Umut AKGÜN, Rüştü NURAN, Mustafa KARAHAN

Modified Fulkerson osteotomy in recurrent patellofemoral dislocations

Amaç: Bu çalışmada, tekrarlayan patellofemoral çıkıklar nedeniyle modifiye Fulkerson yöntemi uygulanan olgularda tedavi sonuçları değerlendirildi. Çalışma planı: Patellofemoral dizilim bozukluğu nedeniyle aynı cerrah tarafından ameliyat edilen 16 hastanın (11 erkek, 5 kadın; ort. yaş 25; dağılım 15-43) 17 dizi incelendi. Ameliyat öncesi yakınmaların süresi ortalama 3.4 yıl (dağılım 1-12 yıl) idi. Ameliyat öncesinde çıkık sayısı üç dizde 1-5, beş dizde 6-10 arasında, dokuz dizde ise 10’dan fazlaydı. Tüm hastalarda ameliyat öncesi endişe testi pozitif ve Q açısı 15 derecenin üzerinde bulundu. Tüm dizler ameliyat öncesi ve sonrasında düz grafiler ve bilgisayarlı tomografi ile incelendi ve ameliyat öncesinde tüm dizlerde subluksasyon ve patellar tilt, iki hastada troklear displazi saptandı. Tüm hastalarda ameliyat sırasında tanısal artroskopiden yararlanıldı. Cilt insizyonu kozmetik nedenlerle iki farklı yatay kesi ile yapıldı. Tüm dizlere patellar tiltin düzeltilmesi için lateral patellar gevşetme, subluksasyon ve dizilim bozukluğunun düzeltilmesi için modifiye Fulkerson osteotomisi uygulandı. Üç dizde ek olarak medial plikasyon yapıldı. Lateral gevşetme sonrasında patellofemoral uyum ve tüberositas tibiada osteotomi ve anteromedializasyon sonrası patella pozisyonu artroskopik olarak kontrol edildi. Hastalara ameliyat sonrasında Kujala ve ark. ve Crosby-Insall tarafından geliştirilen fonksiyonel skorlama çizelgeleri uygulandı. Radyografik osteoartrit derecelendirmesinde, Palmer ve ark. tarafından modifiye edilen Iwano ve ark.nın sınıflama sistemi kullanıldı. Ortalama takip süresi 2.6 yıl (dağılım 24 ay-53 ay) idi. Sonuçlar: Artoskopi sırasında sekiz dizde patella arkası kıkırdakta ciddi hasar (Outerbridge derece III-IV), dokuz dizde orta derecede hasar (derece I-II) saptandı. Ameliyat sonrası takiplerde 17 dizden ikisinde efüzyon, ikisinde devam eden subluksasyon saptandı, üç dizde endişe testi pozitif idi. Fleksiyon kaybı ortalama 8º (dağılım 0º-20º) bulundu, bir hastada izlenen 10 derecelik ekstansiyon kaybı altı haftalık fizik tedavi sonrasında tamamen düzeldi. Ameliyat sonrası tomografik incelemede iki olgu dışında tüm olgularda subluksasyon ve tiltin düzelmiş olduğu izlendi. Ameliyat öncesi grafilerde tibiofemoral eklemde bir dizde (%5.9), ameliyat sonrasında üç dizde (%17.7); patellofemoral eklemde ise ameliyat öncesinde yedi dizde (%41.2), ameliyat sonrasında 11 dizde (%64.7) dejeneratif artrit bulguları saptandı. Crosby-Insall skorlama sistemine göre, sonuçlar beş dizde mükemmel, yedi dizde iyi, beş dizde ise orta olarak değerlendirildi. Ameliyat sonrasında Kujala skoru ortalaması 82.6 (dağılım 44-100) bulundu. Çıkarımlar: Bulgularımız, doğru endikasyon konulduğunda, tekrarlayan patellofemoral eklem çıkıklarının tedavisinde modifiye Fulkerson yönteminin başarılı sonuçlar sağladığını göstermektedir.

Anahtar Kelimeler:

Osteotomi, Diz eklemi, Femur, Tedavi sonucu, Tomografi, x-ışınlı bilgisayarlı, Tekrarlama, Çıkıklar, Patella çıkığı, Yük verme

Tekrarlayan patellofemoral çıkıklarda modifiye Fulkerson osteotomisi

Objectives: We evaluated the results of a modified Fulkerson technique performed for the treatment of recurrent patellofemoral dislocations. Methods: The study included 17 knees of 16 patients (11 males, 5 females; mean age 25 years; range 15 to 43 years) who were operated on by the same surgeon for patellofemoral alignment disorders. The mean duration of complaints was 3.4 years (range 1 to 12 years). Preoperatively, the number of recurring dislocations were 1 to 5 in three knees, 6 to 10 in five knees, and more than 10 in nine knees, and all the patients had a positive apprehension test and a Q angle exceeding 15 degrees. All the knees were assessed by preoperative and postoperative radiographs and computed tomography, which showed both subluxation and patellar tilt in all the knees, and trochlear dysplasia in two knees preoperatively. During surgery, diagnostic arthroscopy was performed in all the patients. The skin incision consisted of two horizontal incisions for cosmetic reasons. Surgical treatment was comprised of lateral patellar release to correct patellar tilt, and a modified Fulkerson osteotomy to correct patellofemoral malalignment, and medial plication in three knees. The patellofemoral congruity following lateral release, and the position of the patella following osteotomy and anteromedialization of the tibial tuberosity were checked arthroscopically. On control examinations, the patients were administered functional scoring questionnaires developed by Kujala et al. and Crosby and Insall. Radiographic grading of osteoarthritis was made according to the classification developed by Iwano et al. and modified by Palmer et al. The mean follow-up period was 2.6 years (range 24 to 53 months). Results: During arthroscopy, eight knees had severe (Outerbridge grade III-IV) and nine knees had moderate (grade I-II) retropatellar cartilage damage. Follow-up evaluations showed effusion in two knees, subluxation in two knees, and a positive apprehension test in three knees. The mean flexion loss was 8° (range 0° to 20°). One patient who had an extension loss of 10° regained full extension following a six-week physical therapy program. Postoperative computed tomography scans showed that patellar tilt and subluxation were corrected in all but two knees. Preoperative radiographies showed degenerative arthritis in the tibiofemoral joint in one knee (5.9%), and in the patellofemoral joint in seven knees (41.2%). The number of knees with degenerative changes increased postoperatively to three knees (17.3%) in the tibiofemoral joint, and to 11 knees (64.7%) in the patellofemoral joint. According to the Crosby-Insall scoring system, five knees had excellent, seven knees had good, and five knees had moderate scores. The mean Kujala score was 82.6 (range 44 to 100) postoperatively. Conclusion: Our results show that, with appropriate indications, the modified Fulkerson method is associated with successful results in the treatment of recurrent patellofemoral dislocations.

Keywords:

Osteotomy, Knee Joint, Femur, Treatment Outcome, Tomography, X-Ray Computed, Recurrence, Dislocations, Patellar Dislocation, Weight-Bearing,

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