Current Concepts in Trochleoplasty for Major Trochlear Dysplasia

Abstract

Although technically demanding, trochleoplasty can be useful as a primary procedure for primary trochlea dysplasia or as a salvage procedure in cases of failure after previous patellar alignment surgery. 

Introduction

The importance of a dysplastic trochlea as a component of patellar instability (especially recurrent dislocation or habitual dislocation) has been recognized for many years. It is usually combined with other static or dynamic abnormalities, such as genu recurvatum, patella alta, patellar tilt, increased Q angle, and bone torsional abnormalities.

Major trochlear dysplasia is characterized by the combination of flat and/or prominent trochlea with a convex shape that is proud of the anterior femoral cortex, rather than a concave geometry, which offer inadequate tracking during flexion and lead to patella subluxation, respectively [1,2].

Many surgical techniques have been proposed for the treatment of patellar instability. Trochleoplasty has been described as corrective treatment for bony abnormalities for many years, with the goal of restoring normal anatomy. Correcting the trochlear depth abnormality plays a major role to stabilizing the patella because it facilitates proper entrance of the patella into the groove of the trochlea. In our experience, restoration of the trochlea groove by trochleoplasty prevents future patellar dislocation and is effective in reducing anterior knee pain.

Elevation of the lateral trochlear facet was first described by Albee [3] in 1915, followed by deepening trochleoplasty, [2,4-12] which tries to create a new sulcus by removing subchondral bone. Recently, Goutallier [13] proposed an easier concept, termed recession trochleoplasty, in which the bump is solely corrected with the trochlea remaining flat. This has now been adopted as our preferred technique [14].

Trochleoplasty is considered to be a demanding technique and may be avoided by many surgeons due to a lack of familiarity. However, it can be a useful addition to the surgical armamentarium of the patellofemoral surgeon and has precise indications.

Trochleoplasty can be proposed as a primary procedure for primary trochlea dysplasia or as a salvage procedure [13] in case of failure after previous patellar alignment surgery, principally anterior tibial tubercle transfer (ATTT).

In most cases, trochleoplasty is performed in association with other procedures (bony procedures such as ATTT transfer, or soft tissue procedure such as medial patello femoral ligament [MPFL] reconstruction). This combined procedures follows the concept of à la carte surgery described by Henri and David Dejour [1,7], which attempts to address all abnormalities during one surgical intervention.