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PubMed1990

The Hauser operation for patellar dislocation. 3-32-year results in 63 knees.

The Hauser operation for patellar dislocation was performed in 34 women and 20 men, median age 18 (3-55) years; one leg was amputated because of wound infection with chronic septic arthritis. At the time of follow-up, 8 (3-32) years after the operation 57 knees had normal or almost normal patellar stability, but only 26 knees were free from pain. Only 16 knees had both normal patellar stability and were without pain. Patellar arthrosis had developed in 16 knees and femorotibial arthrosis in 23 knees. Eleven patients operated on before the age of 15 years showed varying grades of axial deformity of the proximal tibia.

Adolescent↗
PubMed1986

Patellar dislocation and osteochondral fractures.

Follow-up study of nine patients with patellar dislocation in combination with osteochondral fractures. Three of these patients with special problems in relation to knee pathology are discussed in detail. This group of knee injuries is often overlooked because of frequent spontaneous reposition. Etiology, diagnosis and treatment are discussed. Arthroscopy is recommended to visualize chondral defects. Results are presented in combination with follow-up. Four patients still complain of instability of the knee after surgery. Reconstruction is the treatment of choice. The kind of fixation depends on the size of the osteochondral fragment, and consists of either screws or fibrin, in future possibly resorbable pins. Continuous passive motion is to be recommended after operation. Factors predisposing to recurrence are an indication for correction.

Adolescent↗
PubMed1997

Recurrence after patellar dislocation. Redislocation in 37/75 patients followed for 6-24 years.

75 patients had closed treatment for a primary unilateral acute patellar dislocation. All patients were studied clinically, radiographically and for isokinetic thigh muscle performance a median of 11 (6-24) years later. During the follow-up, 37 patients had experienced recurrent dislocations. The functional outcomes were similar in patients with or without recurrence. Radiographically unstable patellar morphology, spontaneous reduction of the dislocation and low volume of hemarthrosis predisposed to recurrence.

Adolescent↗
PubMed2003

Treatment of chronic patellar dislocation with a modified Elmslie-Trillat procedure.

BACKGROUND: This paper describes a modification of the Elmslie-Trillat procedure that is usually performed in severe cases of habitual or recurrent patellar instability. METHODS: Eighteen knees (7 men and 8 women) treated for recurrent or habitual patellar dislocation were evaluated clinically and radiographically at a mean follow-up of 5 years (range 24 months to 9 years). The mean age at follow-up was 26.3 years (range 17-44 years). The IKDC and Kujala and Tegner scores were used for the clinical evaluation. Anteroposterior, lateral and Merchant views were done for radiographic monitoring. When the patella was still unstable during dynamic evaluation after execution of the Elmslie-Trillat procedure, the medial third of the patellar tendon was isolated and harvested with a corresponding 1 cm long and 0.5 cm wide bone plug, maintaining its insertion to the inferior medial side of the patella. This ligament was medialized and put under tension, trying to find a medial insertion that guaranteed patellar stability throughout the full range of motion. RESULTS: IKDC classified 11 knees as A (normal), 4 knees as B (almost normal), 2 knees as C (abnormal) and 1 knee as D (severely abnormal). The Kujala score showed excellent results in 16 knees, 1 fair and 1 poor knee. The mean Tegner score rose from 2 preoperatively to 5 at follow-up. The poor knee presented an over-correction of the congruence angle on radiography. On follow-up radiographs, the parameters were almost completely corrected. Statistical analysis showed a significant correction of radiograph parameters, and significantly worse results in patients who underwent trochleoplasty. CONCLUSION: The technique described tries to achieve a dynamic stability of the patella throughout the full range of motion in severe patellar instability where the Elmslie-Trillat procedure is insufficient. No recurrence of patellar instability has been observed. The stability must be obtained with dynamic control in the initial degrees of flexion, trying to avoid an excessive patellar medialization.

Adolescent↗
PubMed2006

[Medium-term results after m. vastus medialis obliquus-plasty for lateral patellar dislocation].

Progressive retropatellar arthrosis is often seen in dated rigid distal realignment (i.e. osteotomy of tuberositas) at long-term follow-ups. Therefore, operations for lateral dislocation of the patella are still discussed controversially. Dynamic, proximal realignments seem to have lower rates of arthrosis but higher rates of redislocation. Recently, in anatomic and biomechanic studies, the m. vastus medialis obliquus (vmo) was found to be one of the most important proximal restraints to lateral dislocation of the patella.A total of 28 patients (mean age 21.5 years) were treated between 1994 and 2003 with a plasty of the vmo for lateral patellar dislocation. The technique was performed for most etiologies of femoropatellar instability. For this proximal soft tissue technique, the muscle tendon is detached from its patellar insertion. Subsequently, the tendon is reinserted at the patella 10-15 mm more distally and fixed with Mitek anchors. Full weight bearing in extension is possible immediately after surgery. An active vastus medialis training is started after 6 weeks. Of the patients, 27 were evaluated clinically and radiologically in 2004 (a mean of 5 years postoperatively). A total of 83% of the patients estimated the result to be good or excellent, 10% were satisfied and 7% were discontent. The mean Lysholm-Knee-Score was 83.1 points. Two patients suffered a patella redislocation (7%). A statistically significant improvement of the congruence angle was noted in the radiographs, even in medium-term controls. In 89% of the cases no or only little retropatellar arthrosis was observed. These 5 year results are comparable to those of other techniques for distal or proximal realignments. The rate of redislocation was below average. Compared to the rate of retropatellar arthrosis in long-term results of rigid distal realignment, our patients demonstrated a relative low rate after 5 years. We attribute this to the minimal interference in physiological joint mechanics and to the restored anatomy. In terms of future long-term results, our findings are promising. The idea of a proximal dynamic stabilization and the causal operative approach at the origin of pathology using vmo-plasty was confirmed in recent anatomic and biomechanic studies. Over or under correction of soft tissues could be adapted. More rigid techniques of distal realignment do not allow an adaptation to this extent and can lead to prearthrotic hyperpression in the medial femoropatellar and femorotibial joints.

Adult↗
PubMed1997

Patellofemoral osteoarthritis after patellar dislocation.

Clinical and radiographic studies were done for 85 patients treated conservatively for acute primary patellar dislocation occurring an average 13 years (range, 6-26 years) previously. Osteoarthritic changes in the patellofemoral joint were evaluated with special reference to the primary conservative treatment and treatment of redislocations (operative or conservative) or treatment for other subsequent problems such as pain and/or subluxations (late surgery). The patients were divided into two groups on the basis of findings in the unaffected knee and other joints. There were 56 patients (66%) with predisposing factors such as an abnormal quadriceps angle, positive apprehension test, quadriceps muscle atrophy, or generalized joint laxity common to all patients. Patients with or without predisposing factors did not differ from each other in terms of arthritic changes. Patellofemoral joint degeneration was found in the affected knee in 19 patients (22%) and in the unaffected knee in nine (11%). Conservative treatment without subsequent redislocations resulted in osteoarthritic changes in 29% of the cases and in 13% of cases with occasional redislocations. Osteoarthritic changes were found in 17% of patients treated operatively and in 12% of patients treated conservatively for redislocations. Of the patients who underwent late surgery for patellofemoral pain or subluxations, 35% showed osteoarthritic changes. In general, there were more degenerative changes in patients with stable patellae (no redislocations) than in those with occasional recurrences, especially in older and heavier patients.

Acute Disease↗
PubMed2005

Operative treatment of primary patellar dislocation does not improve medium-term outcome: A 7-year follow-up report and risk analysis of 127 randomized patients.

BACKGROUND: The best treatment for primary patellar dislocation has been the subject of debate. Surgery has been recommended for all patients or for special subgroups to improve outcome. We have previously reported similar 2-year results after closed or open treatment. This report concerns 127 patients who were re-evaluated by questionnaire at least 5 years after the primary onset. PATIENTS AND METHODS: At baseline, the patients were randomized regarding closed treatment (57) or individually adjusted proximal realignment operation (70). All patients were re-evaluated after a mean follow-up of 7 (6-9) years. RESULTS: The outcomes were similar: the patient's own overall opinion was excellent or good after closed treatment in 81% of cases and after operative treatment in 67%. Mean Kujala and Hughston VAS knee scores were 90 and 94, respectively, after closed treatment and 88 and 89 after operative treatment. The proportions of stable patellae were 30% and 36% for closed treatment and operative treatment, respectively. In a multivariate risk analysis, there was a correlation between a Kujala score of less than 90 and female sex (OR: 3.5; 95% CI: 1.4-9.0), loose bodies on radiographs (4.1; 1.2-15), and also an initial history of contralateral patellar instability (3.6; 0.9-15). There were 2 risk factors for recurrent instability: initial contralateral instability (4.9; 0.9-28) and young age (0.9; 0.8-1.0/year). Girls with open tibial apophysis had the worst prognosis for instability (88%; 95% CI: 77-98). INTERPRETATION: We do not recommend proximal realignment surgery for treatment of primary dislocation of the patella.

Adolescent↗
PubMedDate not supplied

Patellar dislocation. The long-term results of nonoperative management in 100 patients.

One hundred patients were treated nonoperatively for primary acute patellar dislocations, either by plaster cast (N = 60), by posterior splint (N = 17), or by patellar bandage or brace (N = 23). Follow-up examinations were performed at an average of 13 years later (range, 6 to 26 years). Overall, there were 0.17 redislocations per follow-up year; the redislocation frequencies per follow-up year for each patient group were 0.29, patellar bandages or braces; 0.12, plaster cast; and 0.08, posterior splint. In addition, there were fewer recurrences and subsequent problems (patellofemoral pain or subluxations) in the group treated with posterior splints compared with the two other treatment groups. The most marked restrictions of knee joint movements were seen in the patients treated with plaster casts. Subjective assessment of treatment, however, did not differ significantly between the groups. Patients were also evaluated in relation to the treatment of redislocations and management of subsequent problems (i.e., patellofemoral pain or subluxations). Patients who were treated operatively for their redislocations exhibited better outcomes than patients treated nonoperatively. In the patients who had subsequent problems, the operation did not relieve the symptoms.

Adolescent↗
PubMedDate not supplied

Conservative treatment of patellar dislocations. Influence of evident factors on the tendency to redislocation and the therapeutic result.

The factors predisposing to recurrent dislocation and the results of conservative treatment were investigated in 79 cases of patellar dislocation. Patella alta and subluxation were significantly more common in patients without than in those with a history of injury. No single predisposing factor caused more redislocation than any other. The tendency to redislocation was significantly greater in patients younger than 20 years of age than in those older than 20 years of age at the time of primary dislocation. Corroborating reports in a large literature on the disorder, the present experience validates conservative management for primary dislocations and surgical treatment for redislocations of the patella.

Adolescent↗
PubMed2005

Permanent patellar dislocation and osteoarthritis of the knee after femoral fracture in childhood. A case report.

A 52 year-old woman suffered bilateral femoral shaft fractures when she was 5 years old and they were treated surgically. She had been able to walk without pain and giving way throughout her young and adult life, however, when she came to us with a 1-year history of the right knee pain, she could walk only 10 m continuously. The right knee revealed valgus deformity with complete lateral patellar dislocation. The femoro-tibial angle was 154 degrees and arthritic change was seen in the femorotibial joint. Surfaces of both the patella and the femur were degraded. Twenty-two degrees of rotational deformity was also found internally in the involved side. Varus osteotomy with external rotation of the distal fragment and lateral retinacular release combined with reefing of vastus medialis muscle were performed. Twenty-four months after surgery, knee score and functional score were, respectively, 85/100 and 71/100, using knee society clinical rating system and there was no pain associating patella incongruity.

Bone Transplantation↗
PubMed2003

Arthroscopic removal of a loose body osteophyte fragment after superior patellar dislocation with locked osteophytes.

The authors report the case of a loose body from a fractured osteophyte after a superiorly dislocated patella with locked osteophytes. Few cases of superiorly dislocated patellae have been reported in the literature and no cases of osteophyte fracture fragments after locked osteophytes with subsequent arthroscopic loose body removal have been reported. The loose body was removed and the distal pole of the patella was debrided arthroscopically. This patient and the majority of previously reported cases, herein reviewed, had patella alta with pre-existing patellofemoral arthrosis. Patella alta in the face of patellofemoral arthrosis should be considered a risk factor for loose body formation. Therefore, recurrent superior patellar dislocation and locking osteophytes may be a relative indication for pre-emptive arthroscopic debridement of locked osteophytes.

Arthroscopy↗
PubMed2001

Growth arrest lines and recurrent patellar dislocation: a new sign.

The phenomenon of growth arrest lines has been widely described in the medical literature. They are usually found at the metaphysis of growing long bones and are the result of short periods of partial growth arrest. Recurrent dislocation of the patella is a well-recognised problem, particularly in adolescents. Several radiological features have been reported in association with patellar dislocation or instability. We have reported a hitherto undescribed radiological sign of patellar growth arrest lines on the skyline radiographs of two patients with this condition. The shape of the patella when symptoms were at their worst corresponded remarkably closely to the outline of the subsequent growth arrest line. We postulated that repeated dislocations adversely affect the process of normal maturation of the patella. With the resolution of symptoms, patella ossification resumes, leaving the telltale sign of previous injury in the form of a growth arrest line and an improvement in bone density once the patella has been stabilised and tracks normally.

Adolescent↗
PubMedDate not supplied

Acute patellar dislocation in children: incidence and associated osteochondral fractures.

In a prospective two-year study on urban (city of Helsinki) Finnish children, 72 acute patellar dislocations were observed. The calculated annual incidence rate was 43/100,000 in children under 16 years. A total of 28 knees (39%) had associated osteochondral fractures. These fractures comprised 15 capsular avulsions of the medial patellar margin and 15 loose intra-articular fragments detached from the patella and/or lateral femoral condyle. The intra-articular fragments were found only after spontaneous relocation of the patella. The femoral fracture constantly involved the edge of the articular surface in the middle third of the condylar arc.

Adolescent↗
PubMed1986

Arthroscopic repair of the medial retinaculum and capsule in acute patellar dislocations.

Treatment for acute dislocations of the patella is highly controversial among many knee surgeons. This study proposes an arthroscopic technique for the surgical repair of the retinacular-capsular defects caused from acute patellar dislocation. The clinical material used involved 30 cases with no previous history of patellar instability and with history of documented lateral dislocation accompanied by an acute hemarthrosis. All individuals in this study were treated with arthroscopic medial capsular-retinacular repair and lateral retinacular release. The follow-up on these patients, ranging from 1 to 7 years postoperatively, revealed that the results of treatment were gratifying in all instances with the exception of one traumatic redislocation. It appears that the arthroscopic procedure used in this study was successful in stabilization of the acute dislocation of the patella, and that it is a beneficial addition to present surgical treatment for the acute dislocation of the patella. This technique provides early accurate diagnosis and, thus, early accurate restoration of normal anatomy. This technique is by no means the only way, but it is one way to obtain satisfactory results in the treatment of this most difficult problem.

Arthroscopy↗
PubMed2000

Isokinetic thigh muscle performance after long-term recovery from patellar dislocation.

Eighty-two patients (50 women, 32 men) underwent isokinetic muscle testing on average 13 years after a conservatively treated unilateral primary patellar dislocation. Three study groups were formed according to the natural history of recovery: group A (n = 32), patients with only primary conservative treatment; group B (n = 34) patients with conservative (group B1; n = 24) or surgical (group B2; n = 10) treatment of redislocations; group C (n = 16) patients with other residual complaints (anterior knee, pain subluxations) requiring surgery. The Cybex 6000 dynamometer system was used as the testing machine for quadriceps and hamstrings muscles, with proportional deficits of peak torque as the test parameter. Isokinetic testing revealed both quadriceps and hamstring muscle atrophy even after long-term recovery from injury. There were statistically significant differences between the three study groups at both tested speeds of quadriceps muscles (60 rad/s, P < 0.002; 180 rad/s, P < 0.009). Groups B1 and B2 presented similar results. The muscle performance findings are probably due to more than one factor: primary immobilization, poor outcome, patellofemoral degeneration, redislocations, and residual knee complaints followed by surgery and deficiency in motor control of thigh muscle had--together or separately--an effect on muscle performance.

Adult↗
PubMed1996

Management of the chronic irreducible patellar dislocation in total knee arthroplasty.

Neglected dislocation of the patella with gonarthrosis, genu valgum, flexion, and external rotation deformity is rarely encountered. Experience with five total knee arthroplasties in three patients with chronic patellar dislocation and gonarthrosis is reported. All knees had a modified proximal patellar realignment and arthroplasty with a constrained prosthesis. Preoperative Hospital for Special Surgery knee scores averaged 55. Average follow-up period was 40 months. At latest follow-up examination, the average Hospital for Special Surgery knee score was 83, the Knee Society knee score was 95, and the functional score averaged 50. There was one complication: a full-thickness lateral skin necrosis requiring flap coverage. The patellar score was zero in all knees. Four knees had mild quadriceps weakness. Three knees rated as excellent and two as good on both The Hospital for Special Surgery and Knee Society rating systems. Radiographic analysis revealed no radiolucent lines or osteolysis. The patellas were centralized in the trochlear groove in all patients. Patellar height averaged 14 mm (range, 12-17 mm). In conclusion, satisfactory results were obtained by restoring axial alignment with a constrained implant and realigning the patella with an extensive proximal realignment.

Aged↗
PubMed2002

Correlation of MR imaging findings and open exploration of medial patellofemoral ligament injuries in acute patellar dislocations.

The purpose of this investigation was to correlate magnetic resonance (MR) images of medial patellofemoral ligament (MPFL) injuries with gross macroscopic findings. Twenty-seven knees with MPFL injury following an initial patellar dislocation were examined using axial proton-density and T2-weighted fast spin-echo MR imaging. MR findings were subsequently correlated with open exploration. MPFL injury was observed in 26 (96%) of the 27 knees. From the MR images, discontinuity, irregularity and/or high-signal intensity changes anterior to the femoral attachment were seen in 13 (82%) of the 16 knees with substantial-tear type injuries of the MPFL. In 8 (80%) of the 10 knees with avulsion-tear type injuries, detachment of the MPFL from the femoral attachment, accompanied with or without high-signal intensity changes, was confirmed. MPFL injury types could be accurately diagnosed on 21 (81%) out of 26 knees using MR imaging. MR imaging was an acceptable method in diagnosing MPFL injury types.

Acute Disease↗