Lurie Benjamin, Hatch George F
Department of Orthopedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
Video J Sports Med. 2024 Jul 22;4(4):26350254241234677. doi: 10.1177/26350254241234677. eCollection 2024 Jul-Aug.
Patellar instability with symptomatic cartilage lesions in young patients is a challenging problem to treat. The use of osteotomies to correct malalignment and fresh osteochondral allograft transplantation (OCA) to address cartilage lesions and patellofemoral dysplasia is a viable treatment option for carefully selected patients.
The patient is a 22-year-old woman with medial patellar instability caused by iatrogenic distal femoral external rotation and uncontained grade IV patellofemoral lesions. The patient was indicated for OCA because the lesions were too large for an osteochondral autograft transfer system (OATS) and were uncontained and not amenable to autologous chondrocyte implantation. Bipolar OCA also addresses the patient's patellofemoral dysplasia by restoring a more morphologically normal patellofemoral joint. The external rotation and mild varus deformity are corrected with a biplanar distal femoral osteotomy. Correction of malalignment is necessary prior to OCA transplantation to avoid abnormal graft loading and thereby decrease the risk of graft failure.
(1) Diagnostic arthroscopy and fluoroscopic examination under anesthesia. (2) Lateral closing wedge de-rotational distal femoral osteotomy. (3) Bipolar OCA with tibial tubercle osteotomy and removal of hardware.
In this case, the patient had significant improvement in her symptoms and had full knee range of motion with a normal gait at 3 months after surgery. Depending on a patient's preoperative function and the specific pathology, full recovery can take considerably longer. A successful outcome is considered return to activities of daily living without significant pain. Return to higher level athletic activities is significantly more unpredictable. Graft survival of bipolar patellofemoral OCA is variable, and the literature is limited by the small number of procedures performed, but published series range from 60% to 85% at 5 years.
DISCUSSION/CONCLUSION: A successful outcome in these unique, complex cases depends on good patient selection, preoperative planning, and surgical execution. Patellar instability can be reliably treated when the predisposing anatomical factors are appropriately corrected. Bipolar OCA can provide significant improvement in pain and function, but continues to have the highest rate of graft failure compared with other sites within the knee, and should be considered a salvage operation for patients with significant limitations in activities of daily living.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
年轻患者出现伴有症状性软骨损伤的髌骨不稳定是一个具有挑战性的治疗难题。对于经过精心挑选的患者，采用截骨术纠正对线不良以及新鲜骨软骨异体移植（OCA）来处理软骨损伤和髌股发育异常是一种可行的治疗选择。
该患者为一名22岁女性，因医源性股骨远端外旋导致内侧髌骨不稳定以及开放性IV级髌股损伤。该患者适合进行OCA，因为损伤面积太大，无法使用骨软骨自体移植转移系统（OATS），且损伤为开放性，不适合自体软骨细胞植入。双极OCA还可通过恢复形态上更正常的髌股关节来解决患者的髌股发育异常问题。通过双平面股骨远端截骨术纠正外旋和轻度内翻畸形。在进行OCA移植之前，必须纠正对线不良，以避免移植物异常受力，从而降低移植物失败的风险。
（1）麻醉下进行诊断性关节镜检查和透视检查。（2）外侧闭合楔形股骨远端去旋转截骨术。（3）双极OCA联合胫骨结节截骨术并取出内固定物。
在该病例中，患者症状有显著改善，术后3个月膝关节活动范围完全正常，步态正常。根据患者术前功能和具体病理情况，完全恢复可能需要更长时间。成功的结果被认为是能够在无明显疼痛的情况下恢复日常生活活动。恢复到更高水平的体育活动则更难以预测。双极髌股OCA的移植物存活率各不相同，由于实施的手术数量较少，相关文献有限，但已发表的系列研究显示，5年时移植物存活率在60%至85%之间。
讨论/结论：在这些独特、复杂的病例中取得成功的结果取决于良好的患者选择、术前规划和手术执行。当诱发解剖因素得到适当纠正时，髌骨不稳定可以得到可靠的治疗。双极OCA可以显著改善疼痛和功能，但与膝关节内的其他部位相比，其移植物失败率仍然最高，对于日常生活活动有显著限制的患者，应将其视为一种挽救性手术。
作者证明已获得本出版物中出现的任何患者的同意。如果个体可能被识别，作者已随本提交物附上患者的豁免声明或其他书面批准形式以供发表。
