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ISAKOS/PFF Travelling Fellowship Report (2017)
By Drs Jacqueline Munch Brady and Nicholas Paschos
We began our journey in beautiful Lyon, France with Dr David Dejour. We focused on instability, discussing the principles of clinical and radiographic evaluation of the patellofemoral joint, and indications for procedures such as distalizing tibial tubercle osteotomy and trochleoplasty. Dr. Dejour explained the thought process behind identifying patella alta and/or trochlear dysplasia as the major contributing factor to instability, and correcting each accordingly.
Dr. Philippe Neyret was our next host, across the city in Lyon. With him, we shifted our focus to the extensor mechanism of the knee, discussing considerations for surgical intervention in chronic quadriceps or patellar tendon insufficiency. He demonstrated a technique for complex reconstruction of a deficient patellar tendon using mesh augmentation, for instances where the native tendon is insufficient for repair.
Next, we stopped in London to visit Dr. Andrew Amis. His lab at the Imperial College is equipped to study everything from soft tissue anatomy to complex joint kinematics. We discussed the difficulties in studying the patellofemoral joint biomechanically: for instance, a dearth of trochlear dysplasia in cadaveric material, and the complexity of the soft tissue envelope surrounding the joint. We toured his laboratory and the neighboring robotics laboratory, and then had a great discussion with Dr. Amis and his colleague Dr Jo Stephen regarding their recent interest in the anatomy of the infrapatellar fat pad and its contributions to symptoms in the patellofemoral joint.
We departed London, inspired to continue our studies. In Tampere, Finland, we shifted our research discussion to the clinical world with Dr. Petri Sillanpaa and his partner, Dr. Frederick Weitz. They collaborate on the majority of their trochleoplasty cases, in order to increase their respective experience and ensure close examination of their outcomes. Among other excellent cases, we observed the technique of thin-flap trochleoplasty, and discussed the surgical indications for the procedure.
At the end of our visit, providers from across Finland gathered in Tampere for a conference focusing on all aspects of the patellofemoral joint, and we had an excellent discussion on the latest developments in PF joint disorders. True to the Finnish tradition, we concluded our conference with a visit to the conference’s sauna!
For our second week, we returned to the United States, landing first in Hartford, Connecticut for a visit with UConn surgeons Dr. John Fulkerson and Dr. Cory Edgar. We shifted gears slightly to discuss chondral lesions and implications for patellofemoral surgery. Dr. Edgar filled us in on his latest biomechanical undertakings, explaining the effects of distalization of the tibial tubercle in early knee flexion. Dr. Fulkerson reviewed the anatomy of the medial patellofemoral complex, and demonstrated his MQTFL technique in addition to the anteromedializing tibial tubercle osteotomy. The UConn residents filled us in on some of their research surrounding patellofemoral anatomy and cartilage restoration techniques, and we were able to see one more case with Dr. Fulkerson, illustrating the treatment of iatrogenic medial instability, before departing for Minnesota.
Our next stop was the Mayo Clinic with Dr. Diane Dahm. After observing an MPFL reconstruction, we focused on patellofemoral arthritis in particular with Dr. Dahm. We discussed indications for unloading procedures versus patellofemoral arthroplasty. She demonstrated a lateral facetectomy in a patient who was too high-risk for arthroplasty. Afterward, we reviewed various patellofemoral implants, and discussed the fact that they vary significantly in design and considerations for technique.
From Rochester, we journeyed to neighboring Minneapolis, MN, where Dr. Elizabeth Arendt hosted us at the University of Minnesota. Dr. Arendt demonstrated her MPFL reconstruction technique of wrapping a graft around the adductor magnus tendon rather than creating a bony socket in the medial femur. We discussed the lateral retinacular complex, and she demonstrated the technique of lateral retinacular lengthening. Dr. Arendt also performed a thick-flap trochleoplasty technique in a severely dysplastic patient, demonstrating the ability of trochleoplasty to significantly improve the level of trochlear dysplasia on direct inspection and lateral fluoroscopic examination. We ended the visit with a morning in the laboratory, reviewing the complex anatomy of the patellofemoral joint and its soft tissue envelope, and trying our hand at tibial tubercle osteotomy and trochleoplasty procedures.
Throughout the journey, we felt incredibly grateful and fortunate to have the opportunity to learn from some of the leaders in our field. We are eternally thankful to our hosts for their time and energy. The trip was challenging and enlightening in all the right ways, and we look forward to using our improved understanding to treat our patients and contribute to the literature.
Our travels in pictures: