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ORIGINAL ARTICLE

Treatment of Recurrent Patellar Instability With a


Modification of the Roux-Goldthwait Technique
James S. Marsh, MD, John P. Daigneault, MD, Paul Sethi, MD, and Gert K. Polzhofer, MD

ment, maltracking, or actual instability.23 As well, no clear


Abstract: Recurrent instability of the patella may be a significant
indications for realignment had been reported until in 2003
disability in the childhood and adolescent population. Numerous
when Kobayashi et al18 set up a 3-dimensional computed
surgical procedures to address this instability have been described,
tomography classification. Further, various articles, in addi-
with variable outcome. This has led to considerable confusion in the
tion to lumping together the diagnostic entities, cite multiple
literature as to how to treat patellofemoral problems in children. This
procedures within the same article for treatment of these
study retrospectively reviews 30 knees in 20 patients with chronic
problems, making an analysis of the literature extremely
recurrent patellar instability who were treated with a modified Roux-
confusing, something already mentioned back in 2003 by
Goldthwait technique including the release of contracted lateral
Hinton et al.15 Stanitski27 has advocated the following: (1)
structures by a single surgeon over a 13-year period, with an average
releasing an abnormal tethering vector, (2) providing a
of 6.2 years follow-up. By Insalls criteria,17 26 knees had an
balance to the medial vector, (3) aligning the quadriceps
excellent result, 3 good result, and 1 fair result. Ten patients
patellar-tibial mechanism, and (4) a combination of the
evaluated using a dynamometer showed that strength achieved in the
above. In the skeletal immature patient, transfer of the tibial
operated leg was greater than 90% in 8 patients and greater than 80%
tubercle must be avoided, if possible, to prevent premature
in 2 patients. Here, we report upon a single operation to treat patellar
physeal closure and subsequent development of genu
instability performed in the pediatric population with consistently
recurvatum. This leaves soft tissue procedures to address
excellent results.
the above problems in this patient population. In this study,
Key Words: recurrent patellar instability, modified Roux- we report upon a single operative technique performed by a
Goldthwait procedure, adolescents single surgeon in children and adolescents for treatment of
recurrent instability (dislocation) only.
(J Pediatr Orthop 2006;26:461Y465)

METHODS
Thirty-four knees were operated on in 24 patients and
P atellar subluxation and dislocation are well-documented
causes of chronic knee pain and instability in the pediatric
and adolescent population. It is considered highly associated
reviewed retrospectively. All procedures were performed by
the first author. There were 10 males and 14 females (male/
with chondral and osteochondral lesions of the patellofemoral female ratio, 1:1.4). Age range was from 3 to 18 years with a
joint.21 Patients present with giving-way, popping, or frank mean of 14.2 years. The follow-up average was 6.2 years with a
dislocation, requiring reduction manually. The etiology of range of 2 to 13 years. The preoperative diagnoses included
patellar instability requires a thorough physical and radio- ligamentous laxity (10), nail-patella syndrome (8), patella
graphic examination of the patient because the causes may alta (7), malrotation (5), genu recurvatum (5), genu valgum
include genu valgum, genu recurvatum, patella alta, patellar (5) (Q-angle greater than 20 degrees), trauma (1), and Down
dysplasias, trauma, femoral anteversion, external tibial torsion, syndrome (1) (Table 1). All patients presented with a history
ligamentous laxity, congenital abnormalities, and syndromes of pain and chronic recurrent patellar dislocation (Fig. 2).
such as nail-patella (Fig. 1) and Down syndromes.3,25,31 The The abnormal Q-angle was defined following Insalls
optimal treatment in this patient population, as well as criteria.17 The patellar reticular tightness was assessed, and
immediately after traumatic patellar dislocation,3 is nonoper- radiographs were obtained for assessment of patellar tilt,
ative, but when physical therapy and/or bracing fails, surgical patellar tracking, patella alta, and various radiographic
repair is indicated.7 parameters as noted below. Vastus medialis obliquus
Several different operative reconstructive procedures strength and thigh girth were assessed as well using a Kin-
are suggested in the literature, indicating that no single Com dynamometer (Chattanooga Group, Hixson, TN).
procedure is predominant.1,3,7,14 Part of this owes to a lack of All patients had a modified Roux-Goldthwait procedure
uniform definition of the problem, when treating malalign- performed in the sense that as a modification, an additional
release of the contracted structures lateral to the extensor
mechanism was performed: following the Roux-Goldthwait
technique, the patellar tendon was split longitudinally, and its
lateral half detached from the tibial tuberosity. The detached
From the Klinik Dr Guth Hamburg, Germany.
None of the authors received financial support for this study. lateral half of the tendon was transferred distally beneath its
Reprints: Dr Gert K Polzhofer, MD, Kuchelweg 3, 22605 Hamburg, Germany. intact medial half. There, the split tendon was sutured to soft
E-mail: polzhofer@web.de. tissues on the medial side of the tibia, if possible to the

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Marsh et al J Pediatr Orthop & Volume 26, Number 4, July/August 2006

FIGURE 2. Ligamentous laxity with lateral dislocation of


patella preoperatively.

because otherwise, too many variables, such as sex, age, side


operated on, preoperative diagnoses, etc, the sample size
FIGURE 1. Patella dislocation due to nail-patella deformity.
would have been too small for valid statistical analysis.

RESULTS
insertion of the sartorius muscle (Fig. 3). We tried to avoid too Four knees in 4 patients were lost to follow-up, giving
much distalization so that the medial half of the patellar 30 knees in 20 patients for evaluation: 10 patients presenting
tendon would relax. We also arranged the lateral half in a way with patellar instability on one side (group 1) and 10 patients
that the vector forces to be transmitted through the tendon
halves align the extensor mechanism in the axis of the femoral
shaft. Postoperatively, all patients were immobilized for
4 weeks in a knee immobilizer, had protected immobilization
for additional 2 weeks, with physical therapy beginning
between the 4th and 6th week. All patients required 8 to
12 weeks of postoperative physical therapy. Patients were
asked to return for reevaluation in which the clinical and
radiographic parameters were reassessed. In those patients
who had a single knee procedure performed, isokinetic
strength testing with a Kin-Com dynamometer was accom-
plished on both the operated and nonoperative legs for
comparison of strength. We analyzed the data descriptively

TABLE 1. Preoperative Diagnoses. All Patients Presenting with


History of Pain and Chronic Recurrent Patellar Dislocation

FIGURE 3. Modified Roux-Goldthwait Technique: patellar


tendon split and transferred medially onto the tibial insertion
of the sartorius muscle (1); modification of the classical
Roux-Goldthwait operation by adding a lateral release
(2); and medial half of patellar tendon (3).

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J Pediatr Orthop & Volume 26, Number 4, July/August 2006 Treatment of Recurrent Patellar Instability

reported upon by Goldthwait11 in 1895 has been studied


TABLE 2. Postoperative Results of 30 Procedures in 20 extensively and stood the test of time with successful results
Patients Following the Q-angle Definition by Install (14- as
Normal, Above 20- as Abnormal)
and a low rate of complications. The transfer of the tibial
tubercle described by Trillat et al,28 with subsequent
modifications by Maquet,19 and more recently, Fulkerson9
have reports with good to excellent results in the 85% to 90%
range. These transfer procedures, however, are not generally
applicable to the skeletally immature population.
Vahasarja et al29 examined lateral release alone, lateral
release with medial reefing, and the Roux-Goldthwait proce-
dures in an effort to address specific indication for specific
procedures. In their study of 57 operations, they concluded that
a lateral release was the choice operation for patellar tilt alone, a
lateral release, and medial reefing was choice for tilt and
subluxation, and that subluxation alone was best treated with a
Roux-Goldthwait procedure. Of the 57 knees in their study,
only 3 were treated with a Roux primarily. Thirteen of the
remaining 54 knees, required reoperation, 10 of which
with patellar instability on both sides (group 2). By Insalls subsequently underwent a Roux-Goldthwait.
criteria17 considering a Q-angle of 14 degrees as normal and In 1985, Fondren et al8 had specifically examined the
above 20 degrees as abnormal, there were 26 excellent results results of the Roux-Goldthwait procedure in response to the
(Q-angle of 14 degrees; 8 in group 1 and 18 in group 2), 3 good complications that resulted from the Hauser procedure. They
results (Q-angle 12-16 degrees; 1 in group 1 and 2 in group 2), achieved good to excellent results in 91% of their subjects. Nine
and 1 fair result (Q-angle of 18 degrees, group 1)17 (Table 2). patients in this study were 14 years old and younger, and all had
The improved radiographic results for 20 randomly selected a good to excellent result. They reported no cases of recurrent
knees of both groups (10 of group 1 and 10 of group 2; t test, dislocations and a zero incidence of epiphyseal injury. Their
n = 20) including sulcus/congruence angle and lateral patellar recommendations of Goldthwait procedure were for patients
deviation/angle are shown below (Table 3). The fair result who have chronic recurrent painful dislocation and giving-way
occurred in a Down syndrome patient, who had recurrent with symptoms and signs suggesting a deficiency of the medial
dislocation requiring reoperation. The good result occurred in capsular structures or an abnormal Q-angle.
2 patients, one of them having bilateral patellar instability on Various tendon transfers to the extensor mechanism
the basis of extreme ligamentous laxity that probably fell into have been suggested by Baker, Lexer, Lange, and Hall. The
the category of a collagen disorder that, at this point, remains report of Hall et al13 suggested using a semitendinosus
undiagnosed. The 10 patients presenting with patellar tenodesis graft. The patients of Hall et al13 had a mean age of
instability on one side (group 1) evaluated by Kin-Com 14.5 years and yielded a 63% good to excellent results. We do
dynamometer showed that strength achieved in the operated not routinely use these procedures at our institution.
leg was greater than 90% in 8 patients (80%) and greater than Chrisman et al5 compared the Hauser and Roux-
80% in 2 patients (20%) (Fig. 4). Goldthwait procedures. In his review of 87 knees, there were
10 Roux-Goldthwait procedures performed on patients who
were 15 years old or younger. One of those 10 had a reported
DISCUSSION failure, consistent with his 93% satisfactory results when
Studies of patellar instability in the skeletally immature compared with 72% satisfactory with the Hauser procedure.
population are rare, and the indications for the different Hughston and Walsh16 reported a 71% good to excellent
procedures are not well documented. Females seem to be outcome (with 90% of athletes returning to normal competi-
more likely to present with patellar-tracking problems, tion) while using a proximal and distal soft tissue procedure.
whereas males are more likely to have knee extensor Although of different etiology, the surgical treatment of
mechanism problems.4 The Roux-Goldthwait procedure, congenital patellar dislocation consists of soft tissue release
initially described by Roux24 in 1888 and subsequently and reefing coupled with patellar tendon transfer. Gao et al10
demonstrated an 87.8% satisfactory result, and Gordon and
Schoenecker,12 who transferred the entire patellar tendon,
claims all patients had a marked increase in activity tolerance
TABLE 3. Averaged Radiographic Results of the Modified and relief of pain.
Roux-Goldthwait Procedure in 20 Knees (t test, n = 20) Beals and Buehler2 reported creating a femoral sulcus
Preoperative Postoperative P in children with severe trochlear dysplasia in 6 patients, who
Sulcus angle (degrees) 138 134 V all had underlying chromosomal abnormalities; with his
Congruence angle (degrees) 15.7 j5.3 G0.001 method, there were no recurrent dislocations.
Lateral patellar deviation (mm) 6.5 0 G0.001 Vahasarja et al30 subsequently reported on 40 adoles-
Lateral patellar angle (degrees) 7 16.7 G0.001 cent knees, which underwent lateral release, medial combi-
nation, and vastus medialis obliquus advancement. This more

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Marsh et al J Pediatr Orthop & Volume 26, Number 4, July/August 2006

FIGURE 4. Kin-Com dynamometer showing an achieved strength in the operated leg of 95% when compared to the healthy
leg as a control.

recent report is a deviation from previous recommendations group 1 and 18 in group 2), 3 good (1 in group 1 and 2 in group
made in the Journal of Pediatric Orthopaedics, first by using 2) and 1 fair result (group 1). Those 10 patients evaluated by
one operation for all cases. Certainly, these cases were Kin-Com dynamometer showed that strength achieved in the
performed before his records were published, but operated leg was greater than 90% in 8 patients and greater
in retrospect, this individual operation was at least equal than 80% in 2 patients.
(82.5 G/E), if not having a better outcome than the 70.5 G/E Numerous surgical procedures to address this instability
reported with his previous records. have been described with variable outcome before and
Deie et al6 reported a technique involving transfer of unfortunately, many studies have lumped all types of patellar
the tendon of the semitendinosus to the patella using the instability together and report performing a single operation,
posterior third of the femoral insertion of the medial collateral whereas other studies have reported performing multiple
ligament as a pulley which led to no recurrent patellar procedures for a single diagnostic entity. This has led to con-
dislocations after surgery. Hypermobility and patella alta siderable confusion in the literature as to how to treat patello-
were not fully correctable with this technique. femoral problems. To further complicate matters, many
Recently, it seems that the primary stabilizing role of studies have been performed in adults, and these procedures
the mediopatellofemoral ligament in the unaffected knee and are being applied to children.
its lesion as an essential key factor for patella instability is By reporting upon a single operation, a modified Roux-
more and more emphasized.1,15,22,26 The trend turns form Goldthwait procedure with additional release of the con-
nonanatomic extensor mechanism reconstructions toward tracted lateral structures, to treat one entity of the different
more anatomic procedures based on using a pulley of the causes/clinical signs of patellofemoral problems in childhood
semitendinosus tendon around the posterior one third of the and adolescence, namely chronic recurrent patellar instability,
medial collateral ligament.26 As to reconstruct the medio we were able to achieve excellent results in the pediatric
patellofemoral ligament, even artificial ligaments have been population. We hope thereby to help in making up ones
successfully used.20 decision on how to treat one spectrum of the field of the
Fithian et al7 also stated recently that, although conser- so called Bpatellofemoral problems[ in childhood and
vative treatment is still the first choice, if surgery is per- adolescence.
formed, the aim should be to repair or reconstruct the passive
retinacular restraints.
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