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Wednesday, May 22, 2013
Proximal Distal Realignment - 15 yrs old
My daughter just turned 15 and has been in PT since early September for her knee pain (both knees). They are now talking surgery since she hasn`t had much, if any, improvement;however I don`t feel she is working hard enough with her exercises. How common is this surgery; does this mean she can return to her sports activities and what are the chances for arthritis when she is older?
The procedure you describe - proximal-distal realignment - refers to a surgery where the patella (kneecap) is "realigned." The "proximal" part is done by detaching the soft tissue attached to the medial (inner) upper part of the patella, then reattaching this in a slightly different position. The "distal" part is done by detaching the portion of the tibia (shin bone) to which the tendon from the patella attaches, then slightly repositioning this "bony block" and reattaching it to the tibia. The result is that when the quadriceps muscles (in the front of the thigh) contract, there will then be a straighter line of pull through the patella, and less of a tendency for the patella to be pulled to the lateral (outer) side of the knee.
A proximal-distal realignment surgical procedure is best done if abnormal "tracking" has been documented to occur... that is, with knee motion, the patella would tend to ride out of the groove in which it is supposed to travel. In general, orthopedic surgical procedures on growing bones are best delayed until growth has stopped, whenever possible. Otherwise, there would be a tendency for bony deformity to occur following surgery as bone growth continues. If such deformity about a joint were to happen, there may be an increased chance of arthritis developing later in life.
You mentioned your daughter may not be working hard enough on her exercises. If that is the case, surgery would probably NOT be a good idea, since the outcome of most orthopedic surgical procedures is significantly dependent on the quality of the postoperative rehabilitation program, which requires a high level of patient motivation and effort, along with willingness to persevere despite pain.
It has been noted that in adolescents, the rate of bone growth may exceed that for muscle lengthening, resulting in relative muscular tightness. Stretching exercises may help this somewhat, but often, with further growth, muscle length will "catch up" to bone length, with less relative muscular tightness as a result, and possibly, less patellar pain.
You should ask your daughter`s orthopedic surgeon how often he or she performs proximal-distal realignment surgery on 15 year olds, and what are the chances of a good - and bad - long term outcome. Return to sports usually requires pain-free range of motion, normal strength, and the ability to engage in progressively more challenging sports-specific drills without producing pain or swelling as a result. These goals, for someone with patellar pain, are usually achieved without surgical intervention.
Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University