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Locked Lateral Patella Dislocation With Generalized Ligamentous Laxity After Arthroscopic Lateral Release of the Knee
Case Report
Locked Lateral Patella Dislocation With Generalized Ligamentous Laxity After Arthroscopic Lateral Release of the Knee Susanne Freitag, M.D., Helmut Lill, M.D., Pierre Hepp, M.D., Christoph Stockmar, M.D., and Christoph Josten, M.D.
Abstract: We describe the case of a 14-year-old boy with patellar instability on both sides resulting from ligamentous hyperlaxity and dysplasia of the lateral femoral condyle who had previously undergone an arthroscopic lateral release as well as plication of the medial capsule. The patient presented to our clinic 2 years after surgery with a locked lateral patella dislocation on the left side. The surgical correction involved a substantial open lateral release including an excision of the scar tissue and stabilization of the patella in the patellofemoral groove by tibial tubercle medialization and plication of the medial capsule. Six months after surgery, the patient achieved a Lysholm score of 90 points and clinical examination indicated a stable knee with a centralized patella without any evidence of subluxation or dislocation. Open lateral release with partial resection of the lateral retinaculum, medial reconstruction, and tibial tubercle osteotomy was the procedure of choice in this patient with habitual patella dislocation caused by generalized ligamentous laxity. Key Words: Irreducible—Lateral patella dislocation—Generalized ligamentous laxity—Realignment—Arthroscopic lateral release.
H
abitual dislocation of the patella often occurs during ordinary movement. Most commonly it is observed on the lateral side and only rarely on the medial, superior, or intra-articular side.1 Predisposing factors for habitual lateral patella dislocation have been frequently reported and include generalized ligamentous laxity, dysplasia of the patella and femoral
From the Department of Trauma and Reconstructive Surgery, University of Leipzig, Leipzig, Germany. Address correspondence and reprint requests to Susanne Freitag, M.D., Department of Trauma and Reconstructive Surgery, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America Cite this article as: Freitag S, Lill H, Hepp P, Stockmar C, Josten C. Locked lateral patella dislocation with generalized ligamentous laxity after arthroscopic lateral release of the knee. Arthroscopy 2005;21:628.e1-628.e4 [doi:10.1016/j.arthro.2005.02.005]. 0749-8063/05/2105-4318$30.00/0 doi:10.1016/j.arthro.2005.02.005
condyles, as well as genu valgum and thigh lateral ligamentous structures.2 Usually a spontaneous reduction occurs. A great variety of surgical procedures to approach recurrent patella subluxation or dislocation has been reported in the literature.3-12 The arthroscopic lateral release procedure of the extensor mechanism has been proven to be an adequate and successful treatment in cases without generalized ligamentous laxity and without subluxation on extension.2 Both the open and arthroscopic procedures have the same goal of decreasing the lateral moment imposed on the lateral patella by an overly tight lateral retinaculum. Complications after arthroscopic lateral release are rare and include weakening of the quadriceps,13 medial patella dislocation,14 and hemarthrosis.3 We present a case of locked lateral patella dislocation in a 14-year-old boy with generalized ligamentous laxity and lateral femoral condyle dysplasia after
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 21, No 5 (May), 2005: pp 628.e1-628.e4
628.e1
628.e2
S. FREITAG ET AL.
an arthroscopic lateral release procedure. To our knowledge, this case is the first to be reported in the literature of such a complication after an arthroscopic lateral release procedure. CASE REPORT A 14-year-old boy presented with a locked patella dislocation on the left side. Two years prior, the patient underwent an arthroscopic lateral release procedure as well as a reconstruction of the medial capsule by plication because of recurrent patella subluxations associated with generalized ligamentous laxity as well as a dysplasia of the lateral femoral condyle at another hospital (Fig 1A and B). Immediately after arthroscopic lateral release, the patient was mobilized on crutches accompanied by toe-touch weight bearing. For the first 3 weeks he was allowed to bend the knee with a maximum of 20° followed by increasing flexion and muscle strengthening. On physical examination at his first visit to our clinic, the patient was unable to climb stairs without an orthosis. He also reported a feeling of instability in his left knee. Inspection revealed marked atrophy of the left quadriceps muscle with a side difference of 7 cm. The patient was unable to perform a straight leg raise, but the passive and active range of motion was
unlimited. On knee flexion, the patella was always palpable to the lateral femoral condyle. The tilt angle was neutral and the medial patellar glide was less than one quadrant. Furthermore, no swelling or effusion and no clinical evidence of a cruciate or collateral ligament instability could be detected. The standard radiographs (anteroposterior and lateral views; Fig 2A and B) revealed a lateral dislocation of the patella (stage II according to Ficat15), early degenerative changes of the femoropatellar joint, a flat articular surface of the femur with a smooth intercondylar groove (160°), as well as a significant dysplasia of the lateral femoral condyle (stage I according to Dejour15). The knee was exposed through a standard medial arthrotomy. The locked patella was mobilized by a substantial open lateral tissue release as well as an osteotomy of the tibial tuberosity. To replace the patella in the correct position, the tuberosity was refixated 1 cm medially using 2 screws (Fig 3A and B). Postoperatively, the patient underwent physical therapy including a gradually increasing flexion and strengthening of the quadriceps. Six months after surgery, the patient was satisfied with the procedure. He had regained a normal gait pattern and had a stable knee with flexion up to 120° and good patellar tracking; the Lysholm score in a clinical evaluation 6 months after surgery was 90 points. Inspection after
FIGURE 1. (A) Standing and (B) seated views of the 14-year-old boy 2 years after arthroscopic lateral release resulting from generalized ligamentous laxity with a locked lateral patella dislocation.
LOCKED LATERAL PATELLA DISLOCATION
628.e3
FIGURE 2. Preoperative (A) anteroposterior and (B) lateral view radiographs.
the open lateral release revealed marked atrophy of the left quadriceps with a side difference of 4 cm. Postoperative radiographs showed the patella correctly placed in the femoral groove (Fig 3C). DISCUSSION To our knowledge, a locked lateral patella dislocation as a complication after arthroscopic lateral release has not previously been reported in the literature. In 1994, Dandy and Desai2 reviewed 41 knees at a mean of 4 years after arthroscopic lateral release due to recurrent patella dislocation. Exclusion criteria were subluxation, maltracking, or lateral pressure syndrome. They found a higher incidence of failure after arthroscopic lateral release procedure in patients with generalized ligamentous laxity than in patients with normal ligamentous laxity. Gao et al.4 and Langenskiold and Ritsila16 had already reported that patients with habitual patella dislocation have the tendency to develop contractures of different kinds of structures of the lateral aspect of the knee including contractures and fibrosis of the quadriceps, mainly the vastus lateralis pulling the quadriceps mechanism to the anterolateral aspect of the knee, contractures of the iliotibial
band preventing reduction of the dislocated patella, and contractures of the lateral capsule. The lateral retinaculum is composed of 2 anatomic layers: superficial and deep.3 Fibers from the iliotibial band and vastus lateralis compose the superficial layer. The deep layer is composed of dense transverse fibers that connect the deeper portion of the fascia lata directly to the lateral patella. The epicondylopatellar and patellotibial ligament are located at the superior and inferior borders of the deep layer, tethering the patella to the lateral epicondyle and anterolateral tibia.3 In the case we present, the arthroscopic lateral retinaculum release failed completely. We assume that the lateral retinaculum release was incomplete because of the limited patellar mobility. An incomplete lateral release is often due to the residual fibers of the patellotibial ligament and, if performed arthroscopically, not being carried out distally enough. On the one hand the predisposition of scarring in the side of the lateral release, and on the other hand the incomplete lateral release, may have led to a locked lateralization of the patella. Certainly the restrictive postoperative physical therapy after arthroscopic lateral release was another reason for the failure, because early knee flexion is important to prevent scarring at
628.e4
FIGURE 3.
S. FREITAG ET AL.
Postoperative (A) anteroposterior, (B) lateral, and (C) axial view radiographs showing the patella correctly placed in the femoral groove.
the lateral release side. Fu and Maday13 suggest full weight bearing with crutches as well as movement of the knee and an isometric quadriceps exercise immediately after arthroscopic lateral release of the extensor mechanism. We conclude that arthroscopic lateral release of the extensor mechanism may not be the procedure of choice in patients with habitual patella dislocations associated with generalized ligamentous laxity. We recommend an open lateral release of the patella and, if necessary, partial resection of the lateral retinaculum, medialization of the tuberositas tibia, as well as plication of the medial capsule in a patient with habitual ligamentous laxity.
5. 6. 7. 8. 9. 10.
11.
REFERENCES 1. Hackl W, Benedetto KP, Fink C, et al. Locked lateral patella dislocation: A rare case of irreducible patellar dislocation requiring open reduction. Knee Surg Sports Traumatol Arthrosc 1999;7:352-355. 2. Dandy DJ, Desai SS. The results of arthroscopic lateral release of the extensor mechanism for recurrent dislocation of the patella after 8 years. Arthroscopy 1994;10:540-545. 3. Ford DH, William RP (197): Open or arthroscopic lateral release. Clin Sports Med 1997;16:29-49. 4. Gao GX, Lee EH, Bose K. Surgical management of congenital
12. 13. 14. 15. 16.
and habitual dislocation of the patella. J Pediatr Orthop 1990;10:255-260. Goldthwait JE. Permanent dislocation of the patella. Ann Surg 1899;29:62. Hauser EDW. Total tendon transplant for slipping patella. A new operation for recurrent dislocation of the patella. Surg Gynecol Obstet 1938;66:199-213. Insall J, Bullough PG, Burstein AH. Proximal tube realignment of the patella for chondromalacia patellae. Clin Orthop 1979;144:63-69. Krämer KL, Jani L. Die Operation nach Elmslie-Trillat. Operat Orthop Traumatol 1991;3:38-48. Liebau Ch, Merkel M, Merk M, et al. Die Medialisierung der Tuberositas tibiae zur Behandlung habitueller Patellaluxationen. Chirurg 1999;70:1307-1314. Madigan R, Wissinger HA, Donaldson WF. Preliminary experience with a method of quadricepsplasty in recurrent subluxation of the patella. J Bone Joint Surg Am 1975;57:600607. Roux C. Luxation habituelle de la rotulement operative. Rev Chir Paris 1988;7:584-586. Strobel W, Grill F. Die Patellaluxation. Orthopade 1998;27: 197-205. Fu FH, Maday MG. Arthroscopic lateral release and the lateral patellar compression syndrome. Orthop Clin North Am 1992; 23:601-612. Hughston JC, Dees M. Medial subluxation of the patella as a complication of lateral retinaculum release. Am J Sports Med 1988;16:383-389. Jerosch J. Orthopädisch-traumatologische Gelenkdiagnostik. Stuttgart: Enke, 1995. Langenskiold A, Ritsila V. Congenital dislocation of the patella and its treatment. J Pediatr Orthop 1992;12:315-323.
Locked Lateral Patella Dislocation With Generalized Ligamentous Laxity After Arthroscopic Lateral Release of the Knee Susanne Freitag, M.D., Helmut Lill, M.D., Pierre Hepp, M.D., Christoph Stockmar, M.D., and Christoph Josten, M.D.
Abstract: We describe the case of a 14-year-old boy with patellar instability on both sides resulting from ligamentous hyperlaxity and dysplasia of the lateral femoral condyle who had previously undergone an arthroscopic lateral release as well as plication of the medial capsule. The patient presented to our clinic 2 years after surgery with a locked lateral patella dislocation on the left side. The surgical correction involved a substantial open lateral release including an excision of the scar tissue and stabilization of the patella in the patellofemoral groove by tibial tubercle medialization and plication of the medial capsule. Six months after surgery, the patient achieved a Lysholm score of 90 points and clinical examination indicated a stable knee with a centralized patella without any evidence of subluxation or dislocation. Open lateral release with partial resection of the lateral retinaculum, medial reconstruction, and tibial tubercle osteotomy was the procedure of choice in this patient with habitual patella dislocation caused by generalized ligamentous laxity. Key Words: Irreducible—Lateral patella dislocation—Generalized ligamentous laxity—Realignment—Arthroscopic lateral release.
H
abitual dislocation of the patella often occurs during ordinary movement. Most commonly it is observed on the lateral side and only rarely on the medial, superior, or intra-articular side.1 Predisposing factors for habitual lateral patella dislocation have been frequently reported and include generalized ligamentous laxity, dysplasia of the patella and femoral
From the Department of Trauma and Reconstructive Surgery, University of Leipzig, Leipzig, Germany. Address correspondence and reprint requests to Susanne Freitag, M.D., Department of Trauma and Reconstructive Surgery, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America Cite this article as: Freitag S, Lill H, Hepp P, Stockmar C, Josten C. Locked lateral patella dislocation with generalized ligamentous laxity after arthroscopic lateral release of the knee. Arthroscopy 2005;21:628.e1-628.e4 [doi:10.1016/j.arthro.2005.02.005]. 0749-8063/05/2105-4318$30.00/0 doi:10.1016/j.arthro.2005.02.005
condyles, as well as genu valgum and thigh lateral ligamentous structures.2 Usually a spontaneous reduction occurs. A great variety of surgical procedures to approach recurrent patella subluxation or dislocation has been reported in the literature.3-12 The arthroscopic lateral release procedure of the extensor mechanism has been proven to be an adequate and successful treatment in cases without generalized ligamentous laxity and without subluxation on extension.2 Both the open and arthroscopic procedures have the same goal of decreasing the lateral moment imposed on the lateral patella by an overly tight lateral retinaculum. Complications after arthroscopic lateral release are rare and include weakening of the quadriceps,13 medial patella dislocation,14 and hemarthrosis.3 We present a case of locked lateral patella dislocation in a 14-year-old boy with generalized ligamentous laxity and lateral femoral condyle dysplasia after
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 21, No 5 (May), 2005: pp 628.e1-628.e4
628.e1
628.e2
S. FREITAG ET AL.
an arthroscopic lateral release procedure. To our knowledge, this case is the first to be reported in the literature of such a complication after an arthroscopic lateral release procedure. CASE REPORT A 14-year-old boy presented with a locked patella dislocation on the left side. Two years prior, the patient underwent an arthroscopic lateral release procedure as well as a reconstruction of the medial capsule by plication because of recurrent patella subluxations associated with generalized ligamentous laxity as well as a dysplasia of the lateral femoral condyle at another hospital (Fig 1A and B). Immediately after arthroscopic lateral release, the patient was mobilized on crutches accompanied by toe-touch weight bearing. For the first 3 weeks he was allowed to bend the knee with a maximum of 20° followed by increasing flexion and muscle strengthening. On physical examination at his first visit to our clinic, the patient was unable to climb stairs without an orthosis. He also reported a feeling of instability in his left knee. Inspection revealed marked atrophy of the left quadriceps muscle with a side difference of 7 cm. The patient was unable to perform a straight leg raise, but the passive and active range of motion was
unlimited. On knee flexion, the patella was always palpable to the lateral femoral condyle. The tilt angle was neutral and the medial patellar glide was less than one quadrant. Furthermore, no swelling or effusion and no clinical evidence of a cruciate or collateral ligament instability could be detected. The standard radiographs (anteroposterior and lateral views; Fig 2A and B) revealed a lateral dislocation of the patella (stage II according to Ficat15), early degenerative changes of the femoropatellar joint, a flat articular surface of the femur with a smooth intercondylar groove (160°), as well as a significant dysplasia of the lateral femoral condyle (stage I according to Dejour15). The knee was exposed through a standard medial arthrotomy. The locked patella was mobilized by a substantial open lateral tissue release as well as an osteotomy of the tibial tuberosity. To replace the patella in the correct position, the tuberosity was refixated 1 cm medially using 2 screws (Fig 3A and B). Postoperatively, the patient underwent physical therapy including a gradually increasing flexion and strengthening of the quadriceps. Six months after surgery, the patient was satisfied with the procedure. He had regained a normal gait pattern and had a stable knee with flexion up to 120° and good patellar tracking; the Lysholm score in a clinical evaluation 6 months after surgery was 90 points. Inspection after
FIGURE 1. (A) Standing and (B) seated views of the 14-year-old boy 2 years after arthroscopic lateral release resulting from generalized ligamentous laxity with a locked lateral patella dislocation.
LOCKED LATERAL PATELLA DISLOCATION
628.e3
FIGURE 2. Preoperative (A) anteroposterior and (B) lateral view radiographs.
the open lateral release revealed marked atrophy of the left quadriceps with a side difference of 4 cm. Postoperative radiographs showed the patella correctly placed in the femoral groove (Fig 3C). DISCUSSION To our knowledge, a locked lateral patella dislocation as a complication after arthroscopic lateral release has not previously been reported in the literature. In 1994, Dandy and Desai2 reviewed 41 knees at a mean of 4 years after arthroscopic lateral release due to recurrent patella dislocation. Exclusion criteria were subluxation, maltracking, or lateral pressure syndrome. They found a higher incidence of failure after arthroscopic lateral release procedure in patients with generalized ligamentous laxity than in patients with normal ligamentous laxity. Gao et al.4 and Langenskiold and Ritsila16 had already reported that patients with habitual patella dislocation have the tendency to develop contractures of different kinds of structures of the lateral aspect of the knee including contractures and fibrosis of the quadriceps, mainly the vastus lateralis pulling the quadriceps mechanism to the anterolateral aspect of the knee, contractures of the iliotibial
band preventing reduction of the dislocated patella, and contractures of the lateral capsule. The lateral retinaculum is composed of 2 anatomic layers: superficial and deep.3 Fibers from the iliotibial band and vastus lateralis compose the superficial layer. The deep layer is composed of dense transverse fibers that connect the deeper portion of the fascia lata directly to the lateral patella. The epicondylopatellar and patellotibial ligament are located at the superior and inferior borders of the deep layer, tethering the patella to the lateral epicondyle and anterolateral tibia.3 In the case we present, the arthroscopic lateral retinaculum release failed completely. We assume that the lateral retinaculum release was incomplete because of the limited patellar mobility. An incomplete lateral release is often due to the residual fibers of the patellotibial ligament and, if performed arthroscopically, not being carried out distally enough. On the one hand the predisposition of scarring in the side of the lateral release, and on the other hand the incomplete lateral release, may have led to a locked lateralization of the patella. Certainly the restrictive postoperative physical therapy after arthroscopic lateral release was another reason for the failure, because early knee flexion is important to prevent scarring at
628.e4
FIGURE 3.
S. FREITAG ET AL.
Postoperative (A) anteroposterior, (B) lateral, and (C) axial view radiographs showing the patella correctly placed in the femoral groove.
the lateral release side. Fu and Maday13 suggest full weight bearing with crutches as well as movement of the knee and an isometric quadriceps exercise immediately after arthroscopic lateral release of the extensor mechanism. We conclude that arthroscopic lateral release of the extensor mechanism may not be the procedure of choice in patients with habitual patella dislocations associated with generalized ligamentous laxity. We recommend an open lateral release of the patella and, if necessary, partial resection of the lateral retinaculum, medialization of the tuberositas tibia, as well as plication of the medial capsule in a patient with habitual ligamentous laxity.
5. 6. 7. 8. 9. 10.
11.
REFERENCES 1. Hackl W, Benedetto KP, Fink C, et al. Locked lateral patella dislocation: A rare case of irreducible patellar dislocation requiring open reduction. Knee Surg Sports Traumatol Arthrosc 1999;7:352-355. 2. Dandy DJ, Desai SS. The results of arthroscopic lateral release of the extensor mechanism for recurrent dislocation of the patella after 8 years. Arthroscopy 1994;10:540-545. 3. Ford DH, William RP (197): Open or arthroscopic lateral release. Clin Sports Med 1997;16:29-49. 4. Gao GX, Lee EH, Bose K. Surgical management of congenital
12. 13. 14. 15. 16.
and habitual dislocation of the patella. J Pediatr Orthop 1990;10:255-260. Goldthwait JE. Permanent dislocation of the patella. Ann Surg 1899;29:62. Hauser EDW. Total tendon transplant for slipping patella. A new operation for recurrent dislocation of the patella. Surg Gynecol Obstet 1938;66:199-213. Insall J, Bullough PG, Burstein AH. Proximal tube realignment of the patella for chondromalacia patellae. Clin Orthop 1979;144:63-69. Krämer KL, Jani L. Die Operation nach Elmslie-Trillat. Operat Orthop Traumatol 1991;3:38-48. Liebau Ch, Merkel M, Merk M, et al. Die Medialisierung der Tuberositas tibiae zur Behandlung habitueller Patellaluxationen. Chirurg 1999;70:1307-1314. Madigan R, Wissinger HA, Donaldson WF. Preliminary experience with a method of quadricepsplasty in recurrent subluxation of the patella. J Bone Joint Surg Am 1975;57:600607. Roux C. Luxation habituelle de la rotulement operative. Rev Chir Paris 1988;7:584-586. Strobel W, Grill F. Die Patellaluxation. Orthopade 1998;27: 197-205. Fu FH, Maday MG. Arthroscopic lateral release and the lateral patellar compression syndrome. Orthop Clin North Am 1992; 23:601-612. Hughston JC, Dees M. Medial subluxation of the patella as a complication of lateral retinaculum release. Am J Sports Med 1988;16:383-389. Jerosch J. Orthopädisch-traumatologische Gelenkdiagnostik. Stuttgart: Enke, 1995. Langenskiold A, Ritsila V. Congenital dislocation of the patella and its treatment. J Pediatr Orthop 1992;12:315-323.