1. PATHOLOGY AND MANAGEMENT OF RECURRENT PATELLA DISLOCATION BY PINK TEAM(HOSPITAL PRESENTATION) FRIDAY 22 ND JULY 2015

2. OUTLINE INTRODUCTION MANAGEMENT  PRESENTATION/RESUSCITATION  HISTORY  PHYSICAL EXAMINATION  INVESTIGATIONS

3.  TREATMENT  POST OPERATIVE REHABILITATION  COMPLICATIONS  FOLLOW-UP  PROGNOSIS  THE JOURNEY SO FAR  CONCLUSION

4. INTRODUCTION Defined as the condition where patella dislocation had occurred at least twice, or where patella instability following initial dislocation had persisted for more than three months Several treatment options are available in the surgeons armamentarium No single surgery is universally successful Need to customize surgery based on underlying pathology

5. Risk factors for Recurrent patella dislocation Generalized ligamentous laxity Under development of the lateral femoral condyle and flattening of the intercondylar groove Mal-development of the patella, which may be too high or too small Valgus deformity of the knee

6. External tibial torsion Primary muscle defect

7. MANAGEMENT Presentation……………..  Emergency  Elective

8. Emergency presentation Resuscitation Reduction  Sedation/muscle relaxation/GA  Closed reduction

9. HISTORY Age Sex bilateral Instability (knee “coming out”) Catching or locking Pain Initial trauma (high or low energy)

10. Frequency of dislocation Position in which dislocation/subluxation occurs Timing of dislocation Determine ease of relocation Current functional limitations Prior intervention Family history Comorbidities / Mental status

11. EXAMINATION General Specific  Both knee…..with normal knee as reference Gait Valgus deformity Atrophy Swelling ….effusion Asymmetry Tenderness Palpate bony prominences

14. ‘Q’ angle  M…......10 degrees  F…......... 15 +/_ 5 degrees  Increase ‘Q’ leads to relative lateral shift of patella J sign Laxity Rotational malalignment Patella apprehension test

16. INVESTIGATIONS Plain radiograph  Long standing weight bearing hip-to-ankle A/P view  Lateral view of the knee {30 degrees of knee flexion) Insall-salvati ratio Trochlear dysplasia  Crossing sign  Double contour

19. Merchant view {45 degrees of flexion} Sulcus angle Congruence angle Lateral patello femoral angle CT scan MRI

24. TREATMENT Non operative Operative

25. Non operative Closed reduction Analgesia Bracing Isometric quadriceps strengthening exercises

26. Indications for operative treatment Failure of non operative therapy Irreducible dislocation Repeated and distressing episodes of dislocation Functional limitation

27. Preoperative planning Assessment of patients expectations Assess mental status of patient Identify osteochondral lesions Identify trochlear dysplasia and patella alta…..........tibia tubercle medialization/distalization Requisite surgical expertise Instrumentation/equipment

28. Principles of operative intervention To repair or strengthen the medial patello- femoral ligaments To realign the extensor mechanism so as to produce a mechanically more favorable angle of pull

29. Operative  Open  Arthroscopic

30. Surgical procedures…......  Proximal realignment of extensor mechanism Lateral retinacular release Medial plication/reefing Vastus medialis obliquus advancement Medial patello femoral ligament reconstruction Suprapatellar realignment (Insall)

32.  Distal realignment of extensor mechanism Medial or anteromedial displacement of tibial tuberosity (Elmslie–Trillat) Infrapatellar soft-tissue realignment (Goldthwait)

37. Postoperative Rehabilitation Weight bearing as tolerated is allowed immediately postoperatively in a knee extension brace Bracing may be continued for up to 6 weeks during ambulation to prevent falls until quadriceps control is restored After the soft tissue procedure, passive ROM exercises are begun as soon as possible to restore ROM and quadriceps control

38. If a tibial tubercle osteotomy is performed, passive ROM using heel slides is begun postoperatively No active extension is allowed for 6 postoperative weeks At that time, full active ROM is begun

39. Patients are allowed to return to stressful activities, when they attain full ROM and have regained at least 80% of their quadriceps strength compared to the non injured limb

40. COMPLICATIONS Hematoma Infection Stiffness Redislocation Excessive medial patellar constraint resulting in a painful, overconstrained patella Patellar fracture Nonunion

41. THE JOURNEY SO FAR….....  The team currently working on……………  10 year hospital based retrospective study  PATTERN OF PRESENTATION OF PATELLA INSTABILITY AT NOHD : A 10 YEAR REVIEW  From January 2006 to December 2015

42. Results so far….......  41 cases  M: F = 3:1  38 had non operative management  4 had operative intervention  1 open procedure  3 Arthroscopic procedures

43. THANK YOU!!!!!!

44. Next week (July 29 th, 2016): PROSTHETIC & ORTHOTICS DEPT Fortnight (August 5 th, 2016): WHITE TEAM …Have a Nice Day