An Oblique Transposition Quadricepsplasty Provides Excellent Outcomes For The Treatment Of Type Iv (Obligatory, Flexion-Range) Patellar Dislocation

An Oblique Transposition Quadricepsplasty Provides Excellent Outcomes For The Treatment Of Type Iv (Obligatory, Flexion-Range) Patellar Dislocation

Philip Wilson, MD, UNITED STATES Clarissa Meza, MD, UNITED STATES Charles W. Wyatt, CPNP, UNITED STATES V. Claire Clark, BS, UNITED STATES Benjamin Johnson, PA-C, UNITED STATES Henry B. Ellis, MD, UNITED STATES

Scottish Rite for Children, Frisco, Texas, UNITED STATES


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Anatomic Location

Diagnosis / Condition

Treatment / Technique

Patient Populations

Sports Medicine


Summary: Oblique transposition quadricepsplasty resulted in 100% patellar stability at intermediate term follow up with low reoperation rates, reliable improvement in PROM and range of motion, and no demonstrated benefit of concurrent MPFLR or distal realignment.


Objectives: Type IV (Obligatory, Flexion-range) patellar dislocation is a challenging condition, requiring quadriceps lengthening and often additional reconstructive procedures. Various lengthening procedures exist with varying reported results. The purpose of this study was to evaluate outcomes following an oblique transposition quadricepsplasty for the treatment of type IV patellar dislocation.

Methods

An IRB-approved retrospective review of patients treated by two pediatric sports surgeons with an oblique transposition quadricepsplasty for type IV patellar dislocation between 2015 and 2022 was accomplished; with Inclusion requiring a minimum of 2-year follow-up. All knees received an oblique distal-medial to proximal-lateral quadricepsplasty with repair in a transposed position at 90° of flexion, and an extensile lateral release and a vastus medialis lateral advancement over the quadriceps and patella. A medial patellofemoral ligament reconstruction (MPFLR) and/or distal realignment (Tibial tubercle, or patellar tendon medialization) was utilized in selected patients. Exam, operative data, complications, and re-operation were recorded. Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala Score, Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) PROMs were evaluated.

Results

18 knees (16 patients) treated with an oblique transposition quadricepsplasty for type IV patellar dislocation were evaluated at an average of 3.5 years post-operatively (r= 2 - 7.4 y). Average age was 12.8 (r= 5-17) years and 9 (56%) patients were female. 6 (38%) patients had associated musculoskeletal diagnoses (DiGeorge, Fibular Hemimelia, Hypochondroplasia, Nail-Patella, Shaken Baby Syndrome, and a Undifferentiated Chromosomal disorder). 44% (8/18) knees had pre-operative extensor lag averaging 12° (r=3°-22°), with average motion arc 129° (r= 100°-147°). All had high-grade trochlear dysplasia [12 (67%) type C, 6 (33%) type D. Five (28%) knees demonstrated a patellar cartilage lesion, and 3 (17%) had a trochlear or lateral condyle cartilage lesion. Nine (50%) knees were treated with concurrent MPFLR and 9 (50%) had distal realignment. Ten (56%) had additional concurrent surgery; most commonly guided-growth implant removal, with two knees receiving concurrent lateral femoral osteochondral allografts.
At final follow-up, 100% of patients reported a stable, anterior patella with only 4 (22%) reporting an extensor lag of 11° (r=10°-15°).Motion arc and PROMs were good and all trended higher than pre-operative [motion arc: pre 129.6° (SD 13.1°) vs post 137° (SD 14.4°), p = 0.15; KOOS: pre 61.4 (SD 18.9) vs post 80.6 (SD 6.5), p = 0.065; Kujala: pre 62.8 (SD 14.5) vs post 81.8 (SD 8.4), p = 0.064] and Pedi-FABS was unchanged (14.4 vs 12.2; p = 0.18). There was 1 (5.6%) Clavien-Dindo (CD) type III complication (reoperation for arthrofibrosis in a case with concurrent osteochondral allograft), and 1 (5.6%) CD II complication (superficial wound dehiscence). There were no differences in patellar stability, re-operation, motion, extensor lag, or PROM in patients treated with isolated oblique quadricepsplasty compared with those receiving additional MPFLR or distal realignment.

Conclusions

Oblique transposition quadricepsplasty resulted in 100% patellar stability at intermediate term follow up with low reoperation rates in this challenging type IV patellar dislocation population. Reliable improvement in PROM and range of motion was achieved with no demonstrated benefit of concurrent MPFLR or distal realignment.