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  • Summary
  • Epidemiology
  • Etiology
  • Anatomy
  • Classification
  • Presentation
  • Imaging
  • Adult Treatment
    • Nonoperative
      • NSAIDS, activity modification, and physical therapy
        • indications
          • mainstay of treatment for first time patellar dislocator
            • without any loose bodies or intraarticular damage
          • habitual dislocator
        • techniques
          • short-term immobilization for comfort followed by 6 weeks of controlled motion
          • emphasis on strengthening
            • closed chain short arc quadriceps exercises
            • quad strengthening
            • core and hip strengthening to improve limb positioning and balance (hip abductors, gluteals, and abdominals)
          • patellar stabilizing sleeve or "J" brace
          • consider knee aspiration for tense effusion
            • positive fat globules indicate fracture
    • Operative
      • Arthroscopic debridement (removal of loose body) vs Repair with or without stabilization
        • indications
          • displaced osteochondral fractures or loose bodies
          • can be an indication for operative treatment in a first-time dislocator
        • techniques
          • arthroscopic vs open removal versus repair of the osteochondral fragment
          • primary repair with screws or pins if sufficient bone available for fixation
      • MPFL repair
        • indications
          • acute first-time dislocation with bony fragment
        • techniques
          • direct repair when surgery can be done within first few days
            • no clinical studies support this over nonoperative treatment
      • MPFL reconstruction with autograft or allograft
        • indications
          • recurrent instability
          • no significant underlying malalignment
        • techniques
          • gracilis or semitendinosus commonly used (stronger than native MPFL)
          • femoral origin can be reliably found radiographically (Schottle point)
            • 1 mm anterior to the posterior femoral cortex, 2.5 mm distal to the adductor tubercle, and proximal to Blumensaat's line
              • a femoral tunnel positioned too proximally results in graft that is too tight ("high and tight")
              • in pediatric patients, the femoral side should be secured more anterior/distal to Schottle's point 
        • outcomes
          • severe trochlear dysplasia is the most important predictor of residual patellofemoral instability after isolated MPFL reconstruction
          • rate of recurrent instability does not differ with regard to graft choice (allograft vs. autograft vs. synthetic graft)
      • Fulkerson-type osteotomy (anterior and medial tibial tubercle transfer)
        • indications
          • may be used with or without MPFL reconstruction for significant malalignment
          • TT-TG >20mm on CT
        • techniques
          • anteromedialized displacement of osteotomy and fixation
            • patellofemoral contact pressures increased proximally and medially
          • correct TT-TG to 10-15mm (never less than 10mm)
      • tibial tubercle distalization
        • indications
          • patella alta
        • techniques
          • distal displacement of osteotomy and fixation
      • lateral release/lengthening
        • indications
          • isolated release no longer indicated for patellainstability
            • may lead to iatrogenic medial instability
          • lateral lengthening has shown better outcomes, less quadriceps atrophy, and lower incidence of medial patellar instability
          • only indicated if there is excessive lateral tilt or tightness after medialization
        • technique
          • arthroscopic
      • trochleoplasty
        • indications
          • rarely addressed (in the USA) even if trochlear dysplasia present
          • severe dysplasia
            • recent literature reports that Dejour types B and D are most amenable to trochleoplasty
          • revision cases with residual patellar instability 
        • techniques
          • arthroscopic or open sulcus deepening procedure
          • open recession wedge trochleoplasty
      • guided growth (temporary hemiepiphysiodesis)
        • indications
          • in those with genu valgum greater than 10° and patellar instability and at least six months of growth remaining
        • techniques
          • tension band (8-plate) 
          • staples
            • believed to be more rigid, providing faster correction
  • Pediatric Treatment
  • Complications
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Knee & Sports | Patellar Instability
  • Knee & Sports
  • - Patellar Instability
22:4 min
10/18/2019
2631 plays
5.0
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