Delee Osteotomy For Patella Baja/Infera and Infrapatellar Contracture Syndrome (IPCS)
"Patella baja and infrapatellar contracture syndrome are one of the worst conditions for a patient to have and for a physician to treat."
These were the words of my first knee specialist doctor.
I was diagnosed with patella baja and infrapatellar contracture syndrome in July of 2001. This came 11 mos after my horseback riding accident, where I broke my tibia and fibula in 4 places. I developed arthrofibrosis of my knee, after the nailing procedure thru my knee, to repair the tibia fractures.
I was referred to a knee specialist in my town, by the OS who performed a tibia/fibula derotational osteotomy, to correct a malunion of the tibia. I had continuing problems with my knee from the surgery in the form of flexion and extension deficits, swelling, pain, heat, very tight patella and subluxation. I had a series of xrays taken by this knee specialist's office. When the doctor came in, he immediately informed me, I had patella baja. He proceeded to show me, on the xrays, how low my patella was sitting. He took various measurements on the xrays to confirm this. He performed a thorough physical exam. This showed a patella with very little movement and obviously sitting low. I had poor, painful, flexion and extension. Because I was only 4 mos post-op from the derotational osteotomy and my xrays showed I had developed osteopenia, which is decrease in bone mass, any surgery would have to be delayed. The osteopenia came about from having several months of inactivity from all the surgeries I had been thru. At this point I had been thru 4 big surgeries in a 7 month period. This surgery would involve placement of one or 2 screws, to my tibia tubercle, which would be holding a lot of tension. The OS felt my bone was not strong enough at this point. He wanted me to recover longer from the derotational surgery, build my quad up and possibly see if there was any improvement in my patella height with a stronger quad. In the meantime. I was placed in a Breg PTO brace for my patella and scheduled for an MRI.
In Oct of 01, the results of the MRI came back. It showed changes to my patella tendon. It showed the shortening and thickening of the tendon. These changes to the patella tendon are permanent. It also showed damage to the patella articular cartilage. My patella cartilage was already showing the damage from being in this baja state. My OS said the patella was scooping out the groove much like an ice cream scoop with ice cream. Damaging the patella with each scoop. The plan was to continue with the quad strengthening and building the bone mass in my leg which would come from physical therapy. I also used swimming to build my quad.
In November of 01, I had a follow-up appointment with the OS, who did the derotational osteotomy. During this osteotomy, 2 plates were placed on my distal tibia. The medial, shorter plate, had been causing problems for several months with pain, swelling, tenderness and redness, to my lower leg. My OS felt it was compressing the Saphenous nerve. He said since I was 9 mos post-op, he felt he could remove this plate. The larger plate would stay in as I am at risk for refracture. In Dec, I had the smaller plate removed. It was done as outpatient surgery. This ended the problem with the saphenous nerve.
In January of 2002, I had another appointment with the OS. I did not show any improvement in regards to my patella, flexion or extension. I did have quad improvement. I accomplished the quad strengthening by swimming. I did the back crawl, swimming laps, 30 min straight. I was unable to do the front crawl because my knee would catch and sublux. I was scheduled for a procedure, called a Delee Osteotomy, to repair the patella baja and IPCS. The OS also said he would first try scoping to see if removal of scar tissue would produce results , then proceed to an open procedure for debridement, known as an anterior interval release, before resorting to the Delee osteotomy. When I talked to the surgery scheduler, she had never heard of this procedure in the 20 yrs she had been doing this job. She had to ask the doctor about my procedure and how to schedule post - op care too. I was scheduled for February of 2002.
February's surgery date quickly arrived. I was issued a polar care unit. This was the first time I used one. It is a great way to deliver continuous cold therapy to the knee, especially post-op. Since this surgery, I have been thru 3 polar care units. I have burned the motors out of all of them, from so much use. I went thru all the usual surgery prep. This was my first time experiencing a femoral nerve block. I didn't like the thought of that and requested I be asleep when it was done !!
The doctor proceeded to do surgery, first he did an arthroscopy. This proved to do very little for the patella position. He next did an open procedure. He performed an anterior interval release. He debrided quite alot of scar tissue from the patella tendon and under. He still couldn't get the patella to budge. My patella tendon was found to be completely adhesed down to the tibia. He then proceeded to do the Delee Osteotomy. This is a type of tibia tubercle transfer, for patella baja and IPCS. My OS made a special cut into the tubercle, where the patella tendon is connected. This cut in the bone was deep and angled, like a wedge. This bone cut was all the way thru and the the bone piece, with the tendon connected, was brought straight up, proximally. The angled cut of the bone also brought the patella, anteriorly, so it would be out of the joint space. This was secured in place with one large screw and washer. My patella was once again back into correct mechanical postion. The area where the bone was cut, was repaired with bone from the tissue bank. The OS also did a z-plasty to the lateral retinaculum. A z-plasty is a surgical procedure where tight tissues are cut in a Z, to provide a gradual, controlled, release of tight tissues. This was done to provide patella decompression. The OS also did a chondroplasty to the articular cartilage of the patella. I was placed in a full leg post-op knee brace, locked at 0. I spent the night in the hospital. I received morphine IM and IV and was hooked up to the polar care ice machine. I spent 8 weeks in the post op brace. I was locked at 0 for 4 weeks except during PT where very gentle ROM was done. I was NWB during this time. Due to the tension on this osteotomy, the NWB was neccessary. I started rehab March 1st. The OS said it would take 8 mos to 1 yr to recover and later amended that to 18 mos. I had 6 mos of scripted PT, then did my own. I had only 15% of my quad after this surgery.
This surgery greatly improved the mechanics of my knee. Once I was rehabbed, I was able to do stairs like a normal person, bend my knee and have full extension. The subluxation went away. I never once regretted having this done and I am grateful I had an OS who knew enough about patella baja and IPCS, to correctly diagnose and treat it. I did go on to develop more scar tissue after this surgery, which resulted in more surgery, during this continuous saga of Arthrofibrosis. At least the baja and IPCS were repaired.
This is one way to treat patella baja and IPCS. There are other techniques for this out there. Two such treatments are patella tendon lengthening and Maquet TTT procedure. All of these types of treatments are usually done as salvage procedures.
