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. Many different surgical techniques have been described in the literature for the treatment of habitual dislocation of patella.
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Habitual dislocation of the patella HDP is a common presentation in pediatric age unlike adults. Many surgical procedures using proximal realignment and distal realignment have been reported to treat HDP in children with satisfactory results. However, late presentation of habitual patellar dislocation with osteoarthritis is rare and treatment plan has not yet been established. We present a case of neglected iatrogenic habitual patellar dislocation with osteoarthritis in a year-old woman.
Two-staged procedure was planned, first with patellar realignment and later with definitive total knee arthroplasty. Quadricepsplasty, medial patello-femoral ligament reconstruction, lateral release and tibial tuberosity transfer was done as primary procedure and total knee arthroplasty, which was planned as secondary procedure, was deferred as the patient improved functionally. Habitual dislocation of the patella is a rare condition among adults, where the patella dislocates during flexion and relocates during extension without pain and swelling unlike the recurrent patellar dislocation.
Various surgical techniques have been reported to treat pediatric population. These techniques are all designed to relocate the patella and regain alignment of the extensor mechanism.
The etiology of patellar instability is multifactorial. Determination of the factors permits an effective elective treatment plan and it has been known that satisfactory or significant treatment results can be obtained with combined procedures,[ 6 ] not with a single procedure. We report a case of iatrogenic habitual dislocation of patella with osteoarthritis of left knee in a year-old female patient, who was treated with lateral release quadricepsplasty, medial patello femoral ligament MPFL reconstruction and tibial tuberosity transfer.
A year-old woman presented with iatrogenic habitual dislocation of left patella from childhood and pain from past 3 years. She recalled a childhood surgery over middle third of left thigh incision and drainage.
Few years after the surgery, she started noticing the giving way of patella and lived for 38 years without much disability. She was carrying out her daily activities without much pain or symptoms, but she was never symptom free during this period. Physical examination did not reveal general joint laxity or malalignment of the lower extremity.
There was a healed surgical scar over middle and lower third lateral aspect of the left thigh. Although the patella was in the femoral trochlear groove in extension, it dislocated laterally with 25 degrees of knee flexion. She complained slight discomfort by an apprehension test, but was not very painful even when dislocated.
The passive lateral patellar tilt test was negative since the soft tissue attachment to the lateral border of the patella was diffusely stiff and tight. Radiological examination revealed evidence of patella alta as defined by Insall and Salvati,[ 7 ] and Q angle was 18 degrees.
Clinically and radiologically Grade III Kellgren and Lawrence classification[ 8 ] tricompartmental degenerative knee arthritis was appreciated [ Figure 1 ]. Preoperative Kujala score[ 9 ] was Preoperative radiographs anteroposterior a and lateral view b of left knee joint showing degenerative changes.
With patient in supine position under epidural anesthesia, an anterior midline knee incision was used with paramedian arthrotomy. The lateral retinaculum was thickened while the medial retinaculum was thinned.
The lateral tether is released by dividing the fibrous adhesions, which extended along the lateral intermuscular septum. The lateral patellar retinaculum and the synovium were divided and vastus lateralis was detached from the quadriceps tendon, leaving a rim of tendon for suturing. Due to shortening of the extensor mechanism, the patella could not be reduced. Quadriceps tendon was lengthened using V Y plasty at aponeurotic junction. Tracking was augmented with MPFL reconstruction using semi-tendinosus tendon and patellar end was fixed with 2.
Patellar maltracking was persistent and so, it was decided to proceed with medial and distal transfer of tibial tuberosity. Knee mobilization and full weight bearing was started after four weeks. Initially patient had extensor lag of 15 degrees as she was immobilized in flexion.
But after vigorous quadriceps exercises, patient improved without any extensor lag. At final followup two years postoperatively, the patient was pain-free.
There was no evidence of patellar maltracking or instability on detailed physical examination. Radiographs showed well reduced patella in both lateral, anteroposterior view and skyline view [ Figure 2 ]. Quadriceps strength was rated 4 MRC grade. Postoperative radiographs anteroposterior a and lateral views b of left knee showing tibial tuberosity transfer fixed with screws and 2.
Clinical photographs showing functional outcome a walking down the stairs b sitting cross legged. Clinical photographs showing range of motion a Flexion of 90 degrees and b extension at left knee postoperatively. Habitual or recurrent dislocation of the patella is common in children unlike adults.
Predisposing factors include ligamentous laxity, contracture of the lateral patellar soft tissues, patella alta, quadriceps contractures, hypoplasia of the lateral femoral condyle and genu valgum bony factors. Permanent patellar dislocation, either congenital or acquired, is diagnosed at an early age in childhood and numerous surgical techniques have been introduced for its treatment.
This is not the same for adult patellar dislocation with arthritis, where no specific treatment protocols are established. However, it has been known that combined procedures, not one single procedure, should be performed to achieve relatively satisfying treatment results.
In our case, the patient was a year-old female with moderate degeneration and an active lifestyle. Hence, TKR was an option and we had decided to go for staged procedures - initially getting the normal patellar tracking and later TKR. When patellar realignment is selected for habitual dislocation of the patella with quadriceps contracture in adults, the gold standard of management has not yet been established. Proximal realignment includes lateral release, reconstruction of the MPFL and quadriceps plasty.
Successful results require combination of these procedures, depending on clinical and intraoperative findings on an individual basis. Habitual dislocation is associated with shortening of the quadriceps muscles and considering that lengthening of the tendon is an essential part of the procedure to allow the patella to remain reduced after realignment. Medial vector augmentation and patellar tendon alignment procedures should be included depending on the degree of quadriceps dysfunction.
Once the knee joint flexion starts, patella tends to dislocate laterally. To prevent this, always lateral release is combined with medial augmentation. In our case, we have done medial patello-femoral ligament reconstruction using semi-tendinosus tendon. The diagnostic relevance of Q angle as an indication for distal realignment was not established in our case and we recommend tibial tuberosity-trochlear groove distance TTTG as measured by CT scan as a better tool.
Contradictory reports are present in the relevant literature. Marmor was the first to perform TKA in an adult patient with congenital dislocation of the patella without reconstructing the extensor mechanism.
He reported replacement of the patella be avoided in adult patients with congenital dislocation of the patella if they can function reasonably well. Unconstrained TKA with extensive soft tissue release in the right knee failed after 14 months. The failed TKA was revised by using constrained-type prosthesis. Total knee arthroplasty in middle-aged patient with habitual dislocation is not a permanent solution.
Though the initial plan was to subject the patient for total knee replacement after soft tissue surgery, the procedure was deferred as there was significant improvement in function kujala score after the soft tissue surgery and the patient herself denied the second procedure.
We believe that the soft tissue surgery as primary procedure will buy additional time for patient to delay the TKA and proper soft tissue balancing will improve the longevity and clinical outcome of the definitive procedures.
Source of Support: Nil. Conflict of Interest: None. National Center for Biotechnology Information , U. Journal List Indian J Orthop v. Indian J Orthop. Raghuveer K Reddy and Vamsi Kondreddi 1. Author information Copyright and License information Disclaimer.
Address for correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Habitual dislocation of the patella HDP is a common presentation in pediatric age unlike adults. Keywords: Habitual dislocation of patella, lateral release, medial patello-femoral ligament, reconstruction, quadricepsplasty, tibial tuberosity transfer.
Open in a separate window. Figure 1. Operative procedure With patient in supine position under epidural anesthesia, an anterior midline knee incision was used with paramedian arthrotomy. Figure 2. Figure 3. Figure 4. Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children. J Bone Joint Surg Br. Surgical management of congenital and habitual dislocation of the patella. J Pediatr Orthop. Treatment of chronic patellar dislocation with a modified Elmslie-Trillat procedure.
Arch Orthop Trauma Surg. Raghuveerreddy K, Somasekharreddy N. Total knee arthroplasty for gonarthrosis with patellar dislocation. J Orthop Sci. Combined proximal and distal realignment procedures to treat the habitual dislocation of the patella in adults. Am J Sports Med. Insall J, Salvati E. Patella position in the normal knee joint.
Treatment of habitual dislocation of patella in an adult arthritic knee
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. This is a preview of subscription content, log in to check access. Blauth, W.
Surgical treatment of habitual dislocation of the patella in childhood
Habitual dislocation of patella: A review
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.