Abstract
Background
Recurrent patellar dislocation have become disabling condition and become a multifactorial disease with a spectrum different condition. Management of the disease remain difficult and controversial. Since it is related on functional anatomy and biomechanics of the patellofemoral joint, assessment of history and clinical evaluation of the patient are imperative to decide appropriate management plan. Surgical management is based on patients unique joint pathoanatomy and may be required different surgical approach either alone or in combination.
Case presentation
This case details the clinical evaluation and surgical management of a female 37 year-old with history of persistent knee pain, recurrent patellar dislocation, and genu valgum. Patient exhibit significant anatomical abnormalities, including laterally dislocated patella, shallow trochlear groove with an anke 155°, sulcus angle between medial and lateral femoral facet is 145°, tibial tuberosity to trochlear groove (TT-TG) distance >20 mm, and patella alta by measuring Insall – Salvati ratio ( 1.4 )
The surgical intervention involve lateral release and debridement arthroscopically, lateral open wedge distal femoral osteotomy, distalization and medialization of tibial tuberosity, and medial patellofemoral ligament (MPFL) reconstruction using gracilis tendon, resulting in successful realignment as confirmed by clinical evaluation and postoperative imaging. In this case, we can infer in addressing recurrent patellar dislocation with valgus deformity comprehensive surgical approach, we must consider complex anatomical variations, providing insight into effective management strategies.
Rehabilitation protocol was applied with passive knee flexion, isometric quadricep contraction and ankle pump. Partial weight bearing was allowed after 4 weeks and gradually return to full weight bearing. Improvement of the patient was measured using Kujala score, average Lysholm score, VAS score and Tegner score showed significant improvement
Discussion
When combination of treatments give patellar instability and function benefit with low rate recurrent instability. In mature skeletal, deformity can be assessed using Dejour criteria. It will lead to the variety of technically challenging surgical technique to reconstruct each found deformity. Medialization of TT combined with MPFL reconstruction can provide stability. Lateral opening wedge DFO medializes the tibial tubercle and decreased Q angle. In combination with lateral retinacular release help reduce subluxation vector on patella and decrease patellar instability
Conclusion
There is an important relationship between mechanical alignment and patellar instability. However there is no clear consensus on a consistent surgical algorithm. The outcome of this case suggests that combination of intervention associated with patellofemoral instability engender high satisfaction of the outcome