Use of a Superolateral Portal and 70° Arthroscope to Optimize Visualization of Patellofemoral Tracking and Osteochondral Lesions in Patients With Recurrent Patellar Instability

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Abstract

Surgical treatment of patellofemoral instability and associated cartilaginous lesions can be technically challenging. Visualization of patellar tracking and underlying osteochondral lesions is paramount to operative success. To treat these conditions effectively, a comprehensive arthroscopic assessment of the patellofemoral joint as well as dynamic visualization of patella tracking must be achieved. Visualization of the patellofemoral joint—in particular, the articular cartilage of the patella and trochlea morphology—can be difficult when using traditional anteromedial or anterolateral portals and a 30° arthroscope lens. The technique described here uses an accessory superolateral portal and a 70° arthroscope to achieve significantly improved visualization of the patellofemoral articulation, in particular the chondral surfaces. This vantage point aids the surgeon in effectively evaluating patellar tracking, trochlea morphology, and importantly, osteochondral lesion location to help guide treatment algorithms in the patellofemoral joint.

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Epidemiology and natural history of acute patellar dislocation.

Donald Fithian, Elizabeth Paxton, Mary Lou Stone … (2015)

The goals of this study were to (1) define the epidemiology of acute patellar dislocation, (2) determine the risk of subsequent patellar instability episodes (subluxation and/or redislocation) during the study period, and (3) identify risk factors for subsequent instability episodes. Prospective cohort study. The authors prospectively followed 189 patients for a period of 2 to 5 years. Historical data, injury mechanisms, and physical and radiographic measurements were recorded to identify potential risk factors for poor outcomes. Risk was highest among females 10 to 17 years old. Patients presenting with a prior history of instability were more likely to be female (P < .05) and were older than first-time dislocation patients (P < .05). Fewer first-time dislocators (17%) had episodes of instability during follow-up than patients with a previous history of instability (49%) (P < .01). After adjusting for demographics, patients with a prior history had 7 times higher odds of subsequent instability episodes during follow-up than first time dislocators (adjusted odds ratio = 6.6, P < .001). Patellar dislocators who present with a history of patellofemoral instability are more likely to be female, are older, and have greater risk of subsequent patellar instability episodes than first-time patellar dislocators. Risk of recurrent patellar instability episodes in either knee is much higher in this group than in first-time dislocators. Copyright 2004 American Orthopaedic Society for Sports Medicine

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Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella.

Anthony D Elias, Halbert L. White, Donald Fithian (2002)

To assess magnetic resonance (MR) imaging findings after acute lateral patellar dislocation (LPD) with emphasis on the medial patella restraints and to describe a medial patellar impaction deformity. Knee MR images obtained within 8 weeks after LPD were evaluated for medial retinacular and medial patellofemoral ligament (MPFL) disruption, vastus medialis obliquus (VMO) edema and/or elevation, and other derangements. One hundred patients with no evidence of prior LPD were evaluated as controls. The Student t test was used for statistical comparisons. Eighty-two examinations were performed in 81 patients with LPD (mean age, 20 years; age range, 9-57 years). Seventy-six percent (62 of 82 examinations) showed medial retinacular disruption at its patellar insertion; 30% (25 of 82), at its midsubstance. The MPFL femoral origin was identified in 87% (71 of 82); of these, 49% (35 of 71) showed injury. Forty-eight percent (39 of 82) showed more than one site of injury to the medial stabilizers; 45% (37 of 82) showed edema or hemorrhage at the inferior VMO. Mean VMO elevation in the coronal plane of the adductor tendon was 2.2 cm, with a range of 0.6-4.5 cm (in control subjects, 0.9 cm; range, 0.1-2.5 cm; P <.001). At the inferomedial patella, 70% (57 of 82) of LPD examinations showed osteochondral injury and 44% (36 of 82) showed concave impaction deformity (0 of 100 control subjects). Other examination findings in LPDs included contusions of the lateral femoral condyle (66 [80%] of 82 examinations) or medial patella (50 [61%] of 82), intraarticular bodies (12 [15%] of 82), effusion (45 [55%] of 82), medial collateral injury (nine [11%] of 82), and meniscal tear (nine [11%] of 82). Injury to the medial retinaculum, MPFL, and VMO may be identified at MR imaging after acute LPD. Concave impaction deformity of the inferomedial patella is a specific sign of prior LPD.

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An Algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation

Alexander Weber, Amit Nathani, Joshua Dines … (2016)

High-level evidence supports nonoperative treatment for first-time lateral acute patellar dislocations. Surgical intervention is often indicated for recurrent dislocations. Recurrent instability is often multifactorial and can be the result of a combination of coronal limb malalignment, patella alta, malrotation secondary to internal femoral or external tibial torsion, a dysplastic trochlea, or disrupted and weakened medial soft tissue, including the medial patellofemoral ligament (MPFL) and the vastus medialis obliquus. MPFL reconstruction requires precise graft placement for restoration of anatomy and minimal graft tension. MPFL reconstruction is safe to perform in skeletally immature patients and in revision surgical settings. Distal realignment procedures should be implemented in recurrent instability associated with patella alta, increased tibial tubercle-trochlear groove distances, and lateral and distal patellar chondrosis. Groove-deepening trochleoplasty for Dejour type-B and type-D dysplasia or a lateral elevation or proximal recession trochleoplasty for Dejour type-C dysplasia may be a component of the treatment algorithm; however, clinical outcome data are lacking. In addition, trochleoplasty is technically challenging and has a risk of substantial complications.

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Author and article information

Contributors

Cory M. Edgar

Journal

Journal ID (nlm-ta): Arthrosc Tech

Journal ID (iso-abbrev): Arthrosc Tech

Title: Arthroscopy Techniques

Publisher: Elsevier

ISSN (Electronic): 2212-6287

Publication date PMC-release: 20 November 2020

Publication date Collection: November 2020

Publication date (Electronic): 20 November 2020

Volume: 9

Issue: 11

Pages: e1731-e1736

Affiliations

[a ]Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, U.S.A.

[b ]Department of Orthopedic Surgery, Augusta University Medical Center, Augusta, Georgia, U.S.A.

Author notes

[∗ ]Address correspondence to Cory M. Edgar, M.D., Ph.D., Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, 263 Farmington Ave, Farmington, CT 06030, U.S.A. coedgar@ 123456uchc.edu

Article

Publisher Item ID: S2212-6287(20)30193-6

DOI: 10.1016/j.eats.2020.07.020

PMC ID: 7695614

SO-VID: e1f71059-e79b-43ad-a67b-84ee46c9a395

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Use of a Superolateral Portal and 70° Arthroscope to Optimize Visualization of Patellofemoral Tracking and Osteochondral Lesions in Patients With Recurrent Patellar Instability

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Most cited references 29

Epidemiology and natural history of acute patellar dislocation.

Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella.

An Algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation

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