[Traumatic dislocations of the patella].
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The X-ray technique for the tangential visualization of the patellofemoral joint is described; 3 X-ray signs (patellofemoral angle, patellofemoral index and patellofemoral displacement) are proposed as diagnostic aids in cases of subluxation of the patella and chondromalacia patellae. Theoretically, the pathogenesis of chondromalacia patellae and patellofemoral osteoarthritis may be explained as manifestations of cartilage damage secondary to lateral patellofemoral hyperpressure and medial patellofemoral hyperpressure.
Proximal and distal reconstruction of the leg extensor mechanisms has been developed and performed in 346 cases over a period of 25 years. Proximal extensor mechanism reconstruction produces very satisfactory results in over 70% of cases and continues to be the basic principle of surgical treatment for patellar subluxation. In patients with Q angles (angle between line of the quadriceps force and the direction of the patellar tendon) greater than 10 degrees distal reconstruction (patellar tendon transfer) is done in addition to, not in lieu of, the dynamic proximal reconstruction. Treatment of the chondromalacia developing secondary to altered extensor mechanism mechanics can be by simple chondrectomy provided that the causal mechanical abnormalities are modified.
The prime indications for tibial tubercle transfer are 2 or more complete patellar dislocations with trivial trauma or recurrent subluxation with or without pain causing "giving way." A high "Q" angle, flat lateral condyle, aplastic patella or positive apprehension test may be associated but are not always prime indications in surgery. Methods of fixation are of individual preference in this series and a single screw sufficed. An arthrotomy is not always necessary but is suggested if indicated. If the proximal tibial epiphysis is open, corrective measures are suggested that do not involve the extension of the proximal tibial epiphysis into the tibial tubercle. The tubercle should be advanced to compensate for patella alta and lined up with the femoral shaft. Transplantation of the tubercle medially 3/4'' and distally 1/2'' was generally satisfactory in a series of 377 operations with an average follow up of 3 1/2 years.
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