AANA Lab Course 910 - Patellofemoral Joint Preservation-AANA PF Course Case Studies-Dr. Clayton W. Nuelle, M.D.

AANA PF Course Case Studies-Dr. Clayton W. Nuelle, M.D.

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This document presents two orthopedic case studies focused on knee pathologies involving patellar instability and cartilage lesions, discussed by Dr. Clayton W. Nuelle.<br /><br />Case Study #1 involves a 20-year-old female with recurrent lateral patellar dislocations beginning in high school, now experiencing pain and fear of dislocation during activities like running or stair navigation. Examination revealed mild inward patellar positioning, limited knee range of motion with anterior pain on deep flexion, positive patellar apprehension tests, and mild joint signs indicating instability. Imaging showed a normal Caton-Deschamps ratio, relatively flat sulcus angle, low congruence angle, symmetric varus alignment, and excessive femoral anteversion (53°, normal 10-15°), with tibial torsion within normal range. Surgical options considered included soft tissue procedures (lateral lengthening, MPFL repair or reconstruction), tibial tubercle osteotomy (TTO), femoral derotational osteotomy, or combinations thereof. The patient underwent MPFL reconstruction combined with anteromedialization TTO, as shown in intraoperative images and postoperative radiographs.<br /><br />Case Study #2 features a 45-year-old male with a 5-year history of left knee pain and swelling aggravated by stairs. He had prior surgery with brief relief and steroid injection. Physical exam revealed knee effusion, pain with patellar compression but no instability, negative J sign, and limited ROM with pain in deep flexion and extension. Imaging demonstrated a slightly elevated Caton-Deschamps ratio, minimal valgus alignment, and on MRI a large (20x18 mm) grade III-IV osteochondral lesion in the central/medial patella with subchondral bone involvement. Radiographic measurements of TT-TG and TT-PCL were within normal limits. Treatment options discussed included debridement, microfracture, TTO, cell-based therapies, osteochondral transplant, and arthroplasty. The patient underwent osteochondral allograft transplantation, supported by intraoperative and postoperative imaging.<br /><br />Together, these cases illustrate diagnostic evaluation and tailored surgical management of complex patellofemoral disorders incorporating alignment, soft tissue stabilization, and cartilage restoration techniques.

Keywords

patellar instability

cartilage lesions

MPFL reconstruction

tibial tubercle osteotomy

femoral derotational osteotomy

osteochondral allograft transplantation

patellofemoral disorders

knee pain

osteochondral lesion

surgical management