Objectives: Patellar malalignment (PM) is common and a deformed valgus knee is an uncommon contributing factor. A deformed valgus knee can magnify the traction forces laterally during knee extension, consequently leading to PM. Treatment of combined disorders without correction of the deformed valgus knee is often less effective. The objective of this study was to assess the possibility of using the retrograde intramedullary nailing technique with some modifications for the treatment of both disorders.
Methods: From January 2011 to December 2020, 36 consecutive adult patients with 36 combined disorders underwent surgical treatment. The distal femur was obliquely osteotomized by creating a posterior cam on the distal bony fragment. The cam was consequently inserted into the marrow cavity of the proximal bony fragment. After the bone marrow was reamed, a dynamically locked intramedullary nail was inserted using the retrograde technique. A lateral retinacular release was performed on the patella, and the articular surfaces of the lateral patellar facet and lateral femoral condyle were drilled. The chi-square test was used to analyze categorical data and the Mann–Whitney U test was used to analyze numerical data.
Results: Thirty-two patients were followed for an average of 2.8 years (range, 1.7–5.4 years) and all osteotomized sites healed (average, 2.8 months). All 32 deformed valgus knees were corrected to the acceptable axis (from an average of valgus 10° initially to valgus 2° finally in 32 knees on the mechanical axis, p < 0.001). All PM had improved congruence angle, lateral patellofemoral angle, and patellofemoral index (p < 0.001 in all three). Both the tibiofemoral and patellofemoral joints achieved satisfactory function in all patients (p < 0.001).
Conclusion: The described technique can concomitantly treat both the tibiofemoral and patellofemoral joints. Although the technique is relatively simple, the effect is remarkable, and the success rate is high. Therefore, it may be a valuable alternative for the treatment of combined disorders.
| [1] |
F. B. Imhoff, M. Cotic, F. G. E. Dyrna, et al., “Dynamic Q-Angle Is Increased in Patients With Chronic Patellofemoral Instability and Correlates Positively With Femoral Torsion,” Knee Surgery, Sports Traumatology, Arthroscopy 29, no. 4 (2021): 1224–1231.
|
| [2] |
S. Taylor and A. Getgood, “Genu Valgum Correction and Biplanar Osteotomies,” Clinics in Sports Medicine 41, no. 1 (2022): 47–63.
|
| [3] |
S. Farrokhi, B. Meholic, W. N. Chuang, J. A. Gustafson, G. K. Fitzgerald, and S. Tashman, “Altered Frontal and Transverse Plane Tibiofemoral Kinematics and Patellofemoral Malalignments During Downhill Gait in Patients With Mixed Knee Osteoarthritis,” Journal of Biomechanics 48, no. 10 (2015): 1707–1712.
|
| [4] |
A. E. Weber, A. Nathani, J. S. Dines, et al., “An Algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation,” Journal of Bone and Joint Surgery (American Volume) 98, no. 5 (2016): 417–427.
|
| [5] |
C. C. Wu, K. M. Yeow, and Y. J. Yeow, “Imaging Approaches for Accurate Determination of the Quadriceps Angle,” Orthopaedic Surgery 12, no. 4 (2020): 1270–1276.
|
| [6] |
D. A. Abelleyra Lastoria, C. K. Benny, and C. B. Hing, “The Effect of Quadriceps Anatomical Factors on Patellar Stability: A Systematic Review,” Knee 41 (2023): 29–37.
|
| [7] |
E. Aksahin, O. Kocadal, C. N. Aktekin, et al., “The Effects of the Sagittal Plane Malpositioning of the Patella and Concomitant Quadriceps Hypotrophy on the Patellofemoral Joint: A Finite Element Analysis,” Knee Surgery, Sports Traumatology, Arthroscopy 24, no. 4 (2016): 903–908.
|
| [8] |
X. P. Shui, F. Ye, C. Y. Li, et al., “Effects of Millimeter-Wave for Preventing Joint Stiffness in the Immobilized Knee Rat Model,” Knee 42 (2023): 236–245.
|
| [9] |
S. Schroter, C. Konrads, M. Maiotti, et al., “In Closed Wedge Distal Femur Osteotomies for Correction of Valgus Malalignment Overcorrection of mLDFA Should Be Avoided,” Knee Surgery, Sports Traumatology, Arthroscopy 31, no. 9 (2023): 3992–3999.
|
| [10] |
A. N. Berk, K. K. Gachigi, D. P. Trofa, D. P. Piasecki, J. E. Fleischli, and B. M. Saltzman, “Early Postoperative Complications and Associated Variables After High Tibial Osteotomy and Distal Femoral Osteotomy: A 15-Year Experience From a Single Academic Institution,” American Journal of Sports Medicine 51, no. 10 (2023): 2574–2582.
|
| [11] |
G. Puddu, M. Cipolla, G. Ceyullo, V. Franco, and E. Gianni, “Which Osteotomy for a Valgus Knee?,” International Orthopaedics 34, no. 2 (2010): 239–247.
|
| [12] |
S. L. Sherman, S. F. Thompson, and J. C. F. Clohisy, “Distal Femoral Varus Osteotomy for the Management of Valgus Deformity of the Knee,” Journal of the American Academy of Orthopaedic Surgeons 26, no. 9 (2018): 313–324.
|
| [13] |
C. C. Wu, “Retrograde Dynamic Locked Nailing for Valgus Knee Correction: A Revised Technique,” International Orthopaedics 36, no. 6 (2012): 1191–1197.
|
| [14] |
Y. G. Park, H. Kang, J. K. Song, J. Lee, J. Y. Rho, and S. Choi, “Minimally Invasive Plate Osteosynthesis With Dual Plating for Periprosthetic Distal Femoral Fractures Following Total Knee Arthroplasty,” Journal of Orthopaedic Surgery and Research 16, no. 1 (2021): 433.
|
| [15] |
H. Peng, A. Ou, X. Huang, et al., “Osteotomy Around the Knee: The Surgical Treatment of Osteoarthritis,” Orthopaedic Surgery 13, no. 5 (2021): 1465–1473.
|
| [16] |
B. S. Lee, T. H. Kim, S. I. Bin, J. M. Kim, and H. Kim, “Clinicoradiologic Outcomes of Medial Open-Wedge High-Tibial Osteotomy Are Equivalent in Bone-On-Bone and Non-Bone-On-Bone Medial Osteoarthritis,” Arthroscopy 37, no. 2 (2021): 638–644.
|
| [17] |
J. M. Kazley and S. Banerjee, “Classifications in Brief: The Dejour Classification of Trochlear Dysplasia,” Clinical Orthopaedics and Related Research 477, no. 10 (2019): 2380–2386.
|
| [18] |
C. C. Wu, “Combined Lateral Retinacular Release With Drilling Chondroplasty for Treatment of Patellofemoral Osteoarthritis Associated With Patellar Malalignment in Elderly Patients,” Knee 18, no. 1 (2011): 24–29.
|
| [19] |
C. C. Wu, “A Novel Approach for Evaluating Acceptable Intra-Operative Correction of Lower Limb Alignment in Femoral and Tibial Malunion Using the Deviation Angle of the Normal Contralateral Knee,” Knee 21, no. 2 (2014): 573–581.
|
| [20] |
M. J. Kraeutler, G. M. Aliberti, A. J. Scillia, E. C. McCarty, and M. K. Mulcahey, “Microfracture Versus Drilling of Articular Cartilage Defects: A Systematic Review of the Basic Science Evidence,” Orthopaedic Journal of Sports Medicine 8, no. 8 (2020): 2325967120945313.
|
| [21] |
C. C. Wu, “Aseptic Femoral Nonunion Treated With Exchange Locked Nailing With Intramedullary Augmentation Cancellous Bone Graft,” Journal of Orthopaedic Surgery and Research 17, no. 1 (2022): 339.
|
| [22] |
J. N. Insall, L. D. Dorr, R. D. Scott, and W. N. Scott, “Rational of the Knee Society Clinical Rating System,” Clinical Orthopaedics and Related Research 248 (1989): 13–14.
|
| [23] |
U. M. Kujala, L. H. Jaakkola, S. K. Koskinen, S. Taimela, M. Hurrne, and O. Nelimarkka, “Scoring of Patellofemoral Disorders,” Arthroscopy 9, no. 2 (1993): 159–163.
|
| [24] |
M. A. Rothermich, N. R. Glaviano, J. Li, and J. M. Hart, “Patellofemoral Pain: Epidemiology, Pathophysiology, and Treatment Options,” Clinics in Sports Medicine 34, no. 2 (2015): 313–327.
|
| [25] |
X. Zhang, J. P. Eyles, J. Makovey, M. J. Williams, and D. J. Hunter, “Is the Effectiveness of Patellofemoral Bracing Modified by Patellofemoral Alignment and Trochlear Morphology?,” BMC Musculoskeletal Disorders 18, no. 1 (2017): 168.
|
| [26] |
J. Corbett, J. Tai, L. Salmon, and J. Roe, “Comparison of CT and EOS in Assessing Coronal Lower Limb Alignment When Planning Total Knee Arthroplasty,” Knee 42 (2023): 400–408.
|
| [27] |
V. Drapeau-Zgoralski, B. Swift, A. Caines, A. Kerrigan, S. Carsen, and M. Pickell, “Lateral Patellar Instability,” Journal of Bone and Joint Surgery (American Volume) 105, no. 5 (2023): 397–409.
|
| [28] |
A. Frank, S. Brianza, M. Plecko, M. J. Raschke, and D. Wahnert, “Variable Fixation Technology Provides Rigid as Well as Progressive Dynamic Fixation: A Biomechanical Investigation,” Journal of Bone and Joint Surgery (American Volume) 102, no. 20 (2020): e115.
|
| [29] |
S. G. Liu, D. J. Yu, H. Li, et al., “Combination of External Fixation Using Digital Six-Axis Fixator and Internal Fixation to Treat Severe Complex Knee Deformity,” Journal of Orthopaedic Surgery and Research 18, no. 1 (2023): 65.
|
| [30] |
J. Fluegel, F. Zimmermann, S. Gebhardt, D. D. Milinkovic, and P. Balcarek, “Combined Distal Femoral Osteotomy and Tibial Tuberosity Distalization Is Effective in Patients Presenting With Patellar Instability and Patellofemoral Pain due to Patella Alta and Femoral Malalignment,” Archives of Orthopaedic and Trauma Surgery 143, no. 5 (2023): 2557–2563.
|
| [31] |
A. Guarino, L. Farinelli, V. Lacono, et al., “Long-Term Survival and Predictors of Failure of Opening Wedge High Tibial Osteotomy,” Orthopaedic Surgery 15, no. 4 (2023): 1002–1007.
|
| [32] |
B. Van Dyke, R. Colley, C. Ottomeyer, R. Palmer, and K. Pugh, “Effect of Blocking Screws on Union of Infraisthmal Femur Fractures Stabilized With a Retrograde Intramedullary Nail,” Journal of Orthopaedic Trauma 32, no. 5 (2018): 251–255.
|
| [33] |
M. Kariksiz and O. Karakoyun, “Acute Correction Ofdistal Femoral Deformities by Retrograde Femoral Nail Using Preoperative Planning,” Journal of Orthopaedic Surgery 30, no. 3 (2022): 10225536221143552.
|
| [34] |
C. C. Wu, “Integrating Various Common Indexes of Bony Alignment in Femoral Supracondyle,” European Journal of Orthopaedic Surgery and Traumatology 24, no. 7 (2014): 1271–1277.
|
| [35] |
E. J. McWaler, J. Cibere, N. J. Maclntyre, S. Nicolaou, M. Schulzer, and D. R. Wilson, “Relationship Between Varus-Valgus Alignment and Patellar Kinematics in Individuals With Knee Osteoarthritis,” Journal of Bone and Joint Surgery (American Volume) 89, no. 12 (2007): 2723–2731.
|
| [36] |
H. Zhang, Y. Chen, H. Jiang, et al., “Comparison of Accuracy for Hip-Knee-Ankle (HKA) Angle by X-Ray and Knee Motion Analysis System and the Relationships Between HKA and Gait Posture,” BMC Musculoskeletal Disorders 24, no. 1 (2023): 452.
|
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2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.
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