Patella re-alignment in children with a modified Grammont technique

Figures & data

Figure 1. a. Lateralized left patella tendon shown through incision. * lateral fixed patellar ligament.

b. The patella tendon dissected sharply from the tibial tuberosity. Then the periosteum gets detached from the tibial crest by using a rasp (° tibial tuberosity, * patellar ligament).

c. New medialized position of the patella tendon through the incision (° tibial tuberosity, * detached patellar ligament).

Figure 2. Schematic drawing of left knee. a. Following arthroscopy, a lateral incision was made starting at the mid-patellar level and extending distally to include the anterolateral arthroscopy portal to reach 1 cm below the tibial tuberosity. b. and c. In cases with concomitant osteochondral fragments, the incision was extended proximally allowing access to the lateral femoral condyle or the patella facet (red). Starting at the tibial tuberosity, the periosteum was split along the tibial crest for 6–8 cm distally without opening the fascia of the tibialis anterior muscle (red). The periosteum was subsequently detached from the tibial crest with a large rasp (blue). In knee flexion, the patella tendon then slides spontaneously medially to track within the femoral groove. Patella alignment was restored (green).

Figure 3. a. Sagittal-plane view of the proximal tibia (deep incision) indicating the relation of the patellar tendon insertion and the anterior tongue of the physis. Note that the physis remains untouched. LP: ligamentum patellae; TA: anterior tongue of the physis; Pe; periosteum. b. The patella tendon gets sharply dissected from the tibial tuberosity. The periosteum is then split along the tibial crest and detached distally by rasp. This leads to a spontaneous slide of the patella tendon medially.

Table 1. Patient demographics and range of knee movement

	Patella re-alignment		Patella re-alignment and osteochondral fragment fixation
	Male	Female	Male	Female
Age (chronological)	14.6	13.2	14.9	13.6
No. of patients	8	25	2	8
No. of knees	11	35	2	10
Bilateral cases	3	10	0	2
Left knee	2	7	2	5
Right knee	3	8	0	1
Knee ROM	3.5/0/135	2.6/0/142.2	5/0/140	0/0/141
range from	0/0/130	0/0/130	0/0/130	0/0/130
to	10/0/145	15/0/145	10/0/145	0/0/145

Table 2. Preoperative evaluation of trochlear dysplasia

Dejour grades of trochlear dysplasia	Radiographic sign	No. of knees
Grade A	Crossing sign	30
Grade B	Crossing sign Supratrochlear spur	14
Grade C	Crossing sign Double contour	4
Grade D	Crossing sign Supratrochlear spur Double contour	0

Table 3. Overview of literature

Author and year	Mean age	Knees/ patients	Follow-up (year)	Technique	Score	Results ^a	Redislocation
Vahasarja 1995	13	57/48	4.2	MIxed ^b	Insall	E 20, G 20, F 11, P 6	13
Schneider et al. 1997	16	?/17	10	Goldwaith procedure	Bentley	recurrent group: E 20%; G 20%, F 20%, P 10% habitual group: E 43%; G 28%; F 14%; P 14%	1
Zeichen et al. 1998	21	?/45 ^c	6.5	prox. realignment with	Larsen,	first-time dislocation: E 3, G 10, F 2
				Insall technique	Lauridsen	recurrent dislocation: E 7, G 12, F 10, P 1	1
Letts et al. 1999	14	26/22	2.4	Semi-membranosus	Lysholm,	E 6, G 12, P 4	1
				tenodesis	Zarins-Rowe
Marsh et al. 2006	14	30/20	6.2	modified Roux-Goldwaith	Insall	E 26, G 3, F 1	0
Ali et al. 2007	26	36/35 ^d	4.3	proximal arthroscopic	Lysholm	E+G 28, F 4, P 4	2
Joo et al. 2007	6	6/5	4.5	4 in 1 technique	Kujala	E 5, G 1	0
Oliva et al. 2009	13	?/25	3.8	3 in 1 technique	Cincinnati, Kujala	scores increased significantly from pre- to postoperative	1
Luhmann et al. 2011	14	27/23	5.1	proximal and/or distal realignment surgery	Tegner, Lysholm	mean Tegner 5.4 mean Lysholm 69.3	2

^a E – excellent, G – good, F – fair, and P – poor

^b Mixed: lateral release with or without medial reefment and/or Roux–Goldwaith procedure

^c 15 first-time dislocations + 30 recurrent dislocations

^d 24 dislocations + 12 subluxations

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