Is there any indication for trochleoplasty?

http://www.healio.com/orthopedics/blogs/patellofemoral-update/is-there-any-indication-for-trochleoplasty

Monday, December 23, 2013

Is there any indication for trochleoplasty?

Patellofemoral Update

Trochleoplasty for patients with recurrent patellar instability has been debated the past few years. The procedure is becoming more common in Europe, while orthopedic surgeons in the United States have a more cautious approach, although a few surgeons are doing the procedure. One can ask if there is a need for trochleoplasties when there are other well-established procedures.

Many surgeons are excited about medial patellofemoral ligament (MPFL) reconstructions. Some studies with long-term follow-up seem to have good results; however, it is not a solution for all patients with patellar instabilities. We have to be aware of the underlying pathomorphology. In a recent meta analysis, Shah and colleagues found a complication rate of 26% after MPFL reconstruction. A major complication was postoperative instability with recurrent apprehension, which was 32% of all complications. Howells and colleagues found that 15 of 25 patients with persistent recurrent symptoms after reconstruction of the MPFL had moderate trochlear dysplasia. Patients with severe trochlear dysplasia already had been excluded.

Wagner and colleagues found a negative relationship between the degree of trochlear dysplasia and outcome after MPFL reconstruction. The situation seems to be that when the native MPFL ruptures, without any major trauma, it is likely an injury caused by continuously stress on the ligament. By making the ligament stronger, we can introduce abnormal joint forces leading to either pain at the insertion side, osteoarthritis (OA) or patella stress fractures.

 

Lars Blønd

MPFL reconstruction

Alternatively or in combination with an MPFL reconstruction, we can transfer the tibial tubercle either medially to reduce the tibial tubercle–trochlear groove distance (TT-TG) distance and/or distally to correct a patella alta. However, it is difficult to ignore the studies from Carney and colleagues and Nakagawa and colleagues, who observed that good to excellent results after transfer of the tibial tubercle declined after 10 years to 15 years, with some patients having increasing pain. Nakagawe and colleagues found radiological osteoarthritic changes grade 2 or worse in 42% of patients after Elmslie-Trillat procedures (no anteriorization at time of medial tibial tubercle transfer).

This brings us back to the question: is there any indication for the trochleoplasty procedure? The procedure is based on the principle of restoring abnormal anatomy in cases with trochlear dysplasia. We know trochlear dysplasia is a main factor for patellar instability and apparently it seems logical to do the trochleoplasty procedure. Trochlear dysplasia is characterized by overstuffing too much bone in the trochlea, resulting in a flat of shallow configuration in the most proximal part of the trochlea. This configuration has impact on many factors. Mostly, the trochlear groove is medialized and this causes an increase of the TT-TG distance.

It is important to notice that in these cases, the abnormal TT-TG is not caused by an external placed tibial tubercle, but an asymmetric trochlea because of a medialized trochlear groove. Furthermore, the patella tilt is caused by overstuffing of the trochlea, forcing the patella to articulate on it lateral facet simply because the patella has no groove to be contained. When a patient has trochlea dysplasia, you will find the trochlea inclination angle is reduced, meaning there is a deficiency of the lateral part of the trochlea which is supposed to give osseous support to the patella. These factors can all be normalized by doing a trochleoplasty and the procedure also has a positive impact on the sulcus angle and eventual patella alta. Depending on the operative trochleoplasty technique, the TT-TG distance can be reduced by 5 mm to 10 mm.

Technically demanding

Most surgeons have a reasonably skeptical approach on the trochleoplasty procedure based on several sound arguments. First, the procedure is technically demanding and should only be done by a selected and dedicated group of surgeons who have special knowledge about the biomechanics of patellar instability and have a routine for more standard patellar stabilizing procedures, such as MPFL reconstructions and osteotomies of the tibial tubercle.

Second, this is a procedure that involves the osteochondral interface. Radin and Rose showed this is a delicate structure and impacts on this can potentially lead to arthritis. Schöttle and colleagues studied the cartilage viability after the Bereiter trochleoplasty and found tissue in the trochlear groove remained viable, with retention of distinctive hyaline architecture and composition. However, some pathological changes were found, as lacunae were seen progressing from the subchondral bone through the calcified layer and, in some cases, even into the basal layer of the cartilage. This can be a sign of cartilage degeneration giving profound impact of subchondral bone disruption in mostly young patients. It was hypothesized that the cartilage flake probably undergoes microfractures while being pressed down into the new groove, resulting in these lacunae and cluster formation.  Pathologic changes were found in the area just beneath the subchondral bone, therefore, showing processes characteristic of epiphyseal fracture healing.

It was concluded that even though a few minor changes in the calcified layers were identified, the results of the microscopic findings in conjunction with the clinical and radiological results seen at 2-year and 5-year follow-up after trochleoplasty could be expected to persist long term. However, further histological studies with a longer follow-up are recommended. If subchondral bone and cartilage stiffness occur in the trochleoplasty area, it is likely that this might eventually lead to OA.

Third, postoperative detachment of the osteochondral flap or chondrolysis may have serious consequences. Fortunately there have not been any reported cases yet. Today, about 20 case series have now demonstrated good short- to mid-term results of the trochleoplasty procedure. In the past three studies, the trochleoplasty has been combined with an MPFL reconstruction. The obtained results seems to be encouraging in patients with trochlear dysplasia (Dejour grade B-D), resulting in consistent statistically significant improvement in all applied knee function scoring systems. Ntagiopaulos and colleagues found no radiologically signs of OA (follow-up: 7 years; range: 3 years to 9 years). This is contrary to Knoch and colleagues, who reported radiologic osteoarthritic changes grade 2 or worse in 30 % (follow-up: 8 years; range: 4 years to 14 years). In this study, patellofemoral pain became worse in 33% of patients and improved in 49% of patients, but the median Kujala score was 94.

Anterior knee pain

Many factors are involved in anterior knee pain. We should pay attention to the study from Keser and colleagues, who found a significant correlation between trochlear dysplasia and anterior knee pain. Also it is interesting that Goutallier and colleagues successfully used the recession trochleoplasty procedure in cases with trochlea dysplasia, where the patella already had been stabilized successfully but the patient continued to have pain.

We know trochlear dysplasia predisposes patients to OA and this is whether or not the patella is unstable. Albee elevation trochleoplasty increases the forces in the patellofemoral joint and causes secondary OA.  Therefore, it is likely to hypothesize that when the forces in an overstuffed dysplastic trochlea are reduced, by doing a deepening or depression trochleoplasty, the risk of OA might be reduced.

In addition to the above mentioned factors, there are other factors involved. For example, the procedure is technically demanding. There is a risk of arthrofibrosis and there is spare data on the long-term follow-up. The differences observed in postoperative stiffness and pain may be attributed to different surgical techniques, rehabilitation protocols and indications. The persistence of instability and the need for reoperation after trochleoplasty procedures are rarely recorded.

In my opinion, we are only at the dawn and hopefully new patient-related outcomes scores, such as the Norwich Patella Instability score and Banff patellar instrument, will be useful instruments to help obtain more precise and comparative data in the future. However, it is difficult to neglect the good clinical results obtained until now. Obviously, trochleoplasty is indicated in some cases, however, is still difficult to say if it is a salvage procedure or if it is also a procedure for primary cases with perhaps less pronounced degrees of trochlear dysplasia. We need to sort out the differences between the types of trochleoplasty techniques including more data on arthroscopic techniques. 

References:

Shah JN. Am J Sports Med. 2012; doi:10.1177/0363546512442330.

Howells NR. J Bone Joint Surg Br. 2012; doi:10.1302/0301-620X.94B9.28738.

Wagner D. Knee Surg Sports Traumatol Arthrosc. 2013;doi:10.1007/s00167-012-2015-5.

Carney JR. Long-term evaluation of the Roux-Elmslie-Trillat procedure for patellar instability: a 26-year follow-up. Am J Sports Med. 2005;33(8):1220-1223.

Nakagawa K. Deterioration of long-term clinical results after the Elmslie-Trillat procedure for dislocation of the patella. J Bone Joint Surg Br. 2002;84(6):861-864.

Radin EL. Role of subchondral bone in the initiation and progression of cartilage damage. Clin Orthop Relat Res. 1986;(213):34-40.

Schöttle EB. Cartilage viability after trochleoplasty. Knee Surg Sports Traumatol Arthrosc. 2007;15(2):161-167.

Blønd L. Knee Surg Sports Traumatol Arthrosc. 2013;doi:10.1007/s00167-013-2422-2.

Banke IJ. Knee Surg Sports Traumatol Arthrosc. 2013;doi:10.1007/s00167-013-2603-z.

Nelitz M. Am J Sports Med. 2013;doi:10.1177/0363546513478579.

Ntagiopoulos PG. Am J Sports Med. 2013;doi:10.1177/0363546513482302.

Knoch F. Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia. A 4- to 14-year follow-up study. J Bone Joint Surg Br. 2006;88(10):1331-1335.

Keser S. Knee Surg Sports Traumatol Arthrosc. 2008; doi:10.1007/s00167-008-0571-5.

Goutallier D. Retro-trochlear wedge reduction trochleoplasty for the treatment of painful patella syndrome with protruding trochleae. Technical note and early results. Rev Chir Orthop Reparatrice Appar Mot. 2002;88(7):678-685.

Smith TO. Knee Surg Sports Traumatol Arthrosc. 2013;doi:10.1007/s00167-012-2359-x.

Hiemstra LA. Am J Sports Med. 2013; doi:10.1177/0363546513487981.

http://well.blogs.nytimes.com/2014/03/07/why-high-impact-exercise-is-good-for-your-bones/?_php=true&_type=blogs&_php=true&_type=blogs&_r=1

Why High-Impact Exercise Is Good for Your Bones

By GRETCHEN REYNOLDS

Illustration by Ben Wiseman

This article appeared in the March 9, 2014 issue of The New York Times Magazine.

Bones should be jarred, for their own good. Past experiments have definitively established that subjecting bones to abrupt stress prompts them to add mass or at least reduces their loss of mass as people age. What has been in dispute, however, is how much force is needed to stimulate bone — and how to apply that force in daily life.

Recently researchers at the University of Bristol gathered male and female adolescents — the body accumulates bone mass rapidly at this time of life — and had them go about their daily routines while they wore activity monitors. The bone density of the volunteers’ hips was also measured.

A week later, the scientists reclaimed the monitors to check each teenager’s exposure to G forces­, a measure of impact. Those who experienced impacts of 4.2 G’s or greater — though these were infrequent — had notably sturdier hipbones. Additional work done by the same researchers showed that running a 10-minute mile or jumping up onto and down from a box at least 15 inches high was needed to produce forces that great. The significance of these findings is that people should probably run pretty fast or jump high to generate forces great enough to help build bone.

Unfortunately, few older adults are likely to be doing so. In follow-up experiments, the same researchers equipped 20 women older than 60 with activity monitors and ran them through an aerobics class, several brief and increasingly brisk walks and a session of stepping onto and off a foot-high box. None of the women reached the 4-G threshold ­— none, in fact, generated more than 2.1 G’s of force at any point during the various exercises.

The implications are somewhat concerning. Dr. Jon Tobias, a professor of rheumatology at the University of Bristol who led the experiments, says that while impacts that produce fewer than 4 G’s of force may help adults maintain bone mass — a possibility that he and his colleagues are exploring in ongoing experiments — it’s unclear what level of force below 4 G’s is needed.

So, Dr. Tobias says, young people and healthy adults should probably pound the ground, at least sometimes. Sprint. Jump off a box 15 inches or higher at your gym and jump back up. Hop in place. A study by other researchers published in January found that women between 25 and 50 who hopped at least 10 times twice a day, with 30 seconds between each hop, significantly increased their hipbone density after four months. Another group of subjects, who hopped 20 times daily, showed even greater gains.

Alas, a kind of Catch-22 confronts older individuals who have not been engaging in high-impact exercise: Their bodies and bones may not be capable of handling the types of activity most likely to improve bone health. Dr. Tobias and his colleagues hope to better understand what level of impact will benefit these people. In the meantime, anyone uncertain about the state of his or her bones should consult a physician before undertaking high-impact exercise (a caveat that also applies to those with a history of joint problems, including arthritis). For his part, Dr. Tobias says, “I plan to keep running until my joints wear out.”

A version of this article appears in print on 03/09/2014, on page MM14 of the NewYork edition with the headline: Hit the Ground, Running.

Asegurar la felicidad del paciente con reemplazo total de rodilla / Assuring the happy total knee replacement patient

http://www.bjj.boneandjoint.org.uk/content/95-B/11_Supple_A/120.abstract

Assuring the happy total knee replacement patient

1. M. Drexler, MD, Orthopaedic Surgeon1;
2. T. Dwyer, MBBS, Orthopaedic Surgeon2;
3. R. Chakravertty, MD, FRCSC, Orthopaedic Surgeon1;
4. A. Farno, MD, FRCSC, Orthopaedic Surgeon1; and
5. D. Backstein, MD, MEd, FRCSC, Head of Orthopaedic Surgery1

+ Author Affiliations

1. 1Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada.
2. 2Women’s College Hospital, University of Toronto Orthopaedic Sports Medicine, 76 Grenville St, Toronto, Ontario M5S 1B1, Canada.

1. Correspondence should be sent to M. Drexler; e-mail: mt.drexler@gmail.com

Resumen 

El reemplazo total de rodilla (PTR) es una de las operaciones más frecuentes en cirugía ortopédica en todo el mundo. A pesar de su reputación científica como todo un éxito, sólo el 81% y el 89% de los pacientes están satisfechos con el resultado final. Nuestra comprensión de esta discordancia entre el paciente y la satisfacción del cirujano es limitada. En nuestra experiencia, se centran en cinco factores principales pueden mejorar las tasas de satisfacción de los pacientes: correcta selección del paciente, la fijación de las expectativas apropiadas, evitando complicaciones prevenibles, el conocimiento de los puntos más finos de la operación, y el uso de ambos pre-y post-operatorio vías. El conocimiento de la existencia, así como la identificación de los factores predictivos de la discordancia paciente-cirujano potencialmente deberían ayudar a mejorar los resultados del paciente.

Abstract

Total knee replacement (TKR) is one of the most common operations in orthopaedic surgery worldwide. Despite its scientific reputation as mainly successful, only 81% to 89% of patients are satisfied with the final result. Our understanding of this discordance between patient and surgeon satisfaction is limited. In our experience, focus on five major factors can improve patient satisfaction rates: correct patient selection, setting of appropriate expectations, avoiding preventable complications, knowledge of the finer points of the operation, and the use of both pre- and post-operative pathways. Awareness of the existence, as well as the identification of predictors of patient–surgeon discordance should potentially help with enhancing patient outcomes.

Cite this article: Bone Joint J 2013;95-B, Supple A:120–3.

EHS-EFORT BAT Instructional Course: Hip pathology in young adults - Basic Course Madrid, Spain, 5-7 March 2014

una publicación de Victor Ravens.

http://www.physiospot.com/research/a-multidisciplinary-enhanced-recovery-programme-allows-discharge-within-two-days-of-total-hip-replacement/

A multidisciplinary enhanced recovery programme allows discharge within two days of total hip replacement

This study presents three- to five- year results of 100 sequential patients undergoing total hip replacement (THR) through a multidisciplinary rapid recovery programme, with mean length of stay (LOS) 1.99 nights. Patients attend pre-admission ‘bone school’, with talks and assessments by the senior sister, physiotherapist and occupational therapist. All received an uncemented Corail-Pinnacle THR via piriformis-sparing mini-posterior approach. ‘Low dose’ spinal plus light general anaesthesia offers sensory block whilst retaining motor function; pain free mobilisation is predictably achieved within a four hours. Following radiograph and haemoglobin check the following morning, patients were discharged upon meeting specific nursing/physiotherapy criteria. Those within 20 miles received outreach follow-up. Follow-up assessment was undertaken using SF36, Visual Analogue, Merle d’Aubigné-Postel and Oxford Hip Scores. Mean age was 65 years (25-91), mean BMI 28.7 (19-43). ASA ranged 1-3 (mode 2), Charlson comorbidity index from 0-9 (mode 3). Major complications were: one dislocation with deep infection, one myocardial infarction, one trochanteric bursitis requiring exploration, one ceramic fracture, and three metal debris reactions. Several more minor complications occurred. LOS was longer in older patients (p = 0.03) and those with higher Charlson index (p = 0.02). Eighty-two patients remain under follow-up, (mean 37.8 months, range 36-61). Six have died; five underwent revision; seven have moved away or been lost. Ninety-seven percent remain quite or very satisfied. This LOS is amongst the shortest in the United Kingdom, with encouraging outcomes. The SSP succeeds by involving all team-members and managing patient expectations. At a time of limited healthcare resources the authors propose that their SSP could readily be reproduced in other places with similar benefits.

Categories: Musculoskeletal

http://traumatologia.diariomedico.com/2013/10/04/area-cientifica/especialidades/traumatologia/tecnica-pionera-protesis-cadera

Técnica pionera en prótesis de cadera

Conservar la cápsula optimiza la recuperación y evita complicaciones.

Karla Islas Pieck. Barcelona | karla.islas@diariomedico.com   |  03/10/2013 17:49

Felipe Delgado, Antoni Salvador , Albert Broch. (Jaume Cosialls)

Un grupo del Servicio de Cirugía Ortopédica y Traumatología del Hospital de Sant Celoni, en Barcelona, encabezado por Antoni Salvador, Felipe Delgado y Albert Broch, ha desarrollado una innovadora técnica que consiste en conservar la cápsula de la articulación durante la cirugía de prótesis de cadera primaria, lo que consigue acortar en un 50 por ciento la estancia hospitalaria y favorece una recuperación mucho más rápida del paciente.

Según han explicado los cirujanos a Diario Médico, este procedimiento denominado Maash permite dinamizar al paciente de forma muy rápida y puede volver a su casa en tres días sin necesidad de limitar sus movimientos y poner alzadores en el baño o evitar sentarse en sitios bajos, tal como sucede con la cirugía convencional.

La técnica, que consiste en realizar una incisión transversal en la cápsula e introducir la prótesis por ahí, como si se tratara de un telón de teatro, está indicada en osteoartritis primaria de cadera, en fracturas intracapsulares de fémur y en displasias acetabulares de tipo 1 y 2. No está indicada en el caso de luxaciones congénitas de cadera y tampoco es viable en las cirugías de revisión, en las que se realiza el recambio de las prótesis, principalmente porque normalmente estos pacientes ya no conservan la cápsula.

El grupo del Hospital de Sant Celoni ha ido perfeccionando poco a poco esta intervención, con la que se ha operado a más de 150 pacientes hasta ahora y los resultados de la serie con el primer centenar de casos demuestran que reduce de forma muy significativa el riesgo de luxación y la diferencia de longitud de las piernas, que son dos de las principales complicaciones de esta cirugía.

Salvador ha comentado que esta variación de la técnica potencia la función natural de la cápsula articular, que es una estructura que alberga los ligamentos y que a su vez ofrece estabilidad a la cadera respetando la anatomía de cada individuo.

La intervención convencional, que consiste en resecar la cápsula para colocar la prótesis, requiere una planificación compleja que normalmente se realiza por medio de navegadores informáticos y que ayuda a los cirujanos a obtener la mayor precisión posible. La opción conservadora no sólo simplifica el proceso de planificación, sino también la propia ejecución de la operación.

Delgado y Broch han señalado que la técnica es relativamente sencilla y que, una vez superada la curva de aprendizaje, es fácilmente reproducible.

Ahorro de costes
La reducción a la mitad de los días de estancia hospitalaria y la minimización de las complicaciones asociadas a la intervención tiene también una traducción importante en cuanto a los costes se refiere.

Según los últimos datos que constan en la literatura científica, del total de pacientes a los que es necesario practicarles una cirugía de revisión tras la colocación de una prótesis de cadera, un 22 por ciento han sufrido luxaciones tras la intervención.

Además, es necesario considerar los riesgos asociados a la cirugía, como las hemorragias o infecciones, y los que implica la propia hospitalización, como las infecciones nosocomiales, cuyo riesgo también se reduce de una manera indirecta.

http://www.ossburbank.com/blog/irritation-of-the-plantar-fascia/

Irritation of the plantar fascia.

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Plantar fasciitis is irritation of the thick tissue on the bottom of the foot. This tissue is called the plantar fascia. It connects the heel bone to the toes and creates the arch of the foot.

In order to reduce the risk it’s important to know the potential reasons for plantar fasciitis:
1. Poor arch support
2. Inadequate shock absorption in your shoe
3. Lack of range of motion in the toe or ankle causing stiffness
4. Poor gait or walking patterns

If you’re experiencing pain that appears to be related to plantar fasciitis, Dr. Mark Mikhael focuses on the management of all musculoskeletal conditions of the foot and ankle.

#OUCH #OSSBurbank #OUCHClinic #plantarfasciitis #plantarfascia