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Figure 13.1. The true lateral radiograph (posterior condyles superimposed) helps in detecting patellar tilt and dysplasia of the trochlea (see Chapter 4).
Figure 13.2. Patellar articular cartilage fibrillation may follow blunt trauma, and isolated debridement of such lesions may bring symptomatic relief when there is no ongoing overload to the affected surface.
Figure 13.3. Normal patellar articular cartilage as seen with an arthroscope. Photo courtesy of Dandy D. Arthroscopy of the Knee slide collection, Gower Medical Publishing.
Figure 13.4. Anteromedial tibial tubercle transfer along an oblique osteotomy plane as described by Fulkerson (20). Note particularly that the deep peroneal nerve and the anterior tibial artery must be avoided and protected at all times. Illustration by Joyce Willis.
Figure 13.5. Chronic lateral patellar tilt and subluxation can cause lateral facet breakdown and arthrosis. Anteromedial tibial tubercle transfer will unload the lateral facet and realign the patella.
Figure 13.6. Instruments necessary to do an anteromedial tibial tubercle transfer include wide and 1/4‑inch Lambotte osteotomes, a mallet, extra‑long drill bits, a drill guide (Howmedica Hoffman Drill Guide or DePuy Tracker Guide), drill bits for cortical screw fixation, depth gauge, tap, power drill, Hemovac, and, alternatively, an oscillating saw (not shown).
Figure 13.7. Before each anteromedial tibial tubercle transfer, routine arthroscopy is performed using a superior approach to view patella tracking and precise description of patella articular lesions as to extent and location. Routine arthroscopy of the entire knee is important to identify any associated or concomitant lesions.
Figure 13.8. Debridement of lesions may be accomplished most effectively with arthroscopic visualization, in many cases.
Figure 13.9. The incision is just lateral to midline and extends from the mid‑patella level to a point located 5 to 9 cm distal to the tibial tubercle.
Figure 13.10. Sharp dissection, with minimal undermining, is used to expose the lateral side of the knee, including the patellar tendon.
Figure 13.11. The patellar tendon is carefully identified as the retinacular fibers along its lateral edge are released while obtaining hemostasis.
Figure 13.12. Lateral retinacular release may be accomplished by the surgeon using Mayo scissors after spreading subcuticular tissue. Again, careful attention must be paid to hemostasis. Also, the surgeon must avoid the main vastus lateralis tendon. Retractors are used as necessary.
Figure 13.13. After lateral release, the surgeon can view the patella completely. Any infrapatellar contracture should be released so that the patella can be everted a full 90 degrees. A precise description of the articular lesion should be recorded in the operation report. This patella demonstrates typical lateral facet and central ridge (Ficat's critical zone) erosion. Note that the proximal patella is intact.
Figure 13.14. Another view more clearly demonstrating a Ficat's critical zone lesion and the intact proximal medial facet.
Figure 13.15. The patellar tendon is completely mobilized and released, if necessary, from any posterior contracture. The anterior tibial crest is exposed for a full 5 cm at least.
Figure 13.16. The patellar tendon should be free, and its insertion into the tibia must be clearly delineated.
Figure 13.17. Sharp dissection is used to incise the periosteum just medial to the patellar tendon and extending distally just medial to the anterior tibial crest.
Figure 13.18. After incising the fascial insertion of the tibialis anterior muscle, the anterior tibial muscle is reflected sharply through the use of an elevator off the lateral side of the tibia, such that the entire lateral tibia may be viewed all the way to the posterolateral corner.
Figure 13.19. Using the drill guide, the surgeon fashions an oblique osteotomy, directing the drill bits posterolaterally and being sure to view the exiting drill bit tip at the posterolateral tibia just anterior to the posterolateral corner. A steep osteotomy permits maximal anteriorization and requires that the initial drill bit be placed immediately medial to the patellar tendon insertion.
Figure 13.20. Note that the exiting drill bit tip is visualized fully, and a retractor is kept at this point to avoid any problem related to the drill bit passing posteriorly where the anterior tibial artery and deep peroneal nerve are located.
Figure 13.21. The distal drill bit is placed precisely parallel to the first drill bit, using the drill guide to assure parallelism. The guide should be slipped up and down on the two drill bits to avoid any binding or lack of parallelism. Some time is taken to assure this precise parallel placement of the second drill bit at the distal extent of the osteotomy. This distal drill bit must be just behind the anterior crest of the tibia, such that it is significantly more anterior than the initial drill bit. There is dense cortical bone at this point, and the drill bit will normally pass exclusively through cortex if it is properly placed. Once the two drill bits are in place, the drill guide is secured, and the two drill bits are left in place. The DePuy Tracker guide uses two 2.0 pins for fixation of a cutting block with slot for an oscillating saw.
Figure 13.22. With the drill guide fixed in place, multiple drill holes are placed between the proximal and distal drill bits to create an osteotomy plane. Both cortices are drilled. A retractor is used to protect the lateral side of the knee from drill bit penetration past the lateral cortex, as noted in this illustration. Several unicortical drill holes are made proximal to the upper drill bit to a level above the patellar tendon insertion medially.
Figure 13.23. A wide Lambotte osteotome connects the most proximal drill bit with a point 5 mm above the patellar tendon insertion laterally. This cut is unicortical and is made to permit freeing of the osteotomy laterally once the osteotomy is complete, such that the bone pedicle may be displaced without fracturing into the metaphysis.
Figure 13.24. A 1/4‑inch osteotome completes the cortical cut 5 mm proximal to the patellar tendon insertion and is carried all the way to the medial cortex. A wide osteotome will complete the osteotomy. An oscillating saw may be used here alternatively. It is critically important that this cut be precisely between the proximal and distal drill bits along the osteotomy plane. Once the osteotome or saw is placed into the bone, it is kept in the osteotomy to complete the osteotomy with careful visualization of the lateral side to avoid damage to the tibialis anterior muscle. The surgeon should avoid removing the osteotome or saw to start a new osteotomy in another location in order to avoid disparate osteotomy planes. Careful attention to detail and patience are necessary at this point. Be sure that the osteotomy tapers anteriorly as it is created distally.
Figure 13.26. Once the osteotomy is completed, the bone pedicle may be displaced in an anterior and medial direction along the osteotomy plane. Notice the tapering of the osteotomy anteriorly at its distal extent.
Figure 13.27. Anteriorization of 1.3 to 1.7 cm is routine.
Figure 13.28. Holding the displaced pedicle in the desired location, after testing the patella alignment and anteriorization, cortical screw fixation will achieve stability of the osteotomy pedicle. The proximal cortex is overdrilled to allow a slight lag effect for compression across the osteotomy site. Notice that this drill hole is placed perpendicular to the osteotomy plane.
Figure 13.29. A countersink will assure that the screw head seats securely into the cortical bone with minimal risk of fracturing the pedicle.
Figure 13.30. A depth gauge is used after the countersink to assure fixation to the posterior cortex.
Figure 13.31. A tap just through the posterior tibial cortex assures secure cortical bone fixation.
Figure 13.32. The first screw is perpendicular to the osteotomy plane and permits further testing of the patella alignment to assure that the distal patella is elevated and the alignment is optimal.
Figure 13.33. A second cortical screw is placed into the posterior cortex to maximize stability of the transferred bone pedicle.
Figure 13.34. The completed anteromedial tibial tubercle transfer before release of the tourniquet and obtaining hemostasis.
Figure 13.35. In this case, at least 1.5 cm of anteriorization has been achieved.
Figure 13.36. A light compressed wrap followed by a Cryocuff (Aircast, Summit, NJ) minimizes swelling and helps diminish postoperative pain. The Hemovac is removed approximately 3 hours after surgery once hemostasis has been achieved, or may be removed at a later time if bleeding persists. Patients are encouraged to elevate the extremity above heart level for 2 to 3 days and use crutches to protect weightbearing for 6 weeks. Motion, however, is started immediately postoperatively.
Figure 13.37. Arrows indicate the bone cut necessary to prevent extension of the osteotomy into the lateral tibial metaphysis. A second screw must be added.
Figure 13.38. Offset bone graft to create straight anteriorization using an oblique osteotomy and local bone graft from the lateral metaphysis.
Figure 13.39. Patellectomy demonstrating the technique of Boyd and Hawkins. Reprinted with permission from Boyd H, Hawkins B. Patellectomy—A simplified technique. Surg Gynecol Obstet 1948;86:357.
Figure 13.40. Anterior tibial tubercle displacement by the Bandi technique. A, Adequate lateral parapatellar incision is necessary. B, Lateral retinacular release and arthroscopy of the joint for removal of loose bodies, trimming of osteophytes, and any indicated ancillary intra‑articular procedure is obligatory. C, Retropatellar tendon area of the tibia is exposed to determine the proximal margin of the insertion of the tendon into the tubercle. D, At 3 cm distal to this proximal border and 3 mm posterior to the anterior cortex, a drill hole is made in order to prevent inadvertent extension of the osteotomy. E, Position of the drill hole and the osteotomy are demonstrated. F, Osteotomy is carried out and the anterior fragment levered anteriorly. G, Bone graft is wedged in the opening using a cortical cancellous wedge from the iliac crest. Because the distal cortex has not been broken, the position is stable and does not usually require internal fixation. Reprinted with permission from Bandi W. Chondromalacia patellae and femoro‑patellare arthrose. Helv Chir Acta (suppl) 1972; 1:3‑70.
Figure 13.41. Mechanical failure of a tibial tubercle anteriorization using bone graft distraction of the osteotomy.
Figure 13.42. Polyethylene replacement of the patella is less desirable than metal because of poor polyethylene wear characteristics on articular cartilage.
Figure 13.43. A, Anterolateral tibial tubercle transfer is possible by creating an osteotomy oriented from the anterolateral side of the tibia, directing it posterolaterally to include the posteromedially placed bone block of a previous Hauser procedure (illustration by Susan Brust). B, C, and D, Oblique osteotomy of the tibial tubercle will permit anterolateral shift of the tibial tubercle.
Figure 13.43. Continued.
Inside Chapter 13: