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Injuries of the sporting

knee
Series editors: Jonathan Webb, Ian Corry
Br J Sports Med 2000;34:467470
Patellar dislocation and lesions of
the patella tendon
Patellar dislocation

Patellar dislocation only in the sports injury context


Does not refer to congenital and habitual dislocation
Dislocation is simply divided into 2 groups : (fig. 1)
Primary acute dislocation
Recurrent dislocation
Primary acute dislocation
Caused by a high energy transfer
A lot of force was needed to displace the patella
May take the form of a tangential blow across the front of the knee or
may be a very violent twisting flexing movement
The diagnosis is usually clear from the history
Examination may disclose the patella still lying lateral to the join
More usually the dislocation has been reduced, swollen knee with a
tender line parallel to the medial border of the patella (reflecting the
retinacular tear)
Primary acute dislocation
Anatomy must be normal before injury
Conservative treatment is appropriate if
Patella lies normally centred in the femoral groove
No separated fragment of bone from the patella or the lateral femoral
condyle
Treatment :
Initial aspiration to relieve the pressure within the joint
Immobilisation
Apply a brace to restrict flexion to a few degrees at first, after two to three
weeks, to gradually increase the amount of bending
Primary acute dislocation
Computed tomography (CT) scan
The patella should be lying centrally in the groove.
Fractures are generally too small to fix and should be removed
arthroscopically.
If the patella is not central, the medial structures need repair
Reccurent dislocation
Low energy transfer phenomenon
Takes little force to dislocate the patella, often a trivial twisting flexion
movement with the foot going into external rotation is enough
Surgery is often necessary to object :
Replace the patella in a central position
Do not medialise the patella excessively as secondary problems can then occur
The anatomical abnormality should be assessed at three levels :
Proximal malalignment
Joint distortion
Distal malalignment
Proximal malalignment
Excessive femoral inward rotation the patella is thrust medially
Strong lateralising forces from the insertion of the patella tendon on
the outer aspect of the proximal tibia
Often compounded by inadequate superomedial structures,
particularly the vastus medialis obliquus muscle (VMO)
CT high radiation dose, high resolution USG or MRI are better
Proximal malalignment
Treatment :
Conservative treatment by trying to build up the VMO plus correction of
tibial rotation with orthotics
Surgery complex, involves either a rotatory femoral osteotomy or a major
muscle slide moving the extensor muscles medially

Recurrent dislocation simply due to proximal malalignment is very


rare.
Joint distortion
The small high patella (patella alta) is a major cause
When knee flexes, patella doest engage properly in the femoral
groove
Kneecap feels smaller and higher than usual
Inadequate groove or flat backed patella.
Genu valgum/ hyperextensio
Joint distortion
Treatment :
Conservative : McConnell technique
Operations at this level are often unsatisfactory
Simple: lateral release,VMO reefing (difficult to balance) risk of
producing medial subluxation
Distalise the patella can produce significant pain
Rebuild the lateral wall of the femoral groove
Distal malalignment
Placed in the patella tendon insertion and in the shape of the
proximal tibia
Amount of lateral offset is described as Q angle
More common in girls wider pelvic
Investigation : naked eye is the best tool, used in conjunction with the
history
Treatment : in surgical term, tendon realignment and tuberosity
transfer are described as simple (after failure of conservative
treatment)
Combination of levels
During observation of the knee, there are two configurations that
alert the examiner to a high risk of patella dislocation
1. Kissing patellae
2. Frog eye patellae
Both of these indicate combinations of levels of malalignment
Patellar tendinitis
Tendinitis
is characterised by patellar tendon discomfort on activity.
the tendon may be tender to palpation over its whole length.
This tenderness is often worse when the knee is flexed, as the tendon is
stretched and the tight tendon becomes the anvil for the hammer of the
palpating finger.
Tendinosis
has a similar set of symptoms but the tenderness seems to be less when the
tendon is under tension in full flexion, perhaps because the area of deep
degeneration is protected from palpation by the tight superficial fibres.
has many causes, probably the result of prolonged repetitive mechanical
stresses.
THE PATELLA POLE
The classic jumpers knee occurs mainly at the bonetendon junction
at the inferior pole of the patella
The pain is well localised to the tip of the patella
The classic cause is microtearing at this site
Investigation
MRI, ultrasound, and CT scanning are all useful

Treatment
Treatment at this level depends on the nature of the lesion
When on CT the lesion is much over 6 mm across, this may not be eVective
and the athlete either lives with the lesion or has surgery.
THE MIDDLE THIRD
Tendinopathy of the main body of the patellar tendon has only
recently been identified as a distinct entity, with a diVerent prognosis
and management plan from classical jumpers knee.
Investigation
Ultrasonography,CT scanning,and MRI are all highly sensitive and specific in
localising intratendinous lesions
The area of tenderness was often located in the main body of the tendon,
some 2 cm distal to the lower pole of the patella.

Treatment
In spite of physiotherapy,local injection,and stretching,this form of patellar
tendinopathy often becomes chronic.
The main complication is altered sensation at the front
ofthekneewhichcanbeaproblemonkneeling
THE DISTAL POLE
In the young patient,Osgood-Schlatters disease is well recognised
It is a painful swelling of the tibial tuberosity which may be
fragmented radiologically
Similar localised pain and tenderness can occur without radiological
change
Investigation
Although the clinical diagnosis is obvious, radiographs should be obtained

Treatment
There is no needtoimmobiliseinanyway,andaneoprenesleeveoVers adequate
protection against the inevitable knocks
In the adult condition, local injection may help but surgical excision is the
usual outcome, again with some risk of a troublesome scar.
TERIMA KASIH