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The Classic: Total Tendon Transplant for Slipping Patella

2006; Lippincott Williams & Wilkins; Volume: 452; Linguagem: Inglês

10.1097/01.blo.0000238831.50186.87

1528-1132

Emil D. W. Hauser,

Body Contouring and Surgery

Emil Hauser's 1938 Classic Article on recurrent dislocation of the patella includes a review of previous treatment methods and his own ideas about improving on them. His tibial tubercle transfer was widely accepted for many years because it was reasonable effective and easy to do. Unfortunately, the posterior and medial transfer of the tibial tubercle increased patellofemoral joint reaction forces and caused patellofemoral osteoarthritis in some patients. Procedures which move the insertion of the infrapatellar tendon anteriorly as well as medially, eg Maquet or Elmslie-Trillet operations, have supplanted Dr. Hauser's way of dealing with this problem, but his paper remains an important milestone. Emil Hauser was born in 1897 and died in 1982. He studied medicine at the University of Minnesota and graduated from that institution in 1922 with an MD degree. He received postgraduate training in surgery at the University of Minnesota and at the Mayo Clinic. Thereafter, he spent time at the Karolinska Institute in Stockholm studying orthopaedics. He earned an MS degree in orthopaedic surgery at the Mayo Clinic in 1927 and spent most of the rest of his working life in the Department of Orthopaedic Surgery at Northwestern University in Chicago. Henry H. Sherk, MD Deputy Editor for Classic Articles RECURRENT dislocations of the patella (slipping patella) may be divided, for clinical purposes, into three types: (1) congenital, which is a true anomaly; (2) traumatic, which is the result of severe injury; and (3) rachitic, which is secondary to a marked genu valgum. The anomalies that occur in the congenital type are not confined to the patella but frequently involve the patellar ligament and the lower end of the femur. The posterior surface, instead of having two equal joint surfaces to glide over the condyles of the femur, is irregular sometimes to the point of being almost wedge-shaped. The surface of the lateral condyle over which the patella glides is flattened and altered from the normal rounded shape, and since it is not fully developed the patella is likely to displace laterally. The patellar ligament is lengthened and the attachment to the tibia lies lateral to the normal attachment. The outer strands are much stronger, while the medial strands have become weakened through disuse, often to the point of atrophy and ultimate loss. The lengthening of the patellar ligament results in a high position of the patella in relation to the knee joint. The effect of this position on the function of the knee joint will be explained later. Congenital anomalies vary in severity, at times being so mild as not to cause any serious disturbance in function. Frequently both knees are involved; sometimes the one may give rise to recurrent dislocations, while the other, even though markedly deformed, carries out its function without any disability. The traumatic type of recurrent dislocation of the patella is relatively rare. It occurs as the result of severe injury which is practically always an indirect trauma. Most frequently it is the result of a forceful twist which brings the leg into abduction at the knee, with a resultant tear not only of the medial ligament of the knee but also of the entire medial fascia, so that the patella and patellar tendon are displaced laterally. Such a knee if permitted to heal with a gap in the fascia, particularly near the upper part of the patella, has a tendency to recurrent dislocation. A traumatic recurrent dislocation of the patella, if allowed to go untreated indefinitely, gives rise to secondary changes in the quadriceps muscle, in the lateral ligament, and in the patellar tendon, and ultimately in the patella itself. These changes are the result of altered use and a certain amount of disuse. The quadriceps muscle becomes weak and atrophic; the patellar tendon is lengthened and displaced laterally; the lateral fascia and capsule are shortened and markedly thickened. The shape of the patella is altered; it becomes wedge-shaped, the thinner part being toward the medial margin and the base toward the outer margin. A severe, neglected, traumatic recurring dislocation of the patella may ultimately reach the point where it becomes chronic, that is, the patella becomes constantly dislocated with nearly complete loss of function.Fig: Dr. Emil D. W. Hauser is shown. This image of Dr. Hauser is ©1983 by the Journal of Bone and Joint Surgery, Inc., and is reprinted with permission from Emil D. W. Hauser, MD: 1897-1982. J Bone Joint Surg Am. 1983;65:423.The rachitic type of slipping patella is associated with a primary anatomical change, namely, a genu valgum. That some other factor plays a rôle is evident, for not all patients with genu valgum are subject to recurrent dislocations of the patella; however, a severe genu valgum and a lengthened patellar ligament will explain a recurrent dislocation of the patella. In severe deformities the lateral condyle may be immaturely developed, particularly on its anterior surface, so that the patella can slide over to dislocate. REVIEW OF LITERATURE Prophylaxis and conservative treatment are not considered in this paper. Before presenting the new type of operation for slipping patella and its advantages, it is pertinent to discuss the operations previously used and their shortcomings, as well as the prerequisites of the operation of choice, so that the operation which is to be described and recommended may be evaluated on the basis of definite criteria. Numerous operations have been described for correction of recurrent dislocation of the patella. The number in itself predicates that the problem has not been solved. No attempt will be made to give a detailed description of each individual operative technique however, in order to give fair consideration to each and every procedure that has been devised, the methods have all been reviewed and will be discussed under groups arranged according to anatomical classification. The various types of operation are divided into 6 groups, namely: (1) those procedures which are directed against the relaxed median capsule; (2) those in which the fascia is transplanted; (3) those in which secondary muscles are used to hold the patella medially; (4) those in which free fascial transplants are used to hold the patella medially; (5) those in which the lower end of the femur is attacked; and (6) those in which the patellar ligament is transplanted. Under the first group we consider the so called reefing of the median capsule and fascia. In the very earliest of this type of operation, the medial side of the capsule was scraped and scarified in order to bring about a contracture (Heller, 1850). The next procedure was to reef the median capsule and fascia (Hoffa and Gocht). This method was soon found to be insufficient to prevent recurrence, so the patella was freed at its lateral margin before the reefing was done (Tubby). Attempts were made to free the patella and to hold it in the medial displacement (Perkins), while Wright sutured the patella to the medial condyle. The benefit attained was ascribed to scarification (Schanz). Later emphasis was placed on extending the incision of the lateral fascia well up along the margin of the conjoined tendon (Perthes). To shorten the fascia and ligament on the medial side, the longitudinal incision was made through the fascia, the margins were undermined and overlapped, imbricated, and sutured (Murphy). The vastus internus was imbricated in a similar manner along with the fascia (Bevan-Fig. 1, A, not shown). These methods proved inadequate because, first, they did not prevent recurrence of the dislocation in a high enough percentage of cases; second, they did not correct the high position of the patella; third, they did not offer any correction of the lengthened patellar ligament; fourth, they did not keep the muscle pull of the quadriceps in a direct line so that it can exert its greatest force in carrying out normal function. The second group attempted the correction by means of a transplant of the fascia. First an oval section was removed from the joint capsule on the medial side and this was then closed with sutures, drawing the patella medially (LeDentu). This operation was also combined with a reefing of the capsule. It was found necessary in many cases to make a second incision lateral to the patella through the fascia. With the drawing of the patella medially an open space resulted at the site of the incision. This was filled in by means of a transplant removed from the medial ligament (Dickson-Fig. 1, C, not shown). The best technique for carrying out this procedure is to transplant a long strip of the medial capsule, the fascia, and the vastus internus over the upper margin of the patella into the gap on the lateral side (Krogius-Fig. 1, B, not shown). This was also used by others (Strater, Lorenz, von Ruediger Rydygier, Klapp and Lueckerath). This type of fascial graft can be combined with a muscle graft (Frangenheim). Another type of fascial plastic operation includes the transplant from the inner side of the capsule to the external side, with a reefing of the medial capsule and a shortening of the quadriceps (Conn). This second type of operation again permitted recurrences although in a smaller percentage of cases than with the first group (Kapel). The patellar ligament is not shortened by this method and, therefore, the patella does not assume its normal position. Furthermore, this type of operation is not applicable to the severe cases in which the patellar ligament inserts too far laterally on the tibia, since it does not bring about a direct pull of the quadriceps upon the tibia, thus permitting the ligament to shoot off at a marked angle from the patella to the tibia. The third group comprises those operations which attempted the correction by operations upon the muscles, particularly by means of transplants. An attempt was made to shorten the quadriceps by reefing the tendon and fastening the aponeurosis of the internal vastus to the patella under tension (Bardenheuer). This method was used by others (Hoffmann and Bunts). The direction of pull of the quadriceps was altered by fastening the semitendinosus to this muscle (Heusner). In addition to the semitendinosus, the gracilis was also fastened to the quadriceps by drawing it through the fascia of the vastus internus (Lanz). The gracilis was also fastened on to the patella in addition to reefing the capsule and transplanting the insertion of the patellar ligament medially (Whitelocke). The sartorius muscle was brought around the quadriceps tendon and fastened into the medial condyle. In this way the sartorius acted as a sling to hold the patella medially (Hoffa and Gocht). A combination of fascial plastic and tendon transfer from the outer to the inner side has been attempted (Pasquale del Torto). The object of these muscle transplants was an attempt to strengthen the weakened quadriceps and to draw the patella medially. The objection to this method, aside from being a highly involved procedure and technically difficult to execute, is that the mechanical forces that draw the patella laterally are much greater than the combined power of all the muscles that can be transplanted. The results are very uncertain. The procedure has been discarded because of the frequency of recurrences (Fig. 1, B, not shown). The fourth group consists of fascial transplants. A strip of fascia lata or peroneal tendon was fastened to the patella and to the medial condyle of the femur (Gallie and Le-Mesurier). Others have used this operation with success (Ryerson) and still others recommend it for selected cases (Cole and Williamson). The fascial strip removed from the lateral side of the knee was run subcutaneously over the patella and fastened to the medial condyle (Klapp). This operation was also used by other authors (Karl and Hartleib). The iliotibial band was passed beneath the aponeurosis and sutured to the medial aspect of the tibia (Ober). A strip of fascia was used to encircle the patella and both ends fastened to the iliotibial tract and the medial condyle (Vorschuetz). A strip of fascia lata was run through a tunnel in the patella and fastened to the tibia to form a new patellar ligament (Soutter). Wilson used silk for a ligament. To correct the patella from above and hold it in alinement, the quadriceps tendon was fastened on to the gracilis muscle by means of a fascial ring (Rene Sommer). An Italian surgeon also did a reconstruction of the quadriceps tendon. Criticism of this method is that active forces, namely, the lateral pull of the quadriceps, continues to act against the ligamentous transplant which may, even if in relatively few cases, stretch or give way with resultant recurrence of the dislocation. Second, it does not correct the high position of the patella nor shorten the lengthened patellar ligament; therefore, it does not reestablish normal function of the quadriceps muscle. The fifth group of operations comprises those upon the lower end of the femur. To prevent the patella from slipping laterally, an oblique osteotomy was performed which permitted a straightening of the leg and rotation into normal position (Graser, Huebscher). An osteotomy from behind forward and from forward above was devised, which lengthened the femur and put tension on the quadriceps (Hacker). To prevent the patella from slipping laterally the external condyle was raised by means of an osteotomy (Sir Robert Jones). The external condyle was raised and an ivory peg inserted (Trendelenburg). Also, the upper end of the fibula was utilized (Boehler) and a wedge-shaped tibial graft has been employed (Albee-Fig. 3, A, not shown). This last type of tibial graft has been combined with plication (Buzby). In extreme cases of genu valgum it may be necessary to carry out the correction by means of a supracondylar osteotomy. Attempts to prevent the slipping of the patella have not always been successful since the quadriceps pull remained laterally in spite of the correction (W. B. Owen). Furthermore, the quadriceps is shortened as a result of bone lengthening and this leads to limitation of flexion at the knee (Finsterer). The operation requires prolonged fixation and would, therefore, not be the operation of choice. With regard to the elevation of the external condyle, this is an ingenious device for those cases in which the slipping is due to the underdevelopment of the external condyle. It necessitates opening the joint. It would not effect a lowering of the patella and shortening of the patellar ligament, and thus would not re-establish the normal capacity of the quadriceps. Good results, however, have been reported with both methods (Drehmann, Schanz, Albee). The sixth type of operation consists in transplanting the patellar ligament. The ligament was split in half, the outer portion drawn under the inner half and fastened through a drill hole in the median side of the tibia (Goldthwaite). Some refinement of this technique was made by MacAusland. The patellar ligament was freed from its insertion and transplanted to the inner condyle of the tibia by excising a triangular piece of periosteum. At the same time the vastus lateralis was divided because it was stronger than the vastus medialis. The fascia of the vastus medialis was reefed (Roux) which increased the tension on the quadriceps muscle. The inner third of the patellar ligament has been split and fastened medially and distally to the tibia under the periosteal bridge (Huebscher). The entire ligament has been transplanted medially (Bade and Parker) and at the same time drawn distally to a level lower than the ordinary insertion. A triangular transplant with its base at the insertion of the patellar ligament is swung from the medial side of the knee to the lateral side (Frank Forty). Camera transplanted the patellar ligament medially and at the same time did an osteotomy of the femur to correct the genu valgum. The patellar ligament has also been fastened by a wire nail (Sir Robert Jones). A block which included the attachment of the patellar ligament has been cut from the tibia and forced to slide medially, thus bringing about a medial transplant of the ligament (Kirschner). Plication of the medial capsule has been done in connection with patellar ligament transplants (Davis). In the congenital type of dislocated patella with contractures in the lateral fascia and capsule, the procedures mentioned will not be adequate since they do not bring the quadriceps pull in direct line to the tibia. The quadriceps force continues to pull laterally and to act as an opposing force against the transplant. Furthermore, the patellar ligament runs at an angle from the patella to the tibial insertion. The force acting in this manner for a long period of time will tend to cause a rotation of the tibia which will result in a deformity of the leg. Another original method of treatment to prevent dislocation of the patella has been to place a bone block taken from the patella itself in the external condyle of the femur (Estor and Estor). Costal grafts have also been used for this purpose (Rocher-Fig. 3, B, not shown). Judging from the recent literature, the present tendency is toward some type of transplant operation. In one such operation there is a complete transplant of the quadriceps extension apparatus with incisions down into the joint. Then a transplant after the manner of Krogius is carried out with a medial shifting of the entire patellar insertion (Fevre and Dupuis, Voelcker, Dencks, Herlyn-Fig. 1, B, not shown). Another method is to make an incision along the patella on both sides, cutting down right through the joint. Then the patella and the medial side of patellar ligament are sutured so that the quadriceps tendon comes back into the midline. This leaves a gap on the lateral side which opens down into the joint. The patellar ligament is transplanted medially and fastened with a nail. The gap is allowed to remain open (H. Strube). In a similar manner the outer margin of the vastus externus and both sides of the patellar tendon were freed and a raw surface made on the inner side of the tibia. The muscle and tendon were displaced inward and sutured, and the surplus capsule was transferred from the inner to the outer side of the joint (Malkin). Another type of procedure is to dissect the patella and the patellar ligament and its insertion so that they are entirely free. Then a slit is made in the middle of the capsule of the knee joint through which the freed patella and patellar ligament are drawn. The opening in the capsule is closed with interrupted sutures. The bony attachment of the patellar ligament is then screwed on to the tibia, and the patellar ligament and patella are fastened to the original capsule of the ligament (Mouchet and Durand-Fig. 3, C, not shown). The objections to these operations are first, that they necessitate extensive opening and suturing in the joint surface which increases the operative risk; second, they are complicated; third, the introduction of a metal screw or nail is not necessary, and finally, the position of the patella is not lowered so as to assume a normal position for leverage at the patella nor to restore normal muscle tension to the quadriceps muscle apparatus. CRITERIA OF A SUCCESSFUL OPERATION The criteria of a successful operation have been indicated in the above objections to previous operations. The prerequisites of an operation for correcting recurrent dislocation of the patella are: (1) the prevention of recurrence, (2) the feeling of absolute security on the part of the patient, (3) the re-establishment of the full functional capacity of the knee joint, (4) the normal appearance of the knee, (5) the minimum risk to the patient, and (6) the short period of convalescence. Judged by these criteria, a review of the operative procedures that have been described up to the present time shows that no procedure devised so far has entirely fulfilled the requirements demanded by an operation that will assure both a satisfactory correction of the anatomical changes and restoration of normal function. In order to meet the requirements of an anatomical correction for all types of recurrent dislocation, it is necessary to re-establish normal pull of the quadriceps muscle from its origin to its insertion. This includes the replacement of the patella into its normal groove as well as the attachment of the patellar ligament to the patella so as to bring the line of pull directly through it to the ligament. The patella must be drawn down to its normal position with regard to its relationship to the knee. It is also important that the quadriceps tendon is not displaced but lies in the midline. Probably more important than anyone of these factors is the fact that the upper margin of the patella must be brought over to the midline, for it is here that the greatest force is exerted in weight-bearing when the knee is flexed. Finally, to re-establish normal capacity of the quadriceps muscle it is necessary to have normal tension, which means that, if patellar ligament is lengthened, it is necessary to lower its insertion or somehow to shorten the mechanism of the quadriceps pull. AUTHOR'S OPERATION The operation about to be described was first performed 5 years ago and has been used in every case of recurrent dislocation that has come to my care since that time. Although the number is still small, the results have been uniformly successful. Four cases are reported, in 2 of which there were bilateral congenital dislocations. The operation is applicable to the most difficult as well as to the simpler cases of the congenital and traumatic types. For the rachitic type with marked genu valgum, the operation of choice undoubtedly is the correction of the genu valgum by means of a supracondylar osteotomy. The technique of the operation referred to is as follows (Figs. 4 and 5, not shown): A curved incision is made, starting above the upper lateral margin of the patella, curving laterally around the patella, and coming back to the midline about one-half inch below the tubercle of the tibia. The skin is freed on both sides to expose the patella, the conjoined tendon, and the patellar ligament. The patellar ligament is then dissected free down to its insertion. A block of bone about one-half inch square, including the attachment of the patellar ligament, is removed from the tibia by means of the electrical saw on three surfaces and an osteotome on the upper surface under the ligament. The entire lateral side of the patella is then dissected free by dividing the fascia down to the capsule. The dissection is carried along the lateral side of the conjoined tendon, well up into the area of the fascia lateral to the vastus muscle; this thickened fascia is divided down to the capsule but the operation remains extra-articular. The patella can now be drawn medially. The insertion of the patellar ligament is drawn to the median side of the tibia and distally until the patella lies low in the normal position between the condyles; this requires some tension of the quadriceps muscle. The periosteum is incised to make two flaps which are reflected. Then, a bony block one-half inch square is removed from the tibia in this area by means of the electrical saw. The attachment of the patellar ligament and its block are countersunk in this space, and the periosteum is then sutured over the block. The second graft is then fitted into the space at the tibial tubercle. Three sutures of No. 1 chromic catgut act as further stays to hold the medial side of the patellar ligament to the periosteum. The stretched medial fascia is then reefed in the region of the upper margin of the patella. It is not necessary to transplant the fascia to fill in the gap on the lateral side. The skin is closed. The fixation is held by means of a plaster-of-Paris cast for from 10 to 14 days. The sutures are removed at the end of this period, after which the quadriceps muscle can be massaged and weight-bearing started, with the leg extended. The fourth week following operation the knee can be flexed and the quadriceps muscle allowed to contract voluntarily. Free flexion is permitted after 6 weeks. A similar operation has been devised and executed by M. S. Henderson of the Mayo Clinic (personal communication), without emphasis on lowering the insertion of the patellar ligament. The operation has proved satisfactory and apparently has the advantage of being a true reconstruction type of operation which permits early use and assures increased strength, as well as being applicable to both congenital and traumatic types of dislocation. The principle of the operation fulfills all the requirements laid down as criteria for a successful operation in cases of slipping patella. It accomplishes full correction of the anatomical deformity, which includes the transplant of the quadriceps tendon, the patella, and the patellar ligament, so there is a direct line of pull in the quadriceps muscle system. It assures the proper position of the patella both in regard to the condyles and in relation to the knee. Furthermore, the upper margin of the patella is in the midline so the force acting there has no tendency to displace it laterally. The tension of the quadriceps muscle can be controlled so that the proper tension is permissible. The case histories of the patients operated upon will further establish that there have been no recurrences, that the function has been returned to normal, that in some cases the capacity has been increased beyond that of the other knee, and finally, as volunteered by the patients, that the knees feel absolutely secure at all times. CASE REPORTS CASE 1. Congenital anomaly of the knee, with osteochondritis dissecans possible, and probably loose body in the knee, plus a slipping patella. G. V. (Clinic No. 274669), 27 years of age was admitted to St. Luke's Hospital on July 15, 1931, complaining of a painful, weak knee which would "catch." Patient stated that ever since childhood he had had trouble with his right knee, that something apparently would slip out of place in the knee and he would fall down. This occurred frequently and was followed by acute pain in the knee. During the last few years these attacks were associated with swelling in the knee. He had sought relief in many clinics throughout the country. He stated that in no instance was any surgery suggested, that he was advised that nothing could be done and that he would have to put up with his disability. During the 2 years preceding his admission to the hospital the attacks of a sharp "catch" in the knee had become more frequent and more severe, and he had been unable to depend upon the knee with any degree of security. Past history included typhoid fever, scarlet fever, mumps, whooping cough, and influenza, excision of a right cervical lymph node, and tonsillectomy at the age of 14. His father died of angina pectoris; his mother was living and well; he had no brothers or sisters. Physical examination showed a well nourished white male, apparently comfortable, who was able to walk into the hospital. Pupils reacted normally; teeth were in good condition; tonsils cleanly removed. Neck was entirely negative save for a slight scar; lungs normal; abdomen negative. The patellar reflex was normal. Examination of the right lower extremity showed atrophy of the quadriceps with a slight decrease in the circumference of the thigh as compared with the left. The patella was movable in a wider range than normal and movement was associated with pain. A "clicking" could be felt over the knee when it was flexed and extended. Both patellæ were smaller in circumference and thicker in diameter than one would normally expect. Wassermann test was negative. Urinalysis was negative. Blood count showed 5,010,000 erythrocytes, 17,550 leucocytes, and hemoglobin 20.2 grams. X-ray examination of the knee showed a defect on the posterior surface of the patella which suggested an osteochondritis dissecans. The pre-operative diagnosis was congenital anomaly of the knee with osteochondritis dissecans possible, and probably a loose body in the knee, plus a slipping patella. The following operation was performed: A curved incision was made, starting above the upper lateral margin of the patella and curving laterally around the patella to come back in the midline about one-half inch below the tubercle of the tibia. The skin was freed on both sides to expose the patella, the conjoined tendon, and the ligament. The patella was found to be displaced laterally. The knee was then opened through an incision on the medial side, about an inch and one-half in length. The inner surface of the knee was examined for loose bodies; the posterior surface of the patella was examined and found to be roughened. The patella was everted to obtain a more satisfactory exposure. The posterior surface showed a demarcation which suggested an osteochondritis dissecans with a fragment loosened but still attached; the attachment was so firm that it resisted prying with a chisel and was, therefore, left intact. The knee was closed. The patellar ligament was then dissected free down to its insertion; the insertion of the ligament was freed by the removal of a block of bone about one-half inch square, which included the attachment of the ligament. The entire lateral side of the patella was dissected free by dividing the fascia down to the capsule. This dissection was carried upward along the lateral side of the conjoined tendon into the area of the fascia lateralis. The patella could then be easily drawn medially. The insertion of the patellar ligament was drawn to the medial side of the tibia, and distally until it was about 1½inches below its former insertion. At this point the periosteum was incised to make two periosteal flaps which were reflecte