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Habitual dislocation of patella is a rare disorder. Sometimes it is associated with angular deformity such as genu valgum. We experienced habitual patella dislocation associated with genu valgum that was treated with corrective osteotomy of distal femur and soft tissue realignment procedure including lateral release and medial reefing. Habitual patellar dislocation is a rare condition where the patella dislocates during flexion and relocates during extension unlike chronic patellar dislocation that occurs during both flexion and extension of the knee, and it usually presents without pain or swelling.
A variety of surgical techniques have been introduced for the treatment of habitual dislocation of the patella with genu valgum. Among them, osteotomy combined with proximal soft tissue realignment procedures including lateral release and medial reefing has been commonly performed. It has been known that significant treatment results can be obtained with combined procedures, not with a single procedure.
We here report a case of habitual dislocation of the patella with genu valgum treated with a corrective osteotomy of the distal femur combined with lateral release and medial reefing. The clinical and radiological outcomes of the treatment were satisfactory. A year-old man visited our institution due to lateral dislocation of the left knee in flexion and instability that had persisted for 7 years Fig.
The patient had a history of femoral growth plate fracture treated conservatively at 13 years of age. In the physical examination, the apprehension test was positive. In the radiographic examination, the congruence angle, sulcus angle, Q-angle, and Insall-salvati Ratio was A skyline view of the knee showed lateral dislocation of the patella.
Arthroscopic examination revealed the hypoplasia of the lateral femoral condyle, Outerbridge grade II cartilage damage on the lateral articular surface, and contracture of the lateral retinaculum and vastus lateralis.
Patellar dislocation during flexion was confirmed with arthroscopy. A lateral retinacular release and an open-wedge distal fermoral varus osteotomy were followed by additional procedures including lateral release and medial reefing because dislocation was still present after the osteotomy.
About 2 cm of the medial retinaculum was reefed because it was excessively elongated. When lateral dislocation of the patella in flexion was no longer observed, a bone graft was inserted into the osteotomy site. Gradual flexion exercises were started postoperatively. Complete flexion was obtained at the 3 rd postoperative week. Weight bearing was gradually permitted and complete weight bearing was allowed at the 3 rd postoperative month.
On the postoperative radiograph, the congruence angle, sulcus angle, Q-angle, and Insall-salvati ratio was Dislocation did not recur at 27 months after surgery. No limitation of joint motion was noted.
The apprehension test for recurrent dislocation was negative Fig. The Kujala score 1 was 96, indicating excellent clinical results. The causes of habitual patellar dislocation include contracture and fibrosis of the quadriceps femoris, vastus lateralis, and lateral retinaculum, abnormal iliotibial band attachment, repeated intramuscular injections into the thigh, patella alta due to the abnormal position of an elongated patellar tendon, systemic ligament laxity, dysplastic lateral femoral condyle, and genu valgum 2 - 4.
A variety of surgical techniques have been introduced for the treatment of habitual dislocation of the patella. However, it has been known that combined procedures, not one single procedure, should be performed to achieve relatively satisfying treatment results.
Hnevkovsky et al. In our patient, genu valgum and lateral femoral condyle hypoplasia following a growth plate fracture were thought as the cause of the dislocation. A quadricepsplasty was considered unnecessary because he had no contracture of the quadriceps femoris.
However, lateral retinacular release alone was not sufficient to achieve joint reduction. Realignment procedures can be performed additionally to reduce the joint. They are broadly classified into proximal and distal realignment procedures or bone and soft tissue realignment procedures. Proximal soft tissue realignment procedures including lateral release and medial reefing and distal realignment procedures are commonly used in adults. Proximal realignment is the most effective treatment for reduction of patellar dislocation.
However, vastus medialis advancement can cause an increase in pressure on the knee, which eventually results in patellofemoral arthritis.
Recently, medial patellofemoral ligament reconstruction using semitendinosus or gracillis tendon is recommended 5. Although the patient's medial retinaculum was extensively elongated, it was thick enough to be reefed and sutured. Therefore, a reconstruction using a medial patellofemoral ligament allograft was not considered necessary and the reduction was maintained at the follow-up examination.
Appropriate surgical treatment methods for habitual dislocation of the patella with genu valgum still remain controversial.
Gao et al. A release of quadriceps femoris contracture can be effective in correcting genu valgum in children who have hypoplasia of the lateral femoral condyle due to growth plate damage 7.
Still, the ideal age for the treatment has yet to be established. In adults, if genu valgum deformity remains after realignment due to the unstable patella, symptoms may also persist. Healy et al. Shen et al. Therefore, we thought proximal soft tissue realignment alone was not sufficient to realign the patella and performed a femoral supracondylar osteotomy in addition.
Femoral supracondylar osteotomy for genu valgum can be performed using an open or closed technique, but the latter has been associated with postoperative joint stiffness 7. Considering that the risk of joint stiffness would be high in our patient because of the complex procedures including lateral retinacular release and medial reefing, we used an open osteotomy technique and took care not to damage the joint capsule during surgery.
We believe that clinical improvement of habitual dislocation of the patella can be obtained with correction of soft tissue imbalance and contracture and realignment of the patello femoral and tibiofemoral joints. In particular, soft tissue procedures should be followed by bony procedures including femoral supracondylar osteotomy in cases of habitual dislocation of the patella with genu valgum.
Keywords : Habitual patella dislocation, Genu valgum, Distal femoral osteotomy. Other Sections Abstract Introduction Case Report Discussion Figures References Introduction Habitual patellar dislocation is a rare condition where the patella dislocates during flexion and relocates during extension unlike chronic patellar dislocation that occurs during both flexion and extension of the knee, and it usually presents without pain or swelling.
Other Sections Abstract Introduction Case Report Discussion Figures References Case Report A year-old man visited our institution due to lateral dislocation of the left knee in flexion and instability that had persisted for 7 years Fig. Other Sections Abstract Introduction Case Report Discussion Figures References Discussion The causes of habitual patellar dislocation include contracture and fibrosis of the quadriceps femoris, vastus lateralis, and lateral retinaculum, abnormal iliotibial band attachment, repeated intramuscular injections into the thigh, patella alta due to the abnormal position of an elongated patellar tendon, systemic ligament laxity, dysplastic lateral femoral condyle, and genu valgum 2 - 4.
Scoring of patellofemoral disorders. Arthroscopy, ;9; Gunn, DR. Contracture of the Quadriceps Muscle. J Bone Joint Surg Br, ;46; Williams, PF. Quadriceps contracture. J Bone Joint Surg Br, ;50; Hnevkovsky, O, Prague,, Czechoslovakia,. Progressive fibrosis of the vastus intermedius muscle in children: a cause of limited knee flexion and elevation of the patella. J Bone Joint Surg Br, ;43; Fulkerson, JP. Diagnosis and treatment of patients with patellofemoral pain.
Am J Sports Med, ;30; Surgical management of congenital and habitual dislocation of the patella. J Pediatr Orthop, ;10; Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children. J Bone Joint Surg Br, ;85; Coventry, MB.
Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg Am, ;67; Distal femoral varus osteotomy. J Bone Joint Surg Am, ;70; Combined proximal and distal realignment procedures to treat the habitual dislocation of the patella in adults. Am J Sports Med, ;35; Search for. All Rights Reserved.
Habitual dislocation of patella is a condition where the patella dislocates whenever the knee is flexed and spontaneously relocates with extension of the knee. It is also termed as obligatory dislocation as the patella dislocates completely with each flexion and extension cycle of the knee and the patient has no control over the patella dislocating as he or she moves the knee 1. It usually presents after the child starts to walk, and is often well tolerated in children, if it is not painful. However it may present in childhood with dysfunction and instability. Very little literature is available on habitual dislocation of patella as most of the studies have combined cases of recurrent dislocation with habitual dislocation.
Habitual dislocation of patella: A review
Appropriate treatment of patellar dislocation in children and adolescents remains a subject of debate. Ligamentous transfer, or patellar tendon transfer, is a technique for realigning the extensor mechanism that can be adapted to children. We analyzed the results obtained in our patients. Complementary procedures were needed in certain cases quadriceps lengthening, trochleoplasty, quadriceps release. All patients were reviewed at skeletal maturity with a mean follow-up of 7. We distinguished two groups of patients: those with major permanent or habitual dislocation of the patella and those with recurrent dislocation.
Surgical treatment of habitual dislocation of the patella in childhood
We'd like to understand how you use our websites in order to improve them. Register your interest. Medial displacement of the medial half or the medial two thirds of the patellar ligament on the proximal tibia; the detached ligament is anchored to a chiselled trough in the bone with a cancellous bone screw and serrated washer. Transfer of the vastus medialis in lateral and distal direction by approximately 1 to 1.