there's the lateral border. Her superior patella is about there. And here's your inferior patella. So I'm actually going to make this incision a little bit medial of her lateral patella. Because we expect once we shift her immediately with the mpfl reconstruction that her patella is going to sit over here. And I like to use this triangle for the bulk of the case. It puts these lateral structures on stretch. And then it actually helps to do the trochlea plasty with a little bit of knee flexion. And then obviously for the Mpfl reconstruction we like to secure that in knee flexion as well. So the first thing we'll do is we're going to come down to the lateral retinaculum. And we're going to do a z lengthening of this. And the beautiful one of the beautiful things about this lateral approach is that you can do this lengthening as an inherent part of the lateral knee arthrotomy. So we'll we'll do the z lengthening at the beginning and then we'll close it on our way out. You can see that's like the the the lateral retinaculum proper right there. So you've got these really nice fibers kind of coming down here and all this other stuff in it. It all gets lengthened as well. But this is like the meat of the fibers right here. And you can see it's sort of like there's the inferior pole and there's the superior pole. It's kind of like mid-level on the, on the patella laterally. You know, I can incise it down here. And that's going to give me two, 2.5cm of, of potential length. And we find that we get at least a centimeter and a half on most these people. So we really we really do go for distance on this. There's the deep layer there and then there's the synovium there. So that's the deep layer of the retinaculum. And then here's the synovium. And you have to cut through the synovium. So we'll cut through that. Next. The layers kind of merge up here. And then I can take this up into the quad. And I'll usually do this with the bovie. And I can usually get my finger in here like this. And I can feel the inner surface of the patella. And I can just kind of just run that. I'll use the cut function. You can see that I can get this, this quad split. Well proximal. I mean that's probably five centimeters of quad split there. So that's great. So then we put this k wire in as a retractor to kind of help hold the patella. Immediately you can see we've got pretty excellent exposure of the entire trochlea. Now I've kind of just marked where I'm going to provisionally start making my cut. What I'll do is I'm going to make these dots. I'm going to just kind of map out where I want my new groove to go. Her current groove kind of goes like this. This is how we change her tibial tubercle to trochlear groove distance. We're going to move it from here to here. We're going to lateralize her trochlea about a centimeter. So whatever her TG is now, we're going to take that down by a full centimeter. So even if she's like 25 we'll take her down to 15. If you're going to consider a bony procedure for patellar instability, I think this is the one that we should be thinking of at least first because it addresses not only the the congruency between the groove, the trochlear groove, and the patella, but it also addresses its relationship to the tibial tubercle. So my thought is I'll probably bring it to the cut to about here. And so I'll just kind of mark that out. Like that. And then what we'll do is we'll bring our we'll elevate the flap down to about there. And that should give us plenty of space to elevate the flap and, and and remove the bone underneath. So I've marked there I'm going to take the cut. I'll start the flap elevation a little bit distal to it. And sometimes in these right through here where I'm making this, this turn, I kind of will use this, The skinnier osteotomy. I've kind of I've been liking that. It allows me to kind of contour it a little bit better. And then I can switch to the bigger one. And we kind of use the curve to our advantage. And then we'll kind of take it up around the horn here. So this is a standard ACL guide here. But this is specially designed for the Trochlea Plasty set. This goes all the way in to the handle and you tighten it. And you can see this has a little sort of smooth surface to it. Metal surface here. And this one is marked five. And what it means is when you stick this through here there's five millimeters between the burr and the top of this. So you can kind of gauge what your clearance is, and the plastic sheath centralizes the burr in here so that you're so that it doesn't wiggle around and become inaccurate. And then also when you're doing some final touches, you can actually take this off and you can hold it like this. And that way you can you can put your hand right here for greater control. And the and the burr isn't like spinning your glove up on you. So we've already kind of started the cut with the osteotomy. So now I'm going to keep firm pressure. And the way that I'll do it is if, if I'm going to air one way, I'll air like this a little bit, because that way I know I'm not going to do this and then sort of come through the cartilage up here. Then this should get in here fairly easily. Yeah. And that goes in nice just like that. And I'll take it to the depth. And then the move is this. It's it's it's kind of like you kind of taking it back and forth in a V. So you're kind of pivoting off the apex of the burr like this, back and forth, back and forth. And I know that my BR is basically at the tip of this of this metal guide right here. So I know what my depth is. I think there's just a little bit more down through here. But that's starting to come. See that? So you can see we're already starting to get this thing to elevate. I usually just take this kind of slow. Just kind of gradually let the cartilage get used to getting picked up. But you can see just bit by bit, it really lifts up nicely. Now we've got enough room here that we can actually kind of get a retractor underneath and hold this flap up like that, and then I can come in and I can start removing bone from underneath this. We're going to start removing bone through here. We'll do We'll do some macro cuts first and then we'll smooth it out. Okay. And what we're doing is we're basically taking the osteotomy. And I'm creating like the depth of the groove, the center point of the groove here. And then what I'm going to do is I can once I've made this bony cut this way I can connect it with the osteotomy this way, and it puts my groove exactly where I want it to go right here. So that's sort of a little helpful trick as far as setting up your groove. And then, you know, you're not having to guess as to where it goes later in general. Or I'm deepening this about a centimeter and I'll really try to and I'm really going to preserve this, this lateral wall. You can see I can cut in to this. And then we're going to save this bone graft. And we can kind of just remove these wedges of bone like this. There's our bump right here. And so we're going to be able to get whack that thing out right now. And then down this way a little bit more. There's the top right there. And there's the base of it. So that's actually a little over a centimeter of bone that we've resected right here. And again this was all confluent with the with the lateral wall. And now we've taken it down a good centimeter. We have to remove some of this medial stuff here. But the most important aspect is this right here we want to reestablish a you know, the lateral trochlear inclination of probably close to 20 degrees or so is a pretty safe bet. I've done the macro now. And now I can go to micro, and I can kind of smooth this out a little bit with this bur. And it's nice because again, this cartilage just gets a little bit more and more flexible as time goes on. Sometimes I'll just take this and I'll come underneath the flap with this and just create a little stress riser right underneath. I might just come underneath here a little bit and just just remove a little bit more bone. So we're actually getting a pretty good mold here already. The contour is really well maintained here. And it just there's really no speed bump or anything on this. This is really looking nice. And her bump is completely gone here. This is three strands of number one vicryl. Okay. And what we're going to do is we're going to make a total of 12 strands here. So here we have our PushLock and we've got now six and six strands. And this will be so a total of 12. And we're going to use this as our center PushLock for fixation of this osteochondral flap so we can bring this up. The flap that we elevated ends about right here. So I'm going to put this just inside. Just right there, not below it, because I'm not going to get as good a compression on the flap if I come just below where the flap was. I'm going to come just inside of it right here, right in the depth of the groove. And this is where we'll put our first PushLock. Yeah. Okay. Okay. Yep. Yep. Good. And several spins until it pulls out. So I'm going to pick four strands, which just sort of seem to want to come up on the superior aspect of Speak to this. And now you know what we've been doing lately. To really help us get a groove is we'll put one instead of just bringing the next one all the way up to the top up here. We'll actually put one about midway about right here. And that really helps us sync it down nicely there. Okay. Okay. And then we'll put one more. Yeah. Right up here like this. And then I'm going to take that about right right there. Okay. So we've got our centerpiece and we've got a really beautiful groove that that we've established here for her now. And now we're just going to add a couple Extra PushLock here for for a little bit of added fixation. We'll put one laterally and then we'll put one medially. Looks really good. Nice. Nice central deep groove here. We can cut the sutures. And then what we can do is we can kind of see how this thing tracks. And again this fixation here with these with these this suture and PushLock construct. It's it's just so robust. We let these people range right away and weight bear right away. The more that they bend their patella, it compresses the patella against this osteochondral flap and helps it heal. And in however many years this procedure has been performed, there has never been a case of case of the osteochondral flap not healing back in place. So it's an extremely reliable thing. I mean, her kneecap already is starting to feel more stable. I mean, obviously I can still push it out because we have to do the mpfl, but it really it's you can already feel it catching on the lateral wall here. So I haven't even done the Mpfl reconstruction already. The stability is significantly improved. So here's the superficial retinaculum. It was here. So it went from here to here. But you can see we've got this lateral portion completely closed. So we don't have to worry about iatrogenic medial instability. We don't have to worry about pain that you can sometimes get from an unhealed lateral release. So this lateral lengthening has been a very very valuable tool and a big improvement in dealing with the lateral side of the patellofemoral joint and patellar instability.

Trochleoplasty for Patellar Instability Due to Trochlea Dysplasia

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