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Case Reports in Orthopedics

Volume 2014, Article ID 647272, 5 pages
http://dx.doi.org/10.1155/2014/647272

Case Report
Treatment of Habitual Patellar Dislocation in an Adult by
Isolated Medial Patellofemoral Ligament Reconstruction

Yoann Bohu,1,2,3 Mathieu Thaunat,1 Nicolas Lefevre,2,3 Shahnaz Klouche,2,3

Serge Herman,2,3 and Yves Catonné1
1
Groupe Hospitalier Universitaire La Pitié Salpêtrière, AP-HP, 75013 Paris, France
2
Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France
3
Clinique du Sport Paris V, 75005 Paris, France

Correspondence should be addressed to Yoann Bohu; [email protected]

Received 18 November 2013; Accepted 19 January 2014; Published 4 March 2014

Academic Editors: E. R. Ahlmann and J. Nyland

Copyright © 2014 Yoann Bohu et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Habitual patellar dislocations are rare in adults. Treatment is difficult, and often associated with significant morbidity. A 30-year-
old man, construction worker, presented a habitual patellofemoral dislocation which was caused by direct trauma to the knee as a
child. Clinical examination showed a 3 cm leg-length discrepancy with no rotational deformities. The patient had a limp and loss of
function; the patella was dislocated laterally and had locked at 20∘ of flexion with a range of motion of 0∘ /0∘ /30∘ . Open surgery was
performed associating lateral retinacular release, reconstruction of the medial patellofemoral ligament with an ipsilateral gracilis
tendon graft. The postoperative course was simple with no complications. Four months after surgery the patient has begun working
normally. At the final 50-month clinical follow-up, knee range of motion was 0∘ /0∘ /130∘ , and functional results were excellent
on clinical assessment scores of Kujala, Lysholm, and subjective IKDC. MPFL reconstruction alone seems effective in habitual
posttraumatic patellar dislocation in adults without any associated bone anomalies.

1. Introduction included a knee injury at the age of 5 in a road accident.

He did remember neither precise diagnosis nor functional
The origin of recurrent patellar instability is usually posttrau- or surgical previous treatment. There were no scars on the
matic. Dislocation results in irreversible injuries due to lateral knee. The patient was 1.76 m tall and weighed 68 kg with varus
translation of the patella [1, 2]. Hawkins et al. [3] reported knee morphology and no leg-length discrepancy. Placing
40% rates of patellofemoral pain and 70% rates of instability weight on one foot resulted in lateral patellar dislocation,
after dislocation. Several factors predisposing to patellar and squatting was impossible. The patella was mobile, but
instability have been described such as trochlear dysplasia or systematically dislocated laterally at 30∘ of flexion (Figure 1).
a patella alta [4]. Recently several studies have shown that the The rest of the clinical examination, in particular the
medial patellofemoral ligament (MPFL) reconstruction in the neurological, muscular, and tendon results were normal. X-
treatment of patellar instability in adults had a high success ray confirmed genu varum, showing a patellar tilt angle of 30∘ .
rate [5] but with a complication rate of 26% [6]. Few cases of The trochlear morphology (groove and depth) was normal as
habitual dislocations have been reported [7]. well as the height of the patella with Caton-Deschamps index
equal to 1 [8]. There was no patellar dysplasia, but the trochlea
was slightly flattened (Figures 2 and 3).
2. Case Presentation
The medial border of the patella was calcified. There was
A 30-year-old man consulted for limping. In the past three no associated leg dysplasia. CT scans of leg rotation showed
years, the patient had been having trouble walking, could not physiological tibial torsion and femoral anteversion. Femoral
squat down, or go up and down stairs. The patient’s history anteversion measured on CT scan between the femoral neck
2 Case Reports in Orthopedics

Figure 1: Preoperative assessment: the patella is in place in extension and dislocated in flexion.

(a) (b)

Figure 2: Comparative weight-bearing X-ray lateral view: (a) without contraction of the quadriceps and (b) with contraction of the
quadriceps.

angle and the biepicondylar axis was symmetrical, 12∘ on the its final position. The graft was placed into the drill holes
right and 13∘ on the left. The preoperative Kujala et al. score then secured to the suture anchor and doubled back on
[9] was 41%. The preoperative Lysholm score was 6%. The itself as described by Thaunat and Erasmus [10, 11]. The
subjective IKDC score was 10% for pain, 17% for symptoms, vastus medialis (vastus internus) was then placed below
and 17% for recreational and sports activities, or a global and outside the patella and secured with “U-” stitches to
IKDC of 14.7%. The diagnosis of habitual posttraumatic provide overlapping reinforcement. The postoperative course
patellofemoral dislocation was made. The indication for was simple with a brace to walk for 45 days and immediate
reconstruction of the stabilizing ligament of the patella was rehabilitation at between 0 and 80∘ of flexion.
based on the significant functional incapacitation and the At 4 months of follow-up, the patient was able to work
lack of appropriate conservative treatment. normally as construction worker in public works. At the final
An open surgery procedure was performed. First lateral 50-month clinical follow-up, the operated knee was stable
retinacular release of the patella was performed. Then the and there was no pain. There was no recurrent dislocation or
ipsilateral gracilis tendon was harvested at its distal insertion apprehension. There was full range of motion (Figures 4 and
with a tendon stripper. The graft was 12 cm long. Two holes 5).
were drilled into the patellar bone by a medial parapatellar Postoperative X-rays show the patella recentered at 60∘ .
approach. After pulling a suture through the holes the femoral The patient was very satisfied with the results.
attachment point was found and with the help of a temporary Results of knee function were excellent on functional
pin in the medial epicondyle, favorable anisometry could be scales for patellar instability with significant improvement of
obtained (the graft relaxed as the knee was flexed) and a all clinical scores. The Kujala score was 83/100 points and the
Corkscrew suture anchor (Arthrex, Naples, FL, USA) was put Lysholm score 90/100. The global IKDC score was 90.8%. The
in place. After confirming patellar centering during 4 to 6 items for pain, symptoms, and leisure and sports activities
flexion-extension cycles, the suture anchor was secured in were scored 93.3%, 90%, and 90%, respectively.
Case Reports in Orthopedics 3

(a) (b)

Figure 3: Preoperative patellofemoral X-ray, tangential view in neutral rotation: (a) 30∘ flexion and (b) 60∘ flexion.

Figure 4: Postoperative photographs: stability, no dislocation.

3. Discussion No predisposing factor was found [4]. Morphological

assessment of the patellofemoral compartment did not reveal
To our knowledge, no other cases of habitual patellofemoral any signs of dysplasia. On the femoral side, there was no
dislocation in young adults secondary to trauma which crossing sign or spurs, and the depth of the trochlear groove
occurred in childhood have been described in the literature. was normal. Patella tilt was increased in a lateral view during
According to the Andrish clinical score for children [12], contraction of the quadriceps but the morphology of the
this patient had “habitual” rather than “fixed” traumatic patella was normal. The height of the patella was normal with
dislocation. This instability was secondary to a childhood no recurvatum.
injury suggested by the patient’s history and the features of The injuries had not affected skeletal development during
medial patellar calcifications found on X-ray, whereas 90% growth. There was no leg-length discrepancy. Femoral antev-
of patellofemoral instability cases in children and adolescents ersion on CT scan was identical to the contralateral side. The
are nontraumatic [13]. The initial medial femoropatellar quadriceps was not retracted. Overall, the cause of dislocation
injuries never healed. Imaging of the soft tissues might have was isolated rupture of the medial stabilizing apparatus of the
provided more specific information. An MRI or ultrasound patella.
might have shown features of the MPFL and the attachment of Because the injury was anatomical, conservative treat-
the vastus medialis (internus) on the patella, but these results ment with rehabilitation was not proposed. The first line
were not available for the preoperative work-up. therapeutic strategy was surgical.
4 Case Reports in Orthopedics

the quadriceps. By increasing tension in the graft to reduce

the patella during flexion, we could obtain stiffness after 90∘ .
During surgery we adjusted graft tension with a pin in the
medial epicondyle attachment. We adjusted the length of the
graft by taking into account engagement of the patella and by
obtaining full range of motion in the knee. The graft was tense
close to extension and relaxed during flexion.
Criteria which allowed him to return to work were no
pain, stability of the patella, no swelling, and full range of
motion. We chose to assess treatment using functional scores.
Although the Lysholm, Kujala, and IKDC scores have been
validated to evaluate this disease, the score by Kujala et al. [9]
is more specific and sensitive for patellofemoral damage. The
improvement from 41 to 83% in the latter score was perfectly
correlated to the functional improvement of the patient, who
(a) (b)
was able to begin working as a construction worker (kneeling,
squatting, climbing, lifting, carrying, etc.).

4. Conclusion
In case of no retraction of the knee extensor apparatus or pre-
disposing bone factors, isolated MPFL reconstruction seems
effective in treating confirmed patellar instability. In case of
stiffness or associated bone anomalies (trochlear dysplasia,
(c) patella alta) other therapeutic procedures would be necessary.
This case was original because of the habitual dislocation
Figure 5: Postoperative X-rays of the knee: (a) anteroposterior, (b)
lateral, and (c) tangential patellofemoral views at 60∘ .
and of the excellent functional results obtained after simple
surgery and a short postoperative follow-up. This report
shows that a case of neglected traumatic patellofemoral dis-
location in childhood can progress to habitual patellofemoral
dislocation in young adult.
Numerous techniques have been described in the lit-
erature for the treatment of patellar dislocations. These
included either lateral retinacular release or proximal or distal Conflict of Interests
realignment. Aglietti et al. [14] and Sherman et al. [15] have
reported a failure rate for lateral retinacular release of 44% The authors declare that there is no conflict of interests
and 25%, respectively. As already mentioned by Fithian et regarding the publication of this paper.
al. [16], we believe that the primary frontal stabilizer of the
patella is the MPFL. References
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