CASE STUDY 11

Chronic patellar dislocation in adults

What are the reasons for chronic

dislocation?

Which is the best imaging modality for

documentation?

How can we treat it?

Table CS11 Patellofemoral joint examination

Diagnostic clues Findings Diagnostic clues Findings

Pain Diffuse patellofemoral Patellar gliding Unstable with lateral patellar

joint mechanism dislocation near extension and
partial reposition with knee flexion
Tenderness Medial and lateral Patellar apprehension Severely positive to lateral
Effusion With overload Q angle Normal value
Swelling With overload Catching Lateral
Patellar position, Severe lateral Locking Sometimes between extension and
relaxed, 0 subluxation 30 flexion
Patellar position, Lateral dislocation Range of motion Decreased in flexion, painful
contracted, 0
Patellar position, Lateralization, Radiographs Dysplastic trochlea, severe patellar
30 subluxation and subluxation
patellar tilt
Patellar mobility Increased to lateral, Other Weakness
decreased to medial

Patellofemoral Disorders: Diagnosis and Treatment. Edited by Roland M. Biedert

2004 John Wiley & Sons, Ltd ISBN: 0-470-85011-6
206 CASE STUDY 11 CHRONIC PATELLAR DISLOCATION IN ADULTS

History
A 27 year-old female came to our clinic com-
plaining about chronic patellofemoral pain,
weakness and feelings of patellar instability. At
the age of 14 years, she had had a surgical lat-
eral release and purse-string sutures of the medial
retinaculum on the left knee. She was disabled in
daily life and sports activities.

Comments
The patients history already revealed the prob-
lem of patellar instability with episodes of com-
plete patellar dislocation. Complaints in both
knees in young age are suggestive of severe dys-
plastic conditions of the patellofemoral joint.

Course of action
Physical examination Figure CS11.1 Severe lateral patella subluxation (left
knee, extension, relaxed)
The physical examination of this patient revealed
identical findings on both sides. The patella
severely subluxed to the lateral side in extension
with relaxed muscles (Figure CS11.1). Contrac-
tion of the quadriceps muscle caused complete
patellar dislocation. The apprehension test was
severely positive laterally. On moving the knee
joint passively from extension to 30 of flex-
ion, the patella reduced medially on the femur.
The apprehension test was now negative and
remained negative with increased flexion. Physical
Figure CS11.2 Well-centred patellae on both sides
examination in the standing position showed nor-
(radiographs, axial views, 30 , relaxed)
mal static situation of the feet but excessive exter-
nal rotation of the proximal tibia. Accordingly,
the tibial tubercle was positioned extremely later- on both sides (Figure CS11.2). This documented
ally. Examination of the hip joint was normal. the significant difference of the patella position
between extension and 30 of flexion.

Radiographs
The anteroposterior view in extension showed
severe lateral subluxation of the patella. The lat-
eral views revealed a severe dysplastic trochlea.1 4
The axial views, performed in 30 of knee flex-
ion, showed well-centred patellae in the trochlea
Axial CT evaluation
Moderate lateral dislocation of the patella is
documented with axial CT scans in exten-
sion (Figure CS11.3).5,6 Quadriceps contrac-
tion even increases the amount of dislocation
 PLAN
Figure CS11.3 Moderate lateral patellar dislocation on
the left side (axial view, extension, relaxed)
Figure CS11.4 Severe lateral patellar dislocation on
both sides with quadriceps contraction. Note the
dysplastic trochlea (missing trochlear groove). A
neo-articulation is formed between patella and lateral
condyle (axial views, extension, contracted)
(Figure CS11.4). The trochlea is severely dysplas-
tic and the sulcus angle cannot be measured.7
Partial reposition of the patella on the trochlea
is noted in 30 of flexion (Figure CS11.5). Addi-
tional CT scans to analyse the alignment of the
lower extremity show normal femoral antetorsion
207
Figure CS11.5 Partial reduction of the patella with
flexion (axial view, 30 , relaxed), left leg
but increased external rotation of the proxi-
mal tibia of 38 on the right and 34 on the
left side.2,4,8
Special considerations
Chronic habitual patellar dislocation is a severe
problem. A long history, beginning with com-
plaints at a young age and persisting disabil-
ity, documents this problem. A severe dysplas-
tic trochlea is the underlying pathoanatomy in
most of these cases and is the target of the treat-
ment concept.
Plan
The goal of the treatment is to eliminate the
dislocation of the patella. We must consider that
a dysplastic trochlea is present, the medial soft
tissue structures are overstretched, and the lateral
structures are too tight. In addition, the patella is
partially reduced in 30 of flexion during physical
examination, when the femoral condyle moves
208 CASE STUDY 11 CHRONIC PATELLAR DISLOCATION IN ADULTS

posteriorly on the tibia and the patella runs

deeper into the trochlear groove.9 The trochlea
is dysplastic in the proximal part, but almost
normal distally. These considerations determine
the choice of the various surgical steps, which
consist of:8,10 13

Lengthening of the lateral retinacula, the

iliotibial tract and the vastus lateralis ten-
donmuscle unit.

Trochlearplasty with raising of the lateral con-
dyle.

Medialization and distalization of the tibial
tuberosity.

Doubling of the medial retinaculum and the
medial patellofemoral ligament.

(Note: In 1999, Teitge, in a handout, endorsed

these considerations and surgical steps.)
The intervention starts with a parapatellar lat-
eral incision and osteotomy of the tibial tuberos-
ity with a bone fragment of 8 1 1 cm.
The pes anserinus remains attached at the tib-
ial tuberosity. Then a lateral arthrotomy is per-
formed, separating the lateral structures into two
layers (see Case Study 3). Incomplete osteotomy
of the lateral condyle is made with a curved chisel
(see Case Study 6). The osteochondral flap is
carefully raised 56 mm, using the chisel or an
osteotome. Cancellous bone, which was taken at
the beginning of surgery from the area of the tib-
ial osteotomy, is put into the gap and carefully
impacted (see Case Studies 6 and 18). This raises
the lateral femoral condyle and forms the lateral
trochlea. The bone fragment of the tibial tuberos-
ity is moved medially and distally until the patella
glides in the centre of the newly-shaped trochlea.
It is important to control the position of the
patella in extension and flexion. Temporary fixa-
tion of the tibial tuberosity using Kirschner wires
allows precise corrections. The tibial tuberosity
is finally fixed with two or three 4.0 cancellous
screws (Figure CS11.6). The medial structures are
Figure CS11.6 Sagittal radiographs after reconstruction
shortened and doubled according to the new posi-
tion of the patella and in reference to the patellar
glide test. The lateral structures are reattached
and lengthened in 8090 of knee flexion. A dias-
tasis remains in most cases. At the end of this
individual reconstruction, the patella was 8 mm
distalized and 12 mm medialized.
The risks of this technique include breaking
of the osteochondral flap of the trochlea and
too much distalization and medialization of the
tibial tuberosity. The most difficult part is the
correct balancing of the medial and lateral soft
tissue structures.
Postoperative care and rehabilitation
Goals

To keep the patella in the trochlea.

To protect the healing of both osteotomies.

To activate all stabilizing muscle groups and
later to strengthen them.
 REFERENCES 209

Timeline

Hospital 7 days

Mobilization 2nd day

Weightbearing Partial 10 kg for 6
weeks
Complete Depends on
healing of
osteotomies
and quality
of muscle
control
Figure CS11.8 Minimal lateralization of the patella

Sports Bicycle, After 6 weeks under quadriceps muscle contraction (axial views,
swimming extension, contracted)
Everything Depends on
final result

Discussion
The case study described represents one of the
most difficult patellofemoral problems. The
underlying pathoanatomy requires different
surgical steps which must be adapted to each
other. The correct balancing of the soft tissue
structures and the amount of correction with the
osteotomies need great experience. The long-term Figure CS11.9 Well-centred left patella in flexion. Note
result of the present case was very positive at the the severe lateral subluxation of the right patella, even
in flexion (axial views, 30 , relaxed)

8 year follow-up, with correction of the left side

only (Figures CS11.7, CS11.8 and CS11.9).

Summary
Multiple corrections and reconstructions at the
same time in cases with most difficult pathologies
can improve the problem but must remain in
the hands of an experienced person to avoid
impairment.

Figure CS11.7 Well-centred patella on the left side in References

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