Sir,
I was delighted to read the paper from Bristol on the results of
the Bereiter trochleoplasty for patellar instability.1
I was also pleased to see that they referenced our paper on the subject.2 However, to make a direct comparison between the two
techniques, as the authors do, is to compare apples and oranges, for the
following reasons:
1. The Bereiter technique is established and the authors are reporting an
independent series. Ours was describing the learning curve and the
necessary modifications to overcome problems.
2. The Bereiter technique requires normal articular cartilage to
develop a thin, flexible flap. Ours develops two thick osteochondral
flaps, and can include cartilage defects. The Bristol group would perform
patellofemoral arthroplasty on many patients in our series.
3. One of the theoretical disadvantages for trochleoplasty is that it
creates a mismatch between the patellar surface and the new groove. This is
beautifully illustrated in Figure 5 of the paper by Utting et al. The thick
flap technique keeps the congruency between the patella and new lateral
facet. Whether this makes a true difference would require a randomised
controlled trial.
The management of patellar instability is at the stage anterior
cruciate ligament reconstruction was 20 years ago. Trochleoplasty is one
of the operations that are currently in vogue. We have some way to go
before we can know the technique that is best for a particular patient
with trochlear dysplasia.
S.T. Donell, BSc FRCS(Orth) MD,
Honorary Reader and Consultant Orthopaedic Surgeon,
University of East Anglia,
Norwich, UK.
1. Utting MR, Mulford JS, Eldridge JDJ. A prospective evaluation of
trochleoplasty for the treatment of patellofemoral dislocation and
instability. J Bone Joint Surg [Br] 2008;90-B:180-5.
2. Donell ST, Joseph G, Hing CB, Marshall TJ. Modified Dejour
trochleoplasty for severe dysplasia: operative technique and early
clinical results. Knee 2006;13:266-73.
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