Dandu Navya, Knapik Derrick M, Darwish Reem Y, Yanke Adam B
Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, USA.
Video J Sports Med. 2022 Feb 22;2(1):26350254211049809. doi: 10.1177/26350254211049809. eCollection 2022 Jan-Feb.
Trochlear dysplasia represents one of the main anatomic risk factors for patellar instability, with risk of failure and unfavorable clinical outcomes in patients with unaddressed dysplasia undergoing patellar stabilization.
Patients with trochlear dysplasia characterized by supratrochlear prominence (DeJour B or D) and recurrent patellar instability, especially following failed soft tissue or bony stabilization. This technique addresses an anterior trochlea without pathologic convexity, as convexity may require conversion to other techniques for groove deepening (eg, DeJour "thick flap" or Schottle "thin flap").
A 6-cm lateral parapatellar arthrotomy is created. A marking pen is used to identify the native center of the trochlea, as well as the location of the planned resection and bony hinge point laterally. An osteotome is used to remove a wedge of bone proximally, such that the posterior aspect of the osteotomy is in line with the anterior femoral cortex. A resection guide is then used to perforate the lateral cortex, with care to avoid damaging the cartilage, and carried laterally and distally to ensure the bony cuts are connected, creating the bony flap. To ensure that all bony bridges are eliminated, the arthroscope is placed into the osteotomy to visualize reduction of the trochlea with manual pressure. A knotless PEEK anchor loaded with 8 loaded sutures is then placed on the roof of the trochlear notch. Sutures are then secured using anchors placed at the center of the trochlea, at the superolateral corner and far lateral edge of the trochlea to reduce the osteotomy, with 2 to 3 sutures placed in each anchor depending on surgeon preference.
Trochleoplasty has been reported to decrease the rate of recurrent patellar dislocation while improving mean Kujala score and knee function. Benefits of trochleoplasty must be balanced against the high rate of potential complications, primarily pain and decreased knee range of motion, secondary to the technical challenges and steep learning curve inherent to effectively performing the procedure.
DISCUSSION/CONCLUSION: Patients with recurrent patellar instability with trochlear dysplasia and failed prior stabilization may experience improved stability and outcomes following trochleoplasty.
滑车发育不良是髌骨不稳定的主要解剖学危险因素之一，对于未处理发育不良而接受髌骨稳定手术的患者，存在手术失败及不良临床结局的风险。
具有滑车上方突出（DeJour B型或D型）且复发性髌骨不稳定的滑车发育不良患者，尤其是在软组织或骨性稳定手术失败后。该技术适用于无前病理性凸度的前滑车，因为凸度可能需要转换为其他加深滑车沟的技术（例如，DeJour“厚瓣”或Schottle“薄瓣”）。
做一个6厘米的髌旁外侧关节切开术。用标记笔确定滑车的自然中心，以及计划切除部位和外侧骨铰链点的位置。用骨刀在近端切除一块楔形骨，使截骨的后缘与股骨干前皮质对齐。然后使用切除导向器在外侧皮质打孔，注意避免损伤软骨，并向外侧和远端延伸以确保骨切口相连，形成骨瓣。为确保消除所有骨桥，将关节镜放入截骨处，通过手动加压观察滑车复位情况。然后将装载有8根缝线的无结聚醚醚酮（PEEK）锚钉置于滑车沟顶部。接着使用置于滑车中心、滑车的上外侧角和远外侧边缘的锚钉固定缝线以复位截骨，根据术者偏好，每个锚钉放置2至3根缝线。
据报道，滑车成形术可降低复发性髌骨脱位的发生率，同时提高平均Kujala评分和膝关节功能。滑车成形术的益处必须与高潜在并发症发生率相权衡（主要是疼痛和膝关节活动范围减小），这是由于有效实施该手术固有的技术挑战和陡峭的学习曲线所致。
讨论/结论：患有滑车发育不良且复发性髌骨不稳定且先前稳定手术失败的患者，在接受滑车成形术后可能会获得更好的稳定性和结局。
