Research question 2a: Which distinct morphologic abnormalities can be described on conventional radiographs of the patellofemoral joint in NPS patients, and can a character- istic ‘NPS knee’ be defined?
Research question 2b: Which measurements for assessing trochlear dysplasia and patellar tilt using magnetic resonance imaging (MRI) can reliable be reproduced?
Section II focused on the radiologic evaluation of the patellofemoral joint. Chapter 2
described that the factors of patellar instability can be diagnosed using common radio- graphs or CT scanning of the knee. In chapter 4, common radiographs were used to eval- uate the patellofemoral joint in patients with NPS and to describe its radiological character- istics. Conventional radiological examination of the knee in 95 Dutch patients with NPS was performed. The observed malformations were described and compared with the type of
LMX1B mutation. Patellar aplasia was present in 4% of patients and hypoplasia in 86%. The
prevailing patellar shapes were Wiberg type III and IV and Hunter’s cap. No patellar shape genotype-phenotype association was detected. A number of distinct malformations of the distal femur were observed; these consisted of shortening of the lateral femoral condyle in 55% of patients, a prominent anterior surface of the lateral femoral condyle in 56% of patients and a flat anterior surface of the medial femoral condyle in 92% of patients.
An easily recognizable characteristic quartet of malformations, consisting of patellar aplasia or hypoplasia and the abovementioned malformations of the distal femur, was established in 27% of patients. The majority of patients with NPS displayed at least three of these malformations. As MRI has become a common modality for evaluating knee pathology, and thus the patellofemoral joint, evaluation of patellar instability using MRI was the objective of chapter 5.
MRI hasa number of advantages over CT scanning for the evaluation of the patellofemoral joint. It allows for imaging of the cartilaginous morphology, identification of chondral lesions after patellar dislocation, and ruptures of the MPFL. We set out to identify normal values for assessment of the patellofemoral joint on MRI with respect to trochlear dysplasia and MPFL insufficiency. An analysis of standard MRI examinations of the knee in 51 asymptom- atic subjects was performed. Sulcus angle (SA), patellar axis (PA), lateral patellofemoral angle (LPFA) and lateral patellofemoral length (LPL) were independently assessed by two raters at a two-week interval. The mean reference values (mean ± SD) were SA: 142.4 ± 6.9°, PA: 5.3 ±
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3.8°, LPL: 0.8 ± 2.9 mm, and LPFA: 13 ± 4.4°. It was shown that MRI is a reliable imaging tech- nique to determine LPL and PA, as these showed a high inter-observer correlation and a high repeatability coefficient. In contrast, LPFA and SA showed poor correlation, and should not be used for evaluation of the patellofemoral joint.
Section III: Evaluation of surgical treatment in patellofemoral
instability and pain
Research question 3a: In patients with nail patella syndrome: 1. What is the frequency and severity of knee symptoms?
2. What are the numbers and types of applied surgical procedures on the knee? 3. What are the self-reported surgical outcomes?
Research question 3b: Are the initially promising results of a self-centring tibial tubercle osteotomy for either patellofemoral pain or instability sustained, or do the results deterio- rate over time? Does an unacceptable increase in patellofemoral osteoarthritis occur? Research question 3c: What are the long-term results of a lateral condyle-elevating troch- leoplasty with respect to clinical and radiological aspects, with an emphasis on (1) the occurrence of osteoarthritis, and (2) the possible deterioration of earlier clinical results? Research question 3c: Can coralline hydroxyapatite be used as a substitute for an intra-ar- ticular bone graft in securing a lateral condyle-elevating trochleoplasty?
Section III evaluated the surgical treatment of patellofemoral instability and pain. The eval- uation of knee symptoms and their surgical treatment in patients with NPS was described in chapter 6. To accomplish this, a questionnaire-based survey was conducted among 139 Dutch patients with NPS. Knee symptoms were assessed using the Knee Injury and Osteoar- thritis Outcome Score (KOOS) and Kujala knee score. In addition to these scores, the question- naire addressed any history of past surgeries, type of surgical procedure performed and the patient-reported outcomes of these procedures. The response rate to this survey was 74%. The results showed mean KOOS and Kujala scores of 73 and 74, respectively, with a wide range and variability between patients. Nearly half (48.5%) of the patients experienced patellofem- oral instability. Surgery was performed in only 22% of patients. In these patients, the majority of performed surgeries were patellar realignment procedures. Other procedures consisted
Chapter 10
of arthroscopies, total knee arthroplasties, a patellectomy, and seven unknown procedures. Although surgically-treated patients reported lower KOOS and Kujala scores, 87% and 30% reported an improvement in pain and function, respectively, after surgery. Most patients were satisfied or highly satisfied with the results of the surgical procedures. Patient satisfaction after patellar realignment procedures was similar, despite the fact that the proportion of patients who reported patellar instability after patellar realignment procedures was equivalent to that of patients who had not undergone surgery. The lower KOOS and Kujala scores of surgical- ly-treated patients, when compared to non-operated patients, appears to indicate that surgical treatment in NPS patients is unfavourable. However, the self-reported results of surgical treat- ment were generally positive, with high rates of patient satisfaction. Therefore, knee surgery in patients with NPS appears to be beneficial. Due to the retrospective nature of this study, it was not possible to compare the pre-operative and postoperative status of the patients.
As described in the first section of this thesis, distal malalignment caused by an increased TT-TG is one of the four factors of patellar instability. A more lateral insertion of the patellar tendon on the proximal tibia leads to increased pressure on the lateral wall of the trochlea and patellar maltracking. This may result in patellofemoral pain or, in more severe cases, in patellofemoral instability. A tibial tubercle transfer is a common treatment option with good short-term results; however, the long-term results tend to deteriorate over time due to progressive osteoarthritis. We hypothesized that this is due to overcorrection of the tibial tubercle, and performed long-term follow-up after a modified tibial tubercle transfer. The effects of this new, self-centring tibial tubercle osteotomy were evaluated in chapter 7. A prospective 10-year follow-up of a self-centring tibial tubercle osteotomy was performed in two groups of 30 consecutive knees, one group with patellar maltracking (pain but no insta- bility) and one with patellar instability. Inclusion criteria were a TT-TG ≥15 mm and complaints for longer than one year. Results showed that in both groups, VAS pain, Lysholm, and Kujala scores improved significantly when compared to their pre-operative values, and did not deteriorate at final follow-up. In the patellofemoral instability group, postoperative instability was low, with only three patients (three knees, 10%) experiencing residual instability, one of whom was treated by additional surgery. An increase in patellofemoral osteoarthritis was observed in 31% of knees, which was limited to a maximum of grade 2 on the Kellgren & Lawrence scale. This was similar to the natural course of osteoarthritis after patellar disloca- tion without surgical treatment. We conclude that this self-centring tibial tubercle osteotomy provides good long-term results for both patellar maltracking and patellofemoral instability without inducing progressive osteoarthritis.
One of the other factors contributing to patellar instability described in section I is trochlear dysplasia. When trochlear dysplasia is the major cause of patellar instability, a trochleoplasty is
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indicated. As this procedure changes the congruency of the articulating surface of the distal femur, it involves a high risk of cartilage damage and an increased risk of early osteoarthritis. The long-term results of a stand-alone lateral condyle elevating trochleoplasty were presented in chapter 8. A 12-year follow-up study was conducted in 16 patients (19 knees) after a lateral condyle elevating trochleoplasty without concomitant procedures. These patients had already been evaluated two years postoperatively, and these results were compared to the results at final follow-up.
Follow-up at a minimum of 12 years was available in 12 patients (15 knees). Three patients were lost to follow-up and one patient underwent a total knee arthroplasty three years post- operatively due to persistent pain. The mean Kujala score at final follow-up was 76, and the mean WOMAC and Lysholm scores were significantly improved from pre-operative values. No significant difference was noted between Kujala, WOMAC and Lysholm scores at the two-year and final follow-up. Residual patellar instability was reported in four of 15 knees (27%), and three knees underwent realignment surgery after the index procedure. When compared to its pre-operative values, a mean increase in radiologic osteoarthritis in all three compartments was observed; however, this was limited to the lower grades on both the Iwano and Kellgren & Lawrence classifications.
We conclude that a stand-alone lateral condyle-elevating trochleoplasty results in signifi- cant improvement in clinical scores. In contrast to general belief, it does not lead to an exces- sive increase in patellofemoral osteoarthritis. When performed as a stand-alone procedure, a lateral condyle elevating trochlear osteotomy leads to a significant amount of residual patellofemoral instability and does not meet the current standard in the surgical treatment of patellofemoral instability. We therefore advise not to use a lateral condyle elevating troch- leoplasty as a stand-alone procedure but always in combination with other patellar stabi- lizing techniques.
Chapter 9 assessed whether coralline hydroxyapatite (CHA) is suitable to support the lateral condyle-elevating trochleoplasty described in chapter 7. Traditionally, this trochleoplasty is supported by an autologous bone graft, which has the disadvantage of autologous graft-as- sociated morbidity. An in vivo study in goats was conducted to evaluate whether CHA is a suitable material for intra-articular use without inducing adverse reactions. The study was performed on two groups of 10 goats. In the CHA group, a femoral condyle defect was filled with CHA. In the control group, this defect was filled with autologous bone graft from the proximal tibia. The goats were culled three months’ postoperatively and the knees dissected. No negative reaction in the synovium of the knee was evoked by the CHA, and the artic- ular cartilage was comparable to the control group, as the cartilage remained viable without surface damage. In the control group, most of the bone graft was resorbed or remodelled and the remnants were incorporated into scattered areas of newly-formed (enchondral)
Chapter 10
bone. In the CHA group, resorption of CHA was limited or absent, and most of the CHA was surrounded by new bone. In areas with fragmented CHA close to the joint surface, numerous giant cells were found. The results of this animal model show that CHA inserted into a bone gap directly communicating with the joint space incorporates into the surrounding bone. Moreover, CHA does not induce negative reactions within the joint or on the cartilage.