Description of Trochlear Dysplasia
One area of the knee that is not discussed as often as some of the other components, is a section called the trochlea. This area of the knee is easy to identify. When the knee is bent, the undersurface of the kneecap (the patella) lies in an area known as the trochlear groove. The sides of the patella and the walls of the groove should be almost parallel. The normal shape of the trochlea groove is concave. In fact, the outside, or lateral aspect of the trochlea groove has a higher bump than the inside part. This allows the patella, or kneecap, to glide down the central aspect of the distal femur rather effortlessly due to its bony constraints. This is important because the patella serves as a fulcrum to increase the overall strength and efficiency of the quadriceps muscles of the thigh.
When the trochlea is flat, or even possibly has a convex or dome shape, it is known as trochlear dysplasia which usually is referred to as an unstable kneecap. In these circumstances, the trochlea is not shaped normally, and the patella does not have the normal bony constraints to provide stability. Thus, one needs to rely on the medial patellofemoral ligament and their quadriceps mechanism to hold the patella in place.
Symptoms of trochlear dysplasia:
- Knee pain and knee aching
- Higher risk of patellar dislocations and instability
A diagnosis of trochlea dysplasia is usually made by a thorough physical exam and radiographic work-up. Patients with trochlear dysplasia often have increased medial and lateral patellar translation near full extension and at 45 degrees of knee flexion. They may also have an apprehension test where they feel their patella is going to dislocate laterally. On plain X-rays, one can see a “crossing sign” on the lateral knee X-ray that would indicate that the trochlea groove is both flat and shallow. The 45-degree patella X-ray would also show a decrease in size of the groove, flattening, and sometimes a dome shape. A frontal view, or AP, radiograph may show some hypoplasia, or a decrease in size, of the medial femoral condyle.
Trochlear dysplasia is often assessed on lateral radiographs. Figure A shows a crossing sign representing a shallow trochlea. A dysplastic trochlea can also include a supratrochlear spur as well as a double contour which represents the hypoplastic medial trochlear facet.
Seen above are sunrise views of the knee showing the patellofemoral joint. In patients with severe dysplasia, as seen above, the trochlear sulcus angle will be increased and in some cases patients will have a hypoplastic medial trochlear facet.
Treatment of Trochlear Dysplasia
The treatment of trochlear dysplasia can be very difficult. It is important to have a thorough workup to include a patient’s overall alignment, their tibial tubercle–trochlea groove angle (TT–TG), and an MRI scan to evaluate the status of the articular cartilage of their patellofemoral joint. This is important because surgical treatments may not always be indicated if there is significant arthritis present. In addition, a plain X-ray to look at the amount of patella alta, or a high-riding patella, is indicated.
The treatment of trochlear dysplasia can be very difficult. Patients who have a lateral patellar dislocation have a much higher risk of recurrence when they have trochlear dysplasia. Because the severity of trochlea dysplasia can run from minor to severe, treatment options are also varied. They can include a reconstruction of the medial patellofemoral ligament, a tibial tubercle osteotomy, a trochleoplasty, where the distal aspect of the femur is cut and reshaped to create more of a normal groove, a distal femoral osteotomy, and other associated treatments. Thus, no one patient has the same treatment as another, and a thorough workup is necessary to determine the best course of action, if any, for a particular patient with trochlear dysplasia.
Patients who have a trochleoplasty need to be non-weightbearing for 6 weeks after surgery. They are also placed into a continuous passive motion (CPM) machine for 6-8 hours a day while they are non-weightbearing. Motion is usually restricted to 90 degrees of knee flexion for the first two weeks after surgery and then increased to full knee motion as tolerated. After x-rays show sufficient healing of the trochleoplasty at 6 weeks postoperatively, patients are allowed to initiate weight bearing as tolerated and may wean off crutches when they can walk without a mill. The use of a stationary bike is also started with low resistance. After 3 months postoperatively, patients may initiate endurance and agility exercises. Full activities are allowed in patients without arthritis in their patellofemoral joint upon passing a sports test, usually at 7-9 months after surgery.