AANA Lab Course 910 - Patellofemoral Joint Preservation-When to Add Osteotomy and What Type

When to Add Osteotomy and What Type_-Dr. James Bicos, M.D.

Pdf Summary

This presentation by Dr. James Bicos discusses the indications and decision-making process for adding osteotomy in the treatment of patellofemoral instability and related knee issues. Key points include a comprehensive evaluation of the patient integrating clinical assessment, anatomy, and imaging to determine the pathology’s location—proximal, distal, or both.<br /><br />Osteotomy is considered when there is a distal problem at the tibial tubercle, especially with instability indicated by elevated tibial tubercle-to-trochlear groove (TT-TG) or tibial tubercle-to-posterior cruciate ligament (TT-PCL) distances, often accompanied by patella alta and closed growth plates. TT-TG measures the lateralization of the tibial tubercle relative to the trochlear groove and is valuable for distinguishing instability; abnormal TT-TG values typically exceed 15-20 mm. TT-PCL measures tubercle lateralization relative to the PCL and is used adjunctively.<br /><br />Several osteotomy options exist: Maquet osteotomy for anteriorization, Elmslie-Trillat for medialization, and Fulkerson for anteromedialization (bi-plane osteotomy). Selection depends on treatment goals—stabilization, off-loading, or both—with Fulkerson osteotomy often preferred in cases with elevated TT-TG and chondrosis. Indications for Fulkerson include pliable skin and avoidance of bone grafts; contraindications include tricompartmental arthritis and motion limitations.<br /><br />Postoperative care for Fulkerson involves initial non-weight bearing, controlled range of motion without straight leg raises, progressive weight bearing after 6 weeks, and follow-up imaging. Outcomes show 85-90% good to excellent results in chondromalacia and about 75% in arthrosis cases, with complications including skin issues, stress fractures, patella baja, and osteotomy site problems.<br /><br />Overall, the presentation emphasizes a logical, anatomy-informed approach to osteotomy decision-making tailored to individual patient pathology for improved patellofemoral stability and function.

Keywords

patellofemoral instability

osteotomy indications

tibial tubercle

TT-TG distance

TT-PCL distance

patella alta

Maquet osteotomy

Elmslie-Trillat procedure

Fulkerson osteotomy

postoperative care