Trochleoplasty: Indications in patellar dislocation with high-grade dysplasia. Surgical technique

Trochlear dysplasia consists in deficient trochlear concavity, giving rise to a flat or convex trochlea, and is the main risk factor for patellar dislocation. Surgical indications depend on familiarity with trochlear dysplasias, and especially those of high grade, identified on clinical examination and standard and cross-sectional imaging, and on quantification of associated instability factors. Treatment strategy is accordingly determined "à la carte" to correct these factors one by one. Sulcus deepening trochleoplasty corrects the morphology and is the appropriate etiological treatment. It gives good results in terms of recurrence of dislocation, but tends to cause knee stiffness and patellofemoral osteoarthritis. Indications are based on objective patellar instability associated to high-grade B or D dysplasia. Medial patellofemoral ligament reconstruction should be systematically associated. The lateral retinaculum is systematically sectioned, as patellar tilt is never reducible in such high-grade dysplasia. Trochleoplasty corrects the sulcus defect, resolves protrusion and enables proximal realignment. The main complications are stiffness and pain due to persistence or onset of cartilage lesions. Trochleoplasty is indicated: 1) in first line for objective patellar instability associated with high-grade dysplasia; or 2) for recurrence in high-grade dysplasia previously managed by other surgery. The aim of the present study was to review the literature on trochleoplasty and address the following questions: how to define high-grade dysplasia? What are the key clinical and radiologic points? What are the risk factors for patellar dislocation? What trochleoplasty techniques are available? What results can be expected? Level of evidence: V; expert opinion.