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Patellofemoral Instability
Sachin Ramchandra Tapasvi
CHAPTER 1:
The Epidemiology and Natural History of Patellar Dislocation
INTRODUCTION
INCIDENCE
BIOMECHANICS OF THE PATELLOFEMORAL JOINT
Static Stabilizers
Dynamic Stabilizers
INCIDENCE IN THE ADOLESCENTS AND CHILDREN
RISK FACTORS
CLINICAL PRESENTATION AND PHYSICAL EXAMINATION
INVESTIGATIONS
NATURAL HISTORY
CHAPTER 2:
Anterior Knee Pain—Pathophysiology and Management
INTRODUCTION
PATHOPHYSIOLOGY OF ANTERIOR KNEE PAIN 1
Pain due to Patellofemoral Malalignment
Dye's Tissue Homeostasis Theory (Fig. 2.1)
Overloading Patellofemoral Joint as a Cause of Anterior Knee Pain and Sometimes Posterior Knee Pain (Fig. 2.2)
Realignment Surgery—Is it Final Solution for Anterior Knee Pain?
“Neural Model” for Development of Anterior Knee Pain
Cause of Giving Away Sensation in PFPS
Neurochemical Mediators for Causing Anterior Knee Pain
Vastus Medialis Obliquus Function and PFPS
CLINICAL FINDINGS 4–7
RADIOLOGICAL ASSESSMENT4,6,8
TREATMENT3,4,6,7,9–12
REHABILITATION PROTOCOL
OPERATIVE TREATMENT
TREATMENT FOR OSTEOCHONDRAL DEFECT IN PATELLA13,14
CHAPTER 3:
Pathoanatomy of Lateral Dislocation
INTRODUCTION
ANATOMICAL FACTORS
SECONDARY FACTORS
OSSEOUS FACTORS
Trochlear Dysplasia
PATELLA ALTA
ROTATIONAL AND AXIAL LIMB DEFORMITIES
SOFT TISSUE ABNORMALITIES
CHAPTER 4:
Imaging in Patellofemoral Instability
INTRODUCTION
NORMAL SOFT TISSUE STABILISERS OF THE KNEE
BONY STABILIZERS OF THE KNEE
RADIOGRAPHS
MAGNETIC RESONANCE IMAGING
Trochlear Dysplasia
Lateral Trochlear Inclination (Fig. 4.5)
Trochlear Facet Asymmetry (Fig. 4.6)
Trochlear Depth (Fig. 4.7)
Patella Alta
TT–TG Distance
Q angle (Fig. 4.13)
Genu Valgum
MRI Imaging Findings after Patellar Dislocation
Acute
Chronic Instability
CT SCAN
POSTOPERATIVE EVALUATION
ADVANTAGE OF MRI OVER ARTHROSCOPY
MOCART SCORE
ROLE OF CARTILAGE MAPPING3
Cartilage Map of the Same Patient
SUMMARY
CHAPTER 5:
Role of Conservative Treatment in Patellar Dislocation
INTRODUCTION
NATURAL HISTORY OF PATELLAR DISLOCATION
TREATMENT PHILOSOPHY—FIRST-TIME DISLOCATOR/RECURRENT DISLOCATOR
EVIDENCE IN LITERATURE COMPARING RESULTS OF NONOOPERATIVE VS OPERATIVE TREATMENT IN ACUTE PATELLAR DISLOCATION
COCHRANE REVIEW AND META-ANALYSIS
MPFL TEAR LOCATION—ITS IMPLICATION IN DECISION MAKING OF CONSERVATIVE VS OPERATIVE TREATMENT FOR PATELLAR DISLOCATION
CONSERVATIVE TREATMENT PROTOCOLS
ROLE OF NONOPERATIVE TREATMENT IN RECURRENT PATELLAR DISLOCATION
SUMMARY
CHAPTER 6:
Surgical Management of Acute Patellar Dislocations
INTRODUCTION
REVIEW OF LITERATURE
INDICATIONS OF SURGERY
Presence of Osteochondral Fracture
MPFL Avulsion at Femoral or Patellar Ends
Severe Disruption of VMO-Adductor-Medial Retinaculum Complex
SURGICAL TECHNIQUE
Osteochondral Fracture Fixation
MPFL Avulsion Fixation
MPFL Reconstruction and Medial Repair
PEARLS AND PITFALLS
CHAPTER 7:
Medial Patellofemoral Ligament Reconstruction
INTRODUCTION
Indications for MPFL Reconstruction
Contraindications for MPFL Reconstruction
Surgical Technique
Examination under Anesthesia
Arthroscopic Examination
Surgical Landmarks and Incisions
Graft Harvest
The Technique
Patellar Side Fixation
Femoral Insertion
Schottle's Point5
Graft Tensioning and Fixation
Closure
OTHER TECHNIQUES
Dynamic MPFL Reconstruction
MPFL Reconstruction in the Skeletally Immature Patient
IMPORTANT PRINCIPLES
POST-OPERATIVE REHABILITATION
COMPLICATIONS
RESULTS
PEARLS AND PITFALLS
CHAPTER 8:
The Superficial Quad Technique
INTRODUCTION
SURGICAL TECHNIQUE 1,5
POSTOPERATIVE CARE5
DISCUSSION
CHAPTER 9:
Medial Patellofemoral Ligament Reconstruction—The ‘Basket Weave’ Technique
INTRODUCTION
SURGICAL TECHNIQUE
POSTOPERATIVE REHABILITATION
ADVANTAGES OF TECHNIQUE
Graft
Construct
Fixation
Biomechanical
Reproducibility
Re-surgeries
Cost Effective
RESULTS
CONCLUSION
CHAPTER 10:
Complications after MPFL Surgery: Tips and Pearls for Prevention of Complication and Successful MPFL Reconstruction
INTRODUCTION
COMPLICATION OF MPFL RECONSTRUCTION
TAKE HOME TIPS FOR A SUCCESSFUL MPFL RECONSTRUCTION
Preoperative Factors
Intraoperative Factors
Postoperative Factors
CHAPTER 11:
Trochleoplasty
INTRODUCTION
NORMAL TROCHLEAR ANATOMY AND BIOMECHANICS
Anatomy
Biomechanics
ABNORMAL TROCHLEAR ANATOMY AND BIOMECHANICS1
Anatomy
Biomechanics
DIAGNOSIS OF TROCHLEAR DYSPLASIA
History and Physical Examination
Radiographic Evaluation
CT Scan/MRI
Arthroscopy
INDICATIONS FOR A TROCHLEOPLASTY
CONTRAINDICATIONS
HOW DOES TROCHLEOPLASTY HELP?
TROCHLEOPLASTY
Elevation of the Lateral Trochlear Facet
Trochlear-deepening Procedure
Recession Trochleoplasty
SURGICAL TECHNIQUE
Deepening Trochleoplasty
Bereiter Or ‘Thin-Flap’ Technique
Arthroscopic Technique5,6
Recession Trochleoplasty8
POSTOPERATIVE REHABILITATION
COMPLICATIONS
OUTCOMES AFTER TROCHLEOPLASTY
CONCLUSION
PEARLS AND PITFALLS
CHAPTER 12:
Tibial Tubercle Osteotomy
INTRODUCTION
ESSENTIAL PRE-OP WORKUP
Clinical
Radiological
Mathematical
Medialization
Distalization
Combined Distalization and Medialization
SURGICAL TECHNIQUE
Positioning and Anesthesia
Examination Under Anesthesia and Diagnostic Arthroscopy
Tibial Tubercle Osteotomy
POSTOPERATIVE PHYSIOTHERAPY AND FOLLOW-UP
PEARLS AND PITFALLS
CHAPTER 13:
Nonsurgical and Surgical Management of the Lateral Patellar Compression Syndrome
INTRODUCTION
PATHOANATOMY
DIAGNOSING THE LATERAL PATELLAR COMPRESSION SYNDROME
NONSURGICAL MANAGEMENT OF LATERAL PATELLAR COMPRESSION SYNDROME
Kinesiotaping
McConnell Taping
SURGERY
Inclusion Criteria
Exclusion Criteria
SURGICAL PROCEDURE
Arthroscopic Chondroplasty and Open Iliotibial Band Release
Postoperative Protocol
DISCUSSION
Advantages of doing Open Iliotibial Band Release
Advantages of the Patellar Chondroplasty
Advantages of the Lateral Retinacular Releases
CHAPTER 14:
Cartilage Lesions in Patellofemoral Instability
INTRODUCTION
DIAGNOSIS
Plain X-rays
CT Scan
MRI
Technetium Scintigraphy
Arthroscopy
WHICH LESIONS SHOULD WE TREAT?
Isolated Cartilage Defects
Generalized Cartilage Defects
DEFECTS TO TREAT
Conservative Treatment
Physical Therapy
Corticosteroids
Viscosupplementation
Nutritional Supplements
Injective Treatments
Arthroscopic Debridement and Lavage
Abrasion Arthroplasty
Operative Treatment
Subchondral Drilling
Autologous Chondrocyte Implantation (ACI)20
First Stage Surgery
Chondrocyte Cell Culture
Second Stage Surgery (Chondrocyte Implantation)
Matrix-associated ACI (M-ACI)
Autologous Matrix-induced Chondrogenesis (AMIC)
Biomimetic Scaffolds
POSTOPERATIVE REHABILITATION
OTHER TREATMENTS
Bone Marrow Stimulation Techniques
Mesenchymal Stem Cells
Bioactive Signals that Enhance Cartilage Repair
Gene Therapy for Cartilage Repair
SUMMARY
PEARLS AND PITFALLS
CHAPTER 15:
Patellofemoral Instability after Total Knee Arthroplasty
INTRODUCTION
ETIOLOGY
Surgical Technique
Femoral Component
Tibial Component
Patellar Component
Soft-tissue Imbalance
Other Causes
Component Design
DIAGNOSIS
Symptoms
Clinical Examination
Imaging Studies
TREATMENT
Revision
Secondary Patellar Resurfacing
Non-revision Reoperations
CONCLUSION
INDEX
TOC
Index
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