Surgical Discussion

Goal 1- motion. Needs an open LOA, possible quad-plasty, and most importantly-recreation of the trochlea, and some sort of soft tissue procedure to get the patella tracking properly. 2) nonunion- clean up and fix 3) osteochondral defect- best dealt with via anatomic osteochondral block allograft (takes a long time to match). Do you want to try to do these things all at once? The risk of failure of each is quite high. On top of that- based on how the patellar cartilage is- even if you do a perfect osteochondral grafting- is he still going to have debilitating patellofemoral pain? For these reasons, I think staged management is super important. For me this is a 2 stage operation with goal 1 being restore motion. Get the knee moving normally, patella tracking normally, and then reassess. That required mega releases, rebuilding the trochlea with pmma and a medial imbrication. Plan was to see how he does and convert to a fresh osteochondral allograft, but he freaking loves his cement trochlea too much to commit to stage 2. Eventually he will show back up, but since his last follow up I haven’t seen him.