Chapter 9:Patellar Subluxation

REFERENCES

  1. Larsen E, Lund PM. Ruptures of the extensor mechanism of the knee joint. Clinical results and patellofemoral articulation. Clin Orthop 1986;213:150‑153.
  2. Kujala UM, Friberg 0, Aalto T, Kvist M, Osterman K. Lower limb asymmetry and patellofemoral joint incongruence in the etiology of knee exertion injuries in athletes. Int J Sports Med 1987;8: 214‑220.
  3. Trillat A, Dejour H, Coutette A. Diagnostic et traitement des subluxations recidivantes de la rotule. Rev Chir Orthop 1964;50:813‑824.
  4. Fulkerson J. Patellofemoral pain disorders. J Am Acad Orthop Surg 1994;2(2):124‑132.
  5. Merle D'Aubigne R, Ramadier JO. La subluxation de la rotule dans l'arthrose du genou. Rev Chir Orthop 1959;45:437‑153.
  6. Goldthwait JE. Slipping or recurrent dislocation of the patella: With the report of eleven cases. Boston Med Surg J 1904;150:169‑174.
  7. MacNab I. Recurrent dislocation of the patella. J Bone Joint Surg 1952;34A:957.
  8. Hughston JC. Subluxation of the patella. J Bone Joint Surg 1968;50A:1003‑1026.
  9. Bennett W, Doherty N, Hollisey M, Fulkerson J. Insertion orientation of terminal vastus lateralis obliquus and vastus medialis obliquus muscle fibers in human knees. Clin Anat 1993;6:129‑134.
  10. MeIvor JB, Gillespie R. Patellar instability in juvenile amputees. J Pediatr Orthop 1987;7: 553‑556.
  11. Casscells SW. Gross pathological changes in the knee joint of the aged individual. A study of 300 cases. J Bone Joint Surg 1975;57A:1003.
  12. Fulkerson J, Tennant R, Jaivin J, Grunnet M. Histologic evidence of retinacular nerve injury associated with patellofemoral malalignment. Clin Orthop 1985;197:196‑205.
  13. Fulkerson J. Evaluation of the peripatellar soft tissues and retinaculum in patients with patellofemoral pain. Clin Sports Med 1989;8:197‑202.
  14. Ficat P. Pathologie Femoro‑Patellaire. Paris: Masson et Cie; 1970.
  15. Hughston J, Deese M. Medial subluxation of the patella as a complication of lateral retinacular release. Am J Sports Med 1988;16:383‑388.
  16. Fox J, Del Pizzo W. The Patellofemoral Joint. New York: McGraw Hill; 1993.
  17. Fulkerson JP, Wright J, Legeyt M, Cautilli RA Jr. Precise criteria of normal and abnormal patellofemoral joint alignment using three dimensional computerized tomography. Orthopedic transactions. J Bone Joint Surg 1993‑1994;17(4):1062.
  18. DuPont JY. Presentation d'Une Forme Rare de Subluxation Rotulienne. J Traumatol Sport 1996;12: 77‑89.
  19. Henry J. Conservative treatment of patellofemoral subluxation. Clin Sports Med 1989;8: 261‑278.
  20. Cotta H. Zur Therapie der Habitullen Pattellaren Luxation. Arch Orthop Unfallchir 1959;51: 256‑271.
  21. Wilbur MD. Recurrent lateral dislocation of the patella: Preliminary results of pes anserinus transfer. South Med J 1974;67:531.
  22. Fulkerson J, Schutzer S, Ramsby G, Bernstein R. Computerized tomography of the patellofemoral joint before and after lateral release or realignment. Arthroscopy 1987;3:19‑24.
  23. Schonholtz G. Lateral retinacular release of the patella. Arthroscopy 1987;3:269‑272.
  24. Brief LP. Lateral patellar instability: Treatment with a combined open‑arthroscopic approach. Arthroscopy 1993;9(6):617‑623.
  25. Post WR, Fulkerson J, Shea K. A cadaver model of patellofemoral realignment. J Bone Joint Surg 1994;8(3):742.
  26. Insall J, Falvo KA, Wise DW. Chondromalacia patellae. J Bone Joint Surg 1976;58A:1‑8.
  27. Bonvallet JM. Resultats de la reflection a la peau de l'aileron rotulien interne dans les luxations recidivantes de la rotule. Chirurgie 1973;99:124‑128.
  28. Hauser EW. Total tendon transplant for slipping patella. Surg Gynecol Obstet 1938;66:199.
  29. Heywood AWB. Recurrent dislocation of the patella. J Bone Joint Surg 1961;43B:507‑517.
  30. Baker RH, Carroll N, Dewar P, Hall JE. Semitendinosus tenodesis for recurrent dislocation of the patella. J Bone Joint Surg 1972;54B:103‑109.
  31. Krogius A. Zur operativen behandlung der habituellen luxation der kniescheibe. Zentralbl Chir 1904;31:254.
  32. Benoist JP, Ramadier JO. Luxations et subluxations de la rotule. Rev Chir Orthop 1969;55: 89‑109.
  33. West FE, Soto‑Hall R. Recurrent dislocation of the patella in the adult. J Bone Joint Surg 1958;40A:386‑393.
  34. Kelly M, Insall J. Patellectomy. Orthop Clin North Am 1986;17(2):289‑295.
  35. Roux, D. Luxation Habituelle de la Rotule. Rev Chir Paris 1888;8:682‑689.
  36. Barbari S, Raugstad TS, Lichtenberg N, Refvem D. The Hauser operation for patellar dislocation. 3‑32‑year results in 63 knees. Acta Orthop Scand 1990;61:32‑35.
  37. Hehne HJ. Biomechanics of the patellofemoral joint. Clin Orthop 1990;258:73‑85.
  38. Loff P, Friedebold G. Die habituelle patellarluxation als präarthrotische deformität. Ergeb Chir 1969;52:60.
  39. Crosby EB, Insall J. Recurrent dislocation of the patella. J Bone Joint Surg 1976;58A:9‑13.
  40. Juliusson R, Markhede G. A modified Hauser procedure for recurrent dislocation of the patella. A long‑term follow‑up study with special reference to osteoarthritis. Arch Orthop Trauma Surg 1984;103:42‑46.
  41. Goutallier D, Debeyre J. Le recentrage rotulien dans les arthroses femoro‑patellaires lateralisees. Rev Chir Orthop 1974;60:377‑386.
  42. Henry J, Craven P. Surgical treatment of patellar instability. Am J Sports Med 1981;9:82‑84.
  43. Southwick W, Becker G, Albright J. Dovetail patellar tendon transfer for recurrent dislocating patella. JAMA 1968;204:665.
  44. Fulkerson JP. Operative management of patellofemoral pain. Ann Chir Gynaecol 1991;80(2): 224‑229.
  45. Post W, Fulkerson J. Distal realignment of the patellofemoral joint. Orthop Clin North Am 1992;23:631‑643.
  46. Cautilli R, Fulkerson J. Operative treatment of patellofemoral disorders. Distal realignment. Sports Med Arthr Rev 1994;2:250‑262.
  47. Henry JH, Goletz TH, Williamson B. Lateral retinacular release in patellofemoral subluxation. Indications, results, and comparison to open patellofemoral reconstruction. Am J Sports Med 1986;14:121‑129.
  48. Cox JS. Evaluation of the Roux‑Elmslie‑Trillat procedure for knee extensor realignment. Am J Sports Med 1982;10:303‑310.
  49. Fulkerson J. Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop 1983;177:129‑133.
  50. Shelbourne D, Porter D, Rozzi W. Use of a modified Elmslie‑Trillat procedure to improve abnormal patellar congruence angle. Am J Sports Med 1994;2:318‑323.
  51. Wootton JR, Cross MJ, Wood DG. Patellofemoral malalignment: A report of 68 cases treated by proximal and distal patellofemoral reconstruction. Injury 1990;21(3):169‑173.

Figure 9.1. This patient demonstrates bilateral subluxation and tilt. Although there is no sign of arthrosis here, this combination usually leads to patellar articular cartilage degeneration.

Figure 9.2. This patient had long‑standing permanent patellar subluxation and tilt after medial arthrotomy. This led eventually to lateral facet arthrosis. Anteromedial tibial tubercle transfer gave excellent relief to the patient by transferring most articular contact load onto the intact medial facet.

Figure 9.3. Despite substantial patellar subluxation throughout knee flexion and extension, some patients have remarkably little pain or evidence of arthrosis.

Figure 9.4. Anteroposterior view of the knee in a 58year‑old obese woman with genu valgum, severe lateral compartment arthrosis, and permanent lateral patella subluxation.

Figure 9.5. A and B, Patient with bilateral subluxation.

Figure 9.6. Patellar subluxation may occur without any evidence of articular cartilage damage in some patients.

Figure 9.7. Chronic lateral patellar subluxation will lead to dysplastic changes, which usually include elongation and deterioration of the lateral facet, distal medial and central cartilage degeneration, lateral subchondral sclerosis, and flattening of the lateral trochlea.

Figure 9.8. Alpine hunter's cap dysplasia associated with a very shallow trochlear sulcus in a patient with recurrent dislocation of the patella.

Figure 9.9. A, The 30‑degree axial view shows mild subluxation. B, Further flexion leads to perfect centering.

Figure 9.10. A, Axial views of a patient complaining only of right knee instability show marked subluxation on 30‑degree view only of both patellae. Perfect recentering is evident on the 60‑ and 90‑degree flexion views, which underscores the need for obtaining radiograms or computerized tomography with knee flexion of 20 to 30 degrees. B, Computerized tomographic view of subluxation without tilt.

Figure 9.11. Mild tilt and subluxation at 20 de­grees of knee flexion. Often, subluxation improves with further flexion, but tilt may either improve or worsen.

Figure 9.12. At 30 degrees of knee flexion (A), the patella is lateral, but on further flexion (B and C), the patella centralizes.

Figure 9.13. Medial retinacular calcification in a patient who, by history, has never had a dislocation. The history, however, was compatible with recurrent subluxation.

Figure 9.14. Several popular methods of extensor mechanism equilibration. Reprinted with permission from Ficat P. Pathologie Femoro‑Patellaire. Paris: Masson et Cie; 1970.

Figure 9.15. The Galliazzi semitendinosus tenodesis provides medial support for major or permanent patellar subluxation in the skeletally immature patient. Reprinted with permission from Baker RH, Carroll N, Dewar P Hall JE. Semitendinosus tenodesis for recurrent dislocation of the patella. J Bone Joint Surg 1972;548:103‑109.

Figure 9.16. Procedures that transfer the tibial tubercle in a medial direction down the medial slope of the tibia are rarely, if ever, indicated. Reprinted with permission from Cox JS. Evaluation of the Roux‑Elmslie‑Trillat procedure for knee extensor realignment. Am J Sports Med 1982;10:303.

Figure 9.17. A, Transection through the tibia at the level of the tibial tubercle, with the tibial plateau superimposed for orientation. O = axis of knee flexion; R = extensor lever arm. B, Lateral view of extensor mechanism and the knee. M1, M2 = quadriceps vectors (see Chapter 2). C, Transected view of proximal tibia showing detrimental effect of tibial tubercle medialization using such methods.

Figure 9.18. Method of medial tibial tubercle transfer fashioned after the method of Elmslie and modified by Goutallier and Debeyre (41). This minimizes diminution of the extensor lever arm.

Figure 9.19. Creating an oblique osteotomy deep to the tibial tubercle will permit anterior as well as medial tibial tubercle displacement. One must beware of the anterior tibial artery and the deep peroneal nerve at the posterolateral corner of the osteotomy.

        

Inside Chapter 9: