Tratamiento de la inestabilidad femoropatelar objetiva. Resultados a cinco años de seguimiento / Treatment of objective patellar instability. Results after five years of follow-up

Resumen: Objetivo: Presentar los diferentes procedimientos quirúrgicos en el tratamiento de las inestabilidades femoropatelares objetivas, incluyendo la osteotomía de la tuberosidad tibial anterior y la trocleoplastía femoral. Material y métodos: Con un diseño prospectivo con seguimiento a cinco años que incluyó a 21 pacientes (21 rodillas) tratados por luxación rotuliana recidivante entre Marzo de 2010 y Agosto de 2014, tratándose de forma quirúrgica mediante dos técnicas diferentes según el tipo de inestabilidad estructural de base. Para determinarlo, se analizó el índice radiográfico de Caton-Deschamps (para la evaluación de la altura rotuliana) y parámetros tomográficos para valorar el configuración troclear y distancia desde la tuberosidad tibial anterior hasta la tróclea femoral (TT-TG) en la superposición de imágenes en el plano axial. Resultados: Hemos tenido resultados satisfactorios tanto con la transferencia de la tuberosidad tibial anterior como con la trocleoplastía. En ambos procedimientos se realizó una reconstrucción del ligamento patelofemoral medial (LPFM). Conclusiones: La recurrencia de inestabilidad es muy rara después de estos procedimientos y es más probable que ésta resulte de anomalías asociadas no diagnosticadas o subestimadas. Se requiere una planificación precisa preoperatoria para determinar la altura rotuliana, la ubicación de la tuberosidad tibial anterior y la configuración troclear para obtener resultados satisfactorios.

Abstract: Objective: To present the different surgical procedures in the treatment of objective femoropateral instability, including osteotomy of anterior tibial tuberosity and femoral trocleoplasty. Material and methods: With a prospective 5-year follow-up design that included 21 patients (21 knees) treated for relapsing patellar dislocation between March 2010 and August 2014, treated surgically using 2 different techniques depending on the type of basic structural instability. To determine this, the Caton-Deschamps X-Ray Index (for the evaluation of the patellar height) and tomographic parameters were analyzed to assess the troclear configuration and distance from the anterior tibial tuberosity to the femoral trochlea (TT-TG) in the overlapping of images in the axial plane. Results: We have had satisfactory results both with the transfer of the anterior tibial tuberosity and with the trocleoplasty. In both procedures, a reconstruction of the medial patelo-femoral ligament (LPFM) was performed. Conclusion: Recurrence of instability is very rare after these procedures and is more likely to result from undiagnosed or underestimated associated abnormalities. Precise preoperative planning is required to determine the patellar height, location of the anterior tibial tuberosity, and troclear configuration for satisfactory results.

The Efficacy of Medial Patellofemoral Ligament Reconstruction Combined with Tibial Tuberosity Transfer in the Treatment of Patellofemoral Instability

A systematic review of the literature was undertaken to evaluate the efficacy of medial patellofemoral ligament (MPFL) reconstruction combined with tibial tuberosity transfer (TTT) in the treatment of patellofemoral instability. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic search was carried out to identify and review the published literature pertinent to MFPL reconstruction combined with TTT. Relevant studies were critically appraised with narrative data synthesis. Studies that met the eligibility criteria were suitable for appraisal and consisted of case series and therapeutic series (levels IV & III). All studies had inherent variations in outcomes reporting and limited follow-up. Combined treatment offers restoration of normal anatomy, thus adding clinical value to the currently recommended anatomic approach to MPFL reconstruction. Nevertheless, the current body of evidence does not determine the threshold at which patellofemoral axis requires the need for adjunctive distal realignment as opposed to MPFL reconstruction alone. This review highlighted numerous recurring limitations in the conduct and presentation of the studies, which inadvertently mitigated the interpretation of their results. Future priority should be awarded to larger randomised controlled trials utilising validated patient reported outcome measures.