Top

Published in:

01-12-2012 | Review Article

Modern management of patellar instability

Authors: Shin-Jae Rhee, George Pavlou, Jeremy Oakley, David Barlow, Farres Haddad

Published in: International Orthopaedics | Issue 12/2012

Abstract

Recurrent patellofemoral instability is a disabling condition, attributed to a variety of anatomical aetiologies. Trochlear dysplasia, patella alta, an increased tibial tubercle trochlear groove distance of greater than 20 mm and soft tissue abnormalities such as a torn medial patellofemoral ligament and inadequate vastus medialis obliquus are all factors to be considered. Management of this condition remains difficult and controversial and knowledge of the functional anatomy and biomechanics of the patellofemoral joint, a detailed history and clinical examination, and an accurate patient assessment are all imperative to formulate an appropriate management plan. Surgical treatment is based on the underlying anatomical pathology with an aim to restore normal patellofemoral kinematics. We summarise aspects of assessment, treatment and outcome of patellofemoral instability and propose an algorithm of treatment.

Hawkins RJ, Bell RH, Anisette G (1986) Acute patellar dislocations. Am J Sports Med 14(2):117–120PubMedCrossRef

Aglietti P, Pisaneschi A, Buzzi R, Gaudenzi A, Allegra M (1989) Arthroscopic lateral release for patellar pain or instability. Arthroscopy 5:176–183PubMedCrossRef

Chen SC, Ramanathan FB (1984) The treatment of patella instability by lateral release. J Bone J Surg (Br) 66:344–348

Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability; an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26PubMedCrossRef

Rhee SJ, Haddad FS (2008) Patellofemoral joint in total knee replacement. Curr Orthop 22(2):132–138CrossRef

Warren JF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee. An anatomical analysis. J Bone J Surg Am 61:56–62

Conlan T, Garth WPJ, Lemons JE (1993) Evaluation of the medial soft-tissue restaints of the extensor mechanism of the knee. J Bone J Surg Am 75:682–693

Desio SM, Burks RT, Bachus KN (1998) Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 26:59–65PubMed

Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM (1998) Medial soft tissue restraints in laterl patellar instability and repair. Clin Orthop 349:174–182PubMedCrossRef

10.

Moutney J, Senavongse W, Amis AA, Thomas NP (2005) Tensile strength of the medial patellofemoral ligament before an after repair or reconstruction. J Bone J Surg Br 87:36–40

11.

Steensen RN, Dopirak RM, McDonald WG (2004) The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med 32(6):1509–1513PubMedCrossRef

12.

Philipott R, Chouteau J, Wegrzyn J, Testa R, Fessy MH, Moyen B (2009) Medial patellofemoral ligament anatomy: implications for its surgical reconstruction. Knee Surg Sports Traumatol Arthrosc 17(5):475–479CrossRef

13.

Fulkerson JP, Gossling HR (1980) Anatomy of the knee joint lateral retinaculum. Clin Orthop 153:183–188PubMed

14.

Grelsamer RP, Klein JR (1998) The biomechanics of the patellofemoral joint. J Orthop Sports Phys Ther 28:286–298PubMed

15.

Tecklenburg K, Dejour D, Hoser C, Fink C (2006) Bony and cartilagenous anatomy of the patellofemoral joint. Knee Surg Sports Traumatol Arthrosc 14:235–240PubMedCrossRef

16.

Senavongse W, Amis AA (2005) The effects of articular, retinacular, or muscular deficiencies on patellofemoral joint stabiloty: a biomechanical study in vitro. J Bone J Surg 87:577–582CrossRef

17.

Wiberg G (1941) Roengenographic and anatomic studies on the femoro-patellar joint. Acta Orthop Scand 12:319–410CrossRef

18.

Brattstrom H (1964) Shape of the intercondylar groove normally and in recurrent dislocation of patella. A clinical and x-ray-anatomical investigation. Acta Orthop Scand 68(suppl 68):1–148

19.

Farahmand F, Senavongse W, Amis AA (1998) Qauntitative study of the quadriceps muscle and trochlea groove geometry related to instability of the patello femoral joint. J Orthop Res 16:136–143PubMedCrossRef

20.

Senavongse W, Farahmand F, Jones J, Anderson H, Bull AMJ, Amis AA (2003) Quantitative measurement of patellofemoral joint stability: force-displacement behaviour of the human patella in vitro. J Orthop Res 21:780–786PubMedCrossRef

21.

Escala JS, Mellado JM, Olona M, GIne J, Sauri A, Neyret P (2006) Objective patellar instability. MR-based quantitative assessment of potentially associated anatomic fecatures. Knee Surg Sports Traumatol Arthrosc 14(3):264–272PubMedCrossRef

22.

Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C (2000) Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first six months of injury. Am J Sports Med 4:472–479

23.

Fithian DC, Paxton EW, Stone ML, Davis DK, Elias DA, White LM (2004) Epidemiology and natural history of actue patellar dislocation. Am J Sports Med 32:1114–1121PubMedCrossRef

24.

Beighton PH, Solomon L, Soskolne CL (1973) Articular mobility in an African population. Ann Rheumat Dis 32:413–417PubMedCrossRef

25.

McConnell J (1986) The management of chondromalacia patellae; a long term solution. Aust J Physiother 32:215–223

26.

Beaconsfield T, Pintore E, Maffuli N, Petri GJ (1994) Radiological measurements in patellofemoral disorders. Clin Orthop Relat Res 308:18–28PubMed

27.

Minkoff J, Fein L (1989) The role of radiography in the evaluation and treatment of common arthritic disorders of the patellofemoral joint. Clin Sports Med 8:203–260PubMed

28.

Grelsamer R, Meadows S (1992) The modified Insall-Salvati ratio for assessment of patellar height. Clin Orthop Relat Res 282:170–176PubMed

29.

Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101:101–104PubMed

30.

Blackburne J, Peel T (1977) A new method of measuring patellar height. J Bone J Surg Br 59(2):241–242

31.

Caton J, Deschamps G, Chambat P, Lerat J, Dejour H (1982) Patella infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot 68(5):317–325PubMed

32.

Blumensaat C (1938) Die Lageabweichungen und Verrenkungen der Kniescheibe. Ergebnisse der Chirurgie und Orthop 228(31):149–223

33.

Merchant AC, Mercer RL, Jacobsen RH, Cool CR (1974) Roentgenographic analysis of patellofemoral congruence. J Bone J Surg Am 56:1391–1396

34.

Laurin CA, Levesque HP, Dussault R, Labelle H, Peides JP (1978) The abnormal lateral patello-femoral angle: roentgenographic sign of recurrent patellar subluxation. J Bone J Surg Am 60:55–60

35.

Shea KP, Fulkerson JP (1992) Preoperative computed tomography scanning and arthroscopy in predicting outcome after lateral retinacular release. Arthroscopy 8:327–334PubMedCrossRef

36.

Stanciu C, Labelle HB, Morin B, Fassier F, Marton D (1994) The value of computed tomography for the diagnosis of recurrent patellar subluxation in adolescents. Can J Surg 37(4):319–323PubMed

37.

Jones RB, Barlett EC, Vainright JR, Carroll RG (1995) CT determination of tibial tubercle lateralisation in patients presenting with anterior knee pain. Skeletal Radiol 24:505–509PubMedCrossRef

38.

Biedert RM, Netzer P, Gal I, Sigg A, Tscholl PM (2011) The lateral condyle index: a new index for assessing the length of the lateral articular trochlea as predisposing factor for patellar instability. Int Orthop 35(9):1327–1331PubMedCrossRef

39.

Mulford JS, Wakeley CJ, Eldridge JD (2007) Assessment and management of chronic patellofemoral disorders. J Bone J Surg Br 89:709–716CrossRef

40.

Sallay PI, Poggi J, Speer KP, Garrett WE (1996) Acute dislocation of the patella: A correlative pathoanatomic study. Am J Sports Med 24:52–60PubMedCrossRef

41.

Thawait SK, Soldatos T, Thawait G, Cosgarea AJ, Carrino JA, Chhabra A (2012) High resolution magnetic resonance imaging of the patellar retinaculum: normal anatomy, common in jury patterns, and pathologies. Skeletal Radiol 41(2):137–148PubMedCrossRef

42.

Barnett AJ, Gardner RO, Lankester BK, Wakeley CJ, Eldridge JD (2007) Magnetic resonance imaging of the patellar; a comparison of the morphology of the patella in normal and dysplastic knees. J Bone J Surg Br 89:761–765CrossRef

43.

Van Huyssteen AL, Hendrix MR, Barnett AJ, Wakeley CJ, Eldridge JD (2006) Cartilage-bone mismatch in the dysplastic trochlea: an MRI study. J Bone J Surg Br 88:688–691CrossRef

44.

Maenpaa H, Lehto MU (1997) Patellar dislocation. The long term results of nonoperative management in 100 patients. Am J Sports Med 25:213–217PubMedCrossRef

45.

Muhle C, Brinkmann G, Skaf A, Heller M, Resnick D (1999) Effect of a patellar realignment brace on patients with patellar subluxation and dislocation. Evaluation with kinematic magnetic resonance imaging. Am J Sports Med 27:350–353PubMed

46.

Shellock FG (2000) Effect of patella-stabilising brace on lateral subluxation of the patella: assessment using kinematic MRI. Am J Knee Surg 13:137–142PubMed

47.

Shellock FG, Mink JH, Deutsch AL, Fox J, Molnar T, Kvitne R, Ferkel R (1994) Effect of a patellar realignment brace on patellofemoral relationships: evaluation with kinematic MR imaging. J Magn Reson Imaging 4:590–594PubMedCrossRef

48.

Gilleard W, McConnell J, Parsons D (1998) The effect of patellar taping on the onset of vastus medialis obliquus and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther 78(25–32)

49.

McConnell J (2007) Rehabilitation and nonoperative treatment of patellar instability. Sports Med Arthrosc Rev 15:95–104CrossRef

50.

Fithian DC, Paxton EW, Cohen AB (2004) Indication in the treatment of patelar instability. J Knee Surg 17:47–56PubMed

51.

Krompinger WJ, Fulkerson JP (1983) Lateral retinacular release for intractable lateral retinacular pain. Clin Orthop 179:183–188

52.

Schonholtz GJ, Zahn MG, Magee CM (1987) Lateral retinacular release of the patella. Arthroscopy 3:269–272PubMedCrossRef

53.

Aglietti P, Pisaneschi A, BIase P De (1992) Recurrent dislocation of patella: three kinds of surgical treatment. Ital J Orthop Traumatol 18:25–36PubMed

54.

Latterman C, Toth J, Bach BR (2007) The role of lateral retinacular release in the treatment of patellar instability. Sports Med Arthrosc Rev 12:57–60CrossRef

55.

Arendt EA, Fithian DC, Cohen E (2002) Current concepts of lateral patella dislocation. Clin Sports Med 21(3):499–519PubMedCrossRef

56.

Ricchetti ET, Mehta S, Sennett BJ, Huffman GR (2007) Comparison of lateral release versus lateral release with medial soft-tissue realignment for the treatment of recurrent patellar instability: a systematic review. Arthroscopy 23:463–468PubMedCrossRef

57.

Haspl M, Cicak N, Klobucar H, Pecina M (2002) Fully arthroscopic stabilisation of the patella. Arthroscopy 18(1):E2PubMedCrossRef

58.

Nam EK, Karzel R (2005) Mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation: a medium term follow-up. Am J Sports Med 33:220–230PubMedCrossRef

59.

Small NC, Glogau AI, Berezin MA (1993) Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy 9:63–67PubMedCrossRef

60.

Coons DA, Barber FA (2006) Thermal medial retinaculum shrinkage and lateral release for the treatment of recurrent patellar instability. Arthroscopy 22:166–171PubMedCrossRef

61.

Fukushima K, Horaguchi T, Okano T, Yoshimatsu T, Saito A, Ryu J (2004) Patellar dislocation: arthroscopic patellar stabilisation with anchor sutures. Arthroscopy 20:761–764PubMed

62.

Halbrecht JL (2001) Arthroscopic patella realignment: An all-inside technique. Arthroscopy 17:940–945PubMedCrossRef

63.

Miller JR, Adamson GJ, Pink MM, Fraipont MJ, Durand P (2007) Arthroscopically assisted medial reefing without routine lateral release for patellar instability. Am J Sports Med 35(622–29)

64.

Nomura E, Inoue M (2006) Hybrid medial patellofemoral ligament reconstruction using the semitendinosus tendon for recurrent patellar dislocation: minimum 3 years follow-up. Arthroscopy 22:787–793PubMedCrossRef

65.

Ahmad CS, Brown GD, Stein BS (2009) The docking technique for medial patellofemoral ligament reconstruction. Am J Sports Med 37(10):2021–2027PubMedCrossRef

66.

Ellera Gomes JR, Stigler Marczyk LR, Cesar de Cesar P, Jungblut CF (2004) Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability. Arthroscopy 20(2):147–151PubMedCrossRef

67.

Schottle P, Fucentese SF, Romero J (2005) Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 13(7):516–521PubMedCrossRef

68.

Thaunat M, Erasmus PJ (2007) The favourable anisometry: an original concept for medial patellofemoral ligament reconstruction. Knee 14(6):424–428PubMedCrossRef

69.

Christiansen SE, Jakobsen BW, Lund B, Lind M (2008) Isolated repair of the medial patellofemoral ligament in primary dislocation of the patella: a prospective randomized study. Arthroscopy 24(8):881–887PubMedCrossRef

70.

Steensen RN, Dopirak RM, Maurus PB (2005) A simple technique for reconstruction of the medial patellofemoral ligament using quadriceps tendon graft. Arthroscopy 21:365–370PubMedCrossRef

71.

Sillanpaa P, Mattila VM, Visuri T, Maenpaa H, Pihlajamaki H (2008) Ligament reconstruction versus distal realignment for patellar dislocation. Clin Orthop Relat Res 466(6):1475–1484PubMedCrossRef

72.

Steiner TM, Torga-Spak R, Teitge RA (2006) Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlea dysplasia. Am J Sports Med 34:1254–1261PubMedCrossRef

73.

Gomes JE (2008) Comparison between a static and a dynamic technique for medial patellofemoral ligament reconstruction. Arthroscopy 24(4):430–435PubMedCrossRef

74.

Nomura E, Inoue M, Kobayashi S (2007) Long-term follow-up and knee osteoarthritis change after medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 35(11):1851–1858PubMedCrossRef

75.

Nomura E, Horiuchi Y, Kihara M (2000) Medial patellofemoral ligament restraint in lateral patellar translation and reconstruction. Knee 7:121–127PubMedCrossRef

76.

Carmont MR, Mafulli N (2007) Medial patellofemoral ligament reconstruction: a new technique. BMC Musculoskelet Disord 8:22–30PubMedCrossRef

77.

LeGrand AB, Greis PE, Dobbs RE, Burks RT (2007) MPFL reconstruction. Sports Med Arthrosc Rev 15:72–77CrossRef

78.

Deie M, Ochi M, Adachi N, Shibuya H, Nakamae A (2011) Medial patellofemoral ligament reconstruction fixed with a cylindrical bone plug and a grafted semitendinosus tendon at the original femoral site for recurrent patellar dislocation. Am J Sport Med 39(1):140–145CrossRef

79.

Deie M, Ochi M, Shumen Y, Adachi N, Kobayashi K, Yasumoto M (2005) A long term follow-up study after medial patellofemoral ligament reconstruction using the transferred semitendinosus tendon for patellar instability. Knee Surg Sports Traumatol Arthrosc 13:522–528PubMedCrossRef

80.

Fernandez E, Sala D, Castejon M (2005) Reconstruction of the medial patellofemoral ligament for patellar instability using semitendinosus autograft. Acta Orthop Belg 71(303–08)

81.

Gomes JLE, Marczyk LRS, CdC P, Jungblut CF (2004) Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-ip study. Arthroscopy 20:147–151CrossRef

82.

Trillat A, Dejour H, Couette A (1964) Diagnostic et traitement des subluxations recidevantes de la rotule. Rev Chir Orthop 50:813–824PubMed

83.

Barber FA, McGarry JE (2008) Elmslie-Trillat procedure for the treatment of recurrent instability. Arthroscopy 24(1):77–81PubMedCrossRef

84.

Carney JR, Mologne TS, Muldoon M, Cox JS (2005) Long term evaluation of the Roux-Elmslie-Trillaat procedure for patellar instability: a 26 year follow up. Am J Sport Med 33:1220–1223CrossRef

85.

Cox JS (1982) Evaluation of the Roux-Elmslie-Trillat procedure for knee extensor realignment. Am J Sports Med 10:303–310PubMedCrossRef

86.

Kumar A, Jones S, Bickerstaff DR, Smith TWD (2001) Functional evaluation of the modified Elmslie-Trillat procedure for patellofemoral dysfunction. Knee 8:287–292PubMedCrossRef

87.

Wang CJ, Chan HH, Chen HH, Wu ST (2005) Factors affecting the outcome of distal realignment for patellofemoral disorders of the knee. Knee 12:195–200PubMedCrossRef

88.

Dannawi Z, Khanduja V, Palmer CR, El-Zebdeh M (2010) Evaluation of the modified Elmslie-Trillat procedure for patellofemoral dysfunction. Orthop 33(1):13CrossRef

89.

Kartaglis D, Green MA, Learmonth DJA (2006) Functional outcome following modified Elmslie-Trillat procedure. Knee 13:464–468CrossRef

90.

Nagawa K, Wada K, Minamide M, Tsuchiya A, Moriya H (2002) Deterioration of long term results after Elmslie-Trillat procedures for dislocation of the patella. J Bone J Surg Br 84:861–864CrossRef

91.

Arnbjornsson A, Egund N, Rydling O, Stockerup R, Ryd L (1992) The natural history of recurrent dislocation of the patella: long-term results of conservative and operative treatment. J Bone J Surg Br 74(140–2)

92.

Lancourt JE, Cristinin JA (1975) Patella alta and patella infera: their etiological role in patellar dislocation, chondromalacia, and apophysitis of the tibial tubercle. J Bone J Surg 57:1112–1115

93.

Simmons EJ, Cameron JC (1992) Patella alta and recurrent dislocation of the patella. Clin Orthop 274:265–269PubMed

94.

Caton JH, Dejour D (2010) Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop 34(2):305–309PubMedCrossRef

95.

Servien E, Verdonk PC, Neyret P (2007) Tibil tuberosity trsnafer for episodic patellar dislocation. Sports Med Arthosc Rev 15:61–67CrossRef

96.

Steinhauser J (1978) Midification of the operative technics for the ventralisation of the tuberositas tibiae (Maquet-Bandi). Z Orthop Ihre Grenzgeb 116(1):126–129PubMed

97.

Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA (1990) Anteromedial tibial transfer without bone graft. Am J Sports Med 18:490–496PubMedCrossRef

98.

Buuck DA, Fulkerson JP (2000) Anteromedialisation of the tibial tubercle: a 4 to 12 year follow-up. Op Tech Sports Med 8:131–137CrossRef

99.

Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, HUrme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9(2):159–163PubMedCrossRef

100.

Tsuda E, Ishibashi Y, Yamamoto Y, Maeda S (2011) Incidence and radiologic predictor of postoperative patellar instability after Fulkerson procedure of the tibial tiberosity for recurrent patellar instability. Knee Surg Traumatol Arthrosc Dec (Epub (ahead of print))

101.

Fulkerson JP (1999) Fractures of the proximal tibia after Fulkerson anteromedial tibial tubercle transfer. A report of four cases. Am J Sports Med 27:265PubMed

102.

Amis AA, Oguz C, Bull AMJ, Senavongse W, Dejour D (2008) The effect of trochleoplasty on patellar stability and kinematics. A biomechanical study in vitro. J Bone J Surg 90(7):864–869CrossRef

103.

Goutallier D, Raou D, Van Driessche S (2002) Retro-trochlea wedge reduction trochleoplasty for the treatment of painful patella syndrome with protruding trochleae. Technical note and eraly results. Rev Chir Orthop Reparatrice Appar Mot 88(7):678–685PubMed

104.

Dejour D, Saggin P (2010) The sulcus deepening trochleoplasty. The Lyon’s procedure. Int Orthop 34(2):311–316PubMedCrossRef

105.

Verdonk R, Jansegers E, Stuyts B (2005) Trochleoplasty in dysplastic knee trochlea. Knee Surg Sports Traumatol Arthrosc 13:529–533PubMedCrossRef

106.

Bollier M, Fulkerson JP (2011) The role of trochlear dysplasia in patellofemoral instability. J Am Ac Orthop Surg 19(1):8–16

107.

von Knoch F, Bohm T, Burgi ML, von Knoch M, Bereiter H (2006) Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia. A 4-14- year follow-up study. J Bone J Surg Br 88(10):1331–1335CrossRef

108.

Morscher E (1978) Osteotomy of the patella in chondormalacia. Preliminary report. Arch Orthop Trauma Surg 92(2–3):139–147PubMedCrossRef

109.

Hejgaard N, Arnoldi CC (1984) Osteotomy of the patella in the patellofemoral pain syndrome. The significance of increased intraosseous pressure during sustained knee flexion. Int Orthop 8(3):189–194PubMedCrossRef

110.

Pecina M, Iykovic A, Hudetz D, Smoljanovic T, Jankovic S (2010) Sagittal osteotomy of the patella after Morscher. Int Orthop 34(2):297–303PubMedCrossRef

Title: Modern management of patellar instability
Authors: Shin-Jae Rhee
George Pavlou
Jeremy Oakley
David Barlow
Farres Haddad
Publication date: 01-12-2012
Publisher: Springer-Verlag
Published in: International Orthopaedics / Issue 12/2012
Print ISSN: 0341-2695
Electronic ISSN: 1432-5195
DOI: https://doi.org/10.1007/s00264-012-1669-4

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Modern management of patellar instability

Abstract

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 12/2012

Are we evaluating osteonecrosis adequately?

Biomechanical concept and clinical outcome of dual mobility cups

What is the risk of stress risers for interprosthetic fractures of the femur? A biomechanical analysis

Arthroscopic radial head excision in managing elbow trauma

Acetabular fracture types vary with different acetabular version

The effects of autologous bone marrow mesenchymal stem cell arterial perfusion on vascular repair and angiogenesis in osteonecrosis of the femoral head in dogs