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Severe patellofemoral arthritis secondary to patellofemoral malalignment treated by Fulkerson osteotomy plus tricortical

bone graft. A retrospective cohort of 45 knees.

Autors: Dr. Edgar William Afanador Acuña *

E-mail: drafanador@gmail.com

Dr. Francisco Javier Sánchez Villa ** E-mail: javi2629@hotmail.com

* Ortopedista y Traumatólogo, Cirugía de Rodilla, Hospital Militar Central - Clínica Universitaria Colombia

** Residente de IV nivel de Ortopedia y Traumatología, Hospital Militar Central, Universidad Militar Nueva Granada.

 

 

 

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ABSTRACT

Background: The surgical treatment options in severe patellofemoral arthritis secondary to patellofemoral malalignment are limited. The majority of the surgical procedures include distal patellar realignment through different types of tibial tuberosity osteotomies, current evidence reports different results. Aim: evaluate the functionality and the level of pain in a cohort of patients with patellofemoral arthritis secondary to patellofemoral malalignment treated by Fulkerson osteotomy plus tricortical bone graft between 2001 y 2011. Methods: We conducted a retrospective cohort study of patients with severe patellofemoral arthritis secondary to patellofemoral malalignment treated by Fulkerson osteotomy plus tricortical bone graft between 2001 and 2011. The results were evaluated using the Lysholm scale modified by Fulkerson and the VAS score. A mean follow-up of44.0± 26.8 months, range 2-11.9 years. Results:A total of 38patients (45 knees, 7 bilateral) were treated using the technique described, 35 women (92.1%). An average age of 44.7±10.9 years (range between 23 and 62 years). All of the patients showed an improvement in the VAS score. The results of the functional scales were 93.3% excellent and good results. During follow up we do not report deterioration. We do not report major complications. Conclusions: Fulkerson osteotomy plus tricortical bone graft is an adequate treatment in functionality and decreased pain severity in the short term in patients with patellofemoral arthritis secondary to patellofemoral malalignment.

Key words: patellofemoral arthritis, patellofemoral malaligment, Fulkerson osteotomy, bone graft,

Level of evidence: IV

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INTRODUCTION

Severe patellofemoral arthritis secondary to patellofemoral malaligment results in great

and progresive impairment in the quality of life and productivity of the patients affected

by this condition. (1, 2). The non surgical options available are ineffective. The surgical

options are limited, require prolonged periods of rest and the results are variable. (3–7).

The most frequently used surgical procedures have in common a distal patellar

realigment through the different type of osteotomies of the tibial tubercle with either

medialization or anteriorization. (3,4,8) (Figures 1 and 2). The elevation of the tibial

tubercle proposed by Bandi and Maquet increases the efficacy of the Quadriceps

augmenting the lever arm while decreasing the reaction force of the patellofemoral joint

(3). Maquet concludes that there is a 50% reduction in the compresive forces at the

patellofemoral joint after a 2 cm anteriorization of the tibial tubercle. This hypothesis

has been confirmed by Ferguson and Brown (9), they proved that anteriorizations of 1,2

cms, 2,5 cms and 3,7 cms resulted in great relieve of the tension. They reported a 57%

relieve with 1,2 cms. Anteriorizations of 2,5 cms and 3,7 cms resulted in relieves of

30% and 9% respectively. These authors concluded that the main benefit is obtained

with the first 1,2cms of anteriorization and that from this point forward the

complications increased while no benefit was obtained. One of the causes of

complications, mainly in the skin, is the use of bone grafts of great size. (10).

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Figura 1: Transverse osteotomy of the tibial tubercle (Elmslie-Trillat) where there is only medialization, anteriorization is obtained with the adition of a bone graft. ( Maquet effect).

In the Fulkerson osteotomy, the degree of inclination of the osteotomy determines the

final medialization and anteriorization. (Figura 2). The greater the degree of inclination

the greater the anteriorization is attained but also the lesser medialization results.

(5,8,11).

A B

 

Figura 2: (A) Fulkerson osteotomy at 30 degrees of inclination, results in greater medialization. (B) Fulkerson osteotomy at 45 degrees of inclination, results in greater anteriorization. From David A Buuck. 2000(5)DAVID A. BUUCK

 

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For the younger patients with severe patellofemoral arthrosis in which whom

arthroplasty is not convenient, is necessary to find surgical options that are capable of

retain a functional knee.

Fulkerson described a modification to his technique, an oblique osteotomy with the

addition of a bone graft to optimize the anteriorization effect. (12,13). (Figure3).

 

Figura 3. Fulkerson osteotomy at 45 degrees plus bone graft at the site of osteotomy. A. Original position of the osteotomy. B. Position after the osteotomy. C. Position with the addition of a bone graft. From Fulkerson. 1994(12).

Taking these biomechanical principles into account, since 2001, at the Hospital Militar

Central and in the Clinica Universitaria Colombia, one of the authors (E. Afanador) has

implemented a Fulkerson osteotomy plus tricortical bone graft to patients with

patellofemoral malaligment and severe ( Outerbridge grade IV) patellofemoral

arthrosis. (14), choosing and oblique osteotomy of the tibial tubercle at 30 degrees,

trying to maintain a balance between the medialization effect for a good patellar

alligment and the anteriorization effect with the use of a tricortical bone graft. (Figure

4). The degree of medialization is determined in the OR through arthroscopy, once the

patellar position desired is evident.

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Figura 4:   Fulkerson   Osteotomy   at   30   degrees   plus   tricortical   bone   graft.   The   medialization   effect   is  maintained  and  the  anteriorization   is  obtained  with  a   low  volume  graft.  The  vertical  doted   lines  represent  the  degree  of  medialization,  which  is  determined  in  the  OR.    

The objective of this study was to evaluate the outcomes and the level of pain in a

cohort of patients with severe patellofemoral arthrosis secondary to patellofemoral

malaligment, treated with the Fulkerson Osteotomy plus a tricortical bone graft between

2001 and 2011.  

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METHODS AND MATERIALS

A retrospective cohort was conducted in patients with severe patellofemoral arthrosis

secondary to patellofemoral malaligment treated by one of the authors (E. Afanador)

between 2001 and 2011 with the tecnique described by Fulkerson, with the addition of a

tricortical bone graft, evaluating functionality and pain.

The including criteria for the patients were: patients with severe patellofemoral

arthrosis demonstrated arthroscopically and patellofemoral malaligment treated with the

tecnique described. Patients with a follow up less than two years were excluded. The

surgical procedure was indicated in patients with anterior knee pain that did not

improved with medical treatment during six months, pain that interfered with daily life

activities, severe patellofemoral arthrosis and patellofemoral malaligment demonstrated

by X rays, Axial CT of the patella at 0º-20º-40º and confirmed by arthroscopy. (14).

The procedure was not indicated in patients with inflamatory diseases, posttraumatic

patellofemoral arthrosis and tricompartmental artrosis.

The main outcomes evaluated were functionality and pain. These were evaluated with

the application of the Lysholm score modified by Fulkerson (5,15) which evaluates 7

points: 1. Limp 2. Support 3. Stair climbing 4. Squatting, 5. Pain 6. Instability 7.

Swelling. This is a 100 points based score, where excellent results are obtained with a

95-100 score, very good results with a 90-94 score, good results wiht a 80-89 score,

mild results with a 70-79 score and poor results with a 70 or less score (Table 1).

The pain was evaluated with the VAS score, (VAS)(16) patients were asked for their

pain before the procedure and at the moment of the evaluation for this study. The

degree of subjective satisfaction after the surgical intervention was evaluated too, if the

patient was better, the same or worst after the procedure (17) and if the patient would

recommend this procedure to other patients. Other variables evaluated were age,

gender, laterality and associated complications.

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The information was obtained post surgery, the scores were used obtaining variable

times among the patienst according to the time of the surgery and the moment when

they were evaluated. All the patients gave their verbal authorization for the realization

of the study, the use of the scales and questionnaires. No patient refused to be in the

study. The patients were taken from the Hospital Militar Central and the Clinica

Universitaria Colombia databases. All the information was condensed in a new

database made with Microsoft Excel software 2007 version. The deparments of

epidemiology and stadistics of the Hospital Militar Central and the Clinica Universitaria

Colombia evaluated also the study to determine its quality. The clinical charts of the

patients were evaluated to confirm the diagnosis and the surgical procedure conducted,

the age, gender, diagnosis, laterality of the affected limb, time of surgery and

complications.

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Tabla 1.Lysholm scale modified by Fulkerson. (5)

 

Statistical analysis

The database was build using Microsoft Excel Software (versión 2007) and the

information was depurated using SPSS version 20 (Statistical Package for de Social

Sciences 20 (BMI/SPSS 20)).

The normal numeric scores were evaluated using the Shapiro Wilk test for the Lysholm

score modified by Fulkerson. This score classified ordinal categories: excellent, very

good, good, mild, poor.

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The VAS score changes were evaluated before the surgery and in the post surgical

period with the non parametric test of Wilcoxon. For determining if it was significant

difference in the functionality Fulkerson score we used the non parametric ANOVA

from Kruskall-Wallis.

The results were statistically significant with a level of 5% (p<0,05).

Surgical Tecnique

The arthroscopy was conducted without the use of a tourniquet. It was verified the

subluxation and the severe patellofemoral arthrosis through the conventional portals for

the knee. Associated lesions were also evaluated. The tricortical bone autograft was

harvested from the ipsilateral iliac crest, shaping it in a trapezoidal way of 10mm. Later

the external liberation was conducted. Anterolateral longitudinal approach of 5-6cm

below the external articular line through caudal parallel to the tibial tubercle.

Subperiostical elevation of the muscular structures of the anterolateral fossa, avoiding

the use of separators in the posterior aspect of the tibia to diminish the risk of

neurological damage.

The external liberation of the lateral retinaculum, capsule and sinovia is completed

from caudal (site of the osteotomy) to cephalic (proximal pole of the patella). Excision

of the infrapatellar fat pad. Delineate of the osteotomy on the lateral cortical of the tibial

tubercle, 7 cms of longitude by 1 cms of thickness in relation with the anterior border of

the tibia, perforation of the lateral cortical through the medial cortical with a 3.2 drill,

with a 30 degrees inclination from posterior to anterior and from lateral to medial.

(Figure 5). The ostetomy is completed with an oscillanting saw.

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Figura 5. Intra-procedure picture of the osteotomy at 30 degrees of inclination.

 

Subperiostal elevation of the medial flap to preserve periostium and to conserve the

pedicle of the fragment of the tibial tubercle. Percutaneous bone perforations at the

external facet of the patella and at the femoral groove with a K-wire of 2.0 mm with a

median distance of 5 mm between each orifice. (Figure 6).

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Figura 6. Extensive Osteochondral lesión Outerbridge Grade IV of the lateral facet of the patella after spongialization.

 

 

Through the tibial incisión any osteophyte is removed from the lateral margin of the

patella and from the lateral femoral condyle. The anteriorization of the tibial tubercle is

obtained with the oblique osteotomy and the addition of the tricortical bone graft of 10

mm of spesor. The degree of medialization of the tibial tubercle is determined once the

patella is in an adequate position. A temporal fixation of the tibial tubercle is obtained

with a K wire of 2.0mm without perforating the bone graft. The right patellofemoral

position is verified arthoscopically and definitive fixation is obtained using two cortical

screws of 4.5 mm with a washer, using a lag screw tecnique, avoiding the perforation

of the bone graft to diminish the risk of fracture. (Figure 7).

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A B

 

Figura 7. A. Anteriorization with the bone graft and fixation with screws. B. medialization effect for patellofemoral malaligment.

 

 

Postoperative care

Low Molecular Weight Heparin is used for ten days. The pain control is obtained using

opioids. After the second day walking is encouraged with crutches, with progresive use

of the extremity according to the patient tolerance. Physical therapy is initiated with

isometric exercises of the Quadriceps, pasive and active movement assisted to gain

flexion. Control x rays are performed every six weeks obtaining consolidation of the

osteotomy between the eight and the ten week. The crutches are used for four weeks,

then from the fifth to the eight week only one crutch is used, and then is suspended if

the muscular calification of the quadriceps muscle is 4/5. The rehabilitation is

continued wiht emphasis in propioception and hydrotherapy. The screws are removed if

the patient reports pain.

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Ethical Aspects

This study is classified as an investigation with minimal risks according to the artículo

5, Res. Nº 008430 from the national ethics code.

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RESULTS

The cohort was conformed by 38 patients and a total of 45 knees. ( 26 right knees and 19

left knees) whom were intervened with a fulkerson osteotomy plus a tricortical bone graft

and spongialization between 2001 and 2011. The most frequent gender was femenine with

a 92,1% (n=35) and the average age was 44,7±10,9 años, with variation between 23 and

62 years. The mean follow up from the date of the surgical procedure to the application of

the questionnaries was 44,0±26,8 months (mean=34,3 months) with a range between 2and

11,9 years. All of the patients showed and improved pain according to the VAS score, with

an average VAS score of 9 in the pre surgical period and an average VAS score of 2 in the

postoperative period, with a seven point improvement in the VAS score. (p <0,001, non

parametric test of Wilcoxon) (Figure 8).

 

Figura 8. Comparison of the pain score befor surgery and afeter the surgical intervention.

 

The numerical values from 2 to 100 of the lysholm score modified by fulkerson showed a

different to normal (p=0,002, Shapiro Wilk test), with left asimmetry (CA=-0,787). The

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score had an average result of 90,4± 7,9 and a mean of 94. The classification found

excellent results in 44,4% of the patients (20 knees), very good results in 11,1% (5 knees),

good results in 37,8% (17 knees), mild results in 6,7 % (3 knees) (Figure 9).

 

Figura 9. Functional distribution of the cohort of patients

 

No differences were found among the age groups and their functionality (p=0,830, non

parametric test of Kruskall-Wallis) (Figure10).

44.4%  

11.1%  

37.8%    

6.7%  

0          0  

5  

10  

15  

20  

25  

Excelente   Muy  bueno   Bueno     Regular   Malo  

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Figura 10. Functionality results among age groups.

Among the follow up groups and the functionality scores we found no differences

(p=0,722, non parametric test of Kruskall-Wallis). The mean functionality scores during the

second year were 94,0; during the third year were 95,0, and of 87,0 at the fourth year or

more (Figure 11).

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Figura 11. Functionality score distribution among follow up groups.

All of the patients reported feeling better after the procedure. None of the patients has

presented a clinical deterioration during follow up. No intra surgical complications were

presented. One patient presented a distal dehiscence of his wound, but this healed without

further intervention. One patient presente arthrofibrosis which required arthroscopy for

adherence removal, with later improvement. No cases of patellar dislocation were presented

at the follow up moment, and no infection or vascular complications were reported.

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DISCUSSION

All of the patients reported an improvement in the VAS score, with a mean

improvement of 7 points. All of the patient manifested their satisfaction with the

functional result obtained with the procedure. The results obtained with the lysholm

score modified by 93,3% of the patients had excellent to good results. Comparing this

cohort with the current reports of the literature in which only a transverse osteotomy is

performed (Elmslie-Trillat-Maquet)(3,4) or only the oblique Fulkerson osteotomy is

performed without the use of bone graft (5,6) we observe an improvement in the

functional result. (Table 2).

 

Tabla 2. Funcitonal results reported by other authors.

 

The anteriorization, medialization and spongialization improves the biomechanical

environment of the patellofemoral joint, achieving a redistributions of the loads and

stabilizing the chondral damage. (18). This explains the subjective functional

improvement of the patients evaluated in this cohort.

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David A. Buuck and J Fulkerson(5) in their series of 42 knees with a mean follow up of

8,2 years reported 86% (36 knees) of excellent to good results with an oblique

osteotomy without the use of a bone graft. Carrillo and Parada(6) in their series of 32

knees with a mean follow up of 2 to 7 years performing a fulkerson osteotomy for

severe patellofemoral arthrosis and patellofemoral malalignment showed a 78% of good

results, 9% of mild results and 13% of poor results after applying the lysholm score

modified by fulkerson. Our study showed a 93,3% of excellent to good results

compared to their study.

We consider that the fulkerson osteotomy at 30 degrees plus the use of a tricortical

bone graft (maquet effect) and spongialization is a good alternative for the treatment of

severe patellofemoral arthrosis secondary to patellofemoral malalignment, it is a secure

option with a low rate of complications which gives the patients, mainly the younger

patients a great improvement in their pain and functionality. Nevertheless, it is

important to conduct prospective studies among the different surgical tecniques to

support these findings. Another future alternative is to combine these tecniques with

the use of implantation of autologus chondrocites for the regeneration of the native

cartilage.

An important aspect is the degree of inclincation of the osteotomy, which determines

the rate of medialization. If a 45 degrees osteotomy is performed and then the bone

graft is used, the medialization effect would be lost, for this reason, with the use of an

osteotomy at 30 degrees of inclination we could obtain the medialization effect while

optimizing the anteriorization effect with the use of a small bone graft.

The surgeon and the patient must know that this procedure is mainly indicated to give

more time for a severe damaged knee in which arthroplasty is not yet an option. The

patients and their families must comprehend the objectives of the procedure.

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One of the limitations of this study was that the lysholm score modified by fulkerson

was not evaluated in a periodic way, was applied in a variable time in the postoperative

period and was not used in the preoperative period.

AGRADECIMIENTOS

Agradecemos al Servicio de Ortopedia y Traumatología del Hospital Militar Central y a La

Clínica Universitaria Colombia Sanitas por su colaboración y a los pacientes de las

respectivas instituciones que autorizaron participar en la elaboración del presente estudio.

A los departamentos de Educación Médica e Investigación del Hospital Militar Central y de

La Clínica Universitaria Colombia Sanitas.

A la Doctora Michelle Cortés, asesora epidemiológica de la SCCOT, por sus valiosas

orientaciones y sugerencias.

Al Doctor Milcíades Ibáñez Pinilla, Experto en Bioestadística y Epidemiología, Centro de

Investigación, Ciencias de la Salud, Fundación Universitaria Sanitas.

Al Doctor Andrés Prada, Médico General, Universidad Militar Nueva Granada, por su

valiosa colaboración en la recolección de la información y desarrollo metodológico.

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