DOCSLIB.ORG

Management of First-Time Patellar Dislocations

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Management of First-Time Patellar Dislocations ■ sports medicine update Management of First-Time Patellar Dislocations MICHAEL GEARY, MD; ANTHONY SCHEPSIS, MD dislocation usually present Merchant or axial views of Patellofemoral instability represents a continuum of with a reduced patellofemoral both knees. These studies abnormal patellofemoral joint mechanics, ranging from joint and a history of feeling should be reviewed for osteo- infrequent subluxation to recurrent dislocation. their knee “go out of place.” On chondral fracture and adequacy examination, a large hem- of patellofemoral joint reduc- arthrosis is typically present, tion. Consideration should also with tenderness over the medi- be given to magnetic resonance he average annual inci- The typical mechanism of al femoral epicondyle and imaging (MRI), which is more Tdence of first-time patella injury is external rotation of the medial border of the patella, in sensitive for osteochondral dislocation is 5.8 per 100,000.1 tibia with concomitant contrac- addition to pain with lateral injury and can also aid in diag- When risk is stratified by age tion of the quadriceps. Less fre- translation of the patella. nosis, given a characteristic set and gender, the risk of first-time quently, glancing blows to the Arthrocentesis should be con- of MRI findings seen with dislocation is highest in females patella may produce a disloca- sidered in the acute setting for patellar dislocation. These aged 10-17 years. In this group, tion. Factors that predispose to both patient comfort and to findings include disruption of the annual incidence of first- dislocation include an allow for a more accurate phys- the medial patellofemoral liga- time patella dislocation is 33 increased quadriceps angle, ical examination. ment and osteochondral bone per 100,000.1 trochlear dysplasia, patella alta, The typical lesion associat- bruises or fractures involving Stability of the patello- vastus medialis obliques atro- ed with lateral patella disloca- the inferomedial patella and femoral joint against lateral dis- phy, insufficient medial tion is injury to the medial lateral femoral condyle.3-5 location is based on osseous patellofemoral ligament, genu patellofemoral ligament.3-5 Treatment recommenda- constraint in Ͼ30° of flexion recurvatum, increased femoral Associated injuries frequently tions for first time patellar dis- and medial soft-tissue restraints anteversion, external tibial tor- include osteochondral frac- locations are controversial. Our in the early flexion range where sion, foot pronation, increased tures, and less frequently medi- practice has been to manage instability usually occurs. The patellar tilt, and patellar hyper- al collateral ligament (MCL) first time patellar dislocations medial patellofemoral ligament mobility. With greater anatomic sprain, anterior cruciate liga- nonoperatively, unless a dis- is the most important of these predisposition, the force ment (ACL) injury, and menis- placed osteochondral fracture medial soft-tissue restraints.2 required to dislocate the patella cal injury.3-5 Initial manage- or asymmetric reduction of the decreases. ment consists of immobilizing dislocated patella is noted From Boston University Medical the affected knee in extension. when compared to the normal Center, Boston, Mass. EVALUATION AND Radiographic evaluation knee. In the latter two cases, Reprint requests: Anthony MANAGEMENT should include anteroposterior arthroscopy is performed and Schepsis, MD, Doctor’s Office Bldg, Ste 808, 720 Harrison Ave, Boston, Patients having sustained a (AP), lateral, and tunnel views the knee is surveyed. Smaller MA 02118. first-time traumatic patella of the affected knee and displaced osteochondral frag- 1058 ORTHOPEDICS | www.orthobluejournal.com ■ sports medicine update patient had a large effusion in the knee and Merchant views of both left knee and pain with minimal knees were obtained. A displaced range of motion. An arthrocentesis osteochondral fragment could be was performed and 120 cc of san- seen on the Merchant and lateral guineous fluid with fat globules views of the left knee (Figure 1). was removed. Crepitus was noted The left patellofemoral joint was with range of motion. The patient reduced and symmetrical in was able to perform a straight leg appearance with the right raise. The knee was stable to varus patellofemoral joint. and valgus stress at 0° and 30°. Magnetic resonance imaging of Lachman and anterior and posterior the left knee demonstrated an effu- drawer tests were negative. The sion and a midsubstance tear of the patient reported tenderness along medial patellofemoral ligament. In the medial patella border and medi- addition, a displaced osteochondral al femoral epicondyle. Pain fracture measuring 2 cm in diame- 1 occurred with lateral translation of ter, involving the lateral femoral the patella. Significantly increased condyle, was present. The ACL, Figure 1: Case 1. Merchant view demonstrating a displaced osteochondral fracture. asymmetric lateral patellar transla- MCL, posterior cruciate ligament ments that are not amenable to fixation are excised; larger fragments are fixed in an arthroscopic or open fashion depending on the size and loca- tion of the injury. If indicated, tears of the medial patello- femoral ligament are repaired primarily in an open fashion. CASE REPORTS Case 1 A 16-year-old high school foot- ball defensive back sustained a first-time lateral dislocation of the left patella during a tackling drill in practice. The patient recalled sud- den knee pain after twisting his knee in the drill. He was diagnosed by the athletic trainer as having a lateral patellar dislocation. This was reduced on the field by extend- ing the injured knee and applying a medially directed force on the dis- located patella. The patient’s left 2 knee was then placed in extension Figure 2: Case 1. Arthroscopic picture demonstrating reduction of the displaced osteochondral fracture to the lateral in a knee immobilizer. femoral condyle. On evaluation the following day, the patient reported no history episode. The patient was otherwise tion was noted at 30° of flexion. (PCL), lateral collateral ligament of patella dislocation or instability healthy. Radiographs, consisting of AP, (LCL), and medial and lateral in either knee prior to the current On physical examination, the tunnel, and lateral views of the left menisci were intact. OCTOBER 2004 | Volume 27 • Number 10 1059 ■ sports medicine update TABLE Summary of Studies on Treatment of Acute Patella Dislocation Study Sample Mean Recurrence Study Design Treatment Size Follow-Up Surgical Technique Outcome Rate (%) Cofield7 Retrospective Conservative 35 11.8 y NA 91% satisfied 44 1977 Hawkins6 Retrospective Conservative 20 40 mo NA 50% moderate/ 15 1986 severe pain Cash8 Retrospective* Conservative 69† 8 y NA 52% G to E 43 1988 34‡ 75% G to E 20 Garth9 Retrospective Conservative 69 2 y NA 78% satisfied 26 1996 Maenpaa10 Retrospective Conservative 100 13 y NA 37% no complaints 44 1997 Dainer13 Retrospective Surgery 29 25 mo Scope, scope + LR 83% G to E 27% with 1988 LR, 0% no LR Vainionpaa14 Prospective Surgery 55 2 y Medial repair +/- LR 80% G to E 9 1990 Avikainen15 Retrospective Surgery 14§ 6.9 y Augment of MPFL 86% G 7 1993 Harilainen12 Prospective Surgery 53 6.5 y Medial repair/reef +/- LR 60% satisfied 17 1993 Sallay16 Retrospective Surgery 12 36 mo MPFL repair +/- LR 58% G to E 0 (33% sublux) 1996 Ahmad11 Retrospective Surgery 8 3 y VMO, MPFL repair + LR 96% satisfied 0 2000 Nikku17 Prospective, Conservative 55 2 y NA 70% G to E 30 1997 randomized Surgery 70 Proximal realignment 70% G to E 20 Fithian1 Prospective Conservative, 64࿣ 2-5 y Scope 9%, stabilize 12% NA 49 Scope 6%, stabilize 5% 17 نsurgery 125 2004 Abbreviations: E=excellent, G=good, LR=ligament repair, MPFL=medial patellofemoral ligament, NA=not applicable, and VMO=vastus medialis obliquus. *2 groups. †Predisposed. ‡Normal. §Chronic and acute. ࿣History of patellofemoral instability. .No history of patellofemoral instabilityن Arthroscopy demonstrated a Postoperatively, the patient was postoperatively. At last follow-up, tially evaluated by the athletic train- displaced osteochondral fracture of placed in a hinged knee brace, approximately 2 years postopera- er, and placed in a knee immobiliz- the lateral femoral condyle measur- locked in extension, and he tively, the patient reported no er. ing 2 cm in diameter, and hemor- remained partial weight bearing for symptoms of instability, pain, or No history of injury or surgery rhage in the medial retinacular 6 weeks. Early range of motion was swelling. of either knee was reported. In region (Figure 2). Both menisci and instituted, initially at 0°-90°, and addition, no history of patello- ACL were intact. progressed to full passive range of Case 2 femoral instability in either knee Open reduction and internal fix- motion by 4 weeks. At 6 weeks the A 19-year-old female NCAA was noted prior to the current ation of the displaced osteochon- patient was advanced to weight division 1 soccer player presented injury. She was otherwise in good dral fracture was performed using bearing as tolerated, with full active with a large effusion and knee pain health. Arthrex Chondral Darts (Arthrex, range of motion while wearing a after sustaining a twisting injury to On physical examination, a Naples, Fla). A 4-cm medial para- dynamic lateral buttress patellar the left knee during a game the pre- large effusion was present and patellar arthrotomy was performed stabilizing brace. Strengthening vious day. The patient reported range of motion was limited sec- and primary repair of the medial exercises were begun 12 weeks immediate onset of pain and the ondary to pain. An arthrocentesis patellofemoral ligament was car- postoperatively, and the patient sensation that her “knee had gone was performed and 70 cc of san- ried out. returned to full activity 16 weeks out of place.” The patient was ini- guineous fluid was obtained. The 1060 ORTHOPEDICS | www.orthobluejournal.com ■ sports medicine update patient had active and passive range cises were instituted with physical of motion of the knee from 0°- therapy. During this time, the 100°.
Load more

Recommended publications
  • Cartilage Restoration in the Patellofemoral Joint
    A Review Paper Cartilage Restoration in the Patellofemoral Joint Betina B. Hinckel, MD, PhD, Andreas H. Gomoll, MD, and Jack Farr II, MD malalignment, deconditioning, muscle imbalance Abstract and overuse) and can coexist with other lesions Although patellofemoral (PF) chondral in the knee (ligament tears, meniscal injuries, and lesions are common, the presence of cartilage lesions in other compartments). There- a cartilage lesion does not implicate a fore, careful evaluation is key in attributing knee chondral lesion as the sole source of pain. pain to PF cartilage lesions—that is, in making a As attributing PF pain to a chondral lesion “diagnosis by exclusion.” is “diagnosis by exclusion,” thorough From the start, it must be assessment of all potential structural appreciated that the vast majority and nonstructural sources of pain is the of patients will not require surgery, key to proper management. Commonly, and many who require surgery Take-Home Points for pain will not require cartilage multiple factors contribute to a patient’s ◾ Careful evaluation is symptoms. Each comorbidity must be restoration. One key to success key in attributing knee identified and addressed, and the carti- with PF patients is a good working pain to patellofemoral lage lesion treatment determined. relationship with an experienced cartilage lesions—that is, Comprehensive preoperative assess- physical therapist. in making a “diagnosis by exclusion.” ment is essential and should include a ◾ Initial treatment is non- thorough “core-to-floor” physical exam- Etiology The primary causes of PF carti- operative management ination. Treatment of symptomatic chon- focused on weight loss dral lesions in the PF joint requires specific lage lesions are patellar instabil- and extensive “core-to- technical and postoperative management, ity, chronic maltracking without floor” rehabilitation.
    [Show full text]
  • Common Problems in Sports Medicine Update and Pearls for Practice
    Common Problems in Sports Speaker Disclosure: Medicine Update and Pearls for Practice Founder, RunSafe™ Anthony Luke MD, MPH, CAQ (Sport Med) Founder, SportZPeak Inc. Benioff Distinguished Professor in Sports Medicine Director, Primary Care Sports Medicine, Departments of Orthopedics & Family & Community Medicine University of California, San Francisco Sanofi, Investigator initiated grant May 25, 2017 Overview Acute Hemarthrosis §Highlight common presentations 1) ACL (almost 50% in children, >70% in adults) 2) Fracture (Patella, tibial plateau, Femoral supracondylar, §Knee Physeal) §Shoulder 3) Patellar dislocation §Hip §Concussion § Unlikely meniscal lesions §Discuss basics of conservative and surgical management Emergencies Urgent Orthopedic Referral 1. Neurovascular injury §Fracture 2. Knee Dislocation §Patellar Dislocation • Associated with multiple ligament injuries “ ” (posterolateral) § Locked Joint - unable to fully extend the knee (OCD or Meniscal tear) • High risk of popliteal artery injury §Tumor • Needs arteriogram 3. Fractures (open, unstable) 4. Septic Arthritis Anterior Cruciate Ligament (ACL) What is True About ACL Tears? Tear Mechanism 1. An MRI is the best test to diagnose the ACL §Landing from a 2. The medial meniscus is most commonly torn jump, pivoting or with an ACL tear decelerating 3. All patients with an ACL tear are better off suddenly getting reconstruction vs non-op treatment §Foot fixed, valgus 4. Athletes can expect full recovery after ACL stress reconstruction Anterior Cruciate Ligament (ACL) ACL physical
    [Show full text]
  • Superior Dislocation of the Patella: Case Report and Literature Review
    Orthopedics and Rheumatology Open Access Journal ISSN: 2471-6804 Case Report Ortho & Rheum Open Access Volume 4 Issue 3 - January 2017 Copyright © All rights are reserved by Paul E. Caldwell DOI: 10.19080/OROAJ.2017.04.555639 Superior Dislocation of the Patella: Case Report and Literature Review Paul E. Caldwell*, Samuel Carter and Sara E. Pearson Orthopedic Research of Virginia (SC, PEC and SEP) and Tuckahoe Orthopedic Associates, Ltd., (PEC), USA Submission: December 20, 2016; Published: January 09, 2017 *Corresponding author: Paul E. Caldwell III MD, 1501 Maple Avenue, Suite 200, Richmond, VA 23226, Ph: ; Fax: (804) 527-5961; Email: Abstract A 46-year-old female presented to the emergency department with a rare superior dislocation of the patella. Magnetic resonance imaging patellar dislocation. A closed reduction was performed, resulting in immediate pain relief and nearly full active range of motion. revealed inferior osteophytes on the patella engaging osteophytes on the superior portion of the trochlear groove resulting in a locked superior Keywords: Superior patellar dislocation; Closed reduction; Non operative treatment Case Report A 46-year-old female presented to the emergency department displacement of the patella without fracture and an unusual X-rays (Figure 1) taken in the ED demonstrated superior anterior tilt of the patella. The initial diagnosis in the ED was (ED) with complaints of significant anterior knee discomfort, a patellar tendon rupture, and a magnetic resonance image swelling and inability to ambulate or actively flex her knee. She on a piano stool. She denied any history of injury to the right reported falling at home and striking her right knee directly (MRI) of the right knee was performed after orthopedic tendon and the remainder of the extensor mechanism were consultation.
    [Show full text]
  • Health Policy & Clinical Effectiveness Program
    Evidence-Based Care Guideline for Conservative Management of patellar instability and dislocation in children and adults aged 8-25 Guideline 44 James M. Anderson Center for Health Systems Excellence Introduction References in parentheses ( ) Evidence level in [ ] (See last page for definitions) Evidence-Based Care Guideline Lateral patellar dislocations/subluxations and lateral patellar instability are conditions that can result in short- Conservative Management of Lateral Patellar term and long-term anterior knee pain, functional Dislocations and Instability disability and potentially degenerative joint changes (Smith 2010b [1b], Fithian 2004 [2a], Atkin 2000 [3b]). Both In children and young adults aged 8-25 yearsa conditions are often managed with a non-surgical, Publication date: March 18, 2014 conservative approach that entails physical therapy care (Stefancin 2007 [1b]). While a variety of expert opinion and Target Population review articles have been published with suggestions for physical therapy interventions for lateral patellar Inclusions: Children or young adults: dislocation and patellar instability, higher level studies With history of lateral patellar dislocation, specifically investigating rehabilitation interventions for subluxation or general patellar instability in one or these conditions are limited. Consequently, optimal both knees who are going to be conservatively physical therapy strategies have not yet been determined managed (Smith 2010b [1b]). Therefore, the purpose of this guideline Ages 8-25 years is to provide a comprehensive description of evaluation and intervention strategies for conservative management Exclusions: Children or young adults: of lateral patellar instability. Following surgical patellar stabilization techniques This guideline was developed based on a synthesis of With Neuro-developmental conditions associated current evidence relative to the non- surgical, with patellar instability or dislocation (e.g.
    [Show full text]
  • Recognition of Injury Patterns in Transient Lateral Patellar Dislocation on Magnetic Resonance Imaging Vijinder Arora1, Abhiraj Kakkar2
    ORIGINAL RESEARCH ARTICLE Recognition of Injury Patterns in Transient Lateral Patellar Dislocation on Magnetic Resonance Imaging Vijinder Arora1, Abhiraj Kakkar2 ABSTRACT Aims and Objectives: To determine the prevalence of various injury patterns in patient with transient lateral patellar dislocation (TLPD) on magnetic resonance imaging (MRI). Materials and methods: Thirty patients with clinical history pointing toward lateral patellar dislocation (LPD) were evaluated for the characteristic associated injury patterns including lateral femoral contusion, medial patellar contusion/osteochondral injury, medial retinaculum/medial patellofemoral ligament (MR/MPFL) injury, significant joint effusion, intraarticular loose bodies, medial collateral ligament (MCL) injury, and medial meniscus tear. Prevalence of all these findings was assessed. Results: Our study showed some commonly observed injury patterns in patients with TLPD. Of 30 patients, 25 (83.3%) had MR/MPFL tear in general. Fifty percentage (15 of 30 patients) showed MPFL tear at its patellar insertion, 16.6% (5 of 30 patients) at its mid-part, and 46.6% (14 of 30 patients) at its femoral insertion; 80% (24 of 30 patients) revealed contusions of the lateral femoral condyle, and 73.33% (22 of 30 patients) had contusion/osteochondral injury of medial patella. Other MRI findings in TLPD included significant joint effusion (20 [66.6%] of 30), patellar tilt (17 [56.6%] of 30), patellar subluxation (17 [56.6%] of 30), medial meniscal tear (7 [23.3%] of 30), medial collateral injury (3 [10%] of 30), and intraarticular bodies (2 [6.6%] of 30). Conclusion: Injury to the MR/MPFL, bony contusion involving lateral femoral condyle, and bony contusion/osteochondral injury involving medial aspect of patella are frequently associated with TLPD.
    [Show full text]
  • Knee—Meniscus
    Meniscus and Patella injuries in Professional Hockey Peter MacDonald MD FRCSC Professor and Head Section of Orthopedics University of Manitoba Head Team Physician Winnipeg Jets Disclosure Institutional (Pan am Foundation) Research and Educational support from: Linvatec Ossur Arthrex Associate Editor JSES COA President elect Objectives • To go over common injury patterns to the knee • Suggest treatment pathways • Role of prevention of these injuries http://highschoolsports.nj.com/school/berkeley- heights-gov-livingston/boysicehockey/photos/ Meniscus tears . Bucket handle . Flap or radial . Cleavage . Complex . Degenerative Supplies periphery Originates from the synovium, capsule Arnoczky and Warren, Am J Sports Med, 1982 Degenerative Meniscus tears Not in professional hockey! . usually in patients > 40 . typically no history of trauma, twisting injury . pre-existing degenerative changes . minimal healing capacity . horizontal cleavage, flap or complex tear TRAUMATIC TEARS . young, athletically active individuals . frequently trauma related . often associated with ACL tears . vertical longitudinal tears most common . followed by vertical transverse tears “RED ZONE” INJURIES . Healing requires some communication with blood supply which permits classic wound healing response . cellular fibro-vascular scar . must have a stable environment . mechanical function and strength remain suspect “WHITE ZONE” INJURIES . No reparative response . similar to articular cartilage . “Red-white zone” . somewhere in between Lateral Meniscus Root injury Subtle
    [Show full text]
  • Unstable-Patella.Pdf
    Table of Contents About the Authors 4 Introduction 6 Basic Knee Anatomy 7 Basic Knee Biomechanics: The Important Structures and How They Should Work to Keep Your Patella Stable and Pain-free 10 The Extensor Mechanism 10 Factors That Influence Patellar Stability 10 Summary 15 The Effects of Patellar Instability 16 Patellar Dislocation Injuries 16 Patellar Subluxation Episodes 16 The Knee Examination 18 History 18 Where Does It Hurt? 18 Patellar Tracking 19 Lower Limb Alignment 20 Ligaments and Menisci 21 Single-leg Squat Test 21 Muscle Strength and Function 21 Imaging Studies 21 Possible Diagnoses Related to Anatomical Problems 22 Treatment for Acute, First-Time Patellar Dislocations 23 General Comments 23 Conservative Treatment, Physical Therapy 24 Knee Braces/Sleeves 26 Training for Return to Sports 26 Results of Conservative Treatment for First-Time Patellar Dislocation Injuries 30 Treatment for Chronic Recurrent Patellar Instability 31 General Comments 31 Conservative Treatment, Physical Therapy 31 What to do When Conservative Management Fails 33 Choosing an Orthopaedic Surgeon in the U.S. 33 Operations to Correct Patella Instability 34 Examination Under Anesthesia 35 Lateral Release 35 Proximal-Distal Realignment Procedures 35 Proximal Realignment (Tightening Existing Tissues) 37 MPFL Reconstruction Plus Proximal Realignment 37 Trochleoplasty 37 Operations for Damage to the Joint Lining (Articular Cartilage) 37 Arthroscopic Debridement 37 Microfracture, Abrasion Arthroplasty 38 Osteochondral Autograft Transfer 39 Autologous Chondrocyte
    [Show full text]
  • Treatment of Patellar Dislocation in Children
    Petri Sillanpää MD PhD Treatment of Patellar Dislocation in Children Introduction Lateral patellar dislocation is a common knee injury in pediatric population1, and is the most common acute knee injury in the skeletally immature. Over half of the cases cause recurrent patellar dislocations and pain. The mechanism of injury is most often with the foot planted and tibia external rotated. It can also occur with jump landing and/or decelerating. The medial patellofemoral ligament (MPFL) is frequently injured in an acute patellar dislocation.2-7 Initial management of the pediatric patellar dislocation is mainly nonoperative. Surgery is indicated if a large osteochondral fragment is present or patella is highly unstable or extensively lateralized due to massive medial restraint injury. Surgical stabilization is recommended if redislocations are frequent and cause pain or inability to attend sports acitivites. Reconstruction of the MPFL is a preferred surgical option in the skeletally immature knee, as operations that involve bone are contraindicated. MPFL reconstruction techniques that do not involve drilling or disruption of the periosteum near the femoral physes are safe for the skeletally immature knee. Treatment of patellar dislocation in the skeletally immature patient is presented with specific discussion of surgical technique and results of double bundle MPFL reconstruction. Epidemiology and predisposing factors A population-based study have estimated annual incidence rate of first-time (primary) patellar dislocations in children,1 resulting in 43 / 100 000. Buchner et al11 reported a 52% redislocation rate in patients aged <15 years compared with 26% for the entire group. Similarly, Cash and Hughston12 showed a 60% incidence of redislocation in children aged 11-14 years compared with 33% in those aged 15-18 years.
    [Show full text]
  • Patella Dislocation
    NEWSLETTEROFTHEAMERICANORTHOPAEDICSOCIETYFORSPORTSMEDICINE SEPTEMBER/OCTOBER 2010 STOP Sports Injuries Continues Making Impact Most Successful Match Ever Traveling Fellowship Tours Announced PATELLA DISLOCATION www.sportsmed.org HOME SEPTEMBER/OCTOBER 2010 CO-EDITORS EDITOR William N. Levine MD EDITOR Daniel J. Solomon MD MANAGING EDITOR Lisa Weisenberger PUBLICATIONS COMMITTEE Daniel J. Solomon MD, Chair Kenneth M. Fine MD Robert A. Gallo MD Richard Y. Hinton MD David M. Hunter MD Grant L. Jones MD John D. Kelly IV MD William N. Levine MD Brett D. Owens MD Kevin G. Shea MD Brian R. Wolf MD, MS BOARD OF DIRECTORS PRESIDENT Robert A. Stanton MD PRESIDENT-ELECT Peter A. Indelicato MD VICE PRESIDENT Christopher R. Harner MD SECRETARY Jo A. Hannafin MD, PhD TREASURER Robert A. Arciero MD UNDER 45 MEMBER-AT-LARGE David R. McAllister MD OVER 45 MEMBER-AT-LARGE Mark E. Steiner MD SECRETARY-ELECT James P. Bradley MD TREASURER-ELECT Annunziato Amendola MD COUNCIL OF EDUCATION Andrew J. Cosgarea MD RESEARCH Constance R. Chu MD COMMUNICATIONS Daniel J. Solomon MD MEMBERS EX OFFICIO (MEMBERSHIP) John D. Kelly IV MD MEMBER-AT-LARGE Mininder S. Kocher MD PAST PRESIDENT James R. Andrews MD PAST PRESIDENT Freddie H. Fu MD 2 Team Physician’s Corner MEMBER EX OFFICIO COUNCIL OF DELEGATES Patricia A. Kolowich MD Primary, Traumatic Patella Dislocation: JOURNAL EDITOR, MEMBER EX OFFICIO Bruce Reider MD Operative Indications AOSSM STAFF EXECUTIVE DIRECTOR Irvin Bomberger MANAGING DIRECTOR Camille Petrick 1 From the President 12 Dr. Harry H. Kretzler, Jr. DIRECTOR
    [Show full text]
  • Christopher Kim, MD, Minh-Ha Hoang, MD, Scott G. Kaar, MD, William Mitchell, MD, Lauren Smith, PA-C
    Christopher Kim, MD, Minh-Ha Hoang, MD, Scott G. Kaar, MD, William Mitchell, MD, Lauren Smith, PA-C Department of Orthopaedic Surgery Sports Medicine and Shoulder Service Patellar Dislocation Nonoperative Rehab Protocol Prescription Patient Name: Date: Diagnosis: Patellar Dislocation L / R knee Number of visits each week: 1 2 3 4 Treatment duration _______ weeks Weeks 1-4 • Brace in full extension at all times, WBAT in hinged brace • PROM 0 – 45 degrees OK in the brace with PT supervision Week 5 • Supervised PT - 3 times a week (may need to adjust based on insurance) • Gentle patellar mobilization exercises • Emphasis full passive extension • AAROM exercises (4-5x/ day) - no limits on ROM • ROM goal: 0-115 • Flexion exercises PROM, AAROM, and AROM with brace off • Stationary bike for range of motion (short crank or high seat, no resistance) • Hamstring and calf stretching • Mini-squats (0-45) and heel raises • Hip strengthening - specifically external rotators • Isotonic leg press (0 - 60 degrees) • D/C hinged brace and advance to patellar stabilization brace if quad control adequate • Progressive SLR program with weights for quad strength with brace off if no extensor lag (otherwise keep brace on and locked) • Theraband standing terminal knee extension • Proprioceptive training bilateral stance • Hamstring PREs • Double leg balance on tilt boards • 4 inch step ups • Seated leg extension (0 to 90degrees) against gravity with no weight • Add water exercises if desired (and all incisions are closed and sutures out) Week 6 • Continue all
    [Show full text]
  • Patellar Dislocation – Conservative and Operative Rehabilitation
    1 Patellar Dislocation – Conservative and Operative Rehabilitation Surgical Indications and Considerations Anatomical Considerations: Patellar stability is dependent upon two components: bony (trochlear groove) and soft tissue structures. There are multiple soft tissue layers that surround the patellofemoral joint. Medially, the superficial layer is consists of the fascia over the sartorius muscle, the second layer contains the medial patellofemoral ligament (MPFL) and the retinaculum, and the third layer contains the medial collateral ligament and joint capsule. The MPFL provides 50-80% of total restraining force medially. Fascial interconnections between fibers of the iliotibial band, lateral hamstrings, lateral collateral ligament, and lateral quadriceps comprise the lateral retinaculum. Pathogenesis: Patellar instability can be correlated with one or more of the following anatomical risk factors: tightness of lateral structures, patella alta, patella or femoral dysplasia, increased Q-angle, increased sulcus angle, generalized laxity, increased femoral anteversion, increased external tibial torsion, lateral position of the tibial tuberosity, abnormal foot pronation, and a vertical vastus medialis oblique (VMO) insertion. Patella dislocation can occur from indirect, twisting or rapid change of direction with the foot planted, or direct trauma to patella. Epidemiology: A higher incidence of patellar dislocations occur in females ages 10 to 17 years of age and the athletically active, with less incidence over age 30. Lateral dislocations are very common and will be the topic of discussion in this guideline. Medially dislocations are typically rare and result from direct trauma, an excessive lateral release or overcorrection of a realignment procedure. Redislocations occur more frequently in patients younger than 20 and tend to decrease with advancing age.
    [Show full text]
  • Patellar Dislocation and Subluxation
    Montefiore Pediatric Orthopedic and Scoliosis Center Children’s Hospital at Montefiore Norman Otsuka MD – Eric Fornari MD Jacob Schulz MD – Jaime Gomez MD – Christine Moloney PA 3400 Bainbridge Avenue, 6th Fl, Bronx, NY 10467 phone 718 920 2060 / fax 718 920 7799 th 1250 Waters Place, 11 Fl, Bronx, NY 10461 PATELLAR DISLOCATION AND SUBLUXATION Description is bent or when the quadriceps muscle is active or both Patellar dislocation and subluxation are injuries to the (each causing force on the patella). kneecap (patella) affecting the joint where it forms with the Risk Increases With thigh bone (femur). The Patella is a V- shaped convex bone • Tight hamstring (back of the thigh), quadriceps (front that sits within a V-shaped concave groove of the femur, of thigh), or calf muscles; weak quadriceps (front of known as the trochlea. Patella Dislocation is a condition in the thigh) muscles which the patella is displaced from its normal position and • Inadequate warm-up before practice or competition no longer sits in the trochlea. Patella Subluxation is a • Sports that involve running, jumping, or squatting condition in which the patella is not centered within the • Poor alignment of the legs (knock knees, kneecaps that trochlea, but the joint surfaces still touch; thus the patella is point toward each other when the feet are straight not in normal relationship to the trochlea. This tends to ahead), poorly formed trochlea (something you are occur in adolescents and young adults. born with), flat feet • Previous injury or surgery to the knee Common Signs and Symptoms • Direct injury to the kneecap (falling on the kneecap) • Severe pain when attempting to move the knee and a feeling of the knee giving way Preventive Measures • Tenderness, swelling, bruising of the knee.
    [Show full text]