Introduction. Genu valgum is a common presentation in paediatric patients with congenital limb deformities. The aim of this study is to assess the outcome of guided growth surgery in paediatric patients referred via our physiotherapy pathway with isolated genu valgum and associated patellar instability. Materials & Methods. Patients were identified from our prospective patellar instability database. Inclusion criteria was acquired or congenital genu valgum associated with patellar instability in skeletally immature patients. The mechanical lateral-distal femoral angle was assessed on long leg alignment radiographs (mLDFA <85 degrees). Surgical treatment was the placement of a guided growth plate (PediPlate, OrthoPediatrics, USA) on the medial distal femoral physis (hemi-epiphysiodesis). KOOS-child scores were collected pre-operatively and post-operatively (minimum at 6 months). Results. Eleven patients (seven female) with mean age of 12(range 5–15) were identified. Five patients had congenital talipes equinovarus(CTEV), one fibular hemimelia, one di-George syndrome, one septic growth arrest and three had idiopathic genu valgum. Pre- and post-operative KOOS-child scores showed overall improvement: 58(range 36–68) to 88(65–99) and knee symptoms subscores: 64(43–71) to 96(68–100) p<0.01, t-test. Mean follow-up was 10 months (range 3–23). No subsequent dislocations/subluxations occurred during follow-up. Conclusions. Guided growth surgery is an effective way of treating symptomatic patellar instability in skeletally immature patients with genu valgum in the absence of other structural pathology. It was most common in our cohort in patients with unilateral CTEV. We would recommend to screen syndromic and congenital limb deformity patients for patellar instability symptoms in the presence of genu valgum

Patellar dislocation is a common presentation with a clear management pathway. Sometimes, however, what a patient experiences as the patella dislocating may, in fact, be ACL insufficiency. We reviewed case notes and imaging of 315 consecutive ACL reconstructions, collecting data on the date and mechanism of injury, time to MRI, and reconstruction. We noted cases initially diagnosed as patellar dislocation. 25 of 315 (7.9%) patients were initially diagnosed with a patellar dislocation. Subsequently, however, MRI scans revealed no evidence of patellar dislocation and instead showed ACL rupture with pathognomonic pivot-shift bony oedema. The false patella dislocation group were 32% female and had an average age of 25; the rest of the group average age was 27.1 and there were a lower proportion of females; 21%. The false patella instability patients had a median waiting time of 412 days from injury to operation (range: 70-2445 days), compared to 392 days (range: 9 – 4212 days) for rest of the patients. 5 of the remaining 290 had MRIs showing patella oedema with medial patello-femoral ligament injury in addition to their ACL rupture. From our literature search this is a new finding which shows that ACL rupture can present with symptoms suggestive of patellar dislocation. These findings raise the risk that there are a group of people who have been diagnosed with patellar instability who instead have ACL insufficiency and so are at risk of meniscal and chondral damage. Further research should analyse those diagnosed with patellar instability to quantify missed ACL injuries

Recurrent patellar instability is a common problem and there are multiple demographic and pathoanatomic risk factors that predispose patients to dislocating their patella. The most common of these is trochlear dysplasia. In cases of severe trochlear dysplasia associated with patellar instability, a sulcus deepening trochleoplasty combined with a medial patellofemoral ligament reconstruction (MPFLR) may be indicated. Unaddressed trochlear pathology has been associated with failure and poor post-operative outcomes after stabilization. The purpose of this study is to report the clinical outcome of patients having undergone a trochleoplasty and MPFLR for recurrent lateral patellofemoral instability in the setting of high-grade trochlear dysplasia at a mean of 2 years follow-up. A prospectively collected database was used to identify 46 patients (14 bilateral) who underwent a combined primary MPFLR and trochleoplasty for recurrent patellar instability with high-grade trochlear dysplasia between August 2013 and July 2021. A single surgeon performed a thin flap trochleoplasty using a lateral para-patellar approach with lateral retinaculum lengthening in all 60 cases. A tibial tubercle osteotomy (TTO) was performed concomitantly in seven knees (11.7%) and the MPFLR was performed with a gracilis tendon autograft in 22%, an allograft tendon in 27% and a quadriceps tendon autograft in 57% of cases. Patients were assessed post-operatively at three weeks and three, six, 12 and 24 months. The primary outcome was the Banff Patellar Instability Instrument 2.0 (BPII 2.0) and secondary outcomes were incidence of recurrent instability, complications and reoperations. The mean age was 22.2 years (range, 13 to 45), 76.7% of patients were female, the mean BMI was 25.03 and the prevalence of a positive Beighton score (>4/9) was 40%. The mean follow-up was 24.3 (range, 6 to 67.7) months and only one patient was lost to follow-up before one year post-operatively. The BPII 2.0 improved significantly from a mean of 27.3 pre-operatively to 61.1 at six months (p < 0 .01) and further slight improvement to a mean of 62.1 at 12 months and 65.6 at 24 months post-operatively. Only one patient (1.6%) experienced a single event of subluxation without frank dislocation at nine months. There were three reoperations (5%): one for removal of the TTO screws and prominent chondral nail, one for second-look arthroscopy for persistent J-sign and one for mechanical symptoms associated with overgrowth of a lateral condyle cartilage repair with a bioscaffold. There were no other complications. In this patient cohort, combined MPFLR and trochleoplasty for recurrent patellar instability with severe trochlear dysplasia led to significant improvement of patient reported outcome scores and no recurrence of patellar dislocation at a mean of 2 years. Furthermore, in this series the procedure demonstrated a low rate (5%) of complications and reoperations

The purpose of this study was to evaluate the reasons for patellar instability in modular rotating hinge TKR, with regards to design of the prosthesis offering unlimited rotation, component positioning and the role of compromised soft tissues. We reviewed six patients with rotating hinge TKR operated over the past 3½ years for either ligamentous instability, bone loss or both. The problem of patellar instability was identified in all patients. Five patients had realignment of extensor mechanism for patellar maltracking, while the remaining one patient with patellar instability was asymptomatic. Post-realignment the HSS scores revealed good results in 3 knees, fair in 2 and poor in 1 patient. All patients had a well aligned knee with satisfactory component positioning. The unlimited rotation offered by the modular rotating hinge TKR because of the absence of a rotational stop causes excessive demands on the soft tissue and is a reason for patellar instability in patients with compromised medial soft tissue integrity. The high incidence of patellar instability compromises the results of TKR and is a cause of concern and this implant should be reserved for patients with severe ligamentous instability and bone loss not amenable to ligament balancing

Introduction. Current problem – Multiple surgical interventions for patellar instability and no defined criteria for use of medial patellofemoral ligament (MPFL) reconstruction. Aims. Investigate the functional outcomes of MPFL reconstructions that had been performed following selection for treatment based on a defined patellar instability algorithm. Methods. Study design – prospective case series. Treatment number – 19 knees in 17 patients. Intervention – medial patellofemoral ligament reconstruction using free gracillis tendon graft. Inclusion critieria – Recurrent patellar dislocation with a trochlear groove - tibial tubercle (TG-TT) offset of 20mm or less, and trochlear dysplasia and patellar alta classed as normal, mild or moderate. Primary outcome measure – Kujala patellofemoral questionnaire, assessed preoperatively and postoperatively at 6 weeks and 3, 6, 9, 12, 18, 24 months and at final follow up. Secondary outcome measures – Fulkerson patellofemoral scores, return to work, return to preoperative sport and complications. Results. Median follow up time was 24 months (range 12 – 36 months). Kujala scores improved from 58 to 96 (p < 0.05) and Fulkerson scores improved from 56 to 95 (p < 0.05) pre- and postoperatively respectively. The median return to work was 8 weeks and return to preoperative sport was 12 weeks. There was one complication of post-operative stiffness, which settled with intensive physiotherapy. There were no instances of repeat dislocation or patellar fracture. There were no cases needing further surgery. Conclusions. MPFL reconstruction, when performed following selection using our defined treatment algorithm is safe and effective for the treatment of patellar instability. Longer follow up is required to see long term outcomes

Purpose Of The Study: Description of a new operative technique of trochleoplasty for patellar instability and its short-term results. Method: we report a new technique of trochleoplasty for Trochlear dysplasia, using Mitek anchor sutures. The purpose of the procedure is to remove the anterior femoral boss associated with Femoral Trochlear dysplasia and make the floor of the trochlea level with the anterior femoral cortex. The operation entails undermining of the trochlear and lateral condylar articular cartilage to a new corrected level where it is held with the use of No 2 Ethibond Mitek anchor sutures. These anchors are placed in the subchondral bone, suture needle passed through the articular cartilage and the sutures tied over it. Approximately 4 -5 anchor sutures are placed to hold the trochlear cartilage down to the new corrected level. This procedure can be combined with proximal and distal patellar realignment. So far, using this technique, we have operated on six patients with trochlear dysplasia and chronic patellar instability. The patients include 4 females and 2 male with an average age of 33 yrs (range 29 – 40). Average follow up is 16 months (range 8 – 24 months). There has not been any recurrence of patellar instability in the operated patients. Conclusion: Short-term follow up of a new operative technique of troachleoplasty for patellar instability shows promising results

Statement of purpose. To determine whether the Q-angle, measured in a defined and reproducible manner, correlates with the TT-TG distance in patients with patellar instability. Methods and results. The Q-angle represents the angle between the vector of action of the quadriceps and patellar tendon. The normal angle is 14. +/−. 3° in males and 17. +/−. 3° in females. An increased Q-angle is associated with an increased risk of patellar instability, although there is disagreement on its reliability and validity. It can be affected by the anatomical points used to record the measurement, the position of the limb and whether the quadriceps are relaxed or contracted. TT-TG is ascertained by axial CT scanning, with a value exceeding 20mm associated with patellar instability. Q-angles were measured in patients presenting to the patella clinic who had previously undergone Lyon protocol CT scanning for patellar instability. Patients were positioned supine with both feet in neutral rotation taped to a specially designed wooden board (the same position used for CT scanning). The anatomical landmarks were the anterior superior iliac spine, the centre of the patella and the centre of the tibial tuberosity. Both knees were measured with the quadriceps relaxed (relaxed Q-angle) and contracted (contracted Q-angle). Thirty-four knees were measured, 24 pathological and 10 non-pathological. Pearson moment correlation demonstrated a significant correlation between relaxed Q-angle and TT-TG in all knees (R=-0.377; p=0.028). In pathological knees, contracted Q-angle also demonstrated a significant correlation with TT-TG but to a lesser extent than relaxed Q-angle (R=-0.428; p=0.037, R=-0.578; p=0.003 respectively). Linear regression analysis demonstrated relaxed Q-angle as a significant predictor of TT-TG distance in pathological knees. Contracted Q-angle was not significant. Conclusion. The relaxed Q-angle, when measured as above, reliably correlates with and is a significant predictor of TT-TG distance in patients with symptomatic patellar instability

Aim: To systematically review the present evidence-base, assessing the clinical and radiological outcomes following trochleoplasty for trochlear dysplasia. Methods: An electronic literature search was performed using the AMED, British Nursing Index, CINAHL, Cochrane, EMBASE, ovid Medline, Physiotherapy Evidence Database, PsycINFO, Pubmed and Zetoc databases from their inception to August 2007. Reference lists of identified papers and a hand search of specialist knee journals was also undertaken. All English language, human subject clinical studies, detailing the clinical and/or radiological outcomes of patellar instability patients following a trochleoplasty were included. Two independent reviewers appraised each paper using the CASP tool. Results: Six papers comprising of 117 trochleoplasty procedures on 99 patients were reviewed. Clinically and radiologically, trochleoplasty was shown to be a safe and effective procedure to correct patellar instability in trochlear dysplasia patients. However, the CASP tool identified that the evidence-base reviewed presented with a number of methodological limitations. These included: limited use of inferential statistics; not applying reliable outcome measurements; poor description of patient recruitment; and evaluating small samples. Conclusion: Although trochleoplasty may be an effective procedure to correct patellar instability in trochlear dysplasia patients, further study is recommended to assess longer-term outcomes using well-designed studies

A prospective study was done to assess the outcome of MPFL reconstruction for patellar instability using quadriceps graft. MPFL reconstruction was done using superficial strip of quadriceps by an anteromedial incision and attached close to medial epicondyle of femur. There were 15 knees in thirteen patients with a mean age of 23.4 years. All patients had MPFL reconstruction and 5 had tibial tuberosity transfers. With a mean follow-up of 39.4 (12–57) months, the mean pre-op Kujala scores improved from 47.8 to 87.2. The mean Lysholm scores improved from 54.2 to 86.8. None of the patients had patella re-dislocations. MPFL reconstruction with quadriceps graft appears to be effective producing good results in patients with patellar instability

Background. Patellar instability is a complex, multi-factorial disorder. Radiological assessment is regarded as an important part of the management of this population. The purpose of this study was to determine the intra- and inter-rater reliability of common radiological measurements used to evaluate patellar instability. Methods. One hundred and fifty x-rays from 51 individuals were reviewed by five reviewers: two orthopaedic trainees, a radiological trainee, a consultant radiologist and an orthopaedic physiotherapist. Radiological measurements assessed included patellar shape, sulcus angle, congruence angle, lateral patellofemoral angle (LPA), lateral patellar displacement (LPD), lateral displacement measurement (LDM), boss height, and patellar height ratios (Caton-Deschamps, Blackburne-Peel, Insall-Salvati). All assessors were provided with a summary document outlining the method of assessing each measurement. Bland-Altman analyses were adopted to assess intra- and inter-rater reliability. Results. The results indicated generally low measurement error on intra-rater reliability assessment, particularly for LPD (within-subject variance 0.7mm to 3.7mm), LDM (0.7mm to 3.5mm) and boss height (0.4mm to 1.6mm) for all assessors. There was greater measurement error for the calculation of sulcus angle (0.7° to 10.6°), congruence angle (0.8° to 18.4°) and LPA (0.8° to 16.5°). Whilst the inter-rater reliability between assessors indicated a low mean difference for assessments of patellar height measurements (0.0° to 0.6°), there was greater variability for LPA (0.1° to 3.6°), LPD (0.2mm to 4.6mm) and LDM (0.1mm to 4.0mm), with wide 95% limits of agreement for all measurements indicated poor precision. Conclusions. Many of the standard measurements used to assess the patellofemoral joint on plain radiographs have poor precision. Intra-rater reliability may be related to experience but it seems likely that to achieve good inter-rater reliability, specific training may be required to calibrate observers. More formal training in the technique of radiological measurement for those who were inexperienced might have improved the inter-rater reliability

Recurrent patellar instability is common in young and active patients. Medial patellofemoral ligament (MPFL) reconstruction with a single bundle hamstring graft is one method of surgical treatment for this problem. This is a retrospective case series of patients who underwent MPFL reconstruction by a single specialist knee surgeon between January 2009 and July 2014. Data was collected prospectively for the purpose of service evaluation. Recorded data included gender, age, length of rehabilitation, complications, Knee Injury and Outcome Score (KOOS) and International Knee Documentation Score (IKDC). Data is expressed as mean (range). 108 knees (103 patients) were identified (56 female, 52 male) with a mean age of 24.5 years (12–58). Mean length of rehabilitation was 3.2 months (0–11 months). Three patients required further revision surgery for recurrent instability. KOOS and IKDC scores improved from 44 (4–86) and 38 (2–81), respectively before surgery, to 77 (49–100) and 69 (37–95) after rehabilitation. MPFL reconstruction with a single bundle hamstring graft produces a marked improvement in knee function with a low recurrence of instability

Purpose: Patellar instability raises serious clinical and therapeutic problems in children. We present our results with the “soft baguette” technique used since 1974. Material and methods: Sixty-four patients (50 girls and 14 boys) (85 knees) treated between 1974 and 2000 were reviewed. Mean follow-up was 140 months (14–234). For eight knees, section of the lateral wing of the patella was associated. The five types of patellar instability, from permanent dislocation to potential instability, were represented. Results: At last follow-up, 84% of our patients were satisfied with significant improvement in pain, instability and patellar track. We had minor complications in 23.5% of the knees (haematoma, effusions) and eleven recurrences (9.5%) at mid- or long-term which were considered failures. There were no cases of epiphysiodesis. A neoTTA developed in eight cases, proving the efficacy of realignment of the medialised patellar ligament. Following changes in the mechanical axis of these knees revealed a clear trend towards increased valgus. Discussion: The soft baguette technique has fulfilled expectations: stabilisation of the extensor system without injuring the growth cartilage, and trochlear remodelling for the younger patients. The trend towards increased valgus raises a problem. Because of this risk, if the initial valgum is greater than 5° we emphasise the theoretical importance of temporary medial epiphysiodesis associated with the soft baguette to control this potential source of recurrence and therapeutic failure

AIMS. The aim of this study was to assess the knee function after MPFL reconstruction with single hamstring autograft. METHODS-RESULTS. In this case series 68 patients (69 knees) were treated in total. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency was documented prior to surgery. The MPFL was reconstructed with semitendinosus autograft. The free end of the graft was rerouted through the most distal part of the medial intermuscular septum proximally to the adductor tubercle, to the superomedial border of the patella, where it was fixed, whereas its distal insertion to the tibia was preserved. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores. There were 46 male and 22 female patients with an average age of 25.8 years (median age 23) ranging from 11 to 54 years. The mean follow-up was 19.6 months (range 6-54 months). Ten of the patients had findings of femoral trochlear dysplasia. All knee functional scores significantly improved postoperatively. Kujala score improved from 56 to 84, Tegner score improved from 2 to 6, IKDC score improved from 48 to 75 and Lysholm score improved from 53 to 80. One of the patients required revision of the MPFL reconstruction following traumatic redislocation of the patella. CONCLUSIONS. Rerouting of the semitendinosus tendon for the reconstruction of the MPFL is an effective method for the treatment of patellofemoral instability with very good to excellent functional results

The aim of the study was to assess the knee function after MPFL reconstruction with single hamstring autograft. In this case series 86 patients (87 knees) were treated in total, from July 2002 till December 2008. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency were documented prior to surgery. The MPFL was reconstructed with semitendinosus autograft. The tibial insertion of the graft was retained whereas its free end was rerouted through the most distal part of the medial intermuscular septum, to the supero-medial border of the patella, where it was fixed. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores. There were 60 male and 26 female patients with an average age of 29.73 years (median age 28) and range 16–54 years. The mean follow-up was 22.4 months (range 6–78 months). All knee functional scores significantly improved postoperatively. Kujala score improved from 61.3 to 84.8, Tegner score improved from 3 to 5.3, IKDC score improved from 52.4 to 73.8 and Lysholm score improved from 58 to 76.5. The comparison was made between the preoperative and the postoperative values at two years after surgery or at the last follow up, if it was shorter than two years. All scores showed significant improvement after the third postoperative month. One of the patients required revision of the MPFL reconstruction following traumatic redislocation of the patella. Rerouting of the semitendinosus tendon for the reconstruction of the MPFL is an effective method for the treatment of patellofemoral instability. Significant functional improvement is achieved between the third and sixth postoperative months

Background: The medial patellofemoral ligament (MPFL) is the primary stabilizer of the patellofemoral joint. Its reconstruction has been recommended in adults over the past decade after recurrent patellar instability. The purpose of this study was to assess outcomes after MPFL reconstruction in children and adolescent and to prospectively evaluate reconstruction by computed tomography (CT scans) before and after surgery. Materials and Methods: Thirteen consecutive patients (5 boys and 8 girls)(13 knees) underwent a double bundle MPFL reconstruction with hamstring tendon autograft (gracilis:6, semitendinosus: 7) for patellar instability. A bone femoral fixation with interference screw in a tunnel was associated with patellar fixation according to Fithian in mature knees, and a soft tissue procedure was performed in skeletally immature knees. In 5 knees the MPFL reconstruction was isolated while it was associated with medialization and distalization of the tibial tubercle in 8 knees. The mean age at time of surgery was 14.4 years (range, 9.6– 16.5). Patients were evaluated preoperatively and postoperatively by physical, radiological and CT Scans examination and subjectively with the IKDC and Kujala questionnaires. During CT scans with knee fully extended and the quadriceps contracted or relaxed, the patellar tilt angle was assessed. In cases where tibial tubercle was mobilized, the tibial tubercle-trochlear groove (TT-TG) distance was measured pre and postoperatively. Results: No recurrent episodes of dislocation or sub-luxation were reported after 10.5 months (range, 3–23) follow-up after surgery. Mean Kujala score was of 90.2 (range, 84–99) at latest follow-up. For all patients the moving patellar apprehension test was positive before and negative after surgery. A firm end point to lateral patellar translation was noticed in all patients at latest follow-up. Objective assessment with CT noted that the patellar tilt on relaxed quadriceps was significantly improved from 28° preoperatively (range, 16–41) to 16° at follow-up (range, 7–32). The patellar tilt on contracted quadriceps was significantly improved from 35° preoperatively (range, 21–52) to 24.6° at follow-up (range, 11–48). In the specific subgroup, the TT-TG distance decreased preoperatively from 15.4 mm (range, 12–19) to 9 mm postoperatively (range, 2.9–14.8). Conclusion: MPFL reconstruction in children and adolescent is an effective procedure. The patellar tilt was efficiently improved by MPFL reconstruction and these results were correlated with Kujala score. Mid and long term results are still to be evaluated

Purpose of study: To evaluate the clinical outcome of operative intervention for chronic patellar instability for patients treated by a single paediatric orthopaedic surgeon over a 74-month period. Method: There were 11 patients (16 knees) with a mean age at operation of 11.9 years (5 to 17 years). Patients were treated with combined proximal and distal patellar realignment. Mean follow-up was 44.6 months (11–86 months). All patients were assessed post-operatively with satisfaction scores, the Trillat grading system and the Activity Scale for Kids (ASK). They were also questioned specifically for patellofemoral symptoms and examined for signs of mal-tracking. Results: Subjective patient rating of all procedures revealed 10 (62.5%) responses of excellent or very good, 4 (25%) good, 1 (6.25%) fair and 1 poor (6.25%). Formal Trillat grading revealed 9 (56.3%) excellent, 6 (37.5%) good, 1 (6.2%) fair and no poor outcomes. The mean ASK score was 82% (39–100%). All except one patient felt that they would choose to undergo the surgery again. There was one complication of a superficial wound infection. Conclusions: These results show improvement in symptoms and function as judged by Trillat grading and a majority of patients satisfied with the results of the procedure. We feel that the advantage of appropriate surgical intervention at a young age is not only the improvement in symptoms, but also that successful realignment of patellar tracking may reduce subsequent degenerative problems associated with chronic instability and allow better rehabilitation of the dynamic stabilisers of the patellofemoral joint

Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor; however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability. Cite this article: Bone Jt Open 2022;3(3):268–274

Lateralisation of the tuberosity tibia causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking patella (LTP), resulting in anterior knee pain, or objective patellar instability (OPI), resulting in recurrent luxations. For a precise preoperative diagnosis the tuberositas tibia (TT) trochlear groove (TG) distance was measured on a CT scan. A distance of more than 15 mm was considered to be pathological. In a prospective study, the clinical results of a subtle, CT-guided medial tuberosity transfer for LTP and OPI were evaluated. 30 Consecutive patients with LTP and 30 patients with OPI and an increased TT TG were included. Outcomes were documented at 3, 12 and 24 months follow-up using the Lysholm scale, the Kujala score, and a visual analogue pain score. Postoperatively all but one patient reported good improvement in stability (no persistent subluxations or luxations). All patients had a marked improvement in pain and functional scores at follow up. Complications seem to be related to the peroperative technique. CT-guided TT transfer appears to be satisfactory and safe method for treating patients with an increased TT TG leading to either LTP or OPI

Medial instability of the patella is most often an iatrogenic condition following surgery for patellofemoral pain or instability. Most often the instability is associated with a previous extensive lateral retinacular release for anterior knee pain without instability.

The symptoms usually involve pain and a sense of medial subluxation at unpredictable times. The clinical diagnosis is based on increased medial laxity of the patella and apprehension with medial translation. A positive gravity subluxation test is often present.

If symptomatic treatment, bracing, and other conservative measures fail, surgery may be helpful. Repair of the vastus lateralis tendon near the proximal patella is usually necessary. The lateral retinaculum should also be reconstituted. At times this can be done with direct repair of the retinacular edges. More frequently the scar tissue filling the defect must be imbricated.

Medial retinacular release has also been reported to be a successful intervention.

Introduction: Patello-femoral instability (PFI) and pain may be caused by anatomical abnormality. Many radiographic measurements have been used to describe the shape and position of the patella and femoral trochlea. Some are difficult to apply when dysplasia is present.

This paper describes a simple new MRI measurement of the axial patellar tendon angle (APTA), and compares this angle in patients with and without patello-femoral instability.

Method: Axial MRI images of the knee of 20 patients with PFI and 20 normal knees (isolated acute ACL rupture) were used for measurement. The angle between the patellar tendon and the posterior femoral condylar line was assessed at three levels from the proximal tendon to its insertion.

Results: In normal knees, the APTA is 11 degrees of lateral tilt at all levels from the proximal tendon to its distal insertion. In PFI knees, the APTA is 32 degrees at the proximal tendon, 27 degrees at the joint line and 22 degrees at the distal insertion. The difference is significant (p< 0.001) at all levels.

Discussion: Measurement of the APTA is reproducible and is easier than many other indices of patello-femoral anatomy. In PFI, the APTA is increased by 21 degrees at the proximal tendon and by 11 degrees at its distal insertion.

In PFI, the patella is commonly tilted laterally. This is matched by the orientation of the patellar tendon. The increased tilt of the tendon is only partially corrected at its distal insertion with an abnormal angle of tibial attachment. When performing distal realignment procedures, angular correction as well as displacement may be appropriate.