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Monday 9 April 2018



Factors stabilizing patella
  • Static factors
    • shape of patella
    • shape of femoral condyles (flattening of lateral condyle destabilizes
    • normal patellofemoral distance (patella alta)
    • normally tensioned medial capsule
  • Dynamic factors
    • vastus medialis obliqus
  • both dynamic and static forces tend to pull patella laterally
  • first described by Brattstorm
  • angle between line of quadriceps pull and patellar tendon
  • line from ASIS to centre of patella and centre of patella to tibial tuberosity
  • normal 8-100 males and 150 females
  • this valgus angle gives a lateral force vector to patellofemoral joint as knee is extended
  • increased Q angle = increased instability
  • causes
    • genu valgum
    • increased femoral anteversion
    • external tibial torsion
    • laterally positioned tibial tuberosity
    • tight lateral retinaculum
  • dysplastic patella
  • dysplasia of femoral condyle
  • patella alta
  • change in orientation of the fibres of m
  • hypertrophy of vastus lateralis
  • generalised ligamentous laxity
Clinical features
  • diffuse pain around knee aggravated by going up/down hill
  • giving away feel
  • patellar crepitus
  • knee effusion
  • Tests
    • patellar grind test
    • patellar glide test
    • patellar tilt test
    • patellar tracking
      • dynamic
      • active
    • apprehension test
    • quadriceps atrophy
    • generalised ligamentous laxity
Radiographic features
  • bipartate patella
  • Blumensat line below lower pole of patella (patella alta)
    • 300 flexion- line through intercondylar notch touches the lower pole of patella
  • Insall's index (LT/LP >1)
  • Blackburne and Peel index
    • ratio of length of articular surface of patella : distance between articular surface of tibial and lower pole of patella
    • Normal .54 to 1.06
  • Axial view of patella – shallow sulcus
    • sulcus angle and congruence angle – for diagnosing minimal subluxation
  • CT – with full extension of knee – lateral tilt of patella and subluxation more pronounced
  • Medial subluxation of patella also described – demonstrated only in Kinetic MRI
  • Non operative
    • quadriceps strengthening exercise
    • stabilization braces
  • Surgical
    • adults
      • lateral retinacular release (open / arthroscopic)
        • for normal Q angle and tight lateral structures
      • proximal extensor realignment
        • for Q angle <200
        • Insall's technique
          • lateral release and advance vastus medialis laterally and distally
        • Madigan's technique
      • distal realignment
        • for Q angle >200
        • Roux Goldthwait surgery
          • in skeletally immature
          • patellar tendon split longitudinally and lateral half transplanted medially
        • Elmslie Trillat operation
          • in skeletally mature
          • lateral release + medial retinacular plication + medial transfer of tibial tuberosity
      • proximal and distal realignment
        • Q angle =~200
        • skeletally mature
        • Hughston, modified Elmslie Trillat
      • patellectomy with extensor realignment
        • as a salvage procedure
          • patellar chondromalacia
          • OA knee
          • >40 yrs of age
        • West and Soto-Hall – patellectomy with plastic repair of Quadriceps
    • in skeletally immature
      • semitenodesis
        • semitendinous tendon is sectioned at musculotendinous junction
        • distal segment of tendon passed through hole in patella and sewn back to itself
      • quadricepsplasty (Green)
        • lateral release with mobilization of vastus lateralis
        • posteromedial portion of vastus medialis advanced distally and laterally
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