MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
(vii) Patellofemoral instability
Neil Upadhyay
Charles Wakeley
Jonathan D J Eldridge
Abstract
The accurate assessment and management of the unstable patellofemoral
joint depends on knowledge of the anatomy and stabilizing structures.
Surgery should not be considered until non-operative interventions
have failed and the recurrent nature of the disease has resulted in func-
tional impairment. The surgical strategy should, whenever possible, aim
to restore normal anatomy rather than introduce new abnormalities.
Often a combination of surgical techniques is required.
Keywords patellar dislocation; patellofemoral dysplasia; patellar insta-
bility; patellofemoral malalignment
Introduction
The rate of first-time dislocation is highest among female
adolescents. Following a first event, 17% of patients will expe-
rience subsequent instability. The younger a patient is at the time
of first dislocation and the more severe the dislocation, the
greater the risk of subsequent dislocation. If the patient has an
established history of subluxation or dislocation the risk of
subsequent episodes rises to 50%.1,2
Stable tracking of the patella relies on complex orchestration
of static ligament and capsular constraints with balanced
dynamic forces from muscle actions working within the
anatomical constraints of the joint. Disorders in any of these
relationships results in maltracking or instability of the patello-
femoral joint. Patients with patellar instability will have either
objective instability (true atraumatic dislocation with an
anatomical abnormality) or potential instability (patellar pain,
a feeling of the knee giving way or locking, with an associated
underlying anatomical abnormality).3
A number of morphological, static and dynamic factors
predispose the patellofemoral joint to instability. Trochlear
dysplasia and patella alta are the most common morphological
abnormalities, with lateral condylar hypoplasia and torsional
abnormalities being occasionally present. Abnormalities in static
Neil Upadhyay MRCS (Eng) Specialist Registrar, Department of Ortho-
paedics, Bristol Royal Infirmary, University Hospitals Bristol, Bristol, UK.
Charles Wakeley FRCS FRCR Consultant Radiologist, Department of
Radiology, Bristol Royal Infirmary, University Hospitals Bristol, Bristol,
UK.
Jonathan D J Eldridge FRCS (Orth) Consultant Orthopaedic Surgeon,
Department of Orthopaedics, Bristol Royal Infirmary, University Hospi-
tals Bristol, Bristol, UK.
ORTHOPAEDICS AND TRAUMA 24:2
structures, including the medial patellofemoral ligament (MPFL),
lateral retinaculum and iliotibial band, or the dynamic soft-tissue
forces may lead to symptoms.
Malalignment of the patellofemoral joint does not necessarily
equate to functional or symptomatic instability. Many patients
will function without problems with simple, non-operative
interventions. When non-operative treatments have failed and
the recurrent nature of the disease has resulted in functional
impairment, the goals of re-alignment surgery are to stabilize
patellar tracking and optimize load transmission within the joint.
Thus, the challenge is not only to understand the different
anatomical abnormalities but also the interplay of
the components described above, before considering corrective
measures.4
Anatomical and physiological considerations
Morphology of the trochlea and patella
The trochlea is a concave trough, its shape dependant on the
contour of the distal femur and depth of overlying articular
cartilage. The depth and steepness of this grove influence the
stability of articulation. The lateral facet of the trochlear groove is
highest on the anterior aspect of the femur and decreases in
height more distally and posteriorly, giving some osseous
constraint to the patella in extension and early flexion. Dysplasia
of the lateral femoral condyle reduces the osseous protection
conferred to the patella.
The role of patellofemoral dysplasia has only recently been
fully appreciated and implicated in patellar dislocation. Trochlear
dysplasia is flattening or elevation of the central area of the
trochlear groove, rather than deficiency of the lateral facet of the
groove (Figure 1). Dysplasia of the femoral trochlea has been
found to correlate most strongly with objective patellar insta-
bility.3 The cartilaginous surface geometry of the patella and
trochlea has been shown to differ from that of the underlying
osseous morphology in patients with trochlear dysplasia.5,6 The
overlying cartilage exacerbates the abnormal shape.
Figure 1 Axial MR scan demonstrating flat dysplastic trochlea with asso-
ciated tilted patellar tendon. As can be seen this patient has patella alta
(only patellar tendon visible).
139 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
Patella alta is associated with instability since the patella lies
superior to the lateral femoral condyle and the trochlear groove
(Figure 2). This results in a greater arc of knee flexion during
which the patella is not engaged within the trochlea and is
therefore at increased risk of instability. The length of the patellar
tendon has been shown to be equal to the diagonal length of the
patella. Variations of more than 20% are considered abnormal.7
A number of established indices have been used to define patellar
height, although the authors find the more recently described
patellotrochlear index is more useful.8
Static soft-tissue constraints
Static soft-tissue constraints are most important before the patella is
fully engaged in the trochlea. The primary static restraint pre-
venting lateral subluxation or dislocation of the patella is the medial
patellofemoral ligament (MPFL). This extra-synovial ligament runs
transversely from the medial femoral condyle, deep to vastus
medialis, inserting into the proximal two-thirds of the patella
(Figure 3). The MPFL is the primary passive soft-tissue restraint to
lateral patellar displacement, reported to provide greater than 50%
of lateral restraint from 0 to 30 of knee flexion.9,10
The lateral sided fascial system has three layers that
contribute to a lateral static soft-tissue constraint. The superficial
layer is confluent with the iliotibial band. The intermediate layer
extends from the deep layer of the iliotibial band to the mid-
lateral aspect of the patella. The deep layer is confluent with
the knee capsule.11
Other stabilizers of the patellofemoral joint include the
patellomeniscal and patellotibial ligaments, which attach on the
medial and lateral sides respectively. At present little
Figure 2 Lateral radiograph demonstrating patella alta.
ORTHOPAEDICS AND TRAUMA 24:2
Figure 3 Axial MR demonstrating a grossly stretched MPFL (arrow) asso-
ciated with patella alta.
consideration has been given to assessment of these ligaments
and management of dysfunction.
Dynamic soft-tissue constraints
The rectus femoris, vastus lateralis, vastus intermedius and
vastus medialis insert in a layered arrangement onto the prox-
imal patella, creating different vectors of force on the patella.12,13
An imbalance of strength may lead to instability, although this
influence on the patellofemoral joint remains controversial.
The lower part of the vastus medialis, known as the vastus
medialis obliquus (VMO), may be important in patellar insta-
bility.13,14 There is attachment of the deep fascia of the VMO to
the MPFL, and they probably act together as a combined dynamic
complex.15 The VMO is the first part of the quadriceps to weaken
and the last to strengthen when function is inhibited.16
The vastus lateralis is variable in length, cross sectional area
and orientation and its role in patellofemoral instability remains
uncertain.4
Coronal and rotational alignment of the lower limb and the
attachment points of the extensor mechanism result in lateral
force vectors through the patellofemoral joint. The direction of
pull of the quadriceps mechanism relative to the patellar tendon
is known as the quadriceps angle (Q angle) (Figure 4). The Q
angle is greater in females than males (15 vs. 10 ) as a result of
a wider pelvis and an associated incidence of valgus knee
alignment. The Q angle can be estimated but is inaccurate. An
objective measurement of the tibial tubercle to trochlea groove
offset (TTTG) from MRI or CT scans is an equivalent, accurate
alternative.
An increased Q angle results in greater lateral displacing
forces acting on the patella. The effect is a more laterally placed
patella; the patella tends to tilt laterally and there is a rise in
patellar contact pressure laterally.17 The overall effects from this
depend on the angle of knee flexion and the competence of the
trochlea and soft-tissue restraints.18
The Q angle is greatest in full extension as the tibia rotates
externally (screw-home mechanism) moving the tibial tubercle
140 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
ASIS
Q angle
TT
Figure 4 The Q angle is the angle formed by a line from the anterior
superior iliac spine (ASIS) to central patella and a second line from the
central patella to the tibial tubercle (TT).
more laterally. Therefore, with the knee in full extension, the
patella is at greatest risk from dislocation. In this position there is
no bony congruity, the compressive forces pushing the patella
onto the trochlea are least and the quadriceps tension pulls the
patella in a proximo-lateral direction. If the patella is unstable it
will sublux laterally.
Anatomical variations that increase the Q angle and therefore
increase the risk of patellofemoral instability include torsional
deformities at the femoral neck or shaft, a laterally positioned
tibial tubercle, external tibial torsion and genu valgum.4 It has
been shown that a TTTG equal to or greater that 20 mm is
significant in contributing to patellar instability.3
Patient assessment
History
Patients with symptomatic patellar instability have been classified
into three categories based on the number of dislocations and the
presence of anatomical abnormalities: ‘‘major patellar instability’’
(with more than one documented dislocation), ‘‘objective patellar
instability’’ (with one dislocation and associated anatomical
abnormality) or ‘‘potential patellar instability’’ (with anatomical
abnormality and occasionally pain or a feeling of instability).3
Patellar instability is typically classified into acute, recurrent
(dysmorphic) or chronic (habitual/permanent).
The direction of dislocation is typically lateral. Dislocation will
occur when a force acting on the patella exceeds those forces
Features in history
First episode/recurrent
Traumatic/atraumatic
Generalized ligament laxity
Regular instability/locking
Previous treatment and response
Family history of instability (one in four patients)
ORTHOPAEDICS AND TRAUMA 24:2
stabilizing it within the joint. This may follow either a direct
blow or an indirect force, typically arising from a planted foot
with a valgus force applied on either an internally rotated femur
or externally rotated tibia. It should be determined whether
symptoms followed a traumatic or atraumatic event, and if
possible the likely force involved should be ascertained.
The patient may present following their first traumatic or
atraumatic dislocation, subsequent to a further dislocation
following a period of apparent knee stability or with symptoms
secondary to chronic subluxation of the patellofemoral joint.
Occasionally the precipitating event is not known and because
the patella often spontaneously reduces, the patient may not
describe their patella as having dislocated. Patients with
chronic instability may not report dislocations but rather
a sense or feeling of the knee giving way, ‘going out’ or lock-
ing. Anterior knee pain may be the only complaint in a patient
with maltracking of the patella from underlying anatomical
abnormalities.
A family history of patellar instability and the presence of risk
factors for developmental dysplasia of the hip are associated with
instability and the patient may describe themself as having lax
ligaments and occasionally demonstrate extreme joint
movements.
If the patient describes previous treatment, their response to
that treatment should be noted. If treatment was unsuccessful, it
is useful to determine whether failure was due to incorrect
diagnosis, inappropriate treatment attempts, poor patient
compliance, or instability exceeding the effectiveness of non-
operative treatment.
Examination
In the acute setting it may not be possible to fully examine the
affected joint because of haemarthrosis, tenderness (particularly
the medial patellar facet and adductor tubercle), bruising
(usually medially) and patient anxiety (positive patellar appre-
hension). Patients with dysplastic patellofemoral joints or
recurrent dislocation often require less force to dislocate and the
acute features may be less marked. Useful information can be
gathered by examining the opposite knee, since abnormal find-
ings are often symmetrical.
Overall lower limb alignment should be assessed. Assessment
of foot progression angle, thigh to foot angle (knee flexed at 90 )
and hip rotation in the prone position with knee flexed should be
noted (Figure 5). Valgus angulation of the knee and knee
hyperextension predispose to instability.
Patellar height, size and mobility can be assessed, although these
are very observer dependant, as is the Q angle. The patient should
be asked to straight leg raise to ensure the extensor mechanism is
Examination
Lower limb alignment
Straight leg raise
Q angle
Patellar apprehension, tilt, glide tests
Ligament examination (ACL/MCL)
Generalized ligament laxity assessment
141 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE

a b

a Foot progression angle, b thigh to foot angle, c hip rotation in the prone position with knee flexed.

Figure 5

intact. Quadriceps inhibition (acute) or wasting (chronic) is Investigations

commonly found. The joint should be palpated to ascertain areas of
maximal tenderness. Particularly, the course of the MPFL and
medial collateral ligament (MCL) should be palpated.
The most reliable signs in the patient with patellofemoral
instability are the apprehension test and perhaps anxiety during
examination. Many other described signs are not routinely used.19
Examination of cruciate and collateral ligaments is necessary
since concomitant injury to the MCL and anterior cruciate liga-
ment (ACL) may occur. ACL injury can be confused with patellar
instability, not only from the episodes of giving way but also
because ACL dysfunction is associated with a relatively high
frequency of anterior knee pain.
Evidence of generalized ligament laxity should be sought
during the examination. Beighton diagnostic criteria20 are often
used but there are several scoring systems available to assess this.
Imaging the knee
Radiographs: An initial conventional radiographic series is
taken to include weight bearing 30o flexed posterioreanterior
and lateral views, plus the skyline (Merchant) view. The poste-
rioreanterior view will reveal tibiofemoral osteoarthritis, osteo-
chondral pathology, relocation injury of the lateral femoral
condyle or avulsion fracture of the medial patella and loose
bodies. The lateral radiograph enables assessment for patella
alta21,22 and trochlear dysplasia. A shallow trochlea and
a crossing sign23 are features of dysplasia. For a reliable crossing
sign a true lateral of the distal femur is required (Figure 6).
The skyline patellar view should be performed at 30 e45 of
knee flexion. This may demonstrate trochlear dysplasia,
subluxation, patellar tilt and patellofemoral degenerative disease.

ORTHOPAEDICS AND TRAUMA 24:2 142 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
Figure 6 Lateral radiograph demonstrating features of trochlear dysplasia.
Arrow indicates crossing sign.
Interpretation of skyline radiographs requires close attention to
detail. Skyline views can falsely give the impression of
a reasonable femoral sulcus due to the angled beam, and since
skyline views are taken with a flexed knee, patellar subluxation
may be corrected (Figure 7a and b).
a Skyline radiograph and b axial MR are of the same patient. The skyline was performed with the knee flexed resulting in correction of patella
subluxation and giving the impression of a more normal trochlea groove and relationship. The axial MR was obtained with the knee extended and
demonstrates significant patellofemoral subluxation.
Figure 7
ORTHOPAEDICS AND TRAUMA 24:2
Numerous other radiographic assessments, such as sulcus
angle,24 congruence angle, lateral patellofemoral angle,25 lateral
trochlea inclination and patellofemoral index have been
described, but their usefulness is questionable. It is essential that,
for accurate interpretation of the radiographs, images need to be
produced by skilled radiographers using standardized
techniques.
Computerized Tomography (CT): CT has been widely used in
assessment of the patellofemoral joint and chronic instability. The
tibial tubercle to trochlear groove offset was first described from
this imaging modality. CT also has a role in assessing complex
rotational and angular deformity of the distal femur.
Magnetic Resonance Imaging (MRI): MRI provides invalu-
able information on the multifactorial aspects of patellofemoral
instability and is the investigation of choice for patients being
considered for surgical intervention. It is sensitive in demon-
strating the characteristic bone bruising pattern following
dislocation/relocation injuries (inferomedial patella and ante-
rolateral femoral condyle) (Figure 8). Axial MR images
demonstrate both trochlear and patellar dysplasia. The osteo-
cartilaginous contour in the trochlea typically varies from that
of the underlying bone and accentuates the dysplasia.6 This is
not appreciable on conventional radiographs or CT. Axial MR
images often allow greater appreciation of potential patellar
subluxation (Figure 7b).
The integrity of the medial structures, particularly the MPFL,
is best appreciated on the axial images. With associated mala-
lignment and patella alta the patellar tendon may be seen to
impinge on the lateral femoral condyle (patella tendon conflict)
(Figure 9).
The axial images can be used to determine the lateral offset of
the tibial tubercle in relation to the trochlear groove (TTTG). An
offset of more than 15e18 mm is considered abnormal.
143 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
Figure 8 Axial stir sequence. This demonstrates bone bruising inferome-
dial patella and slab of oedema on anterior aspect of lateral femoral
condyle peripherally.
Arthroscopy: very occasionally a diagnostic arthroscopy is per-
formed. An additional superolateral portal is positioned just
lateral to the rectus femoris tendon and as high as possible in the
suprapatellar pouch. This enables better assessment of patellar
tracking during early flexion (Figure 10). For ease of portal
placement apply a high thigh tourniquet and, unless required,
avoid a lateral thigh side support.
Arthroscopic assessment is often required at the time of
surgery to confirm or alter the proposed management plan.
Formulating a management plan
The natural history of the unstable patellofemoral joint, with or
without surgery, is not well understood. Surgery should not be
considered until non-operative treatments have failed and the
recurrent nature of the disease has resulted in functional
impairment.
Figure 9 Axial MR showing patellar tendon conflict on the lateral femoral
condyle. (Reproduced with permission and copyright Ó of the British
Editorial Society of Bone and Joint Surgery.4)
ORTHOPAEDICS AND TRAUMA 24:2
Non-operative therapy initially aims to reducing swelling and
increase the range of motion of the knee. This is followed by
muscle strengthening exercises. Physiotherapy is directed
towards closed chain exercises and VMO strengthening (the main
dynamic stabilizer of the patella). Taping may help reduce
excessive displacement of the patella during therapy. Taping has
also been shown to increase quadriceps muscle torque and to
activate the VMO earlier than the vastus lateralis during stair
ascent and descent.26,27 Functional foot orthoses may be bene-
ficial in the presence of flexible deformity.
Any surgical strategy should, whenever possible, aim to
restore normal anatomy and function rather than introduce new
abnormalities. Each symptomatic knee must be carefully
considered and treatment should be individualized. The under-
lying pathology, patient’s age, level of physical activity and
condition of the joint are all important factors. Figure 11 shows
our treatment algorithm. Due to the complex interplay of the
previously described structures, a combination of surgical tech-
niques may be required. The majority of patients are appropri-
ately treated with a trochleoplasty or MPFL reconstruction.
Surgical procedures
Reconstruction of the medial patellofemoral ligament (MPFL)
As discussed above, the MPFL is the primary static stabilizer of the
patella. This ligament is always damaged at the primary dislocation15
and often heals poorly.28 MPFL reconstruction has been shown to
reduce significantly lateral movement of the patella.29 Numerous
techniques for reconstruction of the MPFL have recently been
described with good short-term results.30e33 Ideal candidates for
isolated MPFL reconstruction are those with a normal Q angle, no
significant arthrosis of the medial patellar facet and MPFL insuffi-
ciency initially following a traumatic dislocation.
Operation: the senior author favours the use of a semitendinosus
autograft. A standard knee arthroscopy is performed with an
additional superolateral view. Patellar tracking is assessed
throughout the full range of knee movement. A small incision is
made over the pes anserinus and the semitendinosus tendon is
harvested with a tendon stripper.
An incision is made on the medial border of the patella. An extra-
synovial plane is developed to the femoral attachment. A tunnel is
drilled through the patella at the junction of the proximal and middle
thirds. The graft is passed from medial to lateral and a closed loop
EndoButton suspensory fixation device is used for patellar fixation.
The femoral tunnel site is selected and assessed for isometry before
being drilled. The graft is then passed through the extra-synovial
plane earlier dissected and into the femoral bone tunnel. The graft
is tensioned and patellar tracking is again assessed via the supero-
lateral portal. When the graft tension is correct, an interference
screw is passed into the medial side of the femoral tunnel to secure
the graft. This method of graft placement has been shown to yield
strengths comparable to the native ligament.34
A lateral release may rarely be helpful in the presence of
lateral patellar tilting due to tight lateral structures.
It is important to identify isometric insertion points and ach-
ieve appropriate graft tension. Over-tightening and poor graft
positioning can result in increased joint forces in the medial
patellofemoral joint.
144 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE

The trochlea viewed through a standard anterolateral portal and b the patellofemoral joint viewed through a superolateral portal. (Reproduced
with permission and copyright Ó of the British Editorial Society of Bone and Joint Surgery.4)

Figure 10

Post-operative rehabilitation & outcome: for isolated MPFL
reconstruction, an accelerated rehabilitation programme is
utilized. Full weight bearing and progressive quadriceps
strengthening exercises are introduced. Return to sport is
expected around 4 months from surgery.
Reconstruction of the MPFL has been shown to achieve very
good patellar stability and patient satisfaction levels are
high.3,32,35 Outcomes with MPFL reconstruction alone in patients
with severe trochlear dysplasia may not be as good.36
Lateral retinacular release
Lateral releases are only usually performed in combination
with other stabilizing procedures, when the lateral
retinaculum is tight or there is patellar tilt. An extended extra-
synovial lateral release including the vastus lateralis obliquus
tendon is favoured. Although good results have been reported
with isolated lateral release37 this is not uniformly the case.38
Tibial tubercle medializing or distalization osteotomy
An abnormally lateral position of the tibial tuberosity (increased
Q angle or TTTG) causes lateralization of the extensor mecha-
nism of the knee. This can predispose to lateral tracking of the
patella and anterior knee pain or to objective patellar instability,
characterized by recurrent dislocation.
A symptomatic patient with an isolated TTTG offset of greater
than 18e20 mm will benefit from a medializing osteotomy,

Our treatment algorithm for treating symptomatic patella instability.

Figure 11

ORTHOPAEDICS AND TRAUMA 24:2 145 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
Figure 12 Post-operative lateral radiograph of a patient requiring an MPFL
reconstruction and tibial tubercle osteotomy. (Reproduced with permis-
sion and copyright Ó of the British Editorial Society of Bone and Joint
Surgery.4)
returning the tibial tubercle to a normal position. Several types of
distal re-alignment have been described.
Patients with symptomatic patella alta are appropriately
treated with distalization of the tubercle.
Operation: a standard knee arthroscopy is performed with an
additional superolateral portal. Patellar tracking is assessed
throughout a full range of knee movements.
An incision is made just lateral to the tibial tuberosity and
continued distally for 6 cm. An extra-synovial lateral release is
performed through this incision. The medial and lateral borders
of the patellar tendon and tuberosity are defined and a trans-
verse plane osteotomy from lateral to medial is performed. An
intact hinge is maintained distally. The tubercle is generally
internally rotated in addition to medialization, in order to
address the tilt of the patellar tendon. Care should be taken to
avoid over correction, aiming rather to achieve a normal TTTG
offset. Patella alta with instability or patellar tendon conflict
should be treated with distalization of the tibial tubercle.39 The
position is held temporarily with K-wires and a repeat arthro-
scopic assessment is performed. The tubercle is secured with
two 4.5 mm cortical screws.
The author’s opinion is that an isolated lateral release in the
presence of subluxation is counterproductive and contra-
indicated. Occasionally, subluxation persists in full extension. In
these cases a further proximal soft-tissue procedure may be
performed rather than overcorrection of the TTTG offset
(Figure 12).
ORTHOPAEDICS AND TRAUMA 24:2
Post-operative rehabilitation and outcome: patients are placed
in a knee brace locked in extension for mobilization. Full weight
bearing is permitted but quadriceps loading in flexion is pre-
vented until 6 weeks post-operatively. Range of movement
exercises are encouraged early.
Significant complications are rare but include tibial fracture
and delayed union/non-union of the reattached tubercle. Good
results are reported in patients following the procedure,40
although the long-term results are less favourable, possibly due
to overcorrection.
Trochleoplasty
Trochleoplasty is an umbrella term describing re-shaping the
trochlea to improve patellofemoral stability secondary to troch-
lear dysplasia. Attempts to solve instability with re-alignment
procedures of the extensor mechanism are generally unsatisfac-
tory in patients with trochlear dysplasia, since the underlying
anatomical abnormality is not addressed.41
The logical solution in patients with patellofemoral instability
secondary to trochlear dysplasia is a deepening osteotomy to
create a trochlear groove. The ideal patients for trochleoplasty
are those less than 30 years of age with symptomatic recurrent
patellofemoral instability, severe trochlear dysplasia and no
degenerative change in the patellofemoral joint who have failed
to respond to conservative treatments. In patients over 30 years
of age the procedure is technically more challenging because of
sclerotic subchondral bone and less pliable cartilage. Open
physes are a contraindication.42
Operation: the procedure is performed through a lateral para-
patellar incision. An extra-synovial release is performed. The
synovium is dissected free from the retinaculum and incised. A
thin flexible trochlear osteochondral flap is raised, extending to
the intercondylar notch. A trochlea groove is fashioned in the
subchondral bone, a shallow broad unconstrained sulcus proxi-
mally which becomes deeper and more congruent distally. As
with patellofemoral joint replacement, a lateralized groove is
created, which allows the patella to become captured and later
engaged. This additionally reduces the TTTG and generally
removes the need for medialization of the tibial tubercle. The
osteochondral flap is secured to the subchondral bone with
dissolvable tape. The lateral synovium, and if possible retinac-
ulum, are closed. Occasionally trochleoplasty alone will not
provide sufficient stability and additional surgical procedures are
required.
Post-operative rehabilitation & outcome: full range of knee
movement is allowed immediately after surgery under the anal-
gesia of an epidural. Patients are allowed to mobilize full weight
bearing as soon as the epidural is discontinued (24e48 h) unless
they additionally required a tibial osteotomy.
The viability of the reattached osteochondral flap has been
investigated. Normal cartilaginous matrix and cell distribution
with a normal lamellar pattern of the subchondral bone post-
trochleoplasty43 has been shown. The risk of avascular necrosis
of the flap remains a feared complication.
The early results of trochleoplasty are encouraging. Instability
after trochleoplasty is uncommon and patient satisfaction rates
are high.42,44 In a recent 5-year prospective evaluation of
146 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
trochleoplasty 92.6% were satisfied with their outcome following
the procedure.42 The long-term outcome is awaited.
Patellofemoral arthritis
Abnormal mechanics of the patellofemoral joint leads to
abnormal pressures. Trochlear dysplasia is increasingly recog-
nized as a cause of patellofemoral disease in younger patients. In
the presence of degenerative disease, surgical treatment becomes
more difficult and has a guarded prognosis.
Anatomical abnormalities resulting in instability need to
addressed, and steps to repair, off-load or restore the articular
cartilage may be considered. If the articular lesion is limited to
one side of the joint, cartilage healing can be stimulated with
micro-fracture, or autologous chondrocyte implantation may be
attempted. If articular damage is present on both surfaces,
salvage surgery is usually required. Options include chon-
droplasty, patellofemoral joint off-loading procedures (tibial
tubercle elevation) or patellofemoral arthroplasty.
Patellofemoral arthroplasty
There is currently no long-term evidence that surgical stabiliza-
tion of the patellofemoral joint decreases long-term degenerative
change, despite improving short-term stability. Patients with
persistent dislocation and early arthritic damage with malalign-
ment have been treated successfully with patellofemoral
arthroplasty.
Patellofemoral arthroplasty has been available for the past 50
years, but poor durability had limited its use. More recently,
renewed interest in patellofemoral arthroplasty has emerged with
the development of newer designs that have produced more
consistent outcomes.45 Patellofemoral arthroplasty has many
advantages, especially in younger patients who have failed to
respond to measures to correct malalignment: a smaller incision,
faster post-operative rehabilitation, excellent range of motion
and, importantly, limited resection of bone, making revision to
a total knee replacement straightforward.46
Conclusions
Patellofemoral instability is a complex, multifactorial condition.
Patients will often be significantly disabled by their symptoms.
Traditionally, treatment has been based on a single operative
strategy for all patients, with variable results. Trochlear
dysplasia, in particular, has been increasingly recognized as
a major underlying aetiological factor among a number of other
anatomical abnormalities. A thorough assessment of each patient
should be made, with a tailored individual surgical strategy being
developed, based on correction of any underlying anatomical
abnormalities. The surgical introduction of any new anatomical
abnormality should be avoided. A riding patella. Clin Orthop 1972; 88: 67e9.
REFERENCES
1 Larsden E, Lauridsen F. Conservative treatment of patellar disloca-
tions: influence of evident factors on the tendency to redislocation
and the therapeutic result. Clin Orthop 1982; 171: 131e6.
2 Cofield RH, Bryan RS. Acute dislocation of the patella: results of
conservative treatment. J Trauma 1977; 17: 526e31.
ORTHOPAEDICS AND TRAUMA 24:2
3 Dejour H, Walch G, Nove-Josserand L, Gueier C. Factors of patellar
instability: an anatomic radiographic study. Knee Surg Sports Trau-
matol Arthrosc 1994; 2: 19e26.
4 Mulford JS, Wakeley CJ, Eldridge JDJ. Assessment and management of
chronic patellofemoral instability. J Bone Joint Surg 2007; 89-B:
709e16.
5 Barnett AJ, Gardner ROE, Lankester BJA, Wakeley CJ, Eldridge JDJ.
Magnetic resonance imaging of the patella: a comparison of the
morphology of the patella in normal and dysplastic knees. J Bone
Joint Surg 2007; 89-B: 761e5.
6 van Huyssteen AL, Hendrix MRG, Barnett AJ, Wakeley CJ, Eldridge JDJ.
Cartilageebone mismatch in the dysplastic trochlea: an MRI Study.
J Bone Joint Surg 2006; 88-B: 688e91.
7 Insall J, Salvati E. Patella position in the normal knee joint. Radiology
1971; 101: 101e4.
8 Barnett AJ, Prentice M, Mandalia V, Wakeley CJ, Eldridge JD. 1. Patellar
height measurement in trochlear dysplasia. Knee Surg Sports Trau-
matol Arthrosc 2009; 17: 1412e5.
9 Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar
translation in the human knee. Am J Sports Med 1998; 26: 59e65.
10 Conlan T, Garth Jr WP, Lemons JE. Evaluation of the medial soft-tissue
restraints of the extensor mechanism of the knee. J Bone Joint Surg
Am 1993; 75: 682e93.
11 Terry GC, Hughston JC, Norwood LA. The anatomy of the iliopatellar
band and iliotibial tract. Am J Sports Med 1986; 14: 39e45.
12 Terry GC. The anatomy of the extensor mechanism. Clin Sports Med
1989; 8: 163e77.
13 Lieb FJ, Perry J. Quadriceps function: an anatomical and mechanical
study using amputated limbs. J Bone Joint Surg 1968; 50-A: 1535e48.
14 Reynolds L, Levin TA, Medeiros JM, Adler NS, Hallum A. EMG activity
of the vastus medialis oblique and the vastus lateralis in their role in
patellar alignment. Am J Phys Med 1983; 62: 61e70.
15 Sallay PI, Poggi J, Speer KP, Garrett WE. Acute dislocation of the
patella. A correlative pathoanatomic study. Am J Sports Med 1996;
24: 52e60.
16 Stokes M, Young A. Investigations of quadriceps inhibition: impli-
cations for clinical practice. Physiotherapy 1984; 70: 425e8.
17 Ramappa AJ, Apreleva M, Harrold FR, Fitzgibbons PG, Wilson DR,
Gill TJ. The effects of medialisation and anterior medialization of the
tibial tubercle on patellofemoral mechanics and kinematics. Am J
Sports Med 2006; 34: 749e56.
18 Farahmand F, Senavongse W, Amis AA. Quantitative study of the
quadriceps muscles and trochlear groove geometry related to insta-
bility of the patellofemoral joint. J Orthop Res 1998; 16: 136e43.
19 Smith TO, Davies L, O’Driscoll ML, Donell ST. An evaluation of the
clinical tests and outcome measures used to assess patellar insta-
bility. Knee 2008; 15: 255e62.
20 Beighton P, Solomon L, Soskolne CL. Articular mobility in an African
population. Ann Rheum Dis 1973; 32: 413e8.
21 Insall J, Goldburg V, Salvati E. Recurrent dislocation and the high-
22 Blackburne JS, Peel TE. A new method of measuring patellar height.
J Bone Joint Surg 1977; 59-B: 241e2.
23 Galland O, Walch G, Dejour H, Carret JP. An anatomical and radio-
logical study of the femoropatellar articulation. Surg Radiol Anat
1990; 12: 119e25.
24 Davies AP, Costa ML, Donnell ST, Glasgow MM, Shepstone L. The
sulcus angle and malalignment of the extensor mechanism of the
knee. J Bone Joint Surg 2000; 82-B: 1162e6.
147 Ó 2010 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SOFT TISSUE SURGERY IN THE KNEE
25 Laurin CA, Dussault R, Leveseque HP. The tangential x-ray investi-
gation of the patellofemoral joint: x-ray technique, diagnostic criteria
and their interpretation. Clin Orthop 1979; 144: 16e26.
26 Cowan SM, Bennell KL, Hodges PW. Therapeutic patellar taping
changes the timing of vasti muscle activation in people with patel-
lofemoral pain syndrome. Clin J Sport Med 2002; 12: 339e47.
27 McConnell J. Rehabilitation and nonoperative treatment of patellar
instability. Sports Med Arthrosc 2007; 15: 95e104.
28 Nomura E. Classification of lesions of the medial patellofemoral
ligament in patella dislocation. Int Orthop 1999; 23: 260e3.
29 Ostermeier S, Stukenborg-Colsman C, Hurschler C, Wirth CJ. In-vitro
investigation of the effect of medial patellofemoral ligament recon-
struction and medial tibial tuberosity transfer on lateral patellar
dislocation. Arthroscopy 2006; 22: 308e19.
30 Deie M, Ochi M, Sumen Y, Yasumoto M, Kobayashi K, Kimura H.
Reconstruction of the medial patellofemoral ligament for the treat-
ment of habitual or recurrent dislocation of the patella in children.
J Bone Joint Surg 2003; 85-B: 887e90.
31 Nomura E, Inoue M. Hybrid medial patellofemoral ligament recon-
struction using semitendinosus tendon for recurrent patellar dislo-
cation: minimum 3 years follow-up. Arthroscopy 2006; 22: 787e93.
32 Ellera Gomes JL, Stigler Marczyk LR, César de César P, Jungblut CF.
Medial patellofemoral ligament reconstruction with semitendinosus
autograft for chronic patellar instability: a follow-up study. Arthros-
copy 2004; 20: 147e51.
33 Muneta T, Sekiya I, Tsuchiya M, Shinomiya K. A technique for
reconstruction of the medial patellofemoral ligament. Clin Orthop
1999; 359: 151e5.
34 Mountney J, Senavongse W, Amis AA, Thomas NP. Tensile strength of
the medial patellofemoral ligament before and after repair or
reconstruction. J Bone Joint Surg 2005; 87-B: 36e40.
35 Normura E, Horiuchi Y, Kihara M. A mid-term follow-up of
medial patellofemoral ligament reconstruction using an
ORTHOPAEDICS AND TRAUMA 24:2
artificial ligament for recurrent patellar dislocation. Knee 2000; 7:
211e5.
36 Schöttle PB, Scheffler SU, Schwarck A, Weiler A. Arthroscopic medial
patellofemoral ligament repair after patella dislocation with and
without underlying trochlear dysplasia: a preliminary report.
Arthroscopy 2006; 22: 1192e8.
37 Dandy DJ, Griffiths S. Lateral release for recurrent dislocations of the
patella. J Bone Joint Surg 1989; 7-B: 121e5.
38 Panni AS, Tartarone M, Patricola A, Paxton EW, Fithian DC. Long-term
results of lateral retinacular release. Arthroscopy 2005; 21: 526e31.
39 Simmons Jr E, Cameron JC. Patella alta and recurrent dislocation of
the patella. Clin Orthop 1992; 274: 265e9.
40 Palmer SH, Servant CT, Maguire J, Machan S, Parish EN, Cross MJ.
Surgical reconstruction of severe patellofemoral maltracking. Clin
Orthop Relat Res 2004; 419: 144e8.
41 Arnbjörnsson A, Egund N, Rydling O, Stockerup R, Ryd L. The natural
history of recurrent dislocation of the patella: long term results of
conservative and operative treatment. J Bone Joint Surg 1992; 74-B:
140e2.
42 Utting MR, Mulford JS, Eldridge JDJ. A prospective evaluation of
trochleoplasty for the treatment of patellofemoral dislocation and
instability. J Bone Joint Surg 2008; 90-B: 180e85.
43 Schottle PB, Schell H, Duda G, Weiler A. Cartilage viability after troch-
leoplasty. Knee Surg Sports Traumatol Arthrosc 2007; 15: 161e7.
44 von Knoch F, Böhm T, Bürgi ML, von Knoch M, Bereiter H. Troch-
leoplasty for recurrent patellar dislocation in association with
trochlear dysplasia: a 4- to 14-year follow-up study. J Bone Joint Surg
2006; 88-B: 1331e5.
45 Achroyd CE, Smith EJ, Newman JH. Trochlear resurfacing for extensor
mechanism instability following patellectomy. Knee 2004; 11: 109e11.
46 Ackroyd CE, Newman JH, Evans R, Eldridge JDJ, Joslin CC. The Avon
patellofemoral arthroplasty. Five year survivorship and functional
results. J Bone Joint Surg 2007; 89-B: 310e5.
148 Ó 2010 Elsevier Ltd. All rights reserved.