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patellofemoral instability
- 1. Patello femoral instability Casepresentation Dr. Moahammadreza Piri Orthopaedic surgeon, Isfahan university of medical sciences, Iran 1
- 2. Case number 1 History: 40year-old female History of falling down and left patellar dislocation ten years ago with recurrent dislocation of patella Complaining of knee pain and patellar instability Arthroscopic surgery ten years ago 2
- 3. Physical exam PositiveJ sign Positive glide test Positive grind test Positive apprehension test Positive patellar tilt Q angle:27 Positive active tracking test 3
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- 9. Case number two history: 33 year-old female with past history of falling down and patellar instability Many unsuccessful periods of non operative treatment including rehabilitation 9
- 10. radiography Femoral anteversion:24 RT TT-TG:35.6 LT TT-TG:33.6 RT sulcus angle:166 LT sulcus angle:175 10
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- 14. Anatomy and biomechanics Extensormechanism: Vastus lat.: 7-10degree Vastus med longus: 15-18degree Vastus med obligus: 55 degree VMO is the main dynamic stabilizer of patella 14
- 15. Primary stabilizers (static factors) 1-shapeof patella 2-femoral sulcus 3-normally tensioned m.capsule 4-appropriate length of patellar tendon 15
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- 18. Q Angle normalrange:M:8-10, F:10-15 DDx: 1-genu valgus 2-increased femoral anteversion 3-ext. tibial torsion 4-laterally position of tibia tubercle 5-tight lat. retinaculum 18
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- 20. Physical examination • Palpation •P. glide test(20° flexion and extension) • P. tilt test (extension) • Apprehension test • J sign • Active tracking • Hyperlaxity • Thigh-foot angel • Observation for malalignment • Thigh circumference 20
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- 26. Patella alta Blumensaateline Insall ratio 1.2 Blackburne 1.06 caton-Deschamps 1.3 26
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- 30. CT scan Patellartilt Femoral anteversion External tibia torsion TT-TG distance 30
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- 34. MRI Chronic andrecurrent DX 1st DX in athletes 34
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- 36. Conservative treatment Acute patellaDx or Sx • Knee immobilizer + jones type dressing + Ice + crutch • Quadriceps setting excersises • Rehabilitation(closed-chain exccersise) • Patellar stabilizing brace for 6-8weeks 36
- 37. 37 Conservative treatment PF malaligmentand recurrent patellar Sx Rehabilitation(quadriceps) Patella stabilizer brace
- 38. Surgical treatment 38 Acute patellaDx • Osteochondral fx • Joint incongruity • Competittive athletes
- 39. 39 PF instability The keyto successful surgical interaction is correctly identifying and treating the pathologic anatomy producing the instability Factors in patella instability: • Trochlear dysplasia • Patella tilt • Patella alta • Excessive TT-TG distance Surgical treatment
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- 43. Lateral release 43 Isolated: parapatellarpain secondary to exccesive lateral pressure syndrome: 1. negative patella tilt 2. <1 quadrant passive medial patellar glide In combination: in combination with realignment procedure when tight lat structures prevent patella centering
- 44. Proximal soft-tissue procedures •Insatability secondary to medial laxity • Fine –tuning at distal realignment procedure • Skeletaly immature patients • Acute MPFL tear: MPFL repair Mild to moderate chronic medial laxity: imbrication Moderate to severe chronic medial laxity: MPFL reconstruction 44
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- 47. Distal realignment Malaligment Q angle 20 TT-TG 15 Chondromalacia in lat and inf of patella 47
- 48. Elmslie-trillat procedure transfer TTto medial Insall index 1.2 Grade 2 or less chondromalacia 48
- 49. Oblique osteotomy atthe tuberosity(Fulkerson) Transfer TT to ant and med Chondromalacia grade 3 or 4 49
- 50. Derotational HTO 50 Skeletalymature Thigh -foot angle 30 Tubercle sulcus angle 10
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- 52. Proposed treatmentfor case number one: MPFL reconstruction by STT + lateral release Proposed treatment for case number two: MPFL reconstruction by STT + lateral release + antromedialization of tibial tuberosity 52