Habitual Dislocation Patellaa surgical case summary

Vinod NaneriaGirish Yeotikar

Arjun WadhwaniChoithram Hospital & Research Centre, Indore, India

Types of Dislocations

• Habitual dislocation of the patella in flexion implies that dislocation occurs every time the knee is flexed. The displacement is painless.

• Recurrent dislocation which occurs as isolated episodes, often in response to trauma and is accompanied by pain and followed by swelling.

• Congenital dislocation refers to an irreducible dislocation present since birth and associated with a lateral position of the entire quadriceps mechanism.

The distinction between these groups is important as the surgical treatment for each is quite different.Operations for habitual dislocation of the patella always requires releases proximal to the patella.Operations for recurrent dislocation usually involve procedures distal to the patella.

Persistent & Obligatory

• Persistent Dislocation

• Patella is dislocated lateral and persistent in that location.

• Often obvious in infency• Usually associated with

other anomalies• Knee flexion contracture

present.• Functional disability.

• Obligatory Dislocation

• Patella dislocates and reduces spontaneously with flexion and extension of knee

• Usually present at 5 to 10 years of age

• Usually isolated anomaly• ROM usually normal

optimize quadriceps alignment.

Pathology

Cause - Effect

Surgical management of congenital and habitual dislocation of the patella.Gao GX, Lee EH, Bose K.congenital dislocation patella (CDP) and habitual dislocation patella (HDP) followed for 2-15 years after surgical stabilization of the patella.

The underlying pathology in both conditions was contracture of the quadriceps mechanism, which was more severe in CDP. Surgical stabilization included an extensive lateral release, medial plication, and transfer of the lateral half of the patella tendon. Lengthening of the rectus femoris tendon. With appropriate operative procedures, satisfactory results were achieved in 36 of the 41 knees (87.8%).

J Pediatr Orthop. 1990 Mar-Apr;10(2):255-60.

Typical Procedure

Case summary

• 10 years old Female.• Bilateral habitual dislocations.• No other congenital anomaly.• Painless full range of movements.

Surgical procedure

• Anterio-medial incision• Dissection to lateral side of patella.• Release of lateral patellar retinaculum from patellar

tendon to vastus lateralis.• VMO isolation, and separation.• Semitendinosis tendon isolation, detachment and

plication with superior pole of patella.• VMO advancement and attachment with anterior and

medial part of patella.• Check the position of patella by flexion.

Anterio-medial incision

Exposure of lateral border of patella

medial

superior

inferior

Release of lateral retinaculum

Superior polePatellar tendon

VMO elevation

Isolation of Semitendinosus

superior

inferior

Isolation of semitendinosus

Tendon passed under the superior pole patellaTurned back medially to align patella in center as checkrein.

PatellaRectus femoris tendon

Patellar tendon

Semitendinosus tendon

Semitendinosus TenodesisLateral release

VMO advancement distally and laterally

PatellaRectus femoris tendon

Patellar tendon

Semitendinosus tendon

Vastus Medialis Oblicus

Lateral release

PatellaRectus femoris tendon

Patellar tendon

Semitendinosus tendon

Vastus Medialis Oblicus distal

advancement

Lateral release

VMO advancement complete

Summary

Lateral release - as per requirementMedial plication

VMO advancementSemitendinosus tenodesis

Optional :-Patellar tendon transfer

Rectus femoris lengthening

Extent of Surgery proportional to contractures

DISCLAIMER• Information contained and transmitted by this presentation is based

on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 32 years.

• It is intended for use only by the students of orthopaedic surgery. Many GIF files are taken from Internet/Textbooks.

• Views and opinion expressed in this presentation are personal.• Depending upon the x-rays and clinical presentations viewers can

make their own opinion.• For any confusion please contact the sole author for clarification. • Every body is allowed to copy or download and use the material best

suited to him. • For any correction or suggestion please contact naneria@yahoo.com