title: Effectiveness of Fulkerson Osteotomy with Femoral Nerve Stimulation for Patients with Severe Femoral Trochlear Dysplasia.
abstract: BACKGROUND
  Patients with femoral trochlear dysplasia are at risk for chronic recurrent patellofemoral dislocations, with extreme cases often requiring a surgical procedure. Anteromedialization of the tibial tubercle with intraoperative femoral nerve stimulation and concurrent medial patella-femoral ligament (MPFL) reconstruction is a previously reported method of maximizing patello-femoral congruency. We hypothesize the Fulkerson osteotomy with intraoperative femoral nerve stimulation and concurrent MPFL reconstruction in patients with severe trochlear dysplasia provides equivalent postoperative clinical outcomes to the same procedure in patients with low level trochlear dysplasia.
  
  
  METHODS
  48 knees underwent Fulkerson osteotomy with intraoperative femoral nerve stimulation and concurrent MPFL reconstruction for recurrent lateral patellar dislocations. MRI, surgeon intraoperative assessment, and X-ray were used to assess degrees of trochlear dysplasia; inter-observer and intra-observer error were measured. The knees positive for severe dysplasia on MRI, intraoperative assessment, and X-ray were considered as a comparison cohort to the rest of the study population. We considered postoperative dislocation events and patellar tracking kinematics as outcome measures. Independent student t tests and Fisher exact tests were used to evaluate differences between groups. Significance was set at P<0.05.
  
  
  RESULTS
  11 knees were positive for severe dysplasia (SD) by combined MRI, surgeon intraoperative assessment, and X-ray with the remaining 37 knees categorized as low dysplasia (LD). No patients in either group exhibited apprehension or required re-operation. Mean sulcus angle in the SD group was 175.8 +-2.45 degrees (95% CI 171.0-180.6); the LD group mean sulcus angle was 154.3 +- 0.98 degrees (95% CI 152.4-156.2) (P<.001). Postoperatively there was no significant difference in dislocation events between the SD group (0/11) and the LD group (2/37) (P>0.999). Patellar maltracking decreased in both groups and there were no significant differences in estimates of patellofemoral congruency between the SD (2/11) and LD (8/37) (P>0.999) groups.
  
  
  CONCLUSIONS
  The Fulkerson osteotomy with femoral nerve stimulation aimed at maximizing patellofemoral congruency may be an equally effective procedure for patients with either severe or mild trochlear dysplasia.
  
  
  METHODS
  Level III, Retrospective comparative study.
authors.affiliation: The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics , 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 , USA.
authors.forename: D T
authors.initials: DT
authors.lastname: Crebs
authors.affiliation: The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics , 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 , USA.
authors.forename: C A
authors.initials: CA
authors.lastname: Anthony
authors.affiliation: The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics , 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 , USA.
authors.forename: P T
authors.initials: PT
authors.lastname: McCunniff
authors.affiliation: The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics , 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 , USA.
authors.forename: M J
authors.initials: MJ
authors.lastname: Nieto
authors.affiliation: The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics , 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 , USA.
authors.forename: M W
authors.initials: MW
authors.lastname: Beckert
authors.affiliation: The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics , 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 , USA.
authors.forename: J P
authors.initials: JP
authors.lastname: Albright
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D003131:Combined Modality Therapy; D004558:Electric Stimulation / Q000379:methods; D005260:Female; D005267:Femoral Nerve; D005269:Femur / Q000002:abnormalities; D005500:Follow-Up Studies; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007593:Joint Instability / Q000517:prevention & control; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010027:Osteotomy / Q000379:methods*; D031222:Patellar Dislocation / Q000175:diagnosis / Q000628:therapy*; D017847:Patellar Ligament / Q000601:surgery; D057071:Patellofemoral Joint / Q000601:surgery; D016059:Range of Motion, Articular / Q000502:physiology*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult