AANA Lab Course 910 - Patellofemoral Joint Preservation-Avoiding Complications_ Pearls and Pitfalls-Dr. John P. Fulkerson, M.D.

Avoiding Complications_ Pearls and Pitfalls-Dr. John P. Fulkerson, M.D.

Pdf Summary

This document by Dr. John P. Fulkerson reviews patellofemoral (PF) instability surgery complications and advises on how to avoid and recognize them. Key points include:<br /><br />Many patients with patella instability do not need tibial tubercle transfer (TTT), but if needed, failure to balance patellar tracking with TTT before medial patellofemoral ligament (MPFL) reconstruction can lead to surgical failure and overload, requiring revision.<br /><br />Failures of proximal stabilization (MPFL, MQTFL) often stem from improper tracking correction, failure to address patellar alta, insufficient unloading of distal cartilage lesions, inaccurate femoral graft attachment, or overtensioning. Precise anatomic reconstruction following detailed understanding of knee anatomy is essential.<br /><br />Trochleoplasty is rarely needed and is associated with increased postoperative stiffness and risk of arthritis. Its use should be restricted to carefully selected cases with severe trochlear dysplasia and jumping "J" sign, ideally performed only by surgeons with special training.<br /><br />Medial patella instability is almost always iatrogenic, caused by overrelease or TTT, often missed and disabling. Diagnosis requires specific clinical testing (medial subluxation test). Treatment includes bracing and often lateral-sided reconstruction.<br /><br />Failures due to patella fracture after MPFL reconstruction can be avoided by using medial quadriceps tendon-femoral ligament (MQTFL) reconstruction, avoiding patellar drilling, and ensuring precise femoral fixation.<br /><br />Articular cartilage lesions require unloading procedures such as anteromedialization (AMZ) TTT to avoid progressing joint damage.<br /><br />Non-surgical management of complex chronic PF pain is typically ineffective but may include weight loss, rest, and load management.<br /><br />The overarching recommendation is strict adherence to surgical principles: precise anatomic graft placement, balanced tracking, unloading cartilage lesions, avoiding overtensioning, avoiding routine trochleoplasty, preventing medial subluxation, and early motion for successful outcomes.<br /><br />In summary, meticulous surgical planning and execution, with emphasis on anatomical accuracy and appropriate patient selection, are fundamental for optimizing results and minimizing complications in PF instability surgery.

Keywords

patellofemoral instability

tibial tubercle transfer

medial patellofemoral ligament reconstruction

patellar tracking

trochleoplasty complications

medial patella instability

medial quadriceps tendon-femoral ligament reconstruction

articular cartilage lesions

anteromedialization tibial tubercle transfer

surgical planning in knee instability