As one of the proud recipients of the 2017 PFJ travelling fellowship, I was honoured and humbled to embark on a journey that I hoped would be the answer to all the questions I had regarding some complex and difficult patients that I accumulated over my last few years as a Paediatric and Limb reconstruction surgeon in Brisbane, Australia. The first dilemma was to try and organize a program that satisfied our learning objectives. My interest in consolidating an approach to the adolescent patient with high grade dysplasia and associated bony malalignment, led us to Minneapolis, Baltimore, Banff, NYC and Kobe… although our budget and time constraints saw us regrettably miss out on many centres that would have been valuable learning opportunities.

Having arrived in Minneapolis sans luggage, I met Dr Mauro Nunez in our hotel and prepared for a 3 week immersion in all things PFJ with Dr Eliza Arendt and Dr Marc Tompkins. One of the most salient take home messages was to not get too caught up with exacting numerical assessment of common PFJ parameters. We observed trochleoplasty and PFJ replacement surgery along with several stabilisations. A particularly interesting case involved a proximal tibial corrective osteotomy for a patient with 30 degs of recurvatum and 10 degs of valgus done as a combined case with Dr Mark Dahl.

As soon as my luggage arrived in Minneapolis, we moved on to Baltimore where a cadaver lab with Dr Andy Cosgarea showed us his technique of AMZ and MPFL recon. Dr Miho Tanaka generously spent some time showing us the historical side of Johns Hopkins while discussing their research on defining the J sign.  It was becoming apparent that the complexity of biomechanical forces exerted in the proximal trochlea do not lend themselves to a simple algorithm and that an individualized approach to assessment and management of these cases was critical.

Getting from Baltimore to Banff was not easy, a delayed flight saw us rush to obtain new tickets along with a 1am bus trip from Calgary to Banff. Needless to say my luggage flew back to Minneapolis and waited for me there. Surprisingly for September we were greeted with snow and while the Canadians seemed less than impressed, it is always a beautiful and amazingly picturesque experience for someone from Australia.  Amidst organizing the IPSG meeting later this year, Dr Hiemstra had put together an impressive day of surgeries along with two PFJ clinics and a trip to Lake Louise. Her approach to management involved integration of multiple criteria that she used to generate a surgical prescription for her patients. It was good to see a broad surgical arsenal used to target correction of PFJ biomechanics at the site of deformity. We saw cases of both the Bereiter thin flap trochleoplasty (bump recession) and MPFL recon or the TTO and MPFL reconstruction, as was appropriate.

Our final stop was at HSS where Dr Green, Dr Shubin Stein, Dr Strickland and and Dr Gomoll were kind enough to talk about and demonstrate some complex cases involving malalignment, pain, instability and chondral injury. The management of chondral injury in young patients is a concerning problem in my practice. De Novo chondral augmentation and OATS procedures were used for chondral restoration with correction of bony malalignment to offload the affected areas. The opportunity to observe some paediatric stabilization cases was a particular treat.

Throughout our travels, the recurring debate on what constitute appropriate indications for trochleoplasty were reiterated, with other hot topics being whether to distalise the tubercle in cases of Alta and also what anatomical position to place the Patella insertion of the MPFL. The aptly named alphabet soup of tendinous attachments has thankfully been renamed the PFC or Patellofemoral Complex, an acronym which I am happy to remember.

We cannot reiterate our thanks enough to the incredibly hospitable and talented surgeons that hosted us. Not only were they incredibly generous with their time, but their willingness to teach and express to us their perceptions of the biomechanical balancing act that underpins patellofemoral stability was a pleasure to experience. — Dr. Sheanna Maine

[Images from Drs Sheanna Maine and Mauro Nunez, 2019 Traveling Fellows]

With Dr Miho Tanaka at Johns Hopkins

With Dr Cosgarea

With Dr Marc Tompkins University of Minnesota

PFF traveling fellows Sheanna Maine (Australia) and Mauro Nunez (Costa Rica) have been busy traveling to University of Minnesota with Drs Arendt and Tompkins; Hospital for Special Surgery with Drs Strickland, Shubin Stein, Green, Gomoll, and Fulkerson; Johns Hopkins with Drs Cosgarea and Tanaka; and here, with Dr Laurie Hiemstra in Calgary, Canada. Dr Hiemstra is hosting the next International Patellofemoral Study Group meeting next September in Banff, Canada.

By Drs Jacqueline Munch Brady and Nicholas Paschos

We began our journey in beautiful Lyon, France with Dr David Dejour. We focused on instability, discussing the principles of clinical and radiographic evaluation of the patellofemoral joint, and indications for procedures such as distalizing tibial tubercle osteotomy and trochleoplasty.  Dr. Dejour explained the thought process behind identifying patella alta and/or trochlear dysplasia as the major contributing factor to instability, and correcting each accordingly. 

Dr. Philippe Neyret was our next host, across the city in Lyon.  With him, we shifted our focus to the extensor mechanism of the knee, discussing considerations for surgical intervention in chronic quadriceps or patellar tendon insufficiency.  He demonstrated a technique for complex reconstruction of a deficient patellar tendon using mesh augmentation, for instances where the native tendon is insufficient for repair.

Next, we stopped in London to visit Dr. Andrew Amis.  His lab at the Imperial College is equipped to study everything from soft tissue anatomy to complex joint kinematics. We discussed the difficulties in studying the patellofemoral joint biomechanically: for instance, a dearth of trochlear dysplasia in cadaveric material, and the complexity of the soft tissue envelope surrounding the joint. We toured his laboratory and the neighboring robotics laboratory, and then had a great discussion with Dr. Amis and his colleague Dr Jo Stephen regarding their recent interest in the anatomy of the infrapatellar fat pad and its contributions to symptoms in the patellofemoral joint.

We departed London, inspired to continue our studies.  In Tampere, Finland, we shifted our research discussion to the clinical world with Dr. Petri Sillanpaa and his partner, Dr. Frederick Weitz. They collaborate on the majority of their trochleoplasty cases, in order to increase their respective experience and ensure close examination of their outcomes.  Among other excellent cases, we observed the technique of thin-flap trochleoplasty, and discussed the surgical indications for the procedure. 

At the end of our visit, providers from across Finland gathered in Tampere for a conference focusing on all aspects of the patellofemoral joint, and we had an excellent discussion on the latest developments in PF joint disorders.  True to the Finnish tradition, we concluded our conference with a visit to the conference’s sauna!

For our second week, we returned to the United States, landing first in Hartford, Connecticut for a visit with UConn surgeons Dr. John Fulkerson and Dr. Cory Edgar.  We shifted gears slightly to discuss chondral lesions and implications for patellofemoral surgery.  Dr. Edgar filled us in on his latest biomechanical undertakings, explaining the effects of distalization of the tibial tubercle in early knee flexion.  Dr. Fulkerson reviewed the anatomy of the medial patellofemoral complex, and demonstrated his MQTFL technique in addition to the anteromedializing tibial tubercle osteotomy.  The UConn residents filled us in on some of their research surrounding patellofemoral anatomy and cartilage restoration techniques, and we were able to see one more case with Dr. Fulkerson, illustrating the treatment of iatrogenic medial instability, before departing for Minnesota.   

Our next stop was the Mayo Clinic with Dr. Diane Dahm.  After observing an MPFL reconstruction, we focused on patellofemoral arthritis in particular with Dr. Dahm.  We discussed indications for unloading procedures versus patellofemoral arthroplasty.  She demonstrated a lateral facetectomy in a patient who was too high-risk for arthroplasty.  Afterward, we reviewed various patellofemoral implants, and discussed the fact that they vary significantly in design and considerations for technique. 

From Rochester, we journeyed to neighboring Minneapolis, MN, where Dr. Elizabeth Arendt hosted us at the University of Minnesota.  Dr. Arendt demonstrated her MPFL reconstruction technique of wrapping a graft around the adductor magnus tendon rather than creating a bony socket in the medial femur.  We discussed the lateral retinacular complex, and she demonstrated the technique of lateral retinacular lengthening.  Dr. Arendt also performed a thick-flap trochleoplasty technique in a severely dysplastic patient, demonstrating the ability of trochleoplasty to significantly improve the level of trochlear dysplasia on direct inspection and lateral fluoroscopic examination.  We ended the visit with a morning in the laboratory, reviewing the complex anatomy of the patellofemoral joint and its soft tissue envelope, and trying our hand at tibial tubercle osteotomy and trochleoplasty procedures.

Throughout the journey, we felt incredibly grateful and fortunate to have the opportunity to learn from some of the leaders in our field.  We are eternally thankful to our hosts for their time and energy.  The trip was challenging and enlightening in all the right ways, and we look forward to using our improved understanding to treat our patients and contribute to the literature. 

Our travels in pictures: