Introduction
The Surgical Management of Patellofemoral Instability Masterclass, taught by Prof Julian Feller and Randall Cooper, provides a complete overview of the assessment and management of patellofemoral instability. This Executive Summary provides clinically relevant, actionable information that may be useful to health professionals.
Part 1 - Physical Assessment
The patellofemoral compartment can be a challenging joint to manage with surgery often being the last resort. During the clinical examination, observe the knee first, then assess effusion, range of motion, special ligament tests (e.g ACL/PCL, MCL/LCL), hip rotation, patella mobility/position, a Beighton score screening for hypermobility and functional movement.
- If there is a positive patella apprehension sign, also determine at which degree of knee flexion that apprehension goes away.
- Observe the patella height when the knee is at 90 degree flexion.
- Palpate the tibial tubercle and patella tendon to consider other growth plate related pathologies such as Osgood-Schlatters disease or Sinding-Larsen and Johansson syndrome.
Part 2 - Assessment Considerations
During the subjective interview, it is important to gain an understanding of the patient’s mechanism of injury, any previous dislocations and to rule out a possible ACL injury. The risk factors for patella instability include trochlear dysplasia, previous contralateral dislocation, skeletal immaturity and patella alta. The surgical route is always dependent on the symptoms, goals and lifestyle of the patient.
- Try to distinguish between a subluxation versus a dislocation when performing the subjective interview.
- Avoid splinting the knee into full extension for first time dislocations, as it will not aid in the healing. It is better to do early mobilisation and begin quadriceps exercises.
- If the patient has an osteochondral defect e.g loose body, it is worth getting a surgical opinion.
Masterclass Preview
Check out this free preview of Julian discussing risk factors for recurrent episodes of instability
Part 3 - Management
The surgical options of recurrent patella instability include MPFL reconstructions, Tibial Tubercle Transfers, Trochleoplasty and/or an osteotomy. For the younger patient, it is important to consider their bony maturity for any bony procedure.
- For a MPFL reconstruction surgery, the graft from the semitendinosus tends to give hamstring symptoms, therefore the gracilis is the preferable option.
- The Trochleoplasty has potential to create a painful and stiff knee post surgery due to the nature of the surgical procedure.
Part 4 - Rehabilitation and Patellofemoral Pain
Post operative rehabilitation largely depends on the procedure and the preference of the surgeon. Surgery such as a lateral release, lateral patella facetectomy or patella replacement for patellofemoral pain is rarely indicated, however may be considered as a last resort.
- Try to achieve early flexion through the knee by utilising the stationary bike rather than from overpressure hands-on mobilisation performed by the clinician.
- Performing a chondroplasty on an arthritic patellofemoral joint can bear good results to patient symptoms.
