■ ■ ■ Indications (Who Needs Surgery, When, Why, and Goals)

• If there are loose fragments of bone or cartilage in the knee, surgery to remove the fragments is necessary. Usually, surgery to prevent further dislocations is not performed at the first dislocation, even if surgery is being performed to remove loose fragments.

• If there are no loose fragments of bone or cartilage in the knee, surgery is usually reserved for people who have recurrent patellar dislocation, giving way or knee instability, or patellar pain despite 3 to 6 months of an adequate rehabilitation program.

• Uncommonly, surgery is recommended after the first dislocation, especially in athletes who regularly perform sports that require pivoting, cutting, and jumping.

• Surgery usually is not recommended until the injured knee has full range of motion and there is muscle control of the thigh (usually 3 or more weeks following injury), unless a loose fragment is in the knee.

• Surgery is performed to prevent further dislocations.

• The goal of the operation is to restore normal tracking of the patella; that is, to enable a return to sports that require cutting, pivoting, change of direction, and jumping and landing.

• Return to sports is usually 3 to 9 months after surgery (depending on the type of surgery and rehabilitation).

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■ ■ ■ Contraindications (Reasons Not To Operate)

• Normal tracking of the patella

• Inability or unwillingness to complete the postoperative program or to perform the rehabilitation necessary

• Infection of the knee (current or previous; not an absolute contraindication)

• Skeletal immaturity (not fully grown yet; not an absolute contraindication)

• Severe knee or patellar arthritis

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■ ■ ■ Risks and Complications of Surgery

• Infection, bleeding, or injury to nerves (numbness, weakness, paralysis) of the knee, leg, and foot (some numbness, temporary or permanent, on the outer part of the upper leg is not uncommon)

• Swelling or continued pain of the knee

• Rupture or stretching out of the repair, causing recurrent patellar dislocation

• Patella dislocation or subluxation inward

• Knee stiffness (loss of knee motion) or weakness

• Recurrent dislocation or subluxation of the patella

• Pain from the screw used to hold the bone

• Clot in the veins of the calf or thigh (deep venous thrombosis, phlebitis) that may break off in the bloodstream and go to the lungs (pulmonary embolus) or brain (causing a stroke)

• Reflex sympathetic dystrophy (severe pain)

• Nonhealing of bone

• Inability to remove all the loose bodies in the knee

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■ ■ ■ Technique (What Is Done)

• Different techniques have been used to treat recurrent dislocation of the patella. Procedures are done at or above the patella involving soft tissue only, and there are procedures performed below the patella involving bone.

• Soft tissue procedures include operations to cut the tight structures (retinaculum) on the outer side of the patella (lateral release), with or without tightening the tissues of the inner knee (medial reefing or vastus medialis obliqus muscle [VMO] advancement). Other operations include rerouting tendon or ligament tissue to keep the patella from dislocating (usually for growing children). Surgeries below the patella include cutting the leg bone at the tibial tubercle and moving it inward, which helps the quadriceps mechanism pull in a straight line, reducing the angle and tendency for the patella to dislocate (tibial tubercle transfer).

• Lateral release may be performed with the assistance of the arthroscope and may be done on an outpatient basis (you go home the same day).

• Tibial tubercle transfer (osteotomy) may be preceded by arthroscopy and requires a 1- to 2-day stay in the hospital. When the bone is cut and moved, it is held with screws. After surgery, a brace or cast for 2 to 8 weeks is usually recommended. The screws used to hold the bone usually do not need to be removed unless they bother you.

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■ ■ ■ Postoperative Course

• Keep the wound clean and dry for 10 to 14 days after surgery.

• Ice your knee for 20 minutes every 2 to 3 hours for the first 1 to 2 weeks after surgery.

• You will be given pain medications by your physician.

       Take only as directed.

• You may be given a knee brace or cast after surgery.

• Rehabilitation after patella-stabilizing surgery focuses on reducing knee swelling, regaining knee range of motion, and regaining strength in the leg and thigh muscles. Check with your surgeon or physical therapist for the exact exercises to perform. Often a graduated program is specified.

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■ ■ ■ Return to Sports

Return to sports occurs when there is no pain and full range of motion, muscle strength, and endurance of the knee and functional use has been restored. If a tibial transfer has been performed, the bone must be completely healed. Return to sports usually requires 4 to 6 months following realignment surgery.

 

 

■ ■ ■ Notify Our Office If

• Pain, tenderness, or swelling worsens despite treatment

• You experience pain, numbness, or coldness in the foot

• Blue, gray, or dusky color appears in the toenails

• Any of the following signs of infection occur after surgery: fever, increased pain, swelling, redness, drainage, or bleeding in the surgical area

• New, unexplained symptoms develop (drugs used in treatment may produce side effects)