 SPECIALTY UPDATE: KNEE
Adolescent patellar instability
D. Clark,
A. Metcalfe,
C. Wogan,
V. Mandalia,
J. Eldridge
From Bristol Royal
Infirmary, Bristol,
United Kingdom
 D. Clark, FRCS, MSc, Fellow
Foothills Medical Centre, 1403
29 St NW, Calgary AB T2N 2T9,
Canada.
 A. Metcalfe, PhD, FRCS,
Associate Professor
University of Warwick, Clinical
Trials Unit, Coventry, CV4 7AL,
UK.
 C. Wogan, BSc, MSc,
Extended Scope
Physiotherapist
 J. Eldridge, FRCS, Consultant
Knee Surgeon
Bristol Royal Infirmary, Upper
Maudlin Street, Bristol,
BS15NU, UK.
 V. Mandalia, FRCS,
Consultant Knee Surgeon
Royal Devon and Exeter
Hospital, Barrack Road, Exeter,
EX25DW, UK.
Correspondence should be sent
to D. Clark; email:
clarkdamian@hotmail.com
©2017 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.99B2.
BJJ-2016-0256.R1 $2.00
Bone Joint J
2017;99-B:159–60.
Received 12 April 2016;
Accepted after revision 30
September 2016
VOL. 99-B, No. 2, FEBRUARY 2017
CURRENT CONCEPTS REVIEW
Patellar instability most frequently presents during adolescence. Congenital and infantile
dislocation of the patella is a distinct entity from adolescent instability and measurable
abnormalities may be present at birth. In the normal patellofemoral joint an increase in
quadriceps angle and patellar height are matched by an increase in trochlear depth as the
joint matures. Adolescent instability may herald a lifelong condition leading to chronic
disability and arthritis.
Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial
patellofemoral ligament (MPFL) reconstruction in the young adult prevents further
instability. Although these techniques are proven in the young adult, they may cause
growth arrest and deformity where the physis is open. A vigorous non-operative strategy
may permit delay of surgery until growth is complete. Where non-operative treatment has
failed a modified MPFL reconstruction may be performed to maintain stability until physeal
closure permits anatomical reconstruction. If significant growth remains an extraosseous
reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth
remains image intensifier guided placement of femoral intraosseous fixation may impart a
small, but acceptable, risk to the physis.
This paper presents and discusses the literature relating to adolescent instability and
provides a framework for management of these patients.
Cite this article: Bone Joint J 2017;99-B:159–70.
The understanding of the aetiology, diagnosis frequently during activities of daily living
and management of patellofemoral instability (21%) or rarely as a result of direct trauma
has progressed considerably in recent years. (7%).3
The specific anatomical abnormalities that Several studies have found that adolescent
predispose people to patellar instability are patellofemoral symptoms are the beginning of
now well recognised, with multiple abnormal- a lifelong condition. Even without further dis-
ities often co-existing.1 location 70% of patients complain of residual
Fithian et al2 and Atkin et al3 found that symptoms of pain or instability.7 The largest
69% of individuals with first time patellar dis- longitudinal studies follow patients for
locations are between the ages of ten and 19 between four and 20 years.8,9 They report that
years.2,3 The overall risk of dislocation was at final follow-up 20% to 45% of patients con-
seven in 100 000 annually and in the second tinued to experience pain and 36% had to
decade of life this rose to 31 in 100 000.3 A restrict their activities. There are no clear data
Finnish study calculated an incidence of 43 in on how many of these patients subsequently
100 000 in children under 16 years old.4 The develop osteoarthritis. It is reported that 10%
recurrence rate in all-comers to non-operative of knee arthritis involves the patellofemoral
treatment was reported in Stefancin and joint, but the amount that results from instabil-
Parker’s5 systematic review as 48%. If a ity is uncertain.10 Utting et al11 investigated the
patient dislocates the patella for a second time history of patellofemoral symptoms in a case
the rate of recurrence is then higher.2 controlled study of 150 patients who had
Amongst adolescents and young adults, undergone patellofemoral arthroplasty and
patellar instability may present with a disloca- 150 patients who had undergone unicompart-
tion, or patients can present with a sense of dis- mental knee arthroplasty. Adolescent anterior
comfort and unease, with “something out of knee pain was more common amongst the
place” in the knee.6 The first dislocation fre- patellofemoral group (22% versus 6%) as was
quently occurs whilst playing sport (72%), less patellar instability (14% versus 1%).
159
160 D. CLARK, A. METCALFE, C. WOGAN, V. MANDALIA, J. ELDRIDGE
Fig. 1
Ultrasound image of the neonatal
trochlea (provided by Christian
Øye).27,28
Adolescent patellar instability is a distinct entity from con-
genital and infantile instability which have been described in
numerous complex and overlapping classifications12-21 and
are beyond the scope of this review.
Aetiology
Precisely what initiates the pathway to abnormal anatomy
or unmasks instability in a previously stable joint in adoles-
cence remains unclear. Patellar instability has been demon-
strated to have a familial association in 15% of cases but
the patterns of inheritance have not been identified.22 Ana-
tomical risk factors may be evident in utero. The formation
of the patella has been described in some detail in the liter-
ature.23-26 Soon after the limb bud appears at four weeks,
the quadriceps muscle can be identified, although the motor
unit is undeveloped and the knee remains at a right angle.
At seven weeks, the first evidence of a patellar condensation
is evident between the quadriceps and the femoral condyle.
By 13 weeks of development the femoral condyles have a
similar geometry to the adult knee, and by 23 weeks the lat-
eral patellar facet is dominant.
The sulcus angle of the trochlea using ultrasound has been
evaluated in 348 neonates (Fig. 1).27,28 By applying a defini-
tion of trochlear dysplasia as a sulcus angle of > 159° they
identified 17 cases. Using a case controlled methodology,
they found an odds ratio (OR) of 15 for the presence of
trochlear dysplasia in neonates who had been in a full breech
position (with the knees held in full extension in utero).
These findings suggest a moulding process is involved that
contrasts with an underlying genetic aetiology.
General risk factors. Several authors describe patellar dislo-
cation, like shoulder dislocation, to be more likely to recur
amongst the young.29-31 In Buchner et al’s29 series of 126
primary and 13 recurrent dislocations they found that
patients younger than 15 years had a 52% recurrence rate
compared with 26% in their overall sample. Most recurrent
dislocations occurred within one year of the first disloca-
tion and there was a contralateral patellar dislocation in
10% of cases. Fithian et al2 reported a two- to five-year fol-
low-up after primary dislocation and evaluated risk factors
for recurrent dislocation. They included age, gender, prior
dislocation, family history of problems involving the
patella and risk factors for developmental dysplasia of the
hip (DDH) in the model. Previous dislocation carried an
OR 6.6, whereas advancing age imparted protection (OR
0.92). Risk factors for DDH imparted risk of dislocation in
the non-index knee.
Several authors have described a high prevalence of
hypermobility amongst patients who have suffered a patel-
lar dislocation.32,33 However, the prevalence of hypermo-
bility is not uncommon and in the general population may
be as high as 10% to 20%.34 Rünow35 used a case con-
trolled methodology to describe a six times higher incidence
of patellar dislocation amongst those with hypermobility.
Bilateral instability was also more common amongst these
patients.
Morphological risk factors. Early work by Dejour et al13 has
formed the basis of a structured approach to treating insta-
bility by restoring normal anatomy. They described major
and minor anatomical factors implicated in patellar insta-
bility. The major factors include trochlear dysplasia, patel-
lar alta, a laterally placed tubercle and patellar tilt. The
importance of a secondary medial patellofemoral ligament
(MPFL) rupture and what they termed minor factors were
also described. These minor factors included excessive
external femoral or tibial rotation and genu recurvatum or
valgum. Patellar tilt is seen as a marker of instability as it is
secondary to the other causes.13
Trochlear dysplasia is commonly found amongst patients
who have had a patellar dislocation. Dejour et al13 reported
that trochlear dysplasia was present in 96% of 143 patients
who underwent surgery for patellar dislocation and in only
3% of patients who did not. Lewallen et al36 published a
study of risk factors for recurrent dislocation in the adoles-
cent population. They found that age, gender, body mass
index and patellar alta were not independent predictors of
recurrent dislocation. Where trochlear dysplasia and an
open physis was apparent the recurrent dislocation rate was
69%.
Patellar alta appears to have a strong association with
patellar instability and may be found in 50% to 60% of
cases with a primary dislocation.1,3 The abundance of
patellofemoral height indices is indicative of their short-
comings. There are difficulties in the measurement of patel-
lar height in the more cartilagenous knee of the child on
plain radiograph. This may partially explain Lewallen et
al’s36 finding that patellar alta measured on a plain radio-
graph was not a risk factor for patella dislocation. Patellar
alta also frequently co-exists with trochlear dyplasia.1,37
A laterally placed tubercle as measured by the tibial
tubercle to trochlear groove distance (TTTG) is associated
with patellar instability and is an important consequence of
torsional abnormality. Walch38 studied the tubercle place-
ment in patients with permanent dislocations, episodic dis-
locations, potential dislocations and a control group.
Amongst the 413 patients with episodic dislcations the
THE BONE & JOINT JOURNAL
 ADOLESCENT PATELLAR INSTABILITY
mean TTTG was 18 mm and amongst the control group it
was 11 mm. In a case controlled study with 109 cases and
136 controls, Balcarek et al39 found the TTTG to be 4 mm
greater amongst young athletes with a history of patellar
dislocation.
Steensen et al1 performed a case controlled study with 60
cases and 120 controls to evaluate the prevalence of the
major anatomical abnormalities amongst patients with and
without a history of recurrent patellar instability. They
found all factors to be more common amongst the group
with recurrent instability than those with a stable patella.
Risk factors evaluated included patellar alta with an Insall-
Salvati Ratio (ISR)40 > 1.2 (60% versus 21%), trochlear
dysplasia defined as a flat or convex trochlea (68% versus
6%) and a TTTG of more than 20 mm (42% versus 3.2%).
Multiple factors were identified in 58% of the patients with
recurrent instability.
Dejour et al13 describe excessive femoral anteversion,
excessive external tibial rotation, genu recurvatum and
genu valgum as minor factors contribution to the presence
of instability. Atkin et al3 evaluated physical examination
findings in patellar instability patients and found that limb
alignment and hip rotation were not significantly different
when compared with normal published values or the con-
tralateral limb. Although these factors did not meet statis-
tical significance this may be due to their rarity rather than
lack of clinical significance and they should remain a con-
sideration.
The MPFL contributes 60% of the static restraint to dis-
location of the patella in the normal knee and is the primary
stabiliser when the knee is in full extension to 30° of flex-
ion.41 In the adult it is approximately 55 mm in length and
it is a relatively elastic ligament, failing at up to 49% strain
compared with the posterior cruciate that fails at 18%.42,43
Due to the large excursion of the dislocated patella the
MPFL is inevitably ruptured or avulsed. It is most com-
monly injured at the femoral origin amongst adults,
whereas the injury is usually on the patellar side in children
and frequently includes an avulsion fragment.44
History and examination
A comprehensive history is required including the preg-
nancy, birth and development and any family history. There
may be an associated undiagnosed syndrome, which may
require the involvement of a geneticist.45,46
The symptoms of instability can be extremely disabling,
hard to describe and easily dismissed. Vigilance is required.
Often, a dislocation of the patella is preceded by several
years of anterior knee symptoms including pain, giving way
and a sense of unease. Patients frequently express poor
confidence in their activity levels and sports performance
and may describe low self-esteem.
Examination will include a general musculoskeletal
assessment and specific knee examination. Features of skel-
etal dysplasia, syndromes and joint hypermobility are
recorded in addition to overall lower limb torsional and
VOL. 99-B, No. 2, FEBRUARY 2017
161
angular alignment. Thorough examination of the knee
should exclude an alternative cause of instability. Patellar
height, tracking and apprehension can be helpful when
gauging the severity of instability.
Imaging
Investigation should include plain radiographs and axial
imaging of the chondral surfaces. This enables the surgeon
to determine any morphological factors underlying the
instability. Where necessary the bone age of the patient is
calculated.
Patellar height. In 1930, Boon-Itt45 provided the first com-
prehensive attempt to measure patellar height, and since
then many others have followed.40,45-60 The ISR remains
the most frequently used method.40 It has been criticised
due to its vulnerability to variations in the distal insertion
of the patellar tendon and the patellar shape. Aparicio et
al61 evaluated the plain radiographic techniques for assess-
ing patellar height in children, finding ISR to be an inappro-
priate tool. Of the methods they compared they state a
preference for the method of Caton et al,47 citing superior
intra- and inter-observer reliability and independence from
the influences of skeletal maturation.
We favour Biedert and Albrecht’s60 patellotrochlear
index as assessed by MRI (Fig. 2). It has the advantage of
directly measuring the overlap between femoral and patel-
lar cartilage. Their original description in knees without
patellofemoral instability found the mean overlap to be
31.7%. The upper and lower 95% range was used to
describe patellar alta (12.5%) and patellar baja (50%). Bar-
nett et al62 found a significantly lower average overlap in
patients with trochlear dysplasia (15%).
Trochlear dysplasia. Dejour et al’s13 classification of troch-
lear dysplasia is a well-established research tool; clinical
examples can be seen in Figure 3. For clinical practice the
indication for trochleoplasty includes a domed or laterally
facing chondral surface with closed physes. A flat trochlear
or a shallow groove is not considered an indication for
trochleoplasty.63
TTTG offset and the MPFL. The TTTG offset is a marker of
pathology but it is a measurement that is subject not only to
variations in tubercle position but also to the anatomy of
the distal femur. In the presence of trochlear dysplasia, a
raised TTTG may incorrectly be attributed to a lateralised
tubercle rather than a medialised groove. Careful consider-
ation should be given before proceeding to a tubercle medi-
alisation.
The MPFL may be visualised and measured on axial
MRI scans but defining its functional length is more diffi-
cult.64 If a true patellar dislocation has occurred, it is rea-
sonable to assume that the MPFL has been ruptured and is
incompetent. We do not recommend routine evaluation of
the MPFL by MRI.
Patellofemoral indices in the developing joint. Dejour et al13
described three signs on the lateral radiograph that may indicate
trochlear dysplasia including a double contour, a supratrochlear
162 D. CLARK, A. METCALFE, C. WOGAN, V. MANDALIA, J. ELDRIDGE

Fig. 2a Fig. 2b
60
Patellar height measurement by Biedert and Albrecht’s technique. To calculate the index two parameters are measured:
(a) baseline patella; (b) baseline trochlea overlapping of the patella. These parameters are usually measured at the sagittal
image through the patella with the maximal length of the patellar bone and with the thickest articular cartilage. The index
is expressed as a percentage. A figure less than 12.5% indicates patellar alta and more than 50% patellar infera.

Fig. 3a Fig. 3b Fig. 3c

Fig. 3d Fig. 3e

Radiographs showing normal patella (a) and trochlear dysplasia as assessed by

Dejour et al’s13 classification where: A = fairly shallow trochlea, morphology
preserved (b); B = flat or convex trochlea (c); C = asymmetry of facets, lateral
facet convex, medial hypoplastic (d); D = asymmetry of facets, cliff pattern (e).

bump and a crossing sign. Lippacher et al65 found that these
signs performed adequately amongst children with trochlear
dysplasia but that MRI should remain the benchmark for
assessment.
Dickens et al66 studied 618 knees in children and adoles-
cents and described the TTTG distance increasing with age
as a natural logarithm and plateauing at 16 years (Fig. 4).
Kim et al67 also studied the developing joint. They per-
formed a correlation analysis of measurable osseous mor-
phology with age, gender and physeal patency. They found
no significant variation in trochlear facet asymmetry, troch-
lear depth, TTTG or patellar height ratio in 97 children and
young adults aged between five and 22 years. This study
has been criticised as most of the children were over ten
years old and half of those had undergone closure of the
femoral physis. Mundy et al68 performed a study of 144

THE BONE & JOINT JOURNAL


20
19
18
17
16
TT=TG distance (mm)
15
14
13
12
11
10
9 50th
8
7
6
5
4
3
2
1
0
0 1
Tibial tuberosity (TT) to trochlea groove (TG) percentile growth chart.
near normal knee MRIs (some patients had Baker’s cysts,
discoid menisci or small effusions) in children aged between
one and 16 years old. They assessed TTTG, patellar height
and various measures of trochlear morphology. The meas-
urements from younger children differed from those of
adults, having a shallower trochlea, greater sulcus angle,
more medial tuberosity and a smaller patellar height ratio.
The absolute values of patellofemoral indices can be
expected to increase as the joint increases in size but the
changes in sulcus angle and patellar height ratio point to
age dependant morphology. When these studies are taken
together, we can infer that morphology is age dependant
and that normal ranges need to be adjusted in younger
patients. The indices amongst adolescents have been
scarcely and inconsistently described, but none has corre-
lated with any clinical findings. The surgeon cannot be so
reliant on radiological measurements in the growing, or
incompletely ossified joint.
Non-operative management
The entirety of non-operative management is not within the
scope of this review, but some important observations are
made.
Historically, acute patellar dislocation has been managed
by immobilisation in a cast or brace in extension with
restricted weight-bearing. Immobilisation leads to wasting
of the quadriceps and stiffness in the knee,69 followed by
fear avoidance for the patient, loss of confidence and func-
tion and likely recurrence of dislocation.70,71 These treat-
ments are counter-productive and patients should be
treated with early mobilisation and weight-bearing as toler-
ated, an elasticated bandage and ice therapy to reduce
swelling and referral for urgent physiotherapy. Reducing
pain and swelling after injury is essential to enable quadri-
ceps re-activation and aid return to function.72 For subse-
quent dislocations, the patient is advised to extend the leg
VOL. 99-B, No. 2, FEBRUARY 2017
ADOLESCENT PATELLAR INSTABILITY 163
97th
95th
90th
75th
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age (yrs)
Fig. 4
to relocate the patella, avoid unnecessary visits to the emer-
gency department and return to normal activities as soon as
able.
A progressive closed chain eccentric loading regimen
promotes return of activity and strength following injury.
This should include proximal control of the gluteal and
core muscles, alongside quadriceps and hamstring strength-
ening.73-75 The use of an elastic resistance band is a func-
tional method of strengthening the quadriceps in terminal
extension. Recruitment of the vastus medialis obliquus and
the quadriceps complex post-injury in the presence of swell-
ing is otherwise challenging.72 Recognition and rehabilita-
tion of any hip weakness is also crucial.73
Surgical management
The surgical management of patellar instability may be pur-
sued according to one of two philosophies.76 One view is
that patellar instability is a discreet problem addressed by a
single operation. The other approach involves identifying
any individual anatomical factors responsible for the dislo-
cation and correcting them. Janssen51 recognised instability
as an endpoint of a range of anatomical abnormalities as
early as 1978. Surgical treatment of the unstable adolescent
knee is complicated by the distal femoral and proximal tib-
ial physes that can generate debilitating deformity if dam-
aged.
Distal re-alignment and the tibial tuberosity physis. The
distal tibial tubercle begins ossification at between seven
and nine years of age. This progresses proximally and ante-
riorly, while the main tibial ossification centre also expands
downward into the tubercle.77 A section of epiphyseal car-
tilage usually remains between these two ossification cen-
tres until close to physeal maturity. This physis is both
sensitive and unpredictable. Growth arrest may come
about as a result of trauma, surgery or even prolonged plas-
ter treatment.22,78,79
164 D. CLARK, A. METCALFE, C. WOGAN, V. MANDALIA, J. ELDRIDGE
In a small series Harrison80 found it safe to perform a tib-
ial tubercle transfer after the age of 13 years. When per-
formed before that age, a recurvatum deformity occurred in
four out of five cases. Crosby and Insall22 noted a recurva-
tum deformity in five of 27 cases in children aged under 14
years.
The Roux-Goulthwaite procedure has been used exten-
sively by paediatric orthopaedic surgeons.81,82 The patel-
lar tendon is split longitudinally and the distal portion of
the lateral half rerouted beneath the medial half. Fre-
quently it is combined with other procedures including
lateral retinacular release, plication of the medial retinac-
ulum and advancement of the vastus medialis.83 The
objective of the procedure is to re-align the patellar ten-
don without threatening the physis.83 Sillanpää et al84 per-
formed a retrospective study of 47 patients, comparing
outcomes of young adults (median age 20.2 years; inter-
quartile range (IQR) 19 to 22) who had undergone MPFL
reconstruction with adductor magnus tenodesis or a
Roux-Goldthwaite procedure. Malecki et al85 performed
a similar study in children and adolescents (65 knees)
(median age 14 years; IQR 6 to 18). Neither study found
statistically significant differences in patient reported out-
comes or redislocation rates. Malecki et al85 described
more frequent complications and worst pain scores
amongst those patents who had undergone the Roux-
Goldthwaite procedure. Sillanpää et al84 found more than
25% of the patients in the Roux-Goldthwaite group had
developed osteoarthritis. None was seen in the MPFL
group. The results of these studies suggest that the func-
tional outcomes and redislocation rates are similar for the
two procedures but that MPFL reconstruction has a
reduced complication rate.
Grammont et al86 described a further method of altering
the vector of the patellar tendon without compromising the
tuberosity insertion. The procedure involves undermining
the patellar tendon insertion (except for the most distal sec-
tion) so that it may slide more medially; it is then held in the
new position with sutures through the periosteum. Savarese
et al87 also reported on this technique, noting that as the
periosteum is released, the alignment of the tendon is auto-
matically corrected. Although the objective is to avoid
growth disturbance this remains a concern. Garin et al88
noted in a series of 50 knees that 10% of patients under-
going this procedure developed a reduced tibial slope (< 5°)
which they attributed to a vascular phenomenon. Several
authors have expressed concern that the procedure may
cause growth disturbance or result in catastrophic failure of
the extensor mechanism.12,88 Kraus et al89 reported on the
results of 65 knees of adolescents with patellar instability
where this technique had been used; they demonstrated no
growth disturbance. In 11 cases, the patella dislocated after
surgery and arthritis developed in six.
Distal re-alignment amongst the adolescent population
has been largely superseded by MPFL reconstruction due to
the reduced risk of damaging the physes.
Medial soft-tissue reconstruction. In the 1990s, the main-
stay of treatment was a medial plication and a lateral
release. As in the adult population, several studies have
now demonstrated this to be an ineffective treatment. In a
randomised controlled trial Palmu et al90 found a 71%
recurrence rate amongst 36 young adolescents who had
undergone direct repair of the medial structures. Ma et al91
demonstrated a 30% redislocation rate amongst adoles-
cents after medial capsule reefing. They recommended,
instead, advancement of a large portion of the medial reti-
naculum. Hartmann et al92 demonstrated better results in a
cohort of 33 patients aged 11 to 17 years with a 12% recur-
rence rate. Edmonds and Glaser93 compared the effect of a
medial plication and of an MPFL reconstruction on the
forces applied to the articulation. The biomechanical study
used radiographs and MRI to calculate the patella and
quadriceps moment arms so that joint reaction force at the
patellar articulation could be extrapolated. They found
that medial plication resulted in an increase in joint reac-
tion force and failed to restore the normal moment arm of
the patellofemoral joint. No significant differences were
found between the mechanics of the patellofemoral joint in
the MPFL reconstruction patients and the normal knee con-
trol group.
MPFL reconstruction and the distal femoral physis. The
femoral insertion of the MPFL has been well described in
the adult with most investigators agreeing that it is located
anterior to a midpoint between the medial epicondyle and
the adductor tubercle.94-97 In the adult population, the use
of the anatomical insertion point for location of an isomet-
ric reconstruction is the goal.98 In the presence of a physis
there may be a conflict between perfect isometry and phy-
seal preservation.
The relationship between the footprint of the MPFL and
the physis changes during development.67,99,100 Nelitz et
al101 performed a radiological study of 27 children (mean
age 14.3 years; 12 to 16) and found that the insertion of the
MPFL was a mean of 6 mm (2.9 to 8.5) distal to the physis.
Shea et al99 performed cadaveric dissection of six children
ranging from one month to 11 years. This small study
found that the insertion of the MPFL is distal to the physis
in younger children, but overlies it by the age of ten years.
MPFL reconstruction – extraosseous femoral fixation. Fol-
lowing Avikainen at al’s102 description of an MPFL recon-
struction with extraosseous fixation on the femoral side
there has been a surge of interest in this procedure. They
used the distal adductor magnus tendon as a graft, leaving
the adductor insertion in place as the femoral fixation. Sev-
eral variations have since been described including differ-
ences in patellar fixation, medial fixation and graft.
Extraosseous femoral fixation may use the adductor inser-
tion or medial collateral ligament origin as an anchor or a
pulley. In some techniques, a hamstring graft is left attached
to the pes anserinus, looped around the adductor origin and
secured to the patella.12,103 Patellar fixation may involve
weaving the tendon through patellar periosteum, a suture
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 ADOLESCENT PATELLAR INSTABILITY 165

Table I. Reconstruction of the medial patellofemoral ligament in adolescents by different techniques98,102-118

Age (yrs), Follow up (mths),
Author (yr) Study type mean (range) n Medial fixation Graft Patella fixation mean (range) Outcomes description Complications

Avikainen 1993102 Cohort 20 (15 to 27) 14 Adductor tendon Adductor Sutured to medial 83 (SD 7) Post-operative mean 1 redislocation.
insertion magnus patella and to Lysholm Knee Scoring
tendon residual native Scale116 84 (SD 15)
MPFL
Deie 2003103 Cohort 8.5 (6 to 10) 6 Distal insertion of Semi-t Sutured to surface 89 (60 to 120) Post-operative mean Kujala No redislocation,
semi-t around a MCL of patella Scoring Questionnaire117 no complications
pulley score 96.3 (89 to 100), pre- reported
operative unavailable
Brown 2008104 Surgical 11 2 Distal semi-t insertion, Semi-t Tendon suspended 14 (13 to 15) Mean pre- to post-operative No redislocation,
technique through patella then in patella tunnel, Kujala Scoring Question- no comlpications
sutured to MCL held by transpatella naire scores: 46.5 (43 to 50)
sutures to 93 (88 to 98) and Lysholm
Knee Scoring Scale: 46.5 (35
to 55) to 96 (95 to 97)
Sillanpää 2009105 Surgical - - Adductor tendon Two thirds Suture anchors - - Not described
technique insertion width of
adductor
magnus
Nietosvaara Surgical - - Semi-t insertion and Semi-t Longitudinal tunnel - - Not described
2009106 technique biotenodesis screw at in patella
adductor tubercle
Yercan 2011107 Cohort 8.7 (5 to 13) 4 Tenodesis to adduc- Semi-t U-shape tunnel or 17.7 (15 to 20) Mean post-operative Kujala No redislocation,
tor magnus periosteal weave in Scoring Questionnaire score no complications
young 89.5 (87 to 92) reported
Giordano 2012108 Surgical - - Bone suture anchor at Gracillis and Longitudinal bone - - Not described
technique adductor tubercle semi-t tunnel in patella
Kumahashi Cohort 13.6 (11 to 15) 5 Pulley around Semi-t 1x biotenodesis 27.8 (24 to 36) Mean pre- to post-operative No complications
2012109 proximal MCL screw and suture Kujala Scoring Question- reported
onto patella naire scores: 67.4 (SD 12.6) to
95.4 (SD 3.2) (p =0.01) and
Lysholm Knee Scoring
Scale: 64.4 (SD 14.1) to 96.0
(SD 2.2) (p = 0.006)
Ladenhauf Surgical “skeletally 23 Biotenondesis screw Gracillis or 2x biotenodesis 16 “Excellent stability” No dislocations,
2013110 technique immature” distal to physis semi-t screws in patella no growth disturbance
Parikh 2013111 Cohort 14.5 (6 to 21) 179 Biotenondesis screw Gracillis or Patella bone tunnel 16.2 - 8 redislocations,
distal to physis semi-t 6 patella fractures,
8 stiff knee, 5 pain and
arthrosis
Nelitz 2014112 Surgical - - Biotenondesis screw Superficial Quadriceps tendon - - Not described
technique distal to physis quadriceps insertion
tendon
Lind 2016113 Cohort 12.5 (8 to 16) 24 Proximal MCL inser- Gracillis Patella tunnel 39 (17 to 72) Mean pre- to post-operative 4 redislocations
tion and adductor exiting anterior Kujala Scoring Question-
origin naire scores: 61 (SD 13) to 71
(SD 15), pain at rest and
walking also improved
Monllau 201598 Cohort 25.6 (SD 9.4) 36 Adductor magnus Gracillis V-shape tunnel in 37.6 (SD 18.1 Mean pre- to post-operative 2 had reduced ROM
pulley, graft sutured patella Kujala Scoring Question-
to itself naire scores: 63 (49 to 70) to
90 (79 to 98) and Lysholm
Knee Scoring Scale: 53
(41 to 65) to 95 (85 to 99) and
IKDC:118 51 (39 to 72) to 85
(78 to 96) and Tegner
Activity Scale:116 4 (3 to 4)
to 5 (3 to 7) and visual
analogue scale: 6 (5 to 7)
to 2 (0 to 3)
Malecki 2015114 Cohort 16 (8 to 18) 39 Adductor tendon Adductor Suture through 31 (24 to 36) Mean pre- to post-operative 4 redislocations
insertion magnus patella bone tunnel Kujala Scoring Question-
tendon naire scores: 66 (38 to 80) to
92 (70 to 100) and Lysholm
Knee Scoring Scale: 64 (30
to 95) to 91 (59 to 100)
Nelitz 2013115 Cohort 12.2 (10 to 13) 21 Bioresorbable Gracillis V-shape tunnel in - 18/21 patients satisfied with Reduced ROM and
interference screw patella surgery, 3/21 partially satis- prolonged rehab in
distal to physis fied and mean pre- to post- 1 case
operative Kujala Scoring
Questionnaire scores: 72.9
(37 to 87) to 92.8 (74 to 100)
and Tegner Activity Scale: 6
(3 to 9) to 5.8 (3 to 9)
SD, standard deviation; semi-t, semitendinosus-tendon; MCL, medial collateral ligament; MPFL, medial patellofemoral ligament; ROM, range of movement; IKDC, International Knee
Documentation Committee knee scoring system

anchor or a bone tunnel. Follow-up studies have small
numbers and short follow-up. They have been summarised
in Table I.98,102-118
MPFL reconstruction – intraosseous femoral fixation. A
MPFL reconstruction may be considered with intraosseous
fixation under image intensifier guidance where minimal
growth remains.119-121 Ladenhauf et al,110 Parikh et al111
and Nelitz et al115 described a technique using screw fixa-
tion in the femur (Table I). Whether screw position is
selected by isometry or anatomy, the fixation in the femur is

VOL. 99-B, No. 2, FEBRUARY 2017

166 D. CLARK, A. METCALFE, C. WOGAN, V. MANDALIA, J. ELDRIDGE

Fig. 5a Fig. 5b

The medial patellofemoral ligament footprint identified with Schöttle et

al’s122 technique on lateral radiograph. Line 1 is drawn along the poste-
rior cortical line. Two lines perpendicular to line 1 are drawn, line 2 inter-
sects the contact point of the medial condyle and the posterior cortex.
Line 3 intersects the most posterior point of the Blumensaat line.

distal to the femoral physis, with position confirmed by
image intensifier. No growth disturbance was reported by
any of these authors. No authors have described a trans-
physeal suspensory fixation.
Inspection of an anteroposterior radiograph shows the
physis curving proximally at its most medial extent.
Intraosseous fixation can still be safely achieved whilst
preserving the physis by judicious use of image intensi-
fier. Figure 5a demonstrates that when applying Schöttle
et al’s122 technique for identifying the footprint of the
MPFL, in the adolescent it may appear to overlie the
physis on the lateral view. If fixation on the femur is
used, it may be necessary to direct the screw distally to
avoid the physis (Fig. 5b). Consideration should be given
to how the graft is to be pulled into the tunnel and ten-
sioned without exiting within the joint.
Complications of MPFL reconstruction in the adolescent. Nelitz
et al123 evaluated the causes underlying failed MPFL recon-
struction in 19 young adults (aged 16 to 27). Patients suf-
fered ongoing symptoms including disabling pain,
recurrent dislocation or feeling of instability after MPFL
reconstruction. The most frequent complication was re-dis-
location associated with trochlear dysplasia or graft failure.
They also reported medial pain associated with over-ten-
sioning of the graft or femoral tunnel malposition. Patello-
femoral pain was associated with cartilage damage and
unidentified gross rotational abnormality.
Parikh et al111 found 38 complications amongst 179
knees (16.2%) of adolescents and young patients (mean age
14.5 years; 6 to 21) who had undergone MPFL reconstruc-
tion including recurrent lateral patellar instability, stiffness
with flexion deficits, patellar fractures and patellofemoral
arthrosis and pain. They attributed half of these to avoida-
ble factors related to surgical technique such as erroneous
placement of patellar drill holes.
Treatment beyond skeletal maturity
Once growth is complete, all abnormalities may be
addressed. Patellar alta can be addressed by a distalisation
of the tibial tubercle, trochlear dysplasia by a trochleo-
plasty and if no major abnormality exists, then an MPFL
reconstruction using a standard adult technique may be
used. If major rotational abnormality exists, correction of
these by de-rotational osteotomy may be considered before
focal knee surgery.
There are numerous reports in the literature of non-ana-
tomical reconstructions failing. The eventual recurrence of
instability when an isolated lateral release is performed is
well documented; Latterman et al124 demonstrated that
studies which reported outcomes for less than four years
reported patient satisfaction of 80% compared with 64%
in studies with a longer follow-up. Hopper et al125 found a
recurrence rate of 100% for a MPFL reconstruction in the
setting of severe trochlear dysplasia. Nelitz found that 89%
of patients with recurrent dislocation after a Roux-Goldth-
waite procedure had severe trochlear dysplasia compared
with 21% of satisfied patients.126 Several studies demon-
strate an increased risk of developing osteoarthritis when
all-comers are treated with a medialising tubercle trans-
fer.22,124,127
The techniques and complications of patellar stabilisa-
tion in this age group are better described than the out-
comes. The flow diagram (Fig. 6) is based on the best
available literature, it highlights some of the pitfalls of
operating in this age group and the alternative management
plans that are available.
Conclusions
Recurrent patellar instability is a disabling problem causing
pain and anxiety during simple functional tasks and may be
the onset of lifelong symptoms. More than half of all ado-
lescents with instability experience recurrence and risk sec-
ondary degenerative change. The assessment of the patient
should include an evaluation of anatomical factors known
to predispose to instability and should also consider the
possibility of associated genetic syndromes.
Trochleoplasty and tubercle transfer are contraindicated
when physes are open. Non-operative management is the

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 ADOLESCENT PATELLAR INSTABILITY 167

Are the tibial and femoral

physis open?

Yes No

Does clinical Await Identify major

picture permit Yes physeal anatomical
delay? closure abnormalities

More than
1 yr of Domed/ Normal
Biedert patellar
growth Lateral
ratio < 10% height and
remaining facing
trochlea trochlea

Yes No

MPFL MPFL Tibial Trochleoplasty Adult

Extraosseous radiograph tuberosity +/- MPFL
reconstruction guided distalisation soft-tissue reconstruction
reconstruction re-alignment

Fig. 6

An algorithm for decision-making and indications for surgery in adolescent patellar instability where major rota-
tional deformity is not present. Surgical procedures can be combined if required (for example tibial tubercle dis-
talisation and medial patellofemoral ligament reconstruction).

mainstay but where the effect of instability is severe, an Author contributions:

MPFL reconstruction may be required until an anatomical
reconstruction can be performed. If significant growth
potential remains, reconstruction of the MPFL may be per-
formed by an extraosseous technique. If only minor growth
remains, image intensifier guided placement of femoral
screws allows for fixation with minimal risk of deformity.
Once the physis is closed the authors recommend an indi-
vidual approach to surgery in which major anatomical
causes of instability are identified and corrected.
Take home message:
- Opportunity for major iatrogenic growth disturbance and
deformity exists when treating patella instability in the
adolescent.
- The risks and benefits of surgery must be considered in the context of
growth potential.
- A strategy of delaying anatomic reconstruction can be pursued with
physiotherapy and soft-tissue reconstruction until growth at the knee is
complete.
Supplementary material
Photographs showing squats with a resistance band
and a single knee dip maintaining alignment can be
found alongside the online version of this article at
www.bjj.boneandjoint.org.uk
D. Clark: Data analysis, Writing the paper.
A. Metcalfe: Data analysis, Writing the paper.
C. Wogan: Data analysis, Writing the paper.
V. Mandalia: Data analysis, Writing the paper.
J. Eldridge: Data analysis, Writing, Review the paper, Oversight.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by G. Scott.
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