Anterior tibial tubercle osteotomy in adolescents and young adults: functional results and complications
Abstract
Introduction: Tibial tubercle osteotomy (TTO) is a surgical approach that allows for the restoration of distal patellar alignment in skeletally mature patients. The objectives of this study were to evaluate functional results and to analyze the risk factors associated with complications. Methods: We carried out a retrospective analysis of patients subjected to a TTO between 2008 and 2016 and documented demographic and clinical data. Results were evaluated according to the Kujala Anterior Knee Pain Scale and the Tegner-Lysholm Knee Scoring Scale. Complications were evaluated with a modified Clavien-Dindo Classification of Surgical Complications. Results: We evaluated 33 TTOs in 29 patients (17 women) with a median age of 18 years (IQR 2, range: 14-39) and a median follow-up time of 49 months (IQR 2, range: 12-115). The Kujala and the Tegner-Lysholm scoring improved from 61 and 61.5 to 94 and 92.3, respectively (p=0.001). Union was achieved at a median of 8 weeks. There were 9 complications (27%): a grade II complication (superficial infection) and 8 grade III complications (arthrofibrosis, tibial fractures, and anterior tibial tubercle fractures). Osteotomies in which the tibial tubercle was completely detached had a significantly higher rate of complications (51.5% vs. 11.1%, p=0.029). Conclusions: TTO represents an effective approach for the treatment of several conditions of the patellofemoral joint in adolescents and young adults. In our series, a high percentage of the procedures presented complications, although they did not affect the final result. Osteotomies that involve complete detachment of the tubercle and those associated with ligament reconstruction have an increased risk of complications.Downloads
References
Waterman BR, Belmont PJ, Jr, Owens BD. Patellar dislocation in the United States: role of sex, age, race, and athletic participation. J Knee Surg 2012;25:51-7. DOI: 10.1055/s-0031-1286199
Glaviano NR, Kew M, Hart JM, Saliba S. Demographic and epidemiological trends in patellofemoral pain. Int J Sports Phys Ther 2015;10(3):281-90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458915/
Longo G, Rizzello G, Cuiffreda M, Loppini M, Baldari A, Maffulli N, Denaro V. Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait and other distal realignment procedures for de management of patellar dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy 2016;32(5):929-43. DOI: 10.1016/j. arthro.2015.10.019
Cox JS. An evaluation of the Elmslie-Trillat procedure for management of patellar dislocations and subluxations. A preliminary report. Am J Sports Med 1982;10(5):303- 10. DOI: 10.1177/036354657600400204
Hauser EDW. Total tendon transplant for slipping patella: a new operation for recurrent dislocation of the patella. Surg Gynec Obstet 1938; 66:199-214. DOI: 10.1097/01.blo.0000238831.50186.87
Maquet P. Advancement of the tibial tuberosity. Clin Orthop Relat Res 1976;115:225-30. DOI: 10.1097/00003086-197603000-00039
Fulkerson J, Becker G, Meaney J, Miranda M, Folik M. Anteromedial tibial tubercle transfer without bone graft.
Am J Sports Med 1990;8:490-7. DOI: 10.1177/036354659001800508
Feller J. Distal realignment (tibial tuberosity transfer). Sports Med Arthrosc Rev 2012;20:152-61. DOI: 10.1097/JSA.0b013e318262e8e7
Payne J, Rimmke N, Schmitt LC, Flanigan DC, Magnussen RA. The incidence of complications of tibial tubercle osteotomy: a systematic review. Arthroscopy 2015;31(9):1819-25.
DOI: 10.1016/j.arthro.2015.03.028
Bellemans J, Cauwenberghs F, Witvrouw E, Brys P, Victor J. Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment. Am J Sports Med 1997;25:375-81. DOI: 10.1177/036354659702500318
Shelbourne KD, Porter DA, Rozzi W. Use of a modified Elmslie-Trillat procedure to improve abnormal patellar congruence angle. Am J Sports Med 1994;22:318-23. DOI: 10.1177/036354659402200304
Tomatsu T, Imai N, Hanada T, Nakamura Y. Simplification of the Elmslie-Trillat procedure for patellofemoral malalignment. Is medial capsulorraphy necessary? Int Orthop 1996;20:211-5. DOI:10.1007/s002640050065
Tsuda E, Ishibashi Y, Yamamoto Y, Maeda S. Incidence and radiologic predictor of postoperative patellar instability after Fulkerson procedure of the tibial tuberosity for recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2012;20:2062-70.
DOI: 10.1007/s00167-011-1832-2
Trillat A, Dejour H, Couette A. Diagnosis and treatment of recurrent dislocations of the patella. Rev Chir Orthop Reparatrice Appar Mot 1964;50:813-24.
Luhmann SJ, Fuhrhop S, O’Donnell JC, Gordon JE. Tibial fractures after tibial tubercle osteotomies for patellar instability: A comparison of three osteotomy configurations. J Child Orthop 2011;5:19-26. DOI: 10.1007/s11832-010-0311-5
Sink E, Leunig M, Zaltz I, Gilbert JC, Clohisy J. Reliability of a complication classification system for orthopaedic surgery. Clin Orthop Relat Res 2012;470:2220-6. DOI: 10.1007/s11999-012-2343-2
Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J. The tibial tuberosity-trochlear groove distance: a comparative study between CT and MRI scanning. Knee 2006;13(1):26-31. DOI: 10.1016/j.knee.2005.06.003
Masquijo JJ, Altube G, Ferreyra A, Allende V, Torres-Gómez A. Precisión de la resonancia magnética para la medición de la distancia TT-TG en adolescentes. Artroscopía 2013;20(1):7-10. https://www.revistaartroscopia.com/ediciones-anteriores/2013/volumen-20-numero-1/89-volumen-05-numero-1/volumen-20-numero-1/608-precision-dela-resonancia-magnetica-para-la-medicion-de-la-distancia-tt-tg-en-adolescentes
Miller TT, Staron RB, Feldman F. Patellar height on sagittal MR imaging of the knee. AJR Am J Roentgenol 1996;167:339-41. DOI: 10.2214/ajr.167.2.8686598
Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy 1993;9(2):159-63. DOI: 10.1016/S0749-8063(05)80366-4
Bengtsson J, Möllborg J, Werner S. A study for testing the sensitivity and reliability of the Lysholm knee scoring scale. Knee Surg Sports Traumatol Arthrosc 1996;4(1):27-31.
DOI: 10.1007/BF01565994
Tang JB. Re: Levels of experience of surgeons in clinical studies. J Hand Surg Eur 2009;34(1):137-8. DOI: 10.1177/17531934097321
Koeter S, Diks MJ, Anderson PG, Wymenga AB. A modified tibial tubercle osteotomy for patellar mal- tracking: Results at two years. J Bone Joint Surg Br 2007;89:180-5. DOI: 10.1302/0301-620X.89B2.18358
Shen H-C, Chao K-H, Huang G-S, Pan R-Y, Lee C-H. Combined proximal and distal realignment procedures to treat the habitual dislocation of the patella in adults. Am J Sports Med 2007;35:2101-8. DOI: 10.1177/0363546507305014
Sillanpää P, Mattila VM, Visuri T, Mäenpää H, Pihlajamäki H. Ligament reconstruction versus distal realignment for patellar dislocation. Clin Orthop Relat Res 2008;466:1475-84.
DOI: 10.1007/s11999-008-0207-6
Barber FA, McGarry JE. Elmslie-Trillat procedure for the treatment of recurrent patellar instability. Arthroscopy 2008;24:77-81.
DOI: 10.1016/j.arthro.2007.07.028
Benoit B, Laflamme GY, Laflamme GH, Rouleau D, Delisle J, Morin B. Long-term outcome of surgically-treated habitual patellar dislocation in children with coexistent patella alta. Minimum follow-up of 11 years. J Bone Joint Surg Br 2007;89:1172-7.
DOI: 10.1302/0301-620X.89B9.19065
Nakagawa K, Wada Y, Minamide M, Tsuchiya A, Moriya H. Deterioration of long-term clinical results after the Elmslie-Trillat procedure for dislocation of the patella. J Bone Joint Surg Br 2002;84:861-4. DOI: 10.1302/0301-620X.84B6.0840861
Tompkins M, Arendt EA. Complications in patellofemoral surgery. Sports Med Arthrosc 2012;20:187-93.
DOI: 10.1097/JSA.0b013e31825c74cf
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