Case 6 Patellar Instability


Case 6
Patellar Instability
What happened ?                          Age at first dislocation ?                     Any Trauma ?
Other joint involved ?
Exposure - Patient standing with exposure upto umbilicus wearing undewear
Look
Alignment of lower Extremity
– Both patella facing forward ?
-At same level ?
                                                 -Any Genu Valgum  ?
Walking
Squatting
Skin normal
Quadriceps muscles wasting

Feel
Temperature
Palpation
-          Sost tissue
-          Deep
Trochlear Groove – tenderness
Patellar Surface
Knee ROM





Special Tests
                        Apprehension test at 30 degree flexion
Patellar Tilt > 20 degree abnormal
Patellar Glide > 2 1/2quadrant abnormal
Patellar Grind +
                                                               
Meaurement – Quadriceps muscle wasting and
Q-angle
Hip -  ROM – External rotation (ER) is more than Internal rotaion (IR) . In case of excess Femoral Anteversion , IR > ER
Thigh foot axis – just check it with eye balling
                




Discussion
X-ray –
1)AP and Lateral View Knee
            Osteochondral fragments
            Patella Baja (Insall Salvati Ration < 0.8 )
Patella  Alta ((Insall Salvati Ration > 1.2 )
(Insall Salvati Ratio – diagonal patellar length / patellar tendon length )

Bluemansat Line – at 30 degrees knee flexion in X-ray lateral film of knee , an imaginary line passing through roof of intercondylar notch . Patella lying above this line is also a Patella Alta.
2) Mechant’s View
            Patellar Tilt < 10 degrees
            Congruence angle -16 to -10
            Trochlear Dysplasia
2) MRI Knee – to see Articular lesion , stat of Medial Patellofemoral Ligament
3) CT Knee – to assess TT-TG distance




Pictures
Xray Knee Lateral View
To see Patellar Tilt Angle                                           
Suculus Angle
Congruence Angle
Page 12





CT – TT – TG distance





Types of Patellar Instabilities
Etiological Factors
1)Bony – Increased Q Angle, Trochlear Dysplasia
2) Malalignment – Excess femoral Anteversion , Tibial Extortion ,Genu Valgum
3)Soft tissue –Weak Vastus Medialis Obliqus , Tight lateral Retinaculum
4)Medial Patellofemoral Ligament Rupture
5)Ligamentous Laxity

Treatment
Depends on     Age ,
 Q – Angle ,
TT-TG (Tibia Tuberosity – Trochlear Groove ) distance

Conservative
1)Cylindrical Cast
2)Soft tissue Procedures
a) Above Patella
Lateral Retinacular Release
VMO Advancement
b)Below Patella
                        Roux-Goldthwait (medialization of lateral one third of patellar tendon )
                        Galeazi (rerouting Semi-tendinosis)
3)Bony
            a)Elmslie-Trillat – Medialization TT
            b)Fulkerson – Medialization and Anteriorization of TT
            c)Hauser – medialization , distal and posterior positioning of TT .
                        (Shortcoming – increases patellofemoral joint reaction force and not done anymore )
            d)Macquet – Anterior transfer –TT
                        High incidence of skin necrosis , compartment syndrome , no effect on         Q angle
               
                       
                             


How this  is Different from Habitual Dislocation of Patella ?
Patella Doesnot dislocate every time knee is flexed.

Cause of Habitual dislocation of Patella
Quadriceps Contracture , Hypoplasia of Patella ,Iliotibial band (ITB) contracture , femoral dysplasia




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