Anteromedialization Tibial Tubercle Osteotomy Improves Patellar Contact Forces: A Cadaveric Model of Patellofemoral Dysplasia

Abstract

Background: Patellofemoral (PF) dysplasia is common in patients with recurrent patellar instability. Tibial tubercle osteotomy (TTO) is performed with goals of correcting patellar maltracking and redistributing contact forces across the PF joint. The biomechanical effects of TTO in the setting of PF dysplasia have not been quantified. Purpose/Hypothesis: To quantify patellar contact mechanics and kinematics after TTO in the setting of PF dysplasia. We hypothesized that a simulated anteromedialization (AMZ) TTO would improve PF contact mechanics as compared with a pure medialization TTO. Study Design: Controlled laboratory study. Methods: PF dysplasia with Dejour type D classification was simulated in 7 cadaveric knees by replacing the native patellar and trochlear surfaces with synthetic polymeric patellar and trochlear implants. On each specimen, a flat TTO was fixed in 3 distinct positions simulating a pathologic lateralized tubercle (pathologic condition), a medialized tubercle (Elmslie Trillat), and an AMZ tubercle. The sum of forces acting on the medial and lateral patellar facet and patellar kinematics was computed for each knee for each condition from 0° to 70° of flexion at 10° increments. Results: Relative to the pathologic condition, AMZ TTO decreased contact forces across the lateral facet (20°-50° and 70° of flexion). Relative to the pathologic condition, Elmslie Trillat TTO had no effect on contact forces on either compartment. Relative to the Elmslie Trillat TTO, the AMZ TTO had significantly decreased contact forces across the medial facet (at 40°, 60°, and 70° of flexion). No significant differences in joint kinematics occurred across any groups. Conclusion: Of all groups studied, AMZ TTO resulted in significantly decreased patellar contact forces in simulated dysplastic PF joints. AMZ may be considered in certain patients with PF dysplasia to avoid medial compartment PF chondral overload. Clinical Relevance: PF dysplasia is common in patients with recurrent patellar instability who warrant surgical intervention to prevent subsequent recurrence. Numerous interventions to treat this condition, including various TTOs, have been proposed without a clear consensus. This cadaveric biomechanical study demonstrates that AMZ TTO resulted in more favorable PF contact mechanics than Elmslie Trillat TTO in a model representing PF dysplasia. AMZ TTO may be considered for patients in the setting of recurrent instability with PF dysplasia to avoid cartilage overload on the medial compartment of the PF joint.