MPFL Reconstruction
- EUA + diagnostic arthroscopy
- Semitendinous harvest in routine fashion (use non irradiated allograft if ligamentous lax) through separate incision and then the wound is irrigated and closed
– preparation of the graft by my assistant
– need 18cm in length and aiming for 6-7cm in thickness
o One end is split in two (patella side) and each end prepared with ethibond
- Fixation is via a duel vertical incisions
o First one for femoral sided fixation using my landmarks as adductor tubercule and medial epicondule
• Structure at risk is the saphenous nv bundle • As making this approach ii should be coming in for lateral XRs and identification of Schottle point ( • Drill bicortical tunnel, pass guide wire and non absorbale suture shuttle o 2 tunnels placed in patella with K wires o Development of subcutaneous tunnel in layer II - correct extrasynovial plane with haemostat and passage of graft - fixation is with far cortical button for femoral attachment and tranosseous ethibond for the two patella tunnel - pass my sutures and far cortical button and cycle through ROM - definitive fixation is at 30 flexion and taken through ROM to check isometry – check with contralateral side and should be <2 quadrants ALTERNATE FIXATION = FEMORAL INTERFERENCE SCREW – transossoues sutures = best because stops fracture
Tibial Tubercle Transfer
- +/- initial arthroscopy to assess patella articular wear and pattern
- lateral release is performed
- Lateral longitudinal incision with full thickness flaps
- Small parapatellar medial and lateral arthrotomies are created to identify the insertion of the patella tendon with incision along the infrapatella fat pad and protection of tendon with retractor
– INFRAPATELLAR RELEASE
- Subperiosteal elevation of the anterior compartment musculature to exposure the posterolateral tibia
– retractor is then placed to protect the nv structure
- 2 x k wires used as a template from osteotomy direction
o OBLIQUE Osteotomy is performed from ANTEROMEDIAL to POSTEROLATERAL or PARALLEL in CORONAL PLANE
o Osteotomy 1cm DEEP & 6-10CM LONG
- Using a sagittal saw then I then make the osteotomy parallel with the wires maintain an intact distal hinge and completing it on the lateral side with osteotome and preventing propagation into the joint with careful technique that involves a transverse sagittal osteotome cut just proximal to the patella tendon insertion and then this obliquely joins the rest of the osteotome (tapering anteriorly) -
Then shift the osteotomy and provisional fixation with 2 x k wires
- Check tracking through ROM
- Definitive fixation with 2 x large frag cortical screws
- Bevel the remaining medial ridge
Roux-Goldthwaite Procedure
- medial parapatellar incision extending 2.5 cm distal to the tibial tuberosity
- split the patellar tendon longitudinally and detach its lateral half from the tibial tuberosity
- lateral parapatellar incision extended proximally to the lateral aspect of the vastus lateralis
- transfer the detached lateral half of the patellar tendon beneath the medial half and suture it to the soft tissues on the medial aspect of the tibia (preferably to the insertion of the sartorius muscle)
- careful not to overcorrect and cause the medial half to be relaxed
Proximal Tibial Medial Opening Wedge Osteotomy
- Knee in 30 deg flexion
- ARTHROSCOPIC WORK FIRST and use of NAVIGATION (mark extra and intra articular points)
- Open medial approach incorporating medial arthrscopic portal as proximal extent of incision
- subperiosteal elevation SUPERIFICIAL MCL and pes (attempt to later repair over plate but can’t because of correction and swelling, but still vicryl over the top as best can be done (LEAVE DEEP MCL INTACT)
- small release infra patellar fat pad and some of PT insertion (like difficult TKA patella eversion)
- guide pins x 2 with jig —> aiming fibula head and horizontal if possible
- 4cm below joint line aim at fibula head
- broad saw blade first not the entire way across
- retractors anteriorly and posteriorly to protect the PT and the nv bundles
- osteotome is gradually progress with gloved finger as tactile feedback posteriorly bit by bit (see diagram)
- make sure x>y to prevent crack propagation intraarticularly
- jack open with laminar spreader - navigation as marker of correction/line over 62.5%
- template arthrex plate and femoral head allograft used
- fix + pack more graft
- guide pins x 2 with jig —> aiming fibula head and horizontal if possible
plates out at 1 year as very irritating
Proximal Tibial Lateral Closing Wedge Osteotomy
- Arthroscopy to Assess for Other Pathology
- L Shaped Anterolateral (Hockey Stick) Incision
- ITB Taken off Gerdy Tubercle
- Anterolateral Muscle Stripped off Tibia
- Lateral Retraction Protected CPN (Otherwise Dissect It Out)
- Cobb Elevation of Periosteum posterolaterally
- Cobb Elevation of Periosteum Anterior and Anteromedially Underneath Patella Tendon
- Guide Wire Entry Point 2.5cm Below Lateral Joint Line in Horizontal Direction
- Oscillating Saw Osteotomy Underneath Wire (Prevent Intraarticular Propagation Around the Cortex Anteromedial, Anterior, Anterolateral, Medial & Posteromedial
- Complete Osteotomy Under II via Flexible Osteotomes
- End Osteotomy 1cm from Lateral Cortex
- Plate
- Check Mechanical Axis (Should Run at 62.5% of tibial)
Distal Femoral Lateral Opening Wedge Osteotomy
- Perform ARTHROSCOPY FIRST to assess for intra-articular pathology
- Perform an LATERAL APPROACH TO THE DISTAL FEMUR – ITB SPLIT, then SUBVASTUS
- Split the vastus lateralis longitudinally
- Dissection down to the lateral femoral cortex
- Subperiosteally strip anteriorly & posteriorly
- Place homan retractors anteriorly & posteriorly
- Insertion of K wire 5CM PROXIMAL TO LATERAL EPICONDYLE aiming INFEROMEDIAL to the MEDIAL EPICONDYLE
- PROXIMAL TO PFJ and AIMING FROM PROXIMAL LATERALLY to DISTALLY MEDIALLY
- Confirm on II
- Perform osteotomy via 5 principles
- Sequentially jack open the osteotomy using a DOUBLE OSTEOTOME & WEDGES
- Determine the aim of opening osteotomy using the measured wedges according to the amount calculated during preoperative planning
- Fixation with a TOOTHED LOCKINH COMPRESSSION PLATE (PUDDU PLATE)
- Insertion of STRUCTURAL BONE GRAFT (usually ALLOGRAFT)
- ITB LENGTHENING POST OP
Distal Femoral Medial Closing Wedge Osteotomy
- Perform ARTHROSCOPY FIRST to assess for intra-articular pathology
- Perform an ANTEROMEDIAL APPROACH TO THE DISTAL FEMUR
- Dissection down to the anteromedial femoral cortex
- Subperiosteally strip anteriorly & posteriorly
- Insertion of distal K wire parallel with joint surface
- Measure the angle of osteotomy via II measurements using a goniometer according to the
- amount calculated during preoperative planning
- Perform osteotomy via 5 principles
- Fixation with a COMPRESSSION PLATE or BLADE PLATE
