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Surgery                                                                                                                Case series


         Double tunnel technique for Medial Patellofemoral                                                                      Total knee replacement in elderly patients with

         Ligament Reconstruction                                                                                                distal femoral fracture



                                                                  Follow up was done for 24-36 months
                                                                                                                                                                                         Total knee replacement for DFF in
       Dr. Somasekhar Reddy                                       Mean  IKDC  and  Kujala  score  showed  significant          Dr.Mahesh Kulkarni                                         elderly
                                                                  improvement (p < 0.001) with no recorded recurrence                                                                    A systematic review of primary TKR for DFF reported
       Nallamilli                                                 of dislocation                                              Joint Replacement Surgeon                                  13 studies with a total of 98 patients who underwent

                                                                                                                              Joint Replacement Clinic, Pune                             total knee replacement for the management of DFF.  [2]
       Sr. Consultant Orthopeadic & Joint Replacement             Advantages of this technique
                                                                                                                                                                                         Overall results were encouraging, with most studies
       Apollo Hospitals, Hyderabad                                Anatomic reconstruction  [2]                                                                                           showing  90°  -  135°  of  flexion  to  near  full  extension
                                                                                                                              Introduction                                               after treatment.  [2]
                                                                  Not reliant on implants in the patella  [1]
                                                                                                                              Distal femur fracture (DFF) accounts for 0-4% of all       At  follow-up,  most of the patients achieved  full
       Introduction                                               The double tunnel technique allows a larger ligament        adult fractures and 3% of femoral fractures.  [1]          weight-bearing  and  were  capable  of  walking  on
                                                                  diameter  comprising  a  double  thickness  of  the                                                                    stairs. [2]
       Rupture  of  medial  patellofemoral  (PF)  ligament        hamstring to be reconstructed.  [1]                         Current surgical treatment options for DFF including
       (MPFL)  is  evident  in  recurrent  patellar  dislocation                                                              intramedullary  nailing,  internal  fixation,  and          Modular    constrained   implants  were    found
       resulting in patellar instability.  [1]                    It minimizes graft  impingement without increasing          external  fixation,  are  complicated  by  prolonged        appropriate   for   comminuted     intra-articular
                                                                  the risks of patellar fracture  [1]                         immobility, malunion, and nonunion.  [2]                   fractures,  whereas  extra-articular  fractures  were
       Anatomic  reconstruction  of  the  MPFL  has  been                                                                                                                                sufficiently managed with unconstrained implants.  [2]
       shown  to  restore  patellar  stability  in  cases  with   Less hardware is used with minimal cost and fewer           In elderly patients,  the main surgical  goals  are to
       normal lower-extremity alignment.  [2]                     complications.  [1]                                         minimize operative time and reduce time to mobility        Conclusion
                                                                                                                              which is challenging in cases of DFF.  [2]
       Surgical technique     [1]                                 Disadvantages                                                                                                          Total knee arthroplasty for distal femoral fractures is
                                                                                                                              This article describes total knee replacement (TKR)        a viable treatment option in elderly patients
       Two parallel tunnels are formed with a 1 cm bridge         Dual tunnels may lead to an increased risk of fracture      as a treatment option for DFF in elderly patients.
       covering most of the native MPFL patellar footprint.       [2]                                                                                                                    It provides immediate full weight-bearing and a rapid
                                                                                                                                                                                         return to preoperative functional status.
       An autologous graft (STG) is sutured together to be        Tensioning  can  be  difficult  with  the  docking           Mega knee prosthesis      [1]
       introduced from medial to lateral in one tunnel then       technique  [2]
       passed  from lateral to  medial through  the second                                                                    A case series described the management of complex          References
       tunnel.                                                    Conclusion                                                  DFF using a mega knee-prosthesis in 4 patients with
                                                                                                                              an average age of 79.5 years.  [1]                         1. Ibrahim, S. A., Shohdy, E. M., Ramadan, S. A., Almisfer, A. K.,
       It  forms  a  loop  on  the  lateral  border  of  the  patella   Reconstruction  of  MPFL  by  this  method  provides  a                                                          Abdulsattar,  W.  S.,  &  Khairat,  S.  (2019).  Medial  Patellofemoral
       through a single medial parapatellar incision.             good clinical result in the treatment of PF instability     A standard midline incision and medial para-patellar       Ligament  Reconstruction  in  Traumatic  Patellar  Dislocation
                                                                  by using an autologous graft (STG).                         approach were utilized for all surgical procedures.  [1]   without  Patellar  Fixation.  The  Journal  of  Knee  Surgery.
       Clinical evidence   [1]                                                                                                                                                           doi:10.1055/s-0039-1688841
                                                                  References                                                  The implant used for all cases  was the cemented
                                                                                                                              OSSTM  Orthopaedic Salvage System (Zimmer
       Prospective study of 45 patients with PF instability,                                                                                                                             2.  Chen  F,  Li  R,  Lall  A,  Schwechter  EM.  Primary  Total  Knee
       rupture of MPFL and normal patellar tracking               1. Ibrahim, S. A., Shohdy, E. M., Ramadan, S. A., Almisfer, A. K.,   Biomet, Warsaw, Indiana, USA)  [1]
                                                                                                                                                                                         Arthroplasty for Distal Femur Fractures: A Systematic Review of
                                                                  Abdulsattar,  W.  S.,  &  Khairat,  S.  (2019).  Medial  Patellofemoral
                                                                                                                                                                                         Indications,  Implants,  Techniques,  and  Results.  Am  J  Orthop
                                                                  Ligament  Reconstruction  in  Traumatic  Patellar  Dislocation
       MPFL reconstruction done without patellar fixation          without  Patellar  Fixation.  The  Journal  of  Knee  Surgery.   Preoperative  Postoperative  Oxford  WOMAC  NRS  ROM in  (Belle Mead NJ). 2017;46(3):E163-E171.
                                                                                                                                  Parker score
                                                                                                                                            Parker score
                                                                                                                                                                           degrees
                                                                                                                                                                 score
                                                                                                                                                        score
       hardware through two parallel trans-patellar tunnels       doi:10.1055/s-0039-1688841
       and one screw in the femoral tunnel                                                                                 Patient 1  8         7        36       17   1   0/110
                                                                                                                           Patient 2  9         7        39       8    0   0/135
                                                                  2.  Azimi  H,  Anakwenze  O.  Medial  Patellofemoral  Ligament
                                                                  Reconstruction Using Dual Patella Docking Technique. Arthrosc   Patient 3  8  5        25      37    1   0/100
       Pre-  and  postoperative  functional  scores  were         Tech.   2017;6(6):e2093-e2100.   Published   2017   Nov   6.   Patient 4  9  8         41       7    0   0/125
       recorded to assess clinical results
                                                                  doi:10.1016/j.eats.2017.08.018                                                    [Ref: 1]
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