1. Two Year Outcomes of Southwick-Fulkerson Osteotomy. Chloe Mellecker John P. Albright MD Department of Orthopaedic Surgery

2. Problem ] Repeat patellar dislocators

3. Patient Population ] Patellar dislocations or instability ] Bony attachment ] Patellar tendon ] Soft tissue attachment ] Quadriceps tendon ] Medial Patellofemoral Ligament (MPFL) ] Lateral Patellofemoral Ligament (LPFL)

4. Patellar tracking correction Pre-Operative Post-Operative

5. Southwick-Fulkerson Osteotomy ] Anteriomedialization of the tibial tubercle 1 2 3 4

6. Tibial Tubercle-Trochlear Groove Distance

7. MPFL Repair/Reconstruction ] Torn with dislocation ] Repair (re-tighten) ] Reconstruction

8. Intraoperative Stimulation ] Femoral Nerve Catheter ] Quadriceps Contraction Provides Active Movement

9. Hypothesis Patients who receive… 1) Southwick-Fulkerson Osteotomy 2) MPFL reconstruction or repair 3) Femoral nerve stimulation guidance …will have decreased recovery times and improved final outcomes.

10. Assessment ] Survey ] Knee Osteoarthritis Outcome Score ] International Knee Documentation Committee Score ] General Recovery Questions ] Physical Exam ] J Sign ] Apprehension ] Subsequent Dislocations

11. Results Return Rate31/37 (83.8%) Average Follow-up3.72 (2-5.95)

12. Patients n (%)Avg Age (Range) Men9 (29%)25.77 (16.38) Women22 (71%)23.36 (14- 47) Total31 (100%)24.06 (14- 47)

13. MPFL Procedure n (%) Repair16 (51.6%) Reconstruction15 (48.4%) Total31 (100%)

14. Clinical Results n (%) Subsequent Dislocations 1 (3.2%) Apprehension4 (12.9%) Crepitus22 (71%)

15. J-Sign n (%) None14 (45.2%) Slight8 (25.8%) S-Sign8 (25.8%) Obvious1 (3.2%)

16. Patient Satisfaction n (%) Surgery “Successful” 29 (93.5%) Would Repeat29 (93.5%) Reached Pre-Operative Goals 24 (77.4%)

17. Recovery Times

21. MPFL Type RepairReconstructionDifference (p-value) KOOS Symptom 47.99157.143-9.152 (p=.0666) KOOS Pain73.0987.222-14.13 (p=.0508) KOOS ADL78.21792.941-14.72 (p=.0221) KOOS Sport49.37574.667-25.29 (p=.0221) KOOS QOL57.42271.25-13.83 (p=.1183) IKDC59.15878.273-19.12 (p=.0168)

22. Apprehension (+)(-) MPFL Repair412 MPFL Reconstruction 015

23. ApprehensionKOOS Symptom Positive38.393 Negative54.497 Difference16.104 (p=.0284)

24. Age KOOS Symptom-.3447 (p=.0576) KOOS Pain-.3783 (p=.0358) KOOS ADL-.5026 (p=.004) KOOS Sport-.5376 (p=.0018) KOOS QOL-.4824 (p=.006) IKDC-.5342 (p=.002)

25. Discussion: Recovery Time ] Procedure known for long recovery ] Crutch use 6-8 weeks (Cosgarea) ] Sports 9-12 months (Barber) ] Our patients experienced decreased recovery times ] Driving ] ADL

26. Discussion: Outcomes ] Successful reconstruction is difficult to achieve ] Redislocation rate high ] Danger of overconstraint with MPFL reconstruction (Tom, Colvin)

27. “Normal” Scores Study GroupMy Knee Pain80.67100 Symptom52.6460.71 ADL84.85100 Sport60.3595 QOL64.681.25 IKDC68.495.4

28. Pre/Post KOOS Pre-Operative (Avg) Post- Operative (Avg) Symptom55.6752.41 Pain55.6979.9 ADL62.5385.34 Sport27.6661.61 QOL36.6464.11

29. Discussion: Definition of Successful Outcomes ] Historically ] Re-dislocation ] Re-operation ] Revised ] Tracking ] Apprehension ] Apprehension sign of severe malalignment (Karamehmetoglu) ] 25% of successful Southwick dovetails apprehensive (Gibbons)

30. Discussion: Success Rates ] Historical standard ] MPFL Repair 83% ] MPFL Reconstruction 93% ] Distal Realignment 86% ] Current Study 96.8% ] Revised stricter standard ] 80.6% Success

31. Conclusion ] Femoral nerve stimulation effective answer for how far to transfer tubercle and placement of MPFL reconstruction. ] Recovery time is decreased in this procedure. ] MPFL reconstruction eliminates persistence of apprehension which improves outcome scores.

32. Thank You Questions?