Referat

PATELLA HABITUAL DISLOCATION

Arranged by: Melisa Esti Wahyuni G0007209

Tutor: dr. Tangkas Sibarani, SpOT, FICS

Clinical Department of Orthopaedic & Traumatology Sebelas Maret University Hospital of Dr. Moewardi/ Orthopaedic Hospital of Prof. Dr. Soeharso Surakarta 2012

LEGALY SHEET

Referat entitled Patella Habitual Dislocation is arranged to fulfill the requirement of clinical department of Orthopaedic & Traumatology Sebelas Maret University Hospital of Dr. Moewardi/Orthopaedic Hospital of Prof. Dr. Soeharso, by:

Melisa Esti Wahyuni

G0007209

Has been approved by the referat tutor of the Orthopaedic Hospital of Prof. Dr. Soeharso on February, 2012.

Tutor

dr. Tangkas Sibarani, SpOT, FICS

Patella Habitual Dislocation

Definition The term habitual or obligatory dislocation is preferred for patients in whom the patella moves in and out of its normal position in the trochlear groove whenever the knee is flexed or extended.1 It usually presents after the child starts to walk, and is often tolerated in childhood, if it is not painful. However, it may present in childhood with dysfunction and instability. The patella usually dislocates laterally in flexion and relocates in extension, but the opposite can occur.1

Etiology The etiology of habitual patellar dislocation is multifactorial and is often associated with anatomical abnormalities that predispose to patellar instability, including trochlea hypoplastic patella, genu recurvatum, hyperelastic status, deficient lateral femoral condyle, patellar alta, excessive femoral anteversion, and increased Q angle.2 There is a congenital abnormal insertion of a part of the iliotibial band in the superolateral pole of the patella. Some cases may have acquired injection fibrosis of the quadriceps.3 Acute patellar dislocation can result in anterior knee pain, recurrent dislocation and patellofemoral arthritis, but rarely in habitual dislocation, defined as a dislocation that occurs every time the knee is flexed.4

Clinical features The condition presents in childhood with the complaint of knee giving way and repeated falls and the slipping out of the patella. On examination gradual flexion of the knee will produce the dislocation of the patella laterally. The patella may be smaller and at a higher level (alta). A tight band may be palpable at the lateral pole of the patella. Holding the patella in the midline prevents the knee from flexion beyond 30 degrees. Releasing of the patella allows full flexion. There is a sudden expression of fear of dislocation on attempted flexion of the knee. This is called apprehension test.3

Presence of normal factor dislocation of the patella:. A) the ball on the line of bad either soft tissue or bone abnormalities, will lead to the ball on the line adverse soft tissue abnormalities include a lateral soft tissue contracture of the knee, medial laxity, Maissiat attached to abnormal lateral patellar ligament patellar point only partial, trauma leading to the medial patellar tendon and the inside with a serious injury, abnormal bone structure, including partial external tibial tubercle, the Q-angle greater than 15, the neck forward or femoral rotation femoral intercondylar notch morphological abnormalities, hypoplasia of the lateral condyle slightly below normal, knee valgus, tibial external rotation and so on. b) The morphological variation of the ball, inside the small ball or the ball and showed a convex half the angle between two faces in the shape of an acute angle, it tends to be larger patellar luxation. c) the ball high.5,6

Patellar Instability and Trochlear Hypoplasia Habitual patellar dislocation is often associated with anatomical abnormalities that predispose to patellar instability, including trochlea hypoplastic patella. Patellar instability associated with abnormal ligamentous laxity presents a considerable challenge. In patients with Downs syndrome the indication for patellar stabilisation has been questioned because of the frequent absence of symptoms or functional problems. The parents and children must be advised of the abnormal nature of their collagen and must recognise that surgical correction may not overcome this genetic predisposition to instability. 1

Image showing patella slipping laterally during flexion on a "skyline" projection

Trochlear hypoplasia is one of the common pathoanatomy associated with recurrent patellar dislocation. Sulcus angle and congruence angle on radiographs of the knee are the parameters to describe trochlear hypoplasia. However, they are not the predictors of the surgical outcome. The axial linear displacement measurement correlates well with the congruence angle and is a useful tool to evaluate patellofemoral congruence.2 Neither proximal nor distal realignment alone is adequate enough to correct trochlear dysplasia. Very little information has been written regarding the surgical treatment for trochlear hypoplasia. Trochlear osteotomy is difficult to perform and the long-term outcome is unknown. Furthermore, the effect of trochlear osteotomy on patellofemoral congruence is problematic and unresolved in long-term outcome. However, trochlear osteotomy can be modified to be more anatomic and less disruptive of the articular cartilage and can be used in conjunction with soft tissue balancing procedure.2

Treatment Traditionally, habitual dislocation has been treated in the same way as recurrent dislocation, except for the need for lengthening of the quadriceps tendon. Most authors have reported habitual dislocation in association with shortening of the quadriceps muscles, and consider that lengthening of the tendon is an essential part of the procedure to allow the patella to remain reduced after realignment. Contrary to the research by Joo et al, they have found that normal patellar tracking was maintained in our patients without lengthening of the quadriceps tendon.1 In most cases, patients with recurrent habitual dislocation of the patella require surgical intervention except occasional case report with successful conservative treatment.2 The goal of surgery is to restore normal patellar power lines and prevent recurrent dislocation of the patella should be as much as possible to correct the local pathological anatomy, the reconstruction of the extensor mechanism.7 Domestic and foreign literature on surgical treatment of many diseases, indicating that the cause of the disease caused by the complexity of these surgical procedures can be summarized into two categories: one for setting the ball power

lines to improve the function of the quadriceps or stability of the patella, patellar degeneration of the joint are not material including soft tissue surgery and bone surgery, and the other for the removal of the patella, the structure reconstruction of the quadriceps to a severe degeneration patellofemoral joint of the case should be different depending on the patient's age, degree of dislocation, a condition different local factors, select a different method to obtain good surgical results.8 The type of surgery varied according to the severity and the anatomical abnormality of the knee, and there is no single procedure that can address the complex pathoanatomy of the disorder. Traditionally, proximal realignment and distal realignment are most commonly used in the correction of patellar instability. The proximal realignment alters the medial-lateral position of the patella by reconstruction or repair of the MPFL, whereas distal realignment modifies the position of the patella by transfer of the tibia tubercle.9 Overall, the success rates of patellofemoral realignment were reported from 20% to 70%. In severe cases, combined trochleoplasty and tibia tubercle transfer is indicated to correct the recurrent dislocation of the patella.2 Tibia tubercle transfer has been proven to be effective for the treatment of patellar instability with patellofemoral malalignment.10 The procedure is designed to correct the Q angle by medialization and anteriolization of the tibia tubercle, that in turn, to unload the contact stress of the patellofemoral joint and increase or evenly distribute the patellofemoral contact area. In case of a multilayered patella in MED, habitual patella dislocation could be managed successfully by medialisation of the tibial tuberosity. Multiple epiphyseal dysplasia (MED) is a generalised skeletal dysplasia that is clinically and genetically heterogenous. Due to its clinical heterogeneity, it can be difficult to diagnose. Mutations of at least six separate genes can cause the disease: cartilage oligomeric matrix protein (COMP) gene, type IX collagen genes (COL9A1, COL9A2, COL9A3), matrilin 3 gene (MATN3), and diastrophic dysplasia sulfate transporter gene (DTDST).11 Molecular diagnosis is important for genetic counselling and for an accurate prognosis. The reported case of rMED demonstrates that homozygosity for C653S

mutation in the DTDST gene leads to a relatively mild phenotype that seems to be clinically dominated by a tendency to recurrent dislocation of a bilateral multilayered patella and by early-onset osteoarthritis of the hip joints.11 Another research reports the results of pes anserinus insertion as a dynamic transfer for habitual dislocation of the patella. Dynamic stabilisation of the patella in habitual dislocations yields more successful results. Preserving the vastus medialis helps prevent the extensor lag that usually occurs after these procedures. Abnormal insertion of the vastus lateralis and a tight iliotibial band were identified as the main causes of the dislocation. The failure of reconstructive procedures is perhaps due to the inadequate strength of the soft tissue used as a static medial stabiliser of the patella.12

REFERENCES 1. Joo, et al. The four-in-one procedure for habitual dislocation of the patella in children. J Bone Joint Surg [Br] 2007;89-B:1645-9. http://web.jbjs.org.uk/content/89-B/12/1645.full.pdf+html 2. Lin, Chia-Wei, et al. Surgical treatment of recurrent habitual patellar dislocation associated with severe trochlear hypoplasia and generalized ligament laxity. Formosan Journal of Musculoskeletal Disorders 2 (2011) 20e23.http://download.journals.elsevierhealth.com/pdfs/journals/22107940/PIIS2210794010000428.pdf 3. Anonym. Dislocation of radiography.net/radpath/d/disloc_patella.htm Patella. http://www.e-

4. Ohki et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2010. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949754/pdf/1758-2555-223.pdf 5. J. Andrish surgical options for stabilizing the patella in skeletally immature patients [J] Sports Med Arthrosc, 2007.15 (2). 82 88. 6. G. Harasen patellar luxation: pathogenesis and Surgi cal correction [J] Can Vet J, 2006.47 (10). 1037 1039. 7. Koter S, D pakva, CJ van Loon, and al.Trochlear osteotomy for patellar instability: satisfactory results at least 2 years in patients with dysplasia of the trochlea [J] Knee Surg Sports Trauma Arthrosc, 2007, 15 (3). : 228 232. 8. Arendt EA, Fithian DC, Cohen E, and concepts lateral patellar dislocation al.Current [J] Clin Sports Med, 200,221 (3): 499. 519. 9. A. Tom, J.P. Fulkerson. Restoration of native medial patellofemoral ligament support after patella dislocation. Sports Med Arthrosc 15 (2007) 68e71 10. A. Kumar, S. Jones, D.R. Bickerstaff, T.W. Smith. Functional evaluation of the modified Elmslie-Trillat procedure for patello-femoral dysfunction. Knee 8 (2001) 287e292.

11.

Hinrichs et al. BMC Musculoskeletal Disorders 2010, http://www.biomedcentral.com/content/pdf/1471-2474-11-110.pdf

11:110

12.Rasool, M.N. Pes Anserinus Transfer for Habitual Dislocation of The Patella in Children. J Bone Joint Surg Br 2003 vol. 85-B no. SUPP II 149-150 http://proceedings.jbjs.org.uk/content/85-B/SUPP_II/149.7.abstract