Case Report - Patella baja

   D.SD. is a 39 year old with long standing patellofemoral malalignment. He underwent a distal tibial tubercle osteotomy. A non-union at the osteotomy site developed , and was treated by revising the fixation 6 months post op. Over the next year he gradually lost range of motion of his knee, and had increasing pain. The flexion is 60*.

The bone scan shows only mild uptake, and no evidence for infection or reflex sympathetic dystropy.

The x-ray at this point showed  patella baja.

Does anyone have any ideas why this patient developed such a severe patella baja?

 

 

There are several options being considered:

Anyone have any comments?

Readers Comments:

DJ:

I have done one "proximalization"
of the tibial tuberosity. Mike Stuart of the Mayo Clinic has done
several. Create a long osteotomy and slide it to a point where
Blumenstat's line would be normal. Then fix it with screws.

Peter McDonald

 


Hi ,

The patella baja that is present in the case needs to have better
understanding why it became a baja. If one removes the patella with this much
baja then one should expect a lack in extension in the knee. It appears that
the quadriceps-patella mechanism has been altered and no amount of reefing of
the two tendons upon removal of the patella will take up the slack Let me know
the end results
Joe Tippett

 


Yes!!
I attended the instructional course on knee stiffness and patella baja at AAOS. The panel recommended elongation of the patella tendon. The etiology for this condition to develop is loss of function of the quad. Their results and experience was however not so good - but a guy named Dror Paley, e-mail: dpaley@mcllr.ummc.ab.umd.edu (that was a long one) - told that he had treated 2 cases with elongation of the patellar tendon using the Ilizarov method: 2 half rings with half pins in tibia and 2 wires connected to one half ring on patella, the wires must be placed outside the joint capsule. Pulling speed was or 1 mm/day - he was not sure, but most likely 1 mm.
Gert Kristensen

 


Agree with Gert Kristensen.
message at the Academy was that without good potential quads function,
proximal transfer or Z plasty will fail. Given the severity of case you
have shown, I think Ilizarov transfer is best option, though not without
potential problems. rehab proceeds concurrent with lengthening and
patients are weight bearing so quads are firing. Dror Paley was
encouraged to report his 2 cases so you may want to correspond with him.

Geof Dervin

 


I have treated two cases of patella baja that were secondary to previous surgical treatment. In both there was significant quads dysfunction due to pain following the surgical Rx. I applied an Ilizarov fixator to the tibia with two half rings anteriorly and half pins and wire fixation. I connected this to a half ring at the level of the patella and used two transverse wires to fix the patella. These two wires were in the extracapsular part of the patella and were very close together so that they would not prevent rotation of the patella around the transverse axis. There was no fixation to the femur. The patella tracked with the tibia through flexion and extension. The patients were able to maintain 90 degrees of knee motion during the Rx. I transported the patella proximally at a rate of 1/2mm per day. In one case the transport distance was 40mm and in the other 30mm. After obtaining the correction uneventfully the frame was left in place for an additional 6 weeks to prevent the elastic memory of the patellar tendon from recontracture. No recurrence occurred. Physical therapy was carried out to maintain the quads strength during the treatment and after frame removal. The patients were full WB during the treatment. There were no complications. If there is any pain during transport the distraction can be slowed down to the patients comfort level. This is not a lengthening of bone and therefore one does not need to worry about premature consolidation as a result of slowing the distraction.

I hope this information is helpful to you. I plan to write up our case reports. Please feel free to email, call or write me for further info. My phone no. is 410-448-3394. fax no. 410-448-4229

Dror Paley

email no. dpaley@mcllr.ummc.ab.umd.edu. Good luck.

 


Unfortunately, I have been involved with baja patella since in 1973 when
Martin Blazina , John Jurgutis and myself wrote this up as a
complication of patella realignment.
The technique a described by Dror Paley is interesting but we found the
only thing that seemed to work ( and only about 50% of the time) was to
advance and elevate proximally .
We even tried "v" to "y" patellar tendon lengthening
This is a terrible insult to the patellar and femoral surfaces

James m. Fox MD

Southern California Orthopedic Institute

 


 

Very impressive (and complex) technique! However, I am not happy with
the term "patella baja"! If we use patella alta to describe high-riding
patella, as opposite to the patella baja, than low-riding patella should be
"patella infera". I think that there is no place for confused multi-language
terminology in modern orthopedic surgery, and medicine in general.
Standardisation is essential so that we all know what we are talking about.
Vladimir Bobic, Chester, UK



It is interesting that we had exactly the same conversation in 1973
when we coined the term "patella baja" this was meant more as a
reference to California with its Spanish history i.e. baja California
to connote the southern adjacent border with Mexico therefore we used
the term baja patella indicating the inferior position or lowered
position. there are many terms we use in medicine which do not meet
our Greco-and Latin legacy my favorite is the quadriceps hematoma
which many years we spent trying to getting teams physicians and
trainers to use instead of "charlie horse"

your point is well taken but now that you know history of the term
hopefully you can be patient with us

best wishes James M. Fox MD

Ps should we use the term " patella supera" ( I am just joking )

 


DJ ,
First one must be sure its the real problem. AND the only problem. If
so, splitting the tendon vertically and advancing in a "Tongue-in-grove"
fashion will fix the problem. BUT,,,ALL of the other problems e.g.
malalignment, must be fixed concomitantly.

David McGuire


I really think that this case, is one of the toughest problem a surgeon has to cope with. From my point of view, first to decide which kind of treatment you want to perform, you have to carefully select the patients, as suggested by David McGuire, in order to avoid any further damage to the extensor mechanism. I described in 1994 a technique, that involves the controlateral knee. Basically we harvest a graft from the controlateral knee, which includes a 4-5 cm long and 1 cm wide strips of the quadriceps tendon, a 1 cm wide block of bone from the whole length of the patella, the middle one third of the patellar tendon and a 3 cm long tibial bone plug. Then, once a  Z plasty is performed on the patellar tendon, a notch is cut along the full length of the patella and an osteotomy of the tibial tubercle is performed. Finally, the controlateral graft is fitted into the notch cut in the patella and in the tibial tuberosity.
I treated five patients with this technique and it seems to me that It works very well indeed with good results at medium term follow-up. This surgery is similar to the one proposed by Dejour in 1992 for old ruptures of patellar ligament. The advantage is to restore the physiological length of the patellar tendon with a correct pre-operative planning.
I think that this technique gives to the surgeon one more possibility of surgical approach such a disperate problem.
The paper is published on Knee Surg Sports Traumatol Arthroscopy(1994) 2: 238-41
Finally, I agree with Vladimir Bobic that  the term "patella infera" is more correct. It could be only a semantic question, but it is important  to approach the problem in the same way all around the world!
Please, feel free to contact me for any comments or suggestions you
would make or for a simple question.

Prof. Pier Paolo Mariani
I Orthopedic Clinic, University "La Sapienza" Rome
E-mail: ppm.las@iol.it


Dear Dr Johnson

            You invited comments on the case report, but useful communication will require better and more accurate information

                        Patella baja is wrong. Patella is Latin. Baja is Spanish. Patella infera is the correct diagnosis.

            Malalignment is a waste basket diagnosis which means different things to different people. We should eliminate it as a diagnosis. Did he have recurrent dislocation of the patella? Did he have chronic patella subluxation without dislocations?

Did he have lateral patellar compression syndrome with secondary chondromalacia patellae due to increased ‘Q’ angle:

            What kind of distal tibial tubercle osteotomy was performed. Was the patella moved medially? Was it moved anteromedially? Was it moved anteriorly only? Was it moved distally?

            At the time of discovery of the non-union, was any degree of patella infera noted when comparing his first x-rays to those showing the non-union:

            The most common cause for sever patella infera is quadriceps shutdown postoperatively.

            Treatment options

  1. Patellectomy alone will not lengthen the extensor mechanism enough to restore flexion, and some techniques will even shorten it. If the trochlea has grade 3 or 4 chondromalacia, a patellectomy has even less chance of success.
  2. If the tibial tubercle has been moved distally, consideration should be given to moving it proximally again. Pre-operative comparison of the initial x-rays with the current x-rays will provide the amount of lengthening to be desired. Arthrotomy with resection of the scar tissue binding the distal pole of the patella to the anterior tibial will provide some more length. Intra-operative lateral x-rays will then provide the answer to how much more lengthening needs to be achieved by a Z-plasty. Circlage protection of the lengthening, tied at 90* of flexion, is important. Obsessive attention to quadriceps function and power both preoperatively and postoperatively to avoid secondary shutdown will be mandatory. We surgeons are always being accused of being obsessive-compulsive, we might as well be obsessive about the quadriceps and do our patients some good in the process.

 

A very interesting and challenging case, keep up the good work. 

 Alan Merchant


I read your interesting discussion of Patella Baja on the web back in August 2003, and the accompanying letters from other surgeons.

It seemed to me that Patella Baja is some type of inflammatory condition so any direct assault on the patella tendon, such as a lengthening might inflame the condition. I favor the tubercle proximalization.

My patient was a 32 year old female who had had successful "lateral releases" of both knees in 1987 and 1992. Her patella pain gradually recurred about 2000 and had been worsening ever since. By August 2003 she was in constant unbearable pain in both knees aggravated by activity. The only abnormality on physical examination was tenderness and crepitus of the patellae.

X-rays showed severe Patella Baja in both knees.

On 9/25/03 I took her to surgery and osteotomized "trough" her anterior tibia leaving the tibial tubercle as part of a 10 cm long (1.5 cm wide) piece of bone. I slid this proximally 1.5 cm and fixed it to the tibia with three bone screws, which was the distance necessary to store the patella to a normal relationship to Blumenstat's line. I released the anterior knee capsule from either side of the patella tendon in a proxima direction for approximately 2 cm. I kept her in a knee immobilizer only when out of bed for four weeks.

She is now 4 months after her surgery and is pain free and happy with the result. She currently wants to do the same surgery on the other knee.

Thanks for your efforts with your web site which helped lead to this result.

Feel free to post this communication.

David Aiken, M.D., ABOS, AAOS

New Orleans, Louisiana

 

Does anyone have any other suggestions?



donnie@carletonsportsmed.com