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Distal Femoral Osteotomy, Tibial Tubercle Osteotomy, and Bipolar Patellofemoral Osteochondral Allograft Transplantation for Patellar Instability

March 01, 2020

Contributors: Laith M Jazrawi, MD, FAAOS; Dylan Lowe, MD; Matthew Gotlin, MD

Keywords: diagnostic imaging; Magnetic Resonance Imaging

Background Patellar instability most commonly occurs in young patients and may be acute or chronic. Risk factors for recurrent patellar instability include ligamentous laxity, limb malalignment, and trochlear dysplasia. Dislocation events may lead to osteochondral patellofemoral joint injuries that result in considerable pain and dysfunction. An understanding of the anatomy of the patellofemoral joint and the pathogenesis of patellar instability is important for diagnosis and management. Surgical treatment is considered after nonsurgical treatment options have been exhausted. Surgeons must have a complete understanding of a patient's limb alignment, patellofemoral biomechanics, and pathology before creating a surgical plan. Purpose This video demonstrates a technique for distal femoral osteotomy, tibial tubercle osteotomy, and bipolar patellofemoral osteochondral allograft transplantation in a patient with chronic patellar instability. Methods The video discusses the case presentation of a 21-year-old woman with chronic patellar instability and a osteochondral patellofemoral joint injury. The patient had chronic right knee pain and multiple prior dislocation events. Imaging studies revealed valgus malalignment and a large osteochondral patellar and trochlear injury. The video provides an overview of the pathogenesis, diagnosis, and management of patellar instability in a patient with malalignment and a patellofemoral cartilage injury. In the patient shown in this video, several pathologies were managed via single-stage distal femoral osteotomy, tibial tubercle osteotomy, and bipolar patellofemoral osteochondral allograft transplantation. Results Excellent restoration of the mechanical axis was achieved intraoperatively. A 27.5-mm patellar and a 25-mm trochlear osteochondral allograft were securely placed without complications. The osteotomy sites healed uneventfully. The patient was advanced through a standardized rehabilitation protocol. Postoperatively, the patient had decreased range of motion, warranting arthroscopic lysis of adhesions and manipulation under anesthesia. Ultimately, the patient regained adequate knee range of motion, had no subsequent patellar instability events, and experienced considerable improvements in pain and function. Conclusion Patients with patellar instability secondary to malalignment and associated osteochondral patellofemoral lesions can be successfully treated via single-stage distal femoral osteotomy, tibial tubercle osteotomy, and bipolar osteochondral allograft transplantation. Surgeons must understand a patient's pathology and devise a personalized treatment plan to manage all anatomic abnormalities to achieve a successful outcome.

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