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(A) Preoperatively, the patella (circle) dislocated laterally (arrow) at about 30 of knee flexion. (B) A midline incision was made to expose the laterally dislocated patella (circle and arrow).
Source publication
Background
A habitual patellar dislocation (HPD) is a rare condition in skeletally mature patients, especially for those with severe quadriceps contracture. Until now, no study has reported the effectiveness of tibial tubercle proximalization to lengthen the extensor mechanism in treating severe HPDs in skeletally mature patients.
Purpose
To descr...
Context in source publication
Context 1
... dynamic tracking and lateral dislocations of the patella were evaluated routinely before surgery under anesthesia (Video Supplement 1) and intraoperatively after each step of the comprehensive procedure was performed. A midline incision was made from 5 cm above the patella to 10 cm below the patella to expose the quadriceps muscle and tibial tubercle (Figure 2). Intra-articular pathological findings were recorded, including the grade of chondromalacia in each facet of the patella and the lateral femoral condyle according to the Outerbridge classification system. ...
Citations
... 29 In contrast, quadriceps fibrosis is a major risk factor for HPD, 6,16,21 and tibial tubercle proximalization is required to correct the shortening of extensor mechanism. 4,43 In this study, we adopted both the Insall-Salvati index and the Caton-Deschamps index to assess the height of patella. The measurement failed in 11 out of 21 (52.4%) ...
... Another major defect of the current study is the missing of soft tissue factors such as arthrochalasis, 33 MPFL laxity, 24,53 and quadriceps contracture, 6,16,25,43 which are important in surgical planning. Limiting the age for inclusion for habitual dislocation patients also introduced bias in this study, presenting an incomplete picture of the disease. ...
Background
Recurrent patellar dislocation (RPD) and habitual patellar dislocation (HPD) in flexion are frequently encountered in children and adolescents.
Purpose
To compare the radiological features of RPD and HPD in children and adolescents.
Study Design
Cross-sectional study; Level of evidence, 3.
Methods
Imaging data were collected from patients aged 9 to 15 years who received surgical treatment for HPD or RPD at a single institution between June 2015 and September 2020. The prevalence of trochlear dysplasia, tibial tubercle lateralization, and lower limb rotational deformity was assessed through hip/knee/ankle computed tomography (CT) using the following quantitative indicators: trochlear depth index, lateral trochlear inclination, sulcus angle, tibial tubercle–trochlear groove (TT-TG) distance, ratio of TT-TG distance to femoral width, TT-TG angle, femoral anteversion angle, and tibial external rotation angle. The morphology of trochlea and patella were graded on knee CT using the Dejour and Wiberg classification. The Insall-Salvati index and Caton-Deschamps index were used to evaluate the height of the patella on lateral view radiographs. To evaluate lower limbs malalignment, the mechanical lateral distal femoral angle and medial proximal tibial angle were measured on weightbearing full-length radiographs. The collected data were analyzed and compared between the HPD and RPD groups.
Results
Enrolled were 15 patients (21 knees) diagnosed with HPD and 18 patients (22 knees) diagnosed with RPD. The age of first dislocation was significantly younger in the HPD group (7.6 ± 3.4 vs 11.2 ± 1.4 years; P = 0.003). Knees in the HPD group had a significantly higher proportion of Dejour type C dysplasia (57.1% vs 4.5%; P < .005) and Wiberg type 3 patella (66.7% vs 9.1%; P < .001). There were statistically significant differences between the groups in the trochlear depth index (HPD vs RPD: 1.1 ± 1.7 vs 2.2 ± 1.5 mm; P = .039), sulcus angle (170.3° ± 13.7° vs 157.3° ± 16.0°; P = .007), Insall-Salvati index (1.1 ± 0.2 vs 1.3 ± 0.2; P = .034), and tibial external rotation angle (31.3° ± 7.8° vs 38.4° ± 8.5°; P = .009).
Conclusion
Patients in the HPD group presented with poorer trochlear and patellar development, lower patellar height, and less tibial external rotation compared with patients in the RPG group.
... Im Gegensatz zur "klassischen" Patellainstabilität, welche vorwiegend in strecknahen Kniegelenksstellungen zwischen 0 und 60°auftritt [9], findet die Luxation der Patella beim NPS bei jedem Bewegungszyklus in höheren Beugegraden des Kniegelenks statt. Dies ergibt sich durch die Kombination aus Patella baja, einem zentralen fibrösen Septum, welches die Patella nach lateral verdrängt, und einer wahrscheinlich konsekutiv einsetzenden Kontraktur des lateralen Retinakulums und des Musculus vastus lateralis [5]. Zu achten ist zusätzlich auf eine mögliche Hypoplasie der lateralen Femurkondyle, welche eine nach lateral ansteigende Kniegelenksebene bedingt und dadurch der Luxation in Beugestellung Vorschub leisten kann [2]. ...
Nail–patella syndrome (NPS) is an autosomal dominant hereditary disease which is
characterized by pathognomonic characteristics of the patellotrochlear morphology
leading to habitual flexion instability of the patella. This article describes the combined
surgical procedures to stabilize the patella based on two cases of nail–patella syndrome.
... The extent and severity of injury to the patella retinaculum cannot be determined by clinical symptoms and radiography alone. More than 160 methods of surgical correction of knee joint instability and patellar dislocation are described in the literature [3,8,[10][11][12][13][14][15][16][17] with high rate of poor outcomes (from 3.3 to 36.1 %) [18,19]. Most optimal methods have not yet been determined [20,21] to combine anatomical relevance and minimal trauma, pathogenetic justification and high functional efficiency [10,[21][22][23]. ...
Introduction Surgical options used to treat recurrent patellar dislocations (RPD) in different countries include release of the lateral tendon
retinaculum, tibia medialization, fixation of an autologous graft to the hip, transplantation of the ipsilateral gracilis tendon and medial
patellofemoral ligament reconstruction. The methods may not completely eliminate the dislocation to ensure patellar stability and we
undertook to develop a new surgical technique. The objective was to identify advantages and disadvantages of the new methodology for the
treatment of RPD through comparative analysis. Material and methods 28 patients with RPD of varying degrees treated in the Department
of Sports Trauma, State Institution "RSNPMCTO" the Ministry of Health of the Republic of Uzbekistan between 2015 and 2018 were reviewed.
Dislocations were graded as average (grade 2; n = 3, 10.7 %) and grade 3 (n = 25; 89.3 %). Five (17.8%) of 28 patients had impaired m.
vastus medialis and 23 (82.2 %) were diagnosed with impairment and defect of the retinaculum patella mediale. The patients underwent
physical, laboratory, radiological and instrumentation (ultrasound, magnetic resonance imaging, diagnostic arthroscopy) examinations.
Results Arthroscopic procedure of the knee joint with autoplasty patellar stabilization using the m. gracilis tendon and a biodegradable screw
resulted in good outcomes (n = 27; 96.4 %) and a fair result in a patient (3.6 %) with grade 3 RPD due to synovitis, bursitis and pain in the knee
joint; no poor results reported. Conclusion The patients could completely regain the limb functions through arthroscopic procedure of the knee
joint with autoplasty patellar stabilization using the m. gracilis tendon and a biodegradable screw, optimization of surgical treatment strategy
with regard to severity of displacement and injury to the soft tissues at the medial aspect of the patella.
... Some have suggested using an osseous approach, a tibial tubercle proximalization, instead of a quadricepsplasty to limit scar tissue formation and allow for rigid fixation, enabling early postoperative rehabilitation. 25,26 However, this approach can be accompanied by complications and can further disrupt the delicate balance of patellofemoral forces and alternative anatomy, such as increasing patella alta, which can increase the risk of postoperative instability. Because of these risks, soft tissue reconstruction may be preferred. ...
... 30 Hung et al. 31 reported excellent results in 56 of 76 knees (73.7%) that underwent reconstruction with iliotibial band with concomitant VY quadricepsplasty to improve knee flexion and patellar tracking. In addition, Song et al. 25,32 reported the outcomes of 13 knees who underwent their "4-in-1" approach, which included a tibial tubercle proximalization and medialization, extensive lateral release, and MPFL reconstruction. The authors reported significant improvements in the Kujala score (from 41.4 to 94.9, P < .01) in addition to improvements in congruence angle and lateral patellofemoral angle. ...
Lateral patellar dislocation is a relatively common pathology that can be surgically treated with a medial patellofemoral ligament reconstruction. In rare occurrences patients can present with patellar maltracking that results in obligate patellar instability in flexion but central tracking in extension. This presentation can be much more complicated to treat surgically and may require a combination of multiple patellofemoral procedures. In this technique we describe a four-pronged treatment approach for improving patellar tracking in a patient with obligate flexion patellar dislocation and valgus malalignment including VY quadricepsplasty, distal femoral osteotomy, medial patellofemoral ligament reconstruction , and lateral retinacular and capsular reconstruction with a dermal allograft.
Patellar displacement is limited by passive retinacular tethers and the chondral/bony geometry of the trochlea and patella. Together, they guide the patella into the trochlear groove and keep it engaged in the groove throughout knee range-of-motion.
A habitual patellar dislocation (HPD) is a rare condition. The cardinal physical sign of an HPD is that if the patella is forcibly held in the midline, it is impossible to flex the knee more than 90° [1]. Further flexion is possible only if the patella is allowed to dislocate when a full range of motion (ROM) is readily obtainable. Various pathological factors have been described in the pathogenesis of HPDs, such as femoral trochlear dysplasia, increase in the Q angle, increase in the tibial tubercle-trochlear groove (TT-TG) distance, lateral soft tissue contracture, and medial soft tissue relaxation. Jeffreys [2] in 1963 described an abnormal attachment of the iliotibial tract to the patella, producing HPDs in knee flexion. Later, Gunn [3] in 1964 described the association of quadriceps fibrosis with intramuscular injections to the thighs. He also put forward the idea that quadriceps contracture may sometimes give rise to dislocations of the patella.
Case:
A 55-year-old man with Down syndrome (DS) suffered from chronic irreducible right patellar dislocation. Imaging studies showed an attenuated appearance of the medial patellar retinaculum, and the tibial tubercle to trochlear groove distance measured 1.6 cm. Right medial patellofemoral ligament reconstruction (MPFLR) and lateral lengthening (LL) with proximalization of the tibial tubercle (PTT) were performed with good surgical outcomes.
Conclusion:
The combination of MPFLR, LL, and PTT is a viable option for treating a skeletally mature DS patient with patellofemoral instability causing recurrent patellar dislocation.
Purpose
To examine the indications and outcomes of medial patellofemoral ligament (MPFL) reconstruction with or without tibial tubercle osteotomy (TTO) in treating recurrent or habitual patella dislocation with increased tibial tuberosity-trochlear groove (TT-TG) distance.
Methods
A literature search was performed on the established medical databases Cochrane central, PubMed/MEDLINE, EMBASE, Web of science. Inclusion criteria were as follow: skeletal mature patients with recurrent or habitual patella dislocation and increased TT-TG distance; treating with MPFL reconstruction combined with TTO procedure or isolated MPFL reconstruction; clinical outcomes and complications reported. Each study was assessed for quality and level of evidence. General characteristics, indications, surgical techniques, TT-TG distance, clinical results, imaging evaluation and complications of each study were recorded.
Results
Nine studies consisting of 288 knees met the inclusion criteria. Average of Coleman scores was 71.56 (ranged from 55 to 83). The threshold of increased TT-TG distance ranged from 16 to 20 mm of included studies. And similar good postoperative outcomes were reported in patients with increased TT-TG distance treating with MPFL reconstruction with or without TTO procedure. The mean postoperative Lysholm score ranged from 75.0 to 94.7 (I²=87.6%) in isolated MPFLR group, and from 85.0 to 87.6 (I²=16.3%) in TTO with MPFLR group. Similar postoperative congruence angle (CA) were reported in both groups as well. Postoperative redislocation rate ranged from 0 to 4.2% in TTO with MPFLR group and no redislocation was found in isolated MPFLR group. Postoperative apprehension sign was only reported in isolated MPFL reconstruction.
Conclusion
The outcomes of MPFL reconstruction with or without TTO treating recurrent or habitual patella dislocation with increased TT-TG distance appeared to be similar. However, this study was limited by the considerable heterogeneity, variety of techniques, variety of TT-TG distances, and the variability of patella alta and trochlear dysplasia among the included studies.
