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Habitual dislocation of patella

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Habitual dislocation of patella

  1. 1. Case Presentation Habitual Dislocation of Patella Dr Sushil Sharma First Year MS Orthopaedic Resident
  2. 2. An Interesting Case
  3. 3. Patient Particulars • Name : Amrita Pun • Age : 21 • Sex : F • Address : Salyan-3,Yang • Date of Admission : 2014 July 28
  4. 4. History • Chief Complaints – Difficulty in walking – Giving way of left knee for past 10 years • History of Present Illness – Fall injury 10 years back, sustained injury to left knee following which she had pain in left knee & difficulty in walking. Giving way of left knee.
  5. 5. Clinical Examination • Gait : Normal • Inspection – No swelling, discoloration, scar marks – Wasting of left quadriceps muscle – Position of patella: Centrally placed (In extension) & laterally dislocated in flexion – Size of patella : Left appears small than right – Attitude of leg: B/L varus
  6. 6. Clinical Examination • Palpation: – No rise in superficial temperature – No superficial & joint line tenderness – No tenderness over patella – Patellar movement restricted medially – No patello femoral tenderness and crepitus
  7. 7. Clinical Examination • Movement – Range of movement • Flexion – Left Knee : 0-135 – Right Knee : 0-135 • Loss of Extension : Not present • Internal rotation : 10 degree • External rotation : 10 degree
  8. 8. Clinical Examination • Measurement LEFT RIGHT Q angle 25 degree 20 degree Size of Patella 2.5 X3.5 cm 3 X 4 cm Thigh Foot Angle 30 30
  9. 9. Clinical Examination - Special Tests – Apprehension test : Negative – Patellar grinding test: Negative – Patellar tracking : Positive J Sign (Lateral subluxation of patella in flexion) – Patellar glide test: • 1 quadrant medially • 3 quadrant laterally – Patellar tilt test : Negative
  10. 10. Investigation • Pre-operative investigation: – CBC (Within normal limit) – Serum Na, Serum K, Serum Urea, Serum Creatinine (Within normal limit) – Serology : Non reactive – RBS : Normal – Urine RME : Normal
  11. 11. X-Ray B/L Knee AP • Both leg in varus position
  12. 12. X-Ray B/L Knee Lateral • Blumensaat line : Lower pole of patella on line with intercondylar notch. • Insall-Salvati Ratio (N : 1) • Right: 1 • Left: 0.8 (patella baja)
  13. 13. X-ray B/L Knee Skyline • Left patella dislocated laterally out of the trochlear notch • Left trochlear sulcus shallower than right.
  14. 14. SPECIAL AXIAL VIEWS OF PATELLA HUGHSTON MERCHANT LAURIN •Patellar Index : 14 (N: M – 15, F – 17) •Sulcus angle : 120 (N : 118) •Patellofemoral Index: 2.6 (N:1.6) •Sulcus angle : 145 (N:138)
  15. 15. Management • Surgical realignment is the treatment of choice. • Principle : – Medialization of Patella – Maintenance of proximal & distal alignment • Surgery performed – Insall (Suprapatellar realignment) – Roux Goldthwait operation (Infrapatellar soft-tissue realignment)
  16. 16. Management - Operative • Proximal realignment • Release of tight lateral patellar retinaculum & vastus lateralis completely • Plication of medial capsule & patellar retinaculum to strengthen the lax medial structures. • Vastus medialis obliqus (VMO) was advanced & sutured to lateral border of patella & quadriceps, after locating patella in trochlear notch in 70 degree flexion. LATERAL MEDIAL
  17. 17. Management - Operative Distal realignment • Lateral third of patellar ligament was released from tibial tubersoity and passed underneath medial portion of patellar tendon & sutured upwards & medially to pes anserinus tendon LATERAL MEDIAL
  18. 18. Post Operative • Above knee posterior slab with knee in 5 degree of flexion was given for first 5 days • A long-leg hinged knee brace was applied later with the knee in 20° of flexion • Partial weight bearing with crutches for four weeks was advised, during which the patient was encouraged to do static quadriceps strengthening exercises • Knee mobilization and full weight bearing was started after four weeks.
  19. 19. Post Operative Results • Position of patella : Centrally placed & no lateral dislocation on flexion. • Q angle : 20 • Range of movement : 0 - 135 • Extensor Lag : Not Present
  20. 20. Discussion
  21. 21. Anatomy
  22. 22. Introduction • 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. • Predisposing factors – ligamentous laxity (in women, connective tissue disorder) – contracture of the lateral patellar soft tissues – patella alta – quadriceps contractures – hypoplasia of the lateral femoral condyle – genu valgum
  23. 23. Patho Anatomy • Q angle – Male (8-10) – Female (15±5) • Lateral pull : Vastus lateralis, Iliotibial band • Medial pull : Vastus medialis obliqus (VMO) • Increased Q angle : Patellar dislocation
  24. 24. Patho Anatomy • Genu valgum • Increased femoral anteversion • External tibial torsion • Internal femoral torsion • Tight lateral retinaculum
  25. 25. Types of Patellar Dislocation Type Dislocation Pain Swelling Acute Dislocation In response to trauma Present Present Recurrent Isolated episode in response to trauma Present Present Habitual Everytime when knee is flexed Absent Absent Congenital Since birth Absent Absent
  26. 26. Pathology First episode of traumatic dislocation Tear of capsule on medial side of patella If improper healing Persistent laxity Recurrent dislocation Damage to contiguous surface of patella & fem. Condyles Flattening & then further dislocation
  27. 27. Clinical Features • Symptoms – Feeling of insecurity in knee (Giving way of knee) • Signs – Patellofemoral crepitus – Postive J sign – Increased Q angle
  28. 28. Management • Proximal realignment – Lateral release – Reconstruction of vastus medialis obliquus • Distal realignment – partial medialization of the ligamentum patella – Medialization of tibial tuberosity. • always lateral release is combined with medial augmentation
  29. 29. Typical Procedure
  30. 30. Acknowledgement • Prof Dr S.K. Biswas (HOD, Dept of Orthopaedics) • Asst Prof Dr Niraj Ranjeet • Dr Krishna Sapkota • Dr Pratyunta Raj Onta • Dr Alind Kishore • Dr Pabin Thapa • Dr Upendra Jung Thapa • Dr Manoj Prasad Gupta • Dr Prakash Dware • Department of Anesthesiology • Operation Theatre Staffs
  31. 31. References • Campbell’s Operative Orthopaedics, 12th Edition • Apley’s System of Orthopaedics & Fractures, 9th Edition • Post Graduate Companion in Orthopaedics • Handbook of Fractures, 4th Edition
  32. 32. Thank You Happy Dashain 2071

Editor's Notes

  • Staheli, Lynn T.
    Title: Practice of Pediatric Orthopedics, 2nd Edition
    Copyright ©2006 Lippincott Williams & Wilkins
    > Table of Contents > Chapter 6 - Knee and Tibia
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