NOTES - Surgical Procedures :
Advice Please on TTT or Microfracture and LR repai - - Posted by vicuae (vicuae), 14 December 2004
My OS is recommending a lateral release repair and then microfracture to repair a Grade IV Chondral damage. What I'm looking for is the best compromise between remaining active in sport but being sensible about trying to do the best thing to preserve knee function in 10/20 years time. I am 33 years old and also have prolapsed discs in my spine so am not keen to take too many risks, especially as I have not yet had children.
I have been reading a bit and wander if a microfracture is the right thing as on Steadman Hawkins clinic site it says microfacture is not suitable for knee misalignment problems to quote "Microfracture is not recommended when: the patient's knee is poorly aligned. " As i had the original LR for misalignment and the patella is now still misaligned I wander if, even with the LR repair, Microfarcture is the right choice? From my reading is seems a TTT may be more appropriate for long term recovery?
Posted by hmaxwell (Heather M.), 14 December 2004
Dr. Steadman is my surgeon, and he declined to do any microfracture on the deep chondral lesions on the back of my kneecap. He said this was for a variety of reasons:
1. Microfracture has a good success rate, but not when done on the back of the patella. There, the rate is less than 50% according to him. Location, location, location.
2. He said it would be like throwing good money after bad. The purpose of microfracture is to create fibrocartilage that will serve as a replacement for the missing/eroded articular cartilage. However, unless you fix the mal-alignment that caused the cartilage to be worn away, you will just chew up the fibrocartilage created by microfracture. Worse, the fibrocartilage will erode much faster than the original stuff. Given the length of time required to rehab a knee after microfracture and the low success rate and the practically guaranteed chances of eroding the new fibrocartilage away, Dr. Steadman just didn't feel it was a worthwhile procedure in my case.
Most of the so-called cartilage restoration techniques (microfracture, ACI/Carticel, OATS) are more appropriate for certain types of patients: those who have a highly concentrated or focal lesion that was due to something like traumatic injury or something like that. Not those of us whose knee mechanics are off and whose cartilage is being worn away prematurely because of it. Also, the location of the lesion, as well as its size, has a huge role in determining the appropriate treatment.
Finally, a lateral release isn't really a true patellar realignment procedure. The only thing it reliably does is to correct for patellar tilt...so if your area of damage was only in the spot that would be rubbed if you had patellar tilt, then a lateral release might be appropriate. However, there are a lot of situations where a lateral release can actually make things worse: true mal-alignment, multiple lesions, especially on the medial or proximal facets of the patella--see Dr. Fulkerson's article for definitive info:
Posted by hmaxwell (Heather M.), 14 December 2004
Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer.
Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP
Am J Sports Med 25:533-7
This retrospective study determined that the outcome from anteromedialization of the tibial tubercle correlates well with the location of patellar articular lesions. Detailed descriptions of patellar articular cartilage lesions were obtained from the operative reports of 36 patients who had anteromedialization performed between February 1984 and March 1994. The patterns fell into four distinct groups. Ten patients with type I (distal) patellar lesions and 13 patients with type II (lateral facet) patellar lesions had 87% good to excellent subjective results, and 100% of these patients said they would have the procedure done again. Nine patients with type III (medial facet) lesions had 55% good to excellent results, and 5 patients with type IV (proximal or diffuse) lesions had only 20% good to excellent results. Patients with type I or II lesions were significantly more likely to have good or excellent results than those with type III or IV lesions. Central trochlear lesions were associated with medial patellar lesions and all patients with central trochlear lesions had poor results. There was no significant correlation between the Outerbridge grading of the patellar lesion and the overall results. Workers' compensation issues diminished the likelihood of a satisfactory outcome by 19%; however, this was not statistically significant. This is the first study to correlate the patellar articular cartilage lesion with outcome after tibial tubercle transfer.
For more information, go to http://www.findarticles.com and look up the key words used in the above article--or find the article itself by doing an author search. Dr. Fulkerson also has a comprehensive journal article on mal-alignment and options for treatment--should be in the bibliography of the above article. Here is the abstract, with the title of the article:
[bold]Operative management of patellofemoral pain.
Ann Chir Gynaecol 1991 80:224-9
In short, the surgical treatment of patients with patellofemoral pain will depend on understanding each specific disorder and the pattern of articular degeneration. Tilt alone generally responds well to lateral release. Subluxation, particularly when more severe, may require medial imbrication and/or a distal (Trillat) procedure in addition to lateral release to achieve extensor mechanism balance. When there is significant patellar arthrosis, an oblique osteotomy deep to the tibial tubercle will permit unloading of the patellar articular surface in addition to realignment. A small amount of metaphyseal bone placed in this oblique osteotomy will permit straight anterior displacement of the tibial tubercle of 15-20 mm with minimal bone graft when necessary. These basic surgical procedures will permit adequate treatment of most patients with resistant patellofemoral pain (with or without arthrosis) when non-operative measures have failed and the appropriate procedure is selected for a specific mechanical disorder.
Here is the title and source of another comprehensive Fulkerson article dealing with the decision to do TTT or lateral release:
After failure of conservative treatment for painful patellofemoral malalignment: lateral release or realignment?
Fulkerson JP, Schutzer SF
Orthop Clin North Am 1986 Apr 17:283-8
This article reviews the clinical evaluation that must be undertaken after conservative treatment has failed and presents the indications for lateral release and realignment.
PS check out the patello-femoral joint section for more information on the topic.
Updated Thu Apr 29 2010