How long does it take to recover from a dislocated kneecap. What are the symptoms of a dislocated patella. When is surgery necessary for a dislocated kneecap. How common are patella dislocations in athletes. What causes a kneecap to dislocate. How is a dislocated patella diagnosed and treated.

Understanding Patella Dislocations: More Common Than You Think

Patella dislocations are far more prevalent than previously believed. Many people associate a popping sensation during a sports injury with an ACL tear, but it’s becoming increasingly clear that a significant portion of these incidents are actually patella dislocations. These injuries can be just as painful as ACL tears and present similarly, often leaving athletes unaware that their kneecap has momentarily shifted out of place.

A typical scenario for a patella dislocation involves a sudden twist or turn, followed by a loud pop in the knee. The injured person is unable to walk and experiences significant pain. While this description might sound like an ACL tear, it’s crucial to consider that it could be a dislocated kneecap.

Why do patella dislocations occur?

The kneecap, or patella, sits in a groove on the front of the knee, known as the femoral groove or trochlea. It moves up and down within this groove, held in place by muscles and ligaments. During a severe twisting injury, the kneecap can be forced out of this groove, resulting in a dislocation.

Anatomy and Mechanics of the Kneecap

To understand patella dislocations better, it’s essential to grasp the anatomy of the kneecap and its surrounding structures.

What is the structure of the kneecap?

The patella is an oval-shaped bone that sits within the femoral groove (trochlea) on the front of the knee. Its stability is maintained by two primary ligaments, with the medial patellofemoral ligament (MPFL) playing a crucial role. When the MPFL is stretched or torn, the kneecap becomes more susceptible to dislocation, particularly towards the outer (lateral) side of the knee.

What factors contribute to kneecap stability?

The stability of the patella depends on several factors working in harmony:

• Quadriceps muscles
• Bone anatomy, particularly the depth of the femoral groove
• Quality and integrity of the stabilizing ligaments, especially the MPFL
• Strength and balance of hip and pelvis muscles

Causes and Risk Factors for Patella Dislocations

Several factors can contribute to the likelihood of experiencing a patella dislocation:

1. Trauma: A strong impact on the inner side of the kneecap can force it out of place.
2. Femur rotation: The alignment of the femur affects the orientation of the femoral groove.
3. Ligament status: Torn or loose ligaments increase the risk of dislocation.
4. Femoral groove depth: A shallow groove provides less stability for the kneecap.
5. Patella tendon attachment: An abnormal attachment point can affect kneecap tracking.
6. Patella alta: A high-riding kneecap is more prone to dislocation.

How does muscle strength affect patella stability?

Strong and well-balanced quadriceps muscles are essential for maintaining proper kneecap alignment. Additionally, the strength of hip and pelvis muscles plays a crucial role. Weak hip muscles can lead to abnormal femur rotation, potentially putting the patella at risk for dislocation.

Trochlear Dysplasia: A Key Factor in Recurrent Dislocations

Trochlear dysplasia refers to a condition where the femoral groove (trochlea) is not as deep as it should be, sometimes even appearing flat. This anatomical variation can significantly increase the risk of recurrent patella dislocations.

How is trochlear dysplasia diagnosed?

Trochlear dysplasia is typically identified through MRI scans. Reports may describe the condition as mild, moderate, or severe. Understanding the degree of trochlear dysplasia is crucial in assessing an individual’s risk for future dislocations and determining the most appropriate treatment approach.

Symptoms and Diagnosis of Patella Dislocations

Recognizing the signs of a patella dislocation is crucial for prompt and effective treatment.

What are the primary symptoms of a dislocated kneecap?

The most common symptoms of a patella dislocation include:

• A sudden, audible pop in the knee
• Intense pain, particularly in the front of the knee
• Inability to bear weight on the affected leg
• Visible deformity of the knee (in cases where the kneecap remains dislocated)
• Swelling and bruising around the knee joint

How is a patella dislocation diagnosed?

Diagnosing a patella dislocation typically involves:

1. Physical examination: A healthcare provider will assess the knee’s appearance, range of motion, and stability.
2. Imaging studies: X-rays can confirm the position of the kneecap and rule out fractures. MRI scans may be ordered to evaluate soft tissue damage and assess the femoral groove anatomy.
3. Patient history: Understanding the mechanism of injury and any previous knee problems is crucial for accurate diagnosis.

Treatment Options for Patella Dislocations

The appropriate treatment for a patella dislocation depends on various factors, including the severity of the injury, whether it’s a first-time or recurrent dislocation, and the presence of any associated injuries.

What is the initial treatment for a dislocated kneecap?

Immediate treatment for a patella dislocation typically includes:

• Reduction: If the kneecap remains dislocated, a medical professional will carefully manipulate it back into place.
• RICE protocol: Rest, Ice, Compression, and Elevation to manage pain and swelling.
• Immobilization: A knee brace or splint may be used to stabilize the joint and protect it from further injury.
• Pain management: Over-the-counter or prescription pain medications may be recommended.

When is surgery necessary for a dislocated patella?

Surgery may be considered in the following situations:

1. Presence of loose bone or cartilage fragments in the joint
2. Significant damage to the medial patellofemoral ligament (MPFL)
3. Recurrent dislocations despite conservative treatment
4. Severe trochlear dysplasia contributing to instability

Surgical options may include MPFL reconstruction, tibial tubercle transfer, or trochleoplasty, depending on the specific factors contributing to the instability.

Rehabilitation and Recovery Process

Proper rehabilitation is crucial for successful recovery from a patella dislocation, whether treated surgically or non-surgically.

What does the rehabilitation process involve?

A typical rehabilitation program may include:

• Physical therapy exercises to improve range of motion, strength, and stability
• Gradual return to weight-bearing activities
• Proprioception and balance training
• Specific exercises targeting the quadriceps, hip, and core muscles
• Gait training and sports-specific exercises for athletes

How long does it take to recover from a dislocated kneecap?

Recovery time can vary significantly depending on the severity of the injury and the chosen treatment approach. In general:

1. For non-surgical cases: Full recovery may take 6-8 weeks, with a gradual return to sports activities over 3-4 months.
2. For surgical cases: Recovery can take 4-6 months, with a return to high-impact sports potentially delayed for up to 6-12 months.

It’s important to note that each case is unique, and recovery timelines should be individualized based on the patient’s progress and the guidance of their healthcare team.

Prevention Strategies and Long-Term Outlook

While not all patella dislocations can be prevented, there are strategies to reduce the risk of initial or recurrent dislocations.

How can the risk of patella dislocations be reduced?

Preventive measures may include:

• Strengthening exercises for the quadriceps, hip, and core muscles
• Improving flexibility and range of motion in the lower extremities
• Using proper techniques during sports and physical activities
• Wearing appropriate footwear and considering the use of knee braces during high-risk activities
• Addressing any underlying biomechanical issues or muscle imbalances

What is the long-term outlook for individuals who have experienced a patella dislocation?

The long-term prognosis for patella dislocations can vary:

1. First-time dislocations: With proper treatment and rehabilitation, many individuals can return to their previous level of activity without recurrence.
2. Recurrent dislocations: These cases may require more aggressive treatment, including surgery, to achieve long-term stability.
3. Risk of arthritis: Patella dislocations can increase the risk of developing osteoarthritis in the knee joint over time, particularly if there is associated cartilage damage.

Regular follow-up with healthcare providers and maintaining a consistent strength and flexibility program can help optimize long-term outcomes and minimize the risk of future complications.

It Is More Common Than You Think

Patella dislocations are far more common than we previously thought. Many people assume that an athlete who feels a pop during an injury has torn their ACL.  It is now clear that a certain percentage of these athletes have dislocated their patella. These injuries are just as painful as ACL tears and present in a similar manner. Most athletes just feel a pop when they twist and turn. They often do not know that their patella or kneecap dislocated and went back into place on its own.   

A typical story for someone who dislocated their patella.  You turned or twisted and tried to accelerate rapidly to the ball.  Your knee lets out a loud pop.  You are on the ground, you can’t walk, and you are wondering what you just injured in your knee.  That pop could mean that you dislocated your patella or kneecap.  Many knee injuries cause a snap or a pop.  Most of us think of ACL tears when we hear this story.  But patella or kneecap dislocations are more common than we think.  

The kneecap or patella “floats” in a groove on the front of your knee.  It travels up and down in that femoral groove and is held in place by muscles and ligaments. After a severe twisting injury, the kneecap can dislocate and come out of its groove.

After being carried off the field, what are your next steps?

Turning and twisting during sports puts a lot of stress on the kneecap. What most people are not aware of is that many athletes who felt a pop in the front of their knee during sports actually had a dislocated patella.  The kneecap is also called the patella.  Patella dislocation occurs when the bone slides out of a groove which normally holds the kneecap in place. A dislocation of the kneecap can lead to long term issues such as recurrent dislocations, cartilage injury or arthritic change.  The treatment of a kneecap dislocation and whether or not surgery is necessary will depend on many issues which we will discuss here.

Issues that contribute to patella or kneecap dislocations include: 

1. trauma- a strong hit on the inner side of your kneecap can cause it to dislocate.
2. How your femur is rotated. Technical subject, but this determines which was the femoral groove will face. 
3. the status of your ligaments holding the kneecap in place. Are they torn? Are they just loose? 
4. How deep the “femoral groove” is. 
5. Where your patella tendon attaches to your tibia. Sometimes it is too lateral– we will discuss this soon.  
6. How “high” your patella is. Patella alta, or a high patella is a risk factor for patella dislocations. 

Anatomy of the Kneecap

The kneecap or patella is an oval shaped bone that sits in the femoral groove on the front of your knee.  The femoral groove is called the trochlea.  The kneecap stays in the trochlea groove because of two ligaments that try and prevent it from slipping out.  The ligament which appears to cause the most trouble is the medial patellofemoral ligament or the MPFL.  If the MPFL is stretched or torn, then your kneecap can dislocate. After a traumatic sports injury, the MPFL is usually torn.   When the MPFL is torn, the patella has lost critical support to stop it from dislocating towards the outer side, or lateral side of the knee.

Why Did My Kneecap Dislocate?

Stability or the patella, or its ability to stay in its normal position depends on many different ligaments and muscles working well.  It is also dependent on the shape of your bones.  Not everyone has the same boney anatomy.  In all, the stability of the kneecap is determined by:

• the quadriceps muscles
• the anatomy of your bones – specifically the femoral (trochlea) groove and how deep the groove is.
• the quality of the ligaments(MPFL) that hold the patella in place.

All of the above contribute to keeping the kneecap in place.

1. Your quadriceps muscles need to be strong and well balanced  For that matter, so do the muscles of the hip and pelvis.  If those muscles are weak, they will affect the stability of your kneecap.  For example.  Weak hip muscles allow your femur or thigh bone to externally abnormally.   That can put the patella in an at risk position to jump out of the femoral groove.

2. Discussing the anatomy of your kneecap and the femoral groove that it sits in is a difficult topic to understand.  Many people have a femoral groove on the femur that isn’t very deep.  That’s how you were born. If that femoral or trochlea groove is not very deep we refer to it as being “dysplastic.” 

Many of you who have MRI reports that state that you have mild, moderate or severe “trochlea dysplasia”.  Trochlea dysplasia means that the groove on the front of your femur isn’t very deep, or perhaps it is completely flat.  Trochlea dysplasia can have a significant influence on whether or not you are at high risk for recurrent patella dislocations.  In addition, if you have had more than one patella dislocation, the presence of trochlea dysplasia can affect our decision making about which surgical procedure might be best for you.

3. The MPFL or the medial patellofemoral ligament is the most important structure when it comes to determining why your kneecap dislocated. Certain people have loose ligaments. In those instances, a loose MPFL can let the kneecap jump out of the groove and dislocate.  In sports, the MPFL is usually torn due to injury.  After an injury on the field, the MPFL likely tore when your kneecap dislocated.  If the MPFL is torn, then the patella will be at risk of dislocating again in the future.  In the picture below, the MPFL has torn and that has allowed the patella to dislocate over onto the lateral side of the knee.

How did I tear my MPFL ?

The MPFL can tear because of two different types of injuries.  These can be contact or non contact injuries. Contact injuries imply that you were running and your kneecap was struck or hit by someone.  If you are struck on the inside of your kneecap then the MPFL might tear, thus allowing the patella to slide out of place resulting in a dislocated kneecap.  The more common injury is that your knee was bent when you twisted and tried to turn and run.  That puts a lot of stress on the MPFL, and can cause it to tear. So, similar to ACL injuries there are contact and non-contact injury mechanisms.

We know that most ACL tears in the knee occur due to non-contact twisting or pivoting injuries.  The same is true for kneecap or patella dislocations.  Interestingly, most people who have a patella dislocation will not notice that the patella is out of place.  That is because the kneecap will often reduce or move back into place right after the dislocation.  This is known as a spontaneous relocation or reduction where the patella came out of place and then immediately went back into place.  Some of you may notice that the kneecap is out of place. These are very obvious injuries because the front of your knee just looks very strange.  In those cases, your Athletic Trainer or an Emergency Room physician will put the kneecap back into position with a big push.

How Do I Treat My Dislocated Kneecap?

The initial treatment of a patella dislocation is to have the patella reduced.  This should be done on the field by the Athletic Trainer or sideline physician.   Once the patella is in the proper position you will require an Xray to be sure there are no fractures present.  You will need crutches and you will likely need an MRI to be sure that you did not injure the cartilage when the patella slid out of place.

How we proceed after the initial treatment will depend on whether or not this was your first patella dislocation or whether or not you have now had more than one patella dislocation.  Most people with more than one kneecap dislocation will require surgery.  Very few people will need surgery to treat their first patella dislocation.

The treatment for a dislocated kneecap will depend on what parts of the knee were injured when the patella came out of place.  When you dislocate the kneecap you usually tear a ligament (MPFL) which holds the patella in place (Read below for MPFL reconstruction discussion).  After a traumatic patella dislocation, we have to obtain an MRI.  The MRI will not only show if the MPFL has torn, but it will show if you also injured the cartilage on the patella.   Many athletes will also injure the cartilage on the patella. Many cartilage injuries are small, and do not require treatment.  Some cartilage injuries are larger and may require a repair to decrease the risk of developing osteoarthritis.

This may be your first kneecap dislocation… and for others you have now had two or three dislocations.  Depending on what structures you have injured and how many dislocations you have had will determine what your doctor will tell you regarding your treatment options. In athletes with more than one patella dislocation surgery is often advised.  The type of surgery needed to stop your patella from dislocating will depend on your anatomy (as seen on the MRI), and the integrity of the MPFL.

Most people who dislocate their kneecap notice that the kneecap is not out of place.  That means that it spontaneously reduced and went back into place.  If you felt the knee pop and your knee looks distorted or strange then your kneecap is still dislocated.  That will require a trip to the emergency room if you do not have an Athletic Trainer to put the kneecap back into place.  The sooner the kneecap is reduced the better.

Your knee will swell a lot after a patella dislocation.  This is due to bleeding.  The bleeding will stop, but it will take a few weeks to get your normal motion back.  A physical therapist or Athletic Trainer will be very important as a guide.  Sometimes we will aspirate or remove the blood from the knee, but that is not always necessary.

If you suspect that you had a dislocated kneecap is very important that you see a Sports Medicine Doctor.  Many different injuries can occur after the dislocation. We will need to check to make sure that you did not damage the cartilage on the kneecap or the femur.  Some cartilage injuries can be severe and require treatment sooner rather than later.  We will also be able to determine if your MPFL is torn.

An MRI is almost always necessary after a kneecap dislocation.  The MRI will show if the cartilage has been damaged.  The MRI will also show if the MPFL is torn, and it will also tell us about the anatomy of your bones.  That means that we can tell how deep the groove is that the patella sits in.  Using the information from the MRI and from our examination, we can determine your risk for a second or third dislocation.

Patella dislocation recovery time

The recovery time from a kneecap dislocation will depend on whether or not this was your first dislocation or your second or third.  Your recovery time will also depend on whether or not you have injured the cartilage on your kneecap or patella.

• If this was your first patella dislocation and you do not have an injury to the cartilage then we usually start your physical therapy soon after the injury.  Most people who have had their first patella dislocation will not require surgery.  Many athletes will be able to return to sports within  6-12 weeks after therapy has started.
• If this was your first dislocation and you did have a cartilage injury then you may require surgery to repair the cartilage.  That recovery process will take 4-6 months to allow the cartilage to heal.
• If you have now had more than one patella dislocation then you will need to consider surgery to repair or reconstruct the MPFL ligament which holds the kneecap in place (see below).  Recovery from MPFL ligament surgery can take 6-10 months before considering a return to sports.  There are other procedures available to stabilize the kneecap to prevent further dislocations.  The MRI will help to guide us in determining which procedure is necessary to give you the best chance of having a stable patella.

Does a kneecap dislocation require surgery?

Surgery for patella or kneecap dislocations can be tricky. After you have had more than one dislocation you will likely need surgery to stop the kneecap from dislocating again.  The type of surgery you need will depend on your physical examination and it will depend on your x-ray and MRI findings.   Many unstable kneecaps can be repaired with surgery to fix or reconstruct the MPFL ligament alone.  If you have other issues which show up on your MRI then we may need to consider additional procedures to repair your kneecap to prevent it from dislocating again.

Just to review.  Determining if you need surgery for a patella dislocation involves many different considerations.  We need to determine:

• Was this your first dislocation?
• Was the cartilage damaged?
• Does the cartilage need to be repaired?
• Is your MPFL torn?
• Does your bone anatomy affect your risk?

Most people who have had only one dislocation and do not have any cartilage damage do not need surgery.  You will be rested to let the MPFL try to heal.  Then you will be placed into physical therapy to rehabilitate the knee.

If you have a repairable cartilage injury then we will likely suggest surgery to repair the cartilage, and repair the MPFL ligament at the same time.

MPFL Reconstruction for a patella dislocation

The MPFL is the ligament in the knee which holds the patella or kneecap in its proper position.  It is the ligament that prevents the kneecap from sliding out laterally and dislocating.  If you have had recurrent patellar instability, eg. you have dislocated your patella more than one time, then your MPFL is not working or has stretched out too much to function well.  In order to restore stability to your kneecap we need to consider an MPFL reconstruction.  During an MPFL reconstruction, we will recreate the ligament which will stop the patella from dislocating.

In the picture below you will notice that the MPFL is attached to the kneecap and it is attached to the thigh bone or femur.

During surgery for an  MPFL reconstruction, we will create a small hole in the femur.  That hole will be in a very specific place. We determine where that place is by using a special x ray machine during the surgery.  Once we determine where the hole is we will place your new ligament into that hole and secure it there with a screw.   Now that the new ligament is attached to the femur we need to attach it to the patella.  The new MPFL should have at least two attachment points on the patella.  We will usually stitch or suture that new ligament against the patella.  Overtime that new ligament will heal to the femur and the patella.

For those of you considering surgery for a patella dislocation, your choice of surgeon is very important.  Not many surgeons have the experience necessary to maximize your chance of success. This can be a very challenging surgery for many people.

MPFL Reconstruction Recovery Time

After your MPFL surgery you will need time to allow for the pain and swelling to diminish.  We will brace your knee for a few weeks to limit how much you can bend it.  Within two weeks we will start your physical therapy.  You will not be able to bend the knee beyond 90 degrees for two-three weeks.  We will then allow your physical therapist to start more aggressive rehabilitation.

It will take 6-10 months to recover from an MPFL reconstruction and be able to consider a return to sports. Trying to return to sports too soon following MPFL surgery will put you at risk for developing another injury because your new ligament might stretch too much.

Take Home Message: 

If you have had more than one kneecap dislocation then you will need to consider surgery to repair or reconstruct the MPFL (medial patellofemoral ligament) in order to minimize the risk of another dislocation. Each time your kneecap dislocates there is a risk that you will damage the cartilage.  It is therefore a good idea to repair the kneecap to prevent further damage after your second dislocation.

We created this video which helps you understand our decision making when we consider which operation might be best for your dislocated kneecap. 

In future posts I will go into more depth about the various surgical techniques used to prevent the patella from dislocating again.   This is a very complicated process.  Be sure that you are seeing a physician who is very experienced in managing kneecap or patella dislocations.

Medial patellofemoral Ligament (MPFL) Reconstruction

What is the medial patellofemoral ligament (MPFL)?

The medial patellofemoral ligament is a part of the complex network of soft tissues that stabilize the knee. The MPFL attaches the inside part of the patella (kneecap) to the long bone of the thigh, also called the femur.

Together, the patella and femur compose the patellofemoral joint.

Injury to the MPFL can occur when the patella dislocates or becomes subluxated (partially dislocated) due to a trauma experienced during athletics or an accident, as a result of naturally loose ligaments – most frequently seen in girls and women – or due to individual variations in bony anatomy. People with these injuries are described as having patellar instability.

What is MPFL reconstruction?

MPFL reconstruction is a surgery in which a new medial patellofemoral ligament is created to stabilize the knee and help protect the joint from additional damage.

It offers an excellent treatment option for people who have experienced more than one dislocation. The procedure is relatively new. Historically, although some patients benefitted from surgery to tighten the damaged ligament, as recently as around 2006, many individuals with damage to the MPFL had few treatment options beyond immobilization and rehabilitation.

Injury to the MPFL

In the healthy knee, the bones that make up the patellofemoral joint move smoothly against one another as the joint is flexed or extended. The patella glides in a trochlea (groove) of the femur. The MPFL plays a particularly important role in keeping the patella on track (that is, in this groove) by acting like a leash that restrains the patella’s movement.

When patellar dislocation occurs, soft tissues are damaged as the patella “jumps” the track and then comes forcibly back into place. Because the kneecap dislocates toward the outside of the leg, the ligament on the inside of the knee (the MPFL) gets torn.

Left untreated, an injured MPFL can heal on its own. However, when left alone, the ligament heals in a loosened, lengthened position. This causes instability that makes it easier for the patella to become dislocated again in the future. This, in turn can cause damage to the cartilage in the knee. While the pain, swelling and disability associated with a dislocated kneecap are problems in themselves, the greater concern is subsequent injury to the cartilage that covers the ends of the bones where they meet in the knee joint. Once this cartilage is damaged, you are put at a high risk of developing patellofemoral arthritis, a significantly more difficult condition to treat. For this reason, it always advisable to get treatment that will help prevent further dislocations of the kneecap.

MPFL reconstruction animation

Watch this animation video to understand how MPFL reconstruction surgery works.

MPFL reconstruction protocol

At the Patellofemoral Center at HSS, patients with patellar instability undergo a thorough assessment that includes a physical examination and review of the patient’s medical history. A magnetic resonance imaging (MRI) is also performed to help the doctor understand the condition of the cartilage in the patellofemoral joint and helps determine whether the patient is a candidate for MPFL or a bony procedure, such as tibial tubercle transfer. Often, these images can be obtained on the same day as an initial visit.

Although non-operative treatment does not have a significant role in the treatment of patellar instability, if the patient has experienced a single dislocation without a cartilage injury on MRI he or she will be treated with short term immobilization and physical therapy. Almost all candidates for MPFL reconstruction have dislocated their knee more than once, and in some cases may have experienced multiple dislocations. (MPFL may be performed in a patient who has had single dislocation, but only in the presence of other problems in the knee that also require surgical intervention.)

Patients undergoing MPFL reconstruction receive regional anesthesia – an spinal nerve block that numbs the lower half of the body – and sedation. The orthopedic surgeon then replaces the injured ligament with a portion of a tendon taken either from the patient’s own hamstring or from donor tissue. An arthroscope is used to view the surgical area, and the ligament reconstruction is conducted using two small incisions. The entire surgery takes about an hour, and patients return home the same day, with their knee stabilized in a brace.

MPFL reconstruction produces excellent results and has a very low rate of complication. Rare complications can, however, include fractures, infections or blood clots. The procedure can be performed safely in children with open growth plates (the area where bone grows), as opposed to surgical approaches that change bone alignment and which are not appropriate in young patients. With no alternative available, in the past, children were sometimes placed in a brace, but remained at risk for additional dislocations until they reached skeletal maturity, at which time a surgical reshaping of the bone (osteotomy) would become an option. Today, MPFL reconstruction is a safe option for children and teenagers.

In rare cases, people with patellar instability may be candidates for a surgical repair of their MPFL, rather than a complete MPFL reconstruction, such as when the MPFL has pulled a small piece of bone off the inside part of the kneecap.

MPFL reconstruction as a revision to prior, unsuccessful surgeries

Orthopedic surgeons at the Patellofemoral Center also perform MPFL reconstruction on patients who have had other, less successful surgeries to address the condition. Such prior surgeries may include:

• Arthroscopic, minimally invasive surgery in which torn tissue in the patellofemoral joint is “cleaned up”
• Medial imbrication, a procedure in which the surgeon tightens the MPFL by taking a “tuck” in it, similar to tightening a garment.
• Lateral release, in which the ligament on the outside part of the patellofemoral joint is loosened

Although a lateral release alone is not an effective surgical option for patellar instability, this procedure may be done in conjunction with an MPFL reconstruction to address other problems in the joint and to restore balance in the knee.

Tubercle tibial transfer or osteotomy may also be done in conjunction with an MPFL in patients who have significant mal-alignment of the bones in the patellofemoral joint. This procedure is recommended for patients who have an anatomical abnormality in which the patella tendon attaches to the tibia in such a way that there is a severe sideways pull on the patella.

Those who undergo MPFL reconstruction as a revision surgery generally experience a considerable improvement in stability of the patellofemoral joint.

What to expect after MPFL reconstruction

Immediately following MPFL reconstruction, patients can bear weight on the affected leg, which is placed in a brace that is worn for six weeks. The brace keeps the leg straight during walking. During recovery, a continuous passive motion machine (CPM) is used at home to avoid scar tissue and stiffness from developing in the joint as the ligament heals. The CPM machine moves the patellofemoral joint without the use of a patient’s muscles.

Once the quadriceps (the major muscle in the thigh) is strong enough to support the joint, the patient can begin physical therapy. This is usually about six weeks after surgery. Other measures that can speed up recovery include devices that provide electric stimulation to the muscles around the knee and Game Ready, a machine that compresses and cools the leg, thereby reducing swelling and pain. (Insurance may not cover the cost of these devices.)

Most people can generally return to sport or play sometime between 4 to 7 months after MPFL reconstruction. If you are considering the surgery, be aware than recovery times may vary and can be dependent on your individual anatomy, capacity to heal and general health prior to surgery.

Summary by Nancy Novick

Posted: 6/27/2016

Authors

Beth E. Shubin Stein, MD

Associate Attending Orthopedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopedic Surgery, Weill Cornell Medical College

Sabrina M. Strickland, MD

Associate Attending Orthopedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College

Dislocated kneecap: When is surgery recommended? – InformedHealth.org

Surgery can stabilize the knee and lower the risk of the kneecap becoming dislocated again. It is considered after a second kneecap dislocation or if the knee is very unstable.

The doctor will first push the kneecap back into place. Then there are two treatment options:

• Conservative treatment: The kneecap is stabilized for a few weeks using a brace or bandage. Physical therapy is started at the same time, with the goal of strengthening the muscles that support the kneecap.

• Surgery: Doctors operate on the knee to stabilize the kneecap. During the surgery, cartilage or bone injuries may be treated or misalignments might be corrected as well. Physical therapy is started after surgery too.

What is currently recommended?

Experts often disagree on the issue of whether surgery should be done. Conservative treatment is typically used if it’s the first time you have dislocated your kneecap. If it happens a second time or if it keeps happening, surgery is usually considered. Other factors that also play a role include:

• Which conservative treatments have already been tried

• Whether cartilage or bone have been damaged

• Whether you have misalignments or other risk factors

• Age and sports-related goals

It’s a good idea to discuss the advantages and disadvantages of surgery with your orthopedist and then consider them on your own.

What are the different types of surgery?

There are many different kinds of surgery to treat an unstable kneecap. The basic types are:

• Surgery on the joint capsule and the ligaments: This involves tightening or replacing parts of the capsule and ligaments that stabilize the kneecap on the inner side of the knee, particularly including the medial patellofemoral ligament (MPFL, see illustration). This ligament is usually torn the first time the kneecap is dislocated. Then it can be replaced by part of a tendon taken from the back part of the thigh muscles. This procedure is supposed to ensure that the kneecap doesn’t slip out of place so easily outwards (in the lateral direction).

• Surgery on the bones to correct anatomical misalignments: These procedures can deepen the trochlear groove that the kneecap fits into. It is also possible to move the patellar tendon on the shinbone to the side. The aim of doing this is to keep the kneecap in the middle of the groove when force is put on it. Sometimes the axis (alignment) of the leg is also corrected by straightening the thigh and lower leg and stabilizing them with a plate.

The techniques that are considered depend on the anatomical form of the knee and leg.

Front view of right knee, with ligaments and thigh muscles

How effective is surgery?

Researchers from the Cochrane Collaboration analyzed six studies comparing surgery with conservative treatments. Nearly 350 teenagers and young adults participated in these studies.

Each of them had either conservative treatment or surgery. The surgery in these studies involved stitching and tightening the torn MPFL or replacing it with a tendon. There are currently no comparative studies on any of the other types of surgery.

The studies showed that the procedure can lower the risk of dislocating your kneecap again:

• Without surgery, 21 out of 100 participants dislocated their kneecap again in the following years.

• With surgery, 12 out of 100 participants dislocated their kneecap again.

It’s not clear whether the surgery led to a greater improvement in symptoms and knee function than conservative treatment did. Previous studies have not shown that surgery has any advantages here. Because only a few studies looked into these aspects, further research is needed.

Only one study provided information on the frequency of complications. A few of the people in this study had complications after surgery, such as an infection or a poorly healing wound.

Sources

• IQWiG health information is written with the aim of helping
  people understand the advantages and disadvantages of the main treatment options and health
  care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the
  German health care system. The suitability of any of the described options in an individual
  case can be determined by talking to a doctor. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a
  team of
  health care professionals, scientists and editors, and reviewed by external experts. You can
  find a detailed description of how our health information is produced and updated in
  our methods.

Patellar Dislocation | Medial Patellofemoral Ligament

Patellar (kneecap) dislocation is caused by an unnatural twist, or a blunt impact to the knee. If surrounding ligaments are weak, or if there is an anatomical predisposition, the chances for patellar dislocation increases. Following a patellar dislocation, the most important aspect is to relocate the kneecap back to its proper position, which means relocating the patella into the trochlear groove (groove for the kneecap in the front end of the thigh bone). This often happens spontaneously, or by straightening the leg, but sometimes requires an emergency room. The ligaments that hold the kneecap in place may tear, and pieces of the cartilage lining of the kneecap or trochlear groove may break loose. Without proper therapy, and in some cases surgery, recurrent dislocation, or subluxations (partial dislocation), of the patella can occur. Loose bodies can also cause catching, locking, buckling, or additional cartilage damage.

Symptoms and Diagnosis

Symptoms of a patellar dislocation include rapid, acute swelling and extreme pain. This extreme pain will exist until a relocation of the kneecap occurs; then, the pain will diminish. Other symptoms include the inability to move the knee, bruising, and deformity of the knee, because the kneecap is out of position.

If the kneecap dislocates and pops back into position (relocates) quickly, a more careful history and physical examination is required. Your physician will perform a thorough history and physical exam, but will also assess this injury using an X-ray and an MRI to confirm the diagnosis and to evaluate the medial patellofemoral ligament, loose bodies, cartilage, and other ligaments in the knee.

Treatment

Initial treatment for a patellar dislocation, once the dislocation has been reduced, is to immobilize the knee for a short period of time. For a first time dislocation, without loose bodies, non-surgical treatment with rehabilitation is recommended. Bracing the joint will allow the swelling to decrease and may help to stabilize the patella. Physical therapy is prescribed, and a full recovery can be expected within an 8-12 week period.

In many cases, once a patellar dislocation occurs, laxity of the ligaments (stretching) or complete tearing of the medial patellofemoral ligament will lead to recurrent dislocations or subluxations, or in some cases, loose bodies may occur. For recurrent dislocation, or for patients with loose bodies, surgery is recommended. Arthroscopic surgery is used to remove loose bodies and treat cartilage or other damage. Small incisions are used to repair or reconstruct the medial patellofemoral ligament (MPFL).

Post-Operative

Your physician will prescribe a progressive rehabilitation program that will initially consist of immobilization of the joint, followed by range of motion, strengthening, and physical therapy to regain function of the knee joint. A return to full activities can be expected as early as 8-12 weeks after surgery, depending on a patient’s goals. Athletes participating in contact sport may require additional time to ensure full healing.

Kneecap Dislocation Causes and Treatment

Photo Credit: MedScape.com

The first group may have a trauma to their knee such as being hit playing soccer, basketball, or football. This injury to the knee can cause the patella to move out of its joint, and in most cases will come right back in on its own. This is frequently referred to as a “dislocation” or “subluxation” event.

In the second group, you may simply have very loose ligaments or tendons that normally hold the patella in place, but due to their laxity the knee frequently dislocates or subluxates and causes pain.

For both groups, you may have subtle abnormalities in your anatomy that put you at risk for having one of these dislocation or subluxation events.

Will It Happen Again and Should I Be Worried?

In some instances, if this is the first time you have dislocated or subluxated your patella, it may not happen again. However, if there is significant damage caused by the dislocation or subluxation it is possible it may happen again. Your surgeon should evaluate you in clinic and will likely get an MRI to evaluate the degree of damage. If there is a significant amount of damage, especially of the cartilage, you may be indicated for surgery to fix this.

Do I Need Surgery?

Photo Credit: http://orthopaedics360. com.au/

If this is the first time you have had a dislocation or subluxation of the patella you may not need surgery. However, if there is evidence of damage to the bone, ligaments, or cartilage on MRI you may need surgery. You should meet with your surgeon and review the MRI together to discuss this further. Additionally, if this is a recurring problem you may need surgery to prevent you from creating further damage to the knee.

What Is It Like After Surgery?

After surgery you will typically go home that day. For the first 3-5 days your knee will be sore and a bit swollen from the surgery. During this time you will be applying ice to the knee, elevating your leg to help with swelling, and will need to take pain medications as needed for the first 3-5 days. You will be able to walk with crutches putting some weight on your knee immediately. You will also start physical therapy after the first week to begin strengthening your leg after surgery and to make sure you keep your normal range of motion.

Can I Go Back To Sports After Surgery?

Photo Credit: BroncoSports.com

The goal would be to get you to return to your previous sport at your previous level. The post-operative rehabilitation process will be key to getting your knee reconditioned to return to your sport. A typical timeframe to achieve a return to sport is 10-12 weeks depending on the sport you play.

When Do I Seek Further Evaluation?

If you have had a dislocation or subluxation event due to a trauma or have had recurring dislocation or subluxation events you should see a Sports Medicine trained physician not only to assess the injury but to prevent further injury to your knee. A thorough evaluation and discussion of your treatment options should be made by you, your parents (if you are less than 18), and your trainer/coach (if you are an athlete).

To set up an appointment for further evaluation, please call (208) 336-8250.

Patellar Instability | Johns Hopkins Medicine

What is patellar instability?

The patella (kneecap) attaches to the femur (thigh bone) and tibia (shin bone) by tendons. The patella fits into a groove at the end of the femur (trochlear groove) and slides up and down as the knee bends and straightens. Patellar instability occurs when the kneecap moves outside of this groove.

There are two types of patellar instability. The first is known as a traumatic patellar dislocation. This is most often the result of an injury to the knee. In a patellar dislocation, the patella gets pushed completely out of the groove. The other type of instability is known as chronic patellar instability. In this type, the kneecap usually only slides partly out of the groove. This is known as a subluxation.

What are the signs and symptoms of patellar instability?

Your child may experience pain, swelling, stiffness, difficulty walking on the affected limb, and/or buckling, catching, or locking sensation in the knee. Lastly, there may also be a noticeable deformity in the affected knee.

Most patients experience a sensation that the kneecap has shifted or moved out of place. Usually, the kneecap will move back in on its own but sometimes it will need to be put back in place in the Emergency Room.

With chronic patellar subluxations, the pain may be less severe than in a traumatic injury.

Patients may complain of pain underneath the kneecap, especially with activities that involve deep knee bending.

Patellar Instability Diagnosis

Your provider will most likely make the diagnosis by taking a medical history and performing a physical exam.  X-rays will most likely be obtained, but may be normal if the kneecap has already returned to its normal position. An MRI may also be ordered to evaluate possible cartilage damage caused by a traumatic patellar dislocation. However, an MRI is usually not recommended until you have given your knee a chance to heal.

Patellar Instability Treatment

If the kneecap does not go back in place (reduce) on its own, prompt medical attention is necessary to reduce the patella. Initial dislocations are generally managed non-operatively with rest and often a knee brace and crutches. After a period of rest, Physical Therapy is usually begun to strengthen the muscles in the knee that help keep the kneecap from sliding out of the groove.

There are some circumstances in which operative treatment may be warranted. In episodes of acute patellar dislocations, there may be cartilage that is knocked loose and sits in the knee. This is called a loose body and will need to be removed.

If there are ruptured ligaments in the knee, such as the medial patellofemoral ligament, reconstruction of the ligament may be recommended.

If your child has recurrent patellar dislocations (the kneecap continues to come out of the groove) despite non-operative management, he/she may be a candidate for a surgical procedure to re-align the kneecap and put the patella in a better position. One of these procedures can be done arthroscopically. Another “open” procedure involves an osteotomy, which means cutting the bone and moving it to improve patellar tracking (the way the patella moves when you bend and straighten your knee).

Patellar Instability / Kneecap Dislocation (Pediatric) | ColumbiaDoctors

What is patellar instability?

The kneecap or patella bone is the largest sesamoid bone in the human body. A sesamoid bone is embedded in a tendon and functions to modify friction, diminish pressure, and control the direction of muscle pull. The patella sits in a groove in the thigh bone (femur). When the geometry of the groove or how the patella sits is abnormal or a traumatic accident occurs, the patella dislocates and no longer tracks appropriately in the groove. This is referred to as patellar instability.

Who is affected by patellar instability?

Patellar instability is one of the most common knee injuries in the pediatric and adolescent patient populations. Data includes:

• Incidence of primary patellar dislocation is 5.6 per 100,000 and can increase to 29 in patients ages 10-17 years old.
• Established risk factors for patellar instability are being a young female and having a history of previous patellar dislocation
• Recurrence rate for dislocation is 15-44 percent (17 percent is commonly quoted).
• If there is another subsequent dislocation, rate of recurrence jumps to 50 percent.

What causes patellar instability?

Traumatic injury: This type of patellar dislocation occurs with an outward twisting force at the knee with the foot planted. It occurs with jumping or decelerating and is common in females playing soccer. This type of dislocation usually goes back in place on its own. Young athletes may experience a lot of pain and swelling in the front of their knee and have difficulty sitting. They may also experience pain and have feelings of instability or catching while walking.

Patella dislocates on its own: The kneecap slides in and out with knee motion. This may or may not be painful. If painful symptoms start, have your child see one of our doctors as soon as possible.

Patellar instability can damage the cartilage of the kneecap and thigh bone, and stretch and damage the soft tissue on the medial side of the knee. This can lead to early arthritis of the knee joint in the long term.

What are the symptoms of patellar instability?

Symptoms are:

• Patella tracks off to the side.
• Pain and swelling occur in the front of the knee.
• Knee motion results in popping or creaking sounds.
• There is tenderness to palpation along the medial border of the patella.
• Stiffness and pain occur when straightening the knee.

How is patellar instability diagnosed?

Our doctors do a thorough history and physical examination, which looks at the rotational profile of the lower extremities underlying looseness or laxity of the ligaments and muscles, as well as a focused examination of the knee. Emphasis is placed on how the patella tracks with range of motion of the knee. Radiographs are also essential to our initial evaluation.

In addition, an MRI may be done after a traumatic dislocation if the knee remains unstable on range of motion or there is concern of an injury to the cartilage of the kneecap or femur loose in the joint.

What is the treatment for patellar instability?

Step-by-step nonsurgical treatment entails:

• If your child’s kneecap dislocates traumatically, go to an emergency room if the knee remains out of place. Most of the time it will slide back into the groove with little to no assistance.
• If the knee is still out of place, our doctors might be able to relocate the kneecap in its groove. If not, we may recommend sedation to help put the kneecap back in place.
• After the kneecap is relocated, your child will be placed in a knee immobilizer to keep the knee straight for two weeks. Your child can walk around using the knee immobilizer and crutches. Rest, ice, and elevation of the leg and knee help to reduce pain and swelling.
• At the two-week follow-up, your child will be examined again and transitioned to a different type of knee brace that allows for more motion in the knee.
• Rehabilitation exercises and a visit to physiotherapy address strengthening the core, hip, and thigh muscles and work on regaining complete motion in the knee.
• The final steps of rehabilitation include more specific training to help with a return to sports. Recovery times vary but usually take around three months.
• If the patella remains unstable with motion and continues to slide to the side, or if pain and swelling have not improved, an MRI may be done to look for damage to the cartilage or soft tissue structures of the knee that occurred from the dislocation.

Surgical intervention involves:

• If an MRI shows loose cartilage or tears in the ligament, your child may need surgery to tighten the ligaments and strengthen the area around the knee. Surgery can also be done to stabilize the damaged cartilage, or if irreparable, remove it.
• In addition, measurements taken from X-rays and an MRI are used to determine if any other surgery is necessary to improve the patella’s geometry as it sits in the groove.
• After surgery, your child will likely wear a brace and walk with crutches for six weeks and go to physical therapy.

Our goal is to have your child return to sports in 4-6 months. Recovery depends on the type of surgery needed to reconstruct and repair the patellar instability. A child usually returns to sports after completion of a stepwise rehabilitation program. We also recommend use of a patellar knee brace for high impact sporting activities. Maintaining good core strength is essential to minimize recurring dislocations in the future.

90,000 Treatment Habitual dislocation of the patella – Orthopedics Ruslan Sergienko

The patella, or patella, is a small oval bone that sits above the condyle of the femur in front of and at the top of the knee.

Dislocation of the patella (patella) is a common injury in adolescents. Treatment is possible with rehabilitation or surgery.

Causes of patellar dislocation

One of the most common causes of pain in the patellofemoral joint is a violation of the movement of the patella in the intercondylar sulcus.The quadriceps heads and ligaments help center the patella in the intercondylar groove of the femur during movement. For various reasons, an imbalance in the traction of the muscles is possible, as a result of which one of the heads pulls the patella more than the other. This, in turn, causes a large patellar pressure on the articular cartilage of the intercondylar sulcus on one side compared to the other. Constant asymmetric pressure damages the articular cartilage. In this case, the cartilage in the outer part experiences more pressure during movement.If such an effect occurs for a long time, first softening begins, and then the destruction of the cartilage. This phenomenon is called patellar chondromalacia.

Finally, dislocation of the patella can occur if one of the walls of the intercondylar sulcus (usually the external one) is less developed than the internal one, or the depth of the intercondylar sulcus is not sufficient to keep the kneecap from dislocation. In these cases, the patella also tends to dislocate from the joint. With repeated dislocations, a rapid degeneration of the cartilage of the femur and patella occurs and causes persistent pain in the patient. It is worth noting that dislocations and subluxations tend to recur as the surrounding ligaments that support the patella are stretched or damaged and the femoral condyles are worn out. Complications of patellar dislocation can be considered subchondral fractures.

Conservative treatment

After a patellar dislocation, the main goal of treatment is to restore the knee joint to its normal function and to restore its strength in order to avoid repeated kneecap dislocations.

In case of traumatic dislocation, it is necessary to free the knee joint from the blood and provide it with rest. It is recommended to apply cold. After a few days, rehabilitation begins, the goal of which is to restore the normal functioning of the knee and the breadth of the range of motion. At the initial stage, it is recommended to use a fixing knee pad. The main goal of rehabilitation is to strengthen the extensor muscles of the hip, as the straightening force of the knee passes through the patella.

In some patients, the recovery process occurs due to proper rehabilitation, i.e.e. by conducting conservative treatment. Other patients may have problems, of which the most unpleasant one is the repeated dislocation of the patella. The frequency of patellar dislocation varies from 1-2 times a year to several times a day. This can provoke the development of patellofemoral arthrosis in the knee joint and, in addition, dramatically reduces the quality of life. Recurrent dislocations must be treated with surgery.

Surgical treatment

During the operation, the task becomes to restore the ligament located on the inner side of the patella and femur, which was torn during dislocation.This relatively simple operation is very effective: a result that can be considered good or very good is achieved in more than 90% of cases.

TRUST YOUR HEALTH CARE TO REAL PROFESSIONALS!

90,000 injuries, sprains, ruptures – Treatment and recovery – Department of Traumatology – State Hospital of the Central Clinical Hospital of the Russian Academy of Sciences Central Clinical Hospital RANmptomy, diagnosis, treatment at Central Clinical Hospital RAS

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The ligaments ensure the stability of the knee bones and allow the knee to function normally (extension, flexion and rotation). The patellar ligament (patella) covers the patella and attaches to the tibial tuberosity below the level of the patella. This ligament holds the patella in place and allows it to move during knee movements.

Types of injuries: injury, sprain, rupture of the patellar ligament

Patellar ligament injuries include:

• Partial damage to the patellar ligament , in which the integrity of the soft tissues is partially compromised
• Complete rupture of the patellar ligament , quite rare and represents a complete separation of the patellar ligament from the bone

Main causes of injury

• Injuries (sports or direct injuries of the knee joint: when falling, jumping, hitting, etc.))
• Weakness of the ligamentous apparatus, which can be provoked by: tendinitis (inflammation of the patellar ligaments), chronic diseases (diabetes mellitus, rheumatoid arthritis, infectious diseases, etc.), taking steroid hormones
• Multiple ligament microtrauma
• Previous surgical interventions in the knee region

Signs of injury

• Clicking and crunching in the joint, accompanied by severe pain in the patella
• Hemorrhage and edema in the upper anterior region of the lower leg
• Displacement of the patella upward, to the femur
• Muscle cramps
• “Dips” of the knee when walking
• Severe tenderness in the knee joint
• Failure to extend knee

Diagnostics

Diagnostic measures for trauma to the patellar ligaments include:

For the provision of qualified medical care, you should contact specialists:

Healing and recovery

In case of partial damage to the patellar ligaments, conservative treatment is possible, which consists in anesthetizing the site of injury with the help of anesthetics with further application of a plaster cast. To restore motor ability after removing the plaster, exercise therapy, physiotherapy, mud therapy, etc. are prescribed. Most often, when the patellar ligaments are torn, surgical intervention is necessary. During surgery, the torn ligament is sutured to the apex of the patella using sutures through holes in the bone. After the operation, the patient is prescribed pain relievers, the limb is fixed with a fixator or a plaster cast (to ensure immobility). Moving the patient is possible with crutches.After a certain time, the fixator or plaster cast is removed and the patient is prescribed a course of restorative procedures: therapeutic exercises, laser therapy, massage, ultrasound, etc.

For qualified medical help in Moscow, you can contact the Central Clinical Hospital of the Russian Academy of Sciences.

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Injury to the ligaments of the knee joint

Traumatic injury to the ligamentous apparatus of the knee joint is one of the most common, after the ankle and foot, and is inherent in active young people and athletes.

This type of damage covers the above contingent of people due to their high-energy mechanisms of injury, such as hyperextension of the lower leg, twisting along the axis, excessive abduction, adduction of the lower leg or direct exposure to traumatic force on the lower leg.

There are only 3 levels of damage:

1. Overstretching and damage to individual fibers of the ligament.
2. Partial damage to the ligament, sometimes most of it, while maintaining its function and stability.
3. Completed complete rupture or detachment of the ligament together with the bone fragment at the insertion site, accompanied by a violation of its function.

Stability of the knee joint is mainly provided by:

1. Front and back cruciform
2. Internal and external lateral ligaments.

The “leading” position is occupied by the following state:

Injury of the anterior cruciate ligament (hereinafter ACL)

PKS

originates from the inner surface of the lateral condyle of the femur and attaches to the field, anterior to the intercondylar eminence of the tibia.The bundle consists of 2 spirally located collagen bundles: Anterior – internal and posterior – external. ACL keeps the lower leg from displacement anteriorly and medially.

The mechanisms of damage are very diverse – from rare (contact): impacts or the impact of a traumatic force on the lower leg, leading to its excessive deflection anteriorly, outwardly, inwardly or to overextension, to more frequent (non-contact) – ski injuries during falls, with external rotation of the lower leg or displacement of the thigh posteriorly during a fixed foot.

The most common mechanism of damage is the twisting of the limb along the axis with a fixed foot – when turning the thigh inward, with a supporting foot. A similar mechanism is found in football, handball, volleyball, etc. With continued excessive force, damage to 3 structures at once is possible, called “explosion of the knee joint” or “unhappy Turner triad” in which damage to the ACL is followed by a rupture of the internal lateral ligament and the internal meniscus.

Often, the ACL is damaged by detachment from the attachment site with a fragment of the anterior intercondylar field.

Clinical picture

At the time of injury, the patient feels a sharp pain and often a characteristic crunch in the joint, followed by a feeling of instability and often distention – in connection with developing hemarthrosis (effusion of blood into the joint). Movement in the knee joint is severely limited due to pain, or blocked at all.

Diagnostics

A local examination of the knee joint by a traumatologist is very important for making a diagnosis, which provides most of the information and in which the nature and extent of the damage is assessed.In the absence of hemarthrosis, which complicates the examination of the joint, the doctor conducts tests (front drawer, Lachman, pivot shift) reflecting the consistency of the ACL. Examination is mandatory in comparison with a healthy limb.

Division according to the degree of anterior instability:

1. Calf mobility in comparison with the healthy leg from 1-5 mm.
2. 6-10 mm.
3. More than 10 mm.

Additional examination methods include MRI, ultrasound and X-ray of the joint.

Treatment

First aid consists of immobilizing the knee joint, local application of cold and taking painkillers. In the case of developed hemarthrosis, blood is evacuated from the joint, which reduces pain, and a plaster splint is applied.

The diagnosis of anterior cruciate ligament injury does not indicate the need for an operation, since the treatment tactics depend both on the manifestation of the degree of stability of the knee joint, the duration of the injury, the nature of the injury, the patient’s age and lifestyle and physical needs.

Currently, the most gentle and widespread method of surgical treatment is endoscopic restoration of the ligament integrity (arthroscopic plastic) using an autograft (own tissues) and biodegradable (self-absorbing) fixing screws.

Estimated period of incapacity for work – from 6-14 weeks.

Estimated recovery time after surgery to return to sports – from 6 to 9 months

Internal lateral ligament injury

Injury ranks second in the incidence of traumatic injury to the knee ligaments.

The internal lateral ligament (hereinafter ICL) runs along the inner-lateral surface of the knee joint and starts from the inner condyle of the femur and attaches to the inner condyle of the tibia.

VBS consists of 3 bundles: 1) Superficial – which, when approaching the place of attachment, is divided into 2 legs – short and long 2) Posterior oblique bundle 3) Deep bundle – which is closely related to the nearby internal meniscus.

The function of the ligament consists in static stabilization of the deflection of the lower leg outward.

There are 3 degrees of damage associated with the opening of the medial joint space:

1. 1-5 mm.
2. 6-10 mm.
3. More than 10 mm.

The mechanism of trauma is very diverse, and isolated injury to the IHD is quite rare and only in cases of partial rupture.

In contrast to ACL, the mechanism of injury to the VBS is the specific impact of a direct blow to the outer or anterior region of the lower leg, the knee joint during its extension – at the moment of tension of the ligament.Indirect mechanisms of injury are often associated with a fall or twisting of a limb when the body is deflected outward and the foot is fixed.

Clinical picture

This injury causes a sharp pain along the inner surface of the knee joint, the localization of which is often not possible to determine, and a feeling of “slipping” of the lower leg and uncertain gait.

The intensity of pain, as well as the development of hemarthrosis (joint hemorrhage) directly depends on the degree and nature of the damage.Damage to the medial meniscus, cruciate ligaments, patellar dislocation or fracture is often combined.

First aid has a standard approach as for other injuries of the ligaments of the knee joint – immobilization, cold and taking painkillers

Diagnostics

During the examination, the traumatologist assesses the nature of the damage, if necessary, punctures the joint to remove the accumulated blood. To determine the degree of damage to the VPS, a stress test is used – forcible abduction of the lower leg outward while bending 30 grams in the knee joint.The examination is always carried out in comparison with a healthy knee joint.

As additional methods of examination, MRI, ultrasound and X-ray of the joint are used. In order to clarify the degree of damage, it is possible to carry out functional radiography when performing a stress test.

Treatment

Treatment tactics are always individual, as there are a number of factors that determine the desired end result.

In cases of isolated injuries of the IHD grade 1 and 2, and sometimes even grade 3, a conservative method of treatment is used, consisting of the imposition of a plastic polymer bandage (Scotchcast) or an orthosis with the elimination of the deflection of the lower leg outward and with the possibility of early joint function, preventing rapidly increasing muscle wasting and contracture.

In cases of combined damage and isolated damage to the third degree VBS, as a rule, surgical treatment is used aimed at plastic (restoration of integrity) of the ligaments.

There are many options for surgical treatment for VHD plasty and they are often carried out with open access (i.e., through a classic surgical incision) using an autograft (human own tissues), and only a deep portion can be restored using arthroscopy through 2 punctures – 1 incisions cm.

When a ligament is torn off, osteosynthesis of the fracture is performed using a screw with a compression washer.

Injury to the lateral lateral ligament of the knee joint

Ranked third in terms of the incidence of knee ligament injury.

The external lateral ligament (hereinafter NBL) originates from the external condyle of the femur and attaches to the head of the fibula, which is why it is also called the peroneal collateral ligament

NBS works in conjunction with the posterior – external ligamentous complex consisting of the long and short heads of the biceps femoris, the arcuate ligament, the iliotibial tract and the posterior part of the joint capsule. The function of which is to limit the deflection of the lower leg inward, as well as its rotation.

The degrees of damage to the ligament are similar to the above injuries and are also divided into 3 degrees.

Mechanism of injury – impact of a direct impact or a strong impact leading to excessive deflection of the lower leg inward at the moment of tension of the ligament – with the limb straightened and extended forward. Damage to the NBS and the posterior – external complex occurs with an additional combination of the mechanism of hyperextension of the lower leg and rotation of the body inward with a fixed foot.

Clinical presentation:

At the time of injury, the victim notes a sharp pain and swelling on the outer surface of the knee joint, as well as a feeling of instability and limitation of movement due to pain. With combined damage to the NBS and the posterior – external complex, hemarthrosis manifests itself, and in case of damage to the 3rd stage or a fracture of the fibular head and the phenomenon of post-traumatic neuritis of the peroneal nerve, accompanied by a decrease or absence of active flexion movements of the foot and fingers and impaired sensitivity along the anterior – external surface of the leg and dorsum of the foot . ..

First aid is provided in the same way as in case of damage to other ligaments of the knee joint.

Diagnostics

During the examination, the traumatologist assesses the nature of the damage, if necessary, punctures the joint to remove the accumulated blood. To determine the degree of damage to the NBS, a stress test is used – forcible abduction of the lower leg inward when flexing 30 g in the knee joint, as well as a test for damage to the posterior – outer corner. A patient lying on his stomach is flexed in the knee joints, followed by external rotation of the feet.The test is considered to be positive when the difference is 5 mm or more. The examination is always compared with a healthy limb.

As additional methods of examination, MRI, ultrasound and X-ray of the joint are used. In order to clarify the degree of damage, functional radiography is possible during the stress test when the lower leg is deflected inward.

Treatment

In case of damage to the NBS of the 1st and 2nd stages, the treatment consists in the use of analgesics, venotonics and the imposition of a polymer bandage for up to 4-5 weeks, followed by the beginning of rehabilitation and wearing an orthosis.

In cases of concomitant damage to several structures, in order to avoid the development of complications or to obtain a negative result of conservative treatment, surgical treatment is used, aimed at plasty of the ligaments, both of the NBL and the posterior – external complex.

There are a lot of options for surgical treatment, and the choice of treatment tactics lies with the operating surgeon. In plastic surgery of the ligaments, similar to other injuries, the patient’s own tissues are used.

When the ligament is torn off from the attachment site, osteosynthesis of the fracture is performed.

The development of post-traumatic complications, such as damage to the peroneal nerve or popliteal artery, also influence the choice of treatment tactics. In these cases, treatment is carried out in conjunction with neurosurgeons (neuropathologists) and angiosurgeons.

Posterior cruciate ligament injury

The beginning of the PCS takes from the inner condyle of the femur and attaches to the field, posterior to the intercondylar eminence of the tibia.

ZKS consists of 3 Beams: 1) Anterior-external 2) Posterior-internal 3) Humphrey’s bundle, which is attached to the external meniscus.

The main function of the ZKS is to ensure the knee joint from the posterior displacement of the lower leg.

The mechanism of injury is a bumper injury – a high-energy injury that is applied to the anterior surface in / 3 of the lower leg.

Clinical presentation:

Pronounced and accompanied by pain, swelling, severe limitation of the knee joint movements in parallel with the feeling of “collapse” of the lower leg.

Diagnostics:

First of all, possible bumper is excluded – a fracture, damage to the popliteal artery, damage to ligaments, external meniscus. In the presence of hemarthrosis, a puncture of the joint is performed, followed by immobilization of the limb, due to the difficulty of examination. Analgesics and decongestants are prescribed, a cold heating pad is applied topically on the first day. If a local examination is possible, the traumatologist conducts a posterior drawer test – a pathological posterior displacement of the lower leg with the knee bent at a right angle and the Godfrey test – when flexing the injured limb in the t / femur and knee joints, the depression between the tibia and the patella is determined.At the same time, tests are carried out for the presence of concomitant injuries in comparison with a healthy limb.

There are 3 degrees of posterior instability:

1. Calf mobility in comparison with healthy leg from 1-5 mm
2. 6-10 mm
3. More than 10 mm

Additional instrumental examination methods include MRI, ultrasound and X-ray of the joint.

Treatment:

In case of partial injuries of the PCS, a conservative method of treatment in a polymer splint of rigid fixation with subsequent wearing of an orthosis is used, however, as practice shows, this method of treatment is ineffective due to persisting chronic pain and a feeling of instability. In most cases, the posterior instability of the lower leg is eliminated by therapeutic and diagnostic arthroscopy, plasty of the PCS using an autograft (own tissues) and biodegradable (self-absorbing) fixing screws.

Estimated period of incapacity for work – from 6-14 weeks.

90,000 reasons, types of interventions and rehabilitation

Shulepov Dmitry Alexandrovich

Traumatologist-orthopedist

October 23, 2020

Knee pain is one of the most common reasons for patients visiting a traumatologist.Most often, the source of the disease is injury to the kneecap. But sometimes the cause of discomfort can lie in the femoropatellar region – the place where the patella slides along the intercondylar groove of the femur.

In the normal movement of the patella during flexion / extension in the knee joint, several anatomical structures are controlled:

• The relationship between the intercondylar notch and the kneecap does not allow the latter to move in the external-internal direction.
• The patellar ligaments (retinaculums), together with the patellar ligament and quadriceps tendon, center the patella in all four directions.

If the anatomy of the femoropatellar region is not changed, then the knee joint is working normally. However, if there is any congenital anomaly in this section, then the likelihood of developing lateral instability of the patella increases sharply.

Habitual (recurrent) patellar dislocation is an unnatural condition characterized by recurrent lateral (external) subluxations and dislocations of the patella.

Lateral dislocation of the patella is characterized by rupture of the medial retinaculum (medial patellofemoral ligament) of the knee joint. Repeated dislocation in a patient is the main sign of failure of the medial patellofemoral ligament to perform its functions due to overstretching after the primary injury.

Dislocation of the patella, both primary and repeated, leads to significant damage to the cartilage. As a result, a persistent pain syndrome appears and a decrease in the patient’s physical activity.

How is the lateral instability of the patella formed?

Often a prerequisite for the formation of lateral instability of the patella is dysplasia of the femoropatellar region, a congenital condition characterized by disturbances in the relationship between the patella and an insufficiently pronounced intercondylar groove of the femur (see Fig.).

The presence of dysplasia of varying severity leads to the fact that the movements of the patella during flexion and extension of the knee joint occur with a tendency to its lateral displacement.With additional traumatic effects, this leads to a full-fledged dislocation.

However, dysplasia does not always cause patellar dislocation (recurrent patellar dislocation).

Modern approaches to the diagnosis and treatment of recurrent patellar dislocation

A single patellar dislocation is not an indication for surgery. As a rule, it is successfully eliminated with the help of conservative treatment, which is carried out in three stages:

1. Immobilization and walking on crutches for 4 weeks.
2. Physiotherapy (exercise therapy) with an instructor, physiotherapy treatment (FTL) after the removal of immobilization.
3. Wearing an orthosis with lateral stabilization of the patella.

In most cases, a traumatologist can easily diagnose a habitual patellar dislocation. To do this, a series of stress tests is performed, during which the patient demonstrates the fear of getting a second dislocation. The final diagnosis is made after magnetic resonance imaging (MRI) of the knee.As a rule, the study reveals signs of damage to the medial patellofemoral ligament, a condition of patellar subluxation, and signs of traumatic damage to the cartilage.

As mentioned earlier, a single traumatic dislocation of the patella is not an indication for surgery – conservative treatment is sufficient. In the event of repeated dislocations / subluxations of the patella, the patient is indicated for surgical treatment – surgical stabilization of the patella.

Modern medicine offers several methods of performing surgical interventions for the habitual dislocation of the patella.The optimal technique is arthroscopic reconstruction (plastic) of the medial patellofemoral ligament (MPFS) . With the help of this method, surgery for dislocation of the patella allows to restore the lost anatomical structure that stabilizes the patella (MPPS), and at the same time to grind and resect areas of damaged cartilage without large skin incisions.

How is arthroscopic reconstruction performed?

First, under the control of the video camera, two punctures are made.They allow for a visual examination of all parts of the joint, if necessary, surgically treat the damaged areas of the cartilage. Then, through two new punctures, a tendon graft is inserted and fixed to replace the lost patellar ligament. The tension of the ligament is adjusted under the control of the video camera so as to bring the patella out of the subluxation position, but leave physiologically sufficient freedom for its displacement.

Regardless of the choice of graft-fixing fixators (titanium, plastic, bioresorbable) in the postoperative period, unloading of the joint is required to create conditions for biological fixation and restructuring of the graft.These processes, according to MRI studies, take from 6 to 12 months.

The main stages of rehabilitation after arthroscopy:

1. Creation of joint immobility with the help of an orthopedic splint, as well as the use of crutches during the first 3 weeks;
2. Wearing orthosis with lateral patellar support 6 weeks;
3. Physiotherapy after removal of immobilization under the supervision of a rehabilitation physician. Recommended: increasing the range of motion in the knee, strengthening the thigh muscles, restoring gait biomechanics.In agreement with a physiotherapist, a course of special physiotherapy can be carried out;
4. After 3 months after the operation, swimming pool, exercise bike, muscle strengthening are allowed;
5. Partial return to sports activity – after 6 months, full – after 8-12 months.

Damage to the ligamentous apparatus of the knee – Dr. Erich H. Rembeck

Sports injury

Traumatology and Orthopedics Department

Sport is a great way to maintain a healthy lifestyle: almost everyone thinks so.But are those who are seriously involved in sports so healthy?

More and more people, starting from a very young age, are involved in this or that sport. The popularity of physical education in our country is growing every year. But where there is serious sport, there are also serious injuries.

Sports injury

This is damage that entails a physical violation of the integrity of tissues caused by external influences.
The causes of sports injuries are associated with many factors.

Why does the knee hurt?

Knee pain can be associated with damage to joints, cartilage, ligaments, tendons, as well as with various pathologies of the knee joint.

Major knee injuries:

Why does the shoulder hurt?

A common cause of shoulder pain is increased physical activity. Also, the causes can be inflammation of the joints and / or tendons, ligament damage, pinched nerves and degenerative processes.

Major shoulder injuries:

• Contusions of the shoulder joint.
• Tendon and ligament ruptures.
• Dislocations of the shoulder.
• Rupture of the acromioclavicular joint.

How to treat?

There are two types of treatment for knee and shoulder injuries: conservative and surgical.

Conservative method is a therapeutic treatment using drugs, injections, exercise therapy, physiotherapy, fixation devices.

Arthroscopic surgery is a minimally invasive surgical procedure performed to diagnose and / or treat injuries without opening the joint, which allows you to quickly recover from surgery and return to an active lifestyle.

Treatment of these types of injuries consists in the individual selection of therapeutic measures aimed at unloading the affected area, anesthetizing it, and carrying out physiotherapeutic procedures.

Severe sports injuries (sprains, bruises, dislocations and fractures):

• Stretching – is a non-tearing injury to soft tissues caused by a force acting in the form of traction.
• Bruises – tissue damage without compromising the integrity of the skin.It is accompanied by a violation of the blood vessels. As a result, there is redness of the affected area and swelling.
• Fractures, compression fractures and dislocations – are manifested by severe pain syndrome.

In all cases of injury, see a doctor!

Highly qualified traumatologists and orthopedists of the Regional Clinical Hospital # 1 have tremendous experience in treating all types of sports injuries!

Branch services and prices

Feeling of instability in the knee

When walking, running, in everyday life or when playing sports, we are confident that the legs are
our reliable support.And it is especially uncomfortable to feel that
appears under load on the leg.
feeling of instability, uncertainty. Sometimes it is because of the pain, sometimes because of the fact that
there is some kind of excessive mobility of the joint, its instability. More often it is
characteristic of the knee joint.
The knee joint is surrounded by a large number of powerful ligaments, muscles, has additional protection
in the form of a kneecap, menisci. But a strong simultaneous load on the joint can cause
damage to ligaments and menisci – sprain, rupture.Abrupt braking, “twisting” in
knee joint, direct blow to the knee area, sports overloads are the cause of
damage to the structures of the knee joint and the appearance of a feeling of instability in the knee. Gap
ligaments are manifested by acute pain, swelling of the knee in the area of ​​rupture. Concomitant hematoma
can form not only in the tissues surrounding the damaged ligament, but also in the knee itself
joint – hemarthrosis of the knee joint.
Limitation of range of motion in the knee joint, feeling of instability in the knee, pain in
knee – all these are symptoms that require prompt referral to a specialist. Traumatic
damage to the ligaments, meniscus, joint capsules cannot be left without treatment, complications can
significantly limit mobility in the knee and in the leg in general.