mr michalis zenios consultant paediatric orthopaedic surgeon mbchb (hons), mrcs (eng), msc, frcs...
TRANSCRIPT
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- Mr Michalis Zenios Consultant Paediatric Orthopaedic Surgeon MBChB (Hons), MRCS (Eng), MSc, FRCS (Orth)
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- Paediatric Orthopaedics Fellow Sydney 2006-2007 Consultant Manchester 2007 - 2012
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- Aims Aetiology of patellar instability/subluxation Assessment Treatment (Evidence based) Congenital patellar dislocation
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- Patellofemoral Instability Patellofemoral pain Patellofemoral subluxation Patellofemoral Dislocation
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- Patellofemoral Instability Bony Causes (local) Femoral Trochlea Patella Shape Patella Height
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- Patellofemoral Instability Bony Causes (Lower Limb) Genu Valgum Femoral Torsion Tibial Torsion
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- Patellofemoral Instability Soft tissue restraints Medial Medial patellofemoral (60%) Medial Retinaculum VMO Lateral Vastus Lateralis Lateral Retinaculum
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- Pathology Lateral hypermobility of the patella Dysplastic distal one third of VMO High or lateral position of the patella Previous history of patellar subluxation
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- Patellar dislocations Rare in a child. Common in adolescents. Twisting injury or direct trauma Lateral Acute vs recurrent Osteochondral fractures of patella or femur
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- Patellofemoral Instability Assessment History Acute or spontaneous Duration Number of episodes Circumstances of injury Previous treatment Beware ACL injury (Pop) Syndromes
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- Patellofemoral Instability Assessment Examination Full knee examination Patella Tracking J-sign Medial or lateral tenderness Tilt or lateral tightness Apprehension Test (most reliable) Q-angle Torsional profile General Laxity
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- Patellofemoral Instability Investigation Plain X Rays AP (? Osteochondral lesion) Lateral view 30 deg flexion (Koshino Index) Merchant View 30 deg flexion
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- Radiology Insall index < than o.8 suggests patella alta
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- Patellofemoral Instability Sulcus Angle 140 degrees Congruence angle -6 +/- 11degrees
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- Patellofemoral Instability CT Scans Fulkerson views Vary knee flexion MRI Scans Medial restraints EUA & Arthroscopy Acute (MPFL) Check tracking
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- Radiological measurements Tibial tubercle trochlear groove distance Lateralisation of the patella Abnormal when above 20 mm
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- Patellofemoral Instability Conservative Treatment: RICE SLR/ Isometric Quadriceps Open and closed chain kinetic exercises Gradual return to activities No casts or immobilization Patellar stabilizing orthosis Time
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- Patellofemoral Instability ? Role for acute surgery Treatment: No place for acute operative stabilization in children and adolescents Acute patellar dislocation in children and adolescents. Surgical technique. J Bone Joint Surg Am. 2009 ; 91: 139-45. Nietosvaara Y, Paukku R, Palmu S, Donell ST. The slaying of a beautiful hypothesis by an ugly fact T H Huxley
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- Acute patellar dislocation in children and adolescents: a RCT. J Bone Joint Surg (Am) 2008;90(3):463-470 62 patients younger than 16 who sustained acute patellar dislocation with an osteochondral fragment of 15mm. 36 0peratively 28 non-operatively: 1. 7 only lateral release 2. 29 repair medial structures
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- Acute patellar dislocation in children and adolescents: a RCT. J Bone Joint Surg (Am) 2008;90(3):463-470 14 year follow up Initial operative repair did not improve the long-term outcome. 70 % re-dislocation rates Positive family history was a significant risk factor for recurrence
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- Acute patellar dilsocation in adlescents: operative versus non- operative treatment. Int orthopaedics. Apostolovic 2011;35(10):1483-1487. Non randomised prospective study- 37 adolescent knees Decision for surgery on the basis of clinical and arthroscopic findings. Not clear No difference between operative and non-operative treatment in terms of re-dislocation rates and functional outcome
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- Surgical intervention Recurrent instability with functional compromise Osteochondral lesions. Repair if > 2cm
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- Patellofemoral Instability Surgical Strategy (100 operations in 100 years!) Proximal Re-alignment (TUBS) Acute initial episode Lax soft-tissue restraints Restore anatomy (MPFL reconstruction/ Insall procedure) Distal Re-alignment (AMBRI) Predisposition to patellar subluxation Anatomical factors (Increased Q Angle) Reconstruct anatomy Patellar tendon or Tibial Tubercle
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- Patellofemoral Instability Surgical Strategy (100 operations in 100 years!) Proximal Re-alignment (TUBS) Acute initial episode Lax soft-tissue restraints Restore anatomy (MPFL reconstruction/ Insall procedure) Distal Re-alignment (AMBRI) Predisposition to patellar subluxation Anatomical factors (Increased Q Angle) Reconstruct anatomy Patellar tendon or Tibial Tubercle
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- A Surgical algorithm for the treatment of patellar dislocation. Results of 5 year follow up. Acta Orthop Belgica 2013.
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- Higher re-dislocation rates in immature patients who underwent proximal re-alignment procedures. Mature patients with combined proximal and distal procedures had the lowest re-dislocation rates but low functional scores.
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- Predictors of recurrent instability after acute patellofemoral dislocation in paediatric and adolescent patients. Am J Sports Med 2013;41(3):575-581. USA. 222 knees Mean age 14.9 years Patients with open physes and dysplastic trochlea had the highest dislocation rate at 69% Age, sex, body mass index and patella alta were not associated with recurrent instability
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- Outcomes after patellar re-alignment surgery for recurrent patellar instability dislocations: a minimum 3-year follow-up study of children and adolescents. JPO 2011;31(1):65-71. USA Recurrent dislocation 7% Subjective opinion of knee function was less than expected 5 years post-op.
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- Weight-bearing osteochondral lesions of the lateral femoral condyle following patellar dislocation in adolescents athletes. Orthopaedics 2012;35(7):1033- 1037. USA 80 patients with acute patellar dislocation 27.5% had an osteochondral lesion of the wt bearing area of lateral femoral condyle and 60% required surgical intervention Suggestion of performing an MRI if there is tenderness over the lateral femoral condyle.
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- Surgical treatment for instability - Summary Do not operate acutely Understand and try to correct your anatomy No tibial tubercle transfer in skeletally immature patients
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- Congenital patella dislocation First described by Singer 1856 Present at birth diagnosed then or within first decade The patella should be permanently fixed to the lateral aspect of the femur
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- Congenital patella dislocation Aetiology Failure of the myotome containing the Quadriceps and Patella from internally rotating in the first trimester
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- Congenital patella dislocation Pathology Extensor mechanism inserted antero-laterally Contracture of Iliotibial band, Vastus lateralis, and Lateral capsule Loose and atrophic medial capsule & VMO Hypoplastic femoral trochlea External rotation of tibia and valgus deformity of knee
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- Congenital patella dislocation Treatment Initiated before 1 st birthday Extensive lateral release of whole of Vastus lateralis & knee capsule Extensor mechanism is reduced and medial structures lateralised +/- Roux Goldthwaite
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- What do we do?
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- What do I do?
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- Thank you