Arthroscopic Patella Realignment
Abstract & Commentary
Synopsis: An arthroscopic, all-inside suture technique restored stability and improved function and radiographic alignment for 29 knees with patella instability.
Source: Halbrecht JL. Arthroscopic patella realignment: An all-inside technique. Arthroscopy. 2001;17(9):940-945.
Although a few articles address patella instability using arthroscopic methods, none are truly all-inside and completely arthroscopic. Halbrecht has developed a method to tighten the medial retinaculum using sutures passed and tied arthroscopically. A blunt-tipped epidural needle is used to pass a number 1 absorbable PDS suture from outside-in through the medial retinaculum at 2 locations, one adjacent to the patella and another 2-3 cm posteriorly. The free ends are retrieved through an accessory proximal lateral portal or the anterior medial portal and tied using standard arthroscopic techniques. The medial retinaculum is first roughened with the shaver or the radiofrequency device to stimulate a healing response. A total of 4 or 5 sutures are placed, a lateral retinacular release performed, and the sutures tied.
Over a 5-year period, Halbrecht performed the procedure on 45 knees but only 29 knees were available for follow-up at a minimum of 2 years. Inclusion criteria included patients with true instability and normal alignment (average Q angle just 11°). No patients had patella alta or trochlear hypoplasia. (It is difficult for me to understand why they had instability.) Both acute and chronic patients were included.
Of those patients available for follow-up, none experienced recurrent instability. Nintey-three percent of patients improved subjectively in terms of swelling, pain, crepitus, and return to sport with Halbrecht’s invented scale, and objectively by Lysholm scores (41.5 pre to 79.3 post). Radiographic measurements also improved, including the congruence angle (30.7° pre to 8.2° post) and the lateral patellofemoral angle (-3° pre to +9.4° post).
Comment by David R. Diduch, MS, MD
This is an intriguing study. Several aspects are very persuasive, including the radiographs before and after reconstruction showing the patella tipped way off and then completely centered. Likewise, the 93% subjective improvement and the lack of recurrent instability are excellent outcomes. However, it should be noted that only 29 of 41 knees were available for follow-up, and radiographs were performed only on 24 patients. It should also be noted that Halbrecht was also the surgeon and the person evaluating patients in follow-up. It can be difficult for patients to be critical when questioned by their surgeon. Using established scoring systems in addition to the Lysholm scale, such as the Tegner activity scale, would have been more helpful than an invented subjective score. Also, it has been shown, and has been my own experience, that soft tissue proximal realignments can stretch out over time. A 2-year follow-up may be insufficient to detect this, and it is not clear in the paper when the radiographs were obtained.
A more important concern in my mind is that this technique appears to abandon the recent scientific advances in understanding the role of the medial patellofemoral ligament (MPFL) for patella instability. Several recent reports have identified the MPFL rupture as the essential lesion for patella dislocations. The same studies also demonstrated that the rupture occurs in most cases off of the bony attachment at the medial epicondyle of the femur. This study’s technique of suture imbrication adjacent to the patella would not tighten the MPFL since it would not be anchored more posteriorly to bone. I am concerned that this approach would stretch with time.
It appears to me that our present treatment of patella dislocations is analogous to where we stood with shoulder instability several years ago. We are understanding the essential anatomic lesion better and developing techniques to specifically address this rather than tightening everything indiscriminately. As outcomes improve we are more aggressive with recommending surgical treatment. If an all-inside arthroscopic technique works equally well, then that is even better for our patients. Cadaver and biomechanical studies need to be done to critically evaluate this technique before it can be advocated, especially given the short and incomplete follow- up in this paper.
Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, is Editor of Sports Medicine Reports.
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