EC Paediatrics

Objective: To compare and evaluate the clinical and functional outcomes of two different surgical techniques for the treatment of patellar dislocation in children.

Materials and Methods: A prospective study was conducted from January 1995 to December 2011. Patients with patellar dislocation after antibiotic injection into the quadriceps muscle were recruited. Patellar dislocation was classified according to the Bensahel criteria. Two surgical techniques were performed (1) Transpatellar iliotibial approach and (2) Vastus medialis oblique transfer to the superior patella. The outcomes of the surgeries were classified according to the Kujala knee function scoring system.

Results: There were 148 patients (153 knees) who underwent surgery. There were 23 males and 125 females with patellar dislocation after repeated quadriceps antibiotic injections. There were 108 knees (70.6%) that were Type 1 and 45 knees (29.4%) that were Type 2. Surgery was performed via the iliotibial transpatellar (ITT) approach in 84 patients (86 knees) and the vastus medialis oblique muscle was transferred to the superior border of the patella (VMO) in 64 patients (67 knees). The mean ITT follow-up period ITT/VMO was 20.6/13.5 years, age at last examination mean was 29.7/21.6 years.

The mean Kujala score was 96.5 points in ITT and 92.3 points in VMO (Pvaluate: 0.039684528). ITT surgery has Kujala score better results than VMO. Results were accepted IIT/VMO: 84/62 (PValuate: 0.128881) so there is no comparison value.

Conclusion: In pediatric patellar dislocations due to medically induced quadriceps fibrosis, two surgical techniques have been combined with appropriate lateral retinaculum release, medial retinaculum restoration, and associated quadriceps plasty with high success rates. These techniques are simple, safe, and effective in skeletally immature children.

 Keywords: Patellar Instability; Recurrent Patellar; Dislocation of the Patellar; Congenital Dislocation of the Patella; Muscular Fibrosis

1. Hauser EDW. “Total tendon transplant for slipping patella: a new operation for recurrent dislocation of the patella”. Surgery, Gynecology and Obstetrics 66 (1938): 199-214.
2. Baker RH., et al. “Semitendinosus tenodesis for recurrent dislocation of the patella”. Journal of Bone and Joint Surgery. British Volume 54-B.1 (1972): 103-109.
3. Madigan R., et al. “Preliminary experience with a method of quadricepsplasty in recurrent subluxation of the patella”. Journal of Bone and Joint Surgery. American Volume 57-A (1975): 600-607.
4. Hughston JC. “Subluxation of the patella (Instructional course lectures of The American Academy of Orthopaedic Surgeons)”. Journal of Bone and Joint Surgery. American Volume 50-A (1968): 1003-1026.
5. Letts RM., et al. “Semitendinosus tenodesis for repair of recurrent dislocation of the patella in children”. Journal of Pediatric Orthopaedics 6 (1999): 742-774.
6. Merchant AC. “Classification of patellofemoral disorders”. Arthroscopy4 (1988): 235-240.
7. Hnëvkovský O. “Progressive fibrosis of the vastus intermedius muscle in children”. Journal of Bone and Joint Surgery. British Volume 43-B.2 (1961): 318-325.
8. Gunn DR. “Contracture of the quadriceps muscle”. Journal of Bone and Joint Surgery. British Volume 46-B (1964): 492-497.
9. Insall J., et al. “Chondromalacia patellae: a prospective study”. Journal of Bone and Joint Surgery. American Volume1 (1976): 1-9.
10. Fulkerson JP., et al. “Anteromedial tibial tuberele transfer without bone graft”. American Journal of Sports Medicine 5 (1990): 490-497.
11. Insall J and Salvati E. “Patella position in the normal knee joint”. Radiology1 (1971): 101- 104.
12. Laurin CA., et al. “The abnormal lateral patellofemoral angle. A diagnostic roentgenographic sign of recurrent patellar subluxation”. Journal of Bone and Joint Surgery. American Volume 60-A.1 (1978): 55-60.
13. Grelsamer RP and Proctor CS. “Radiographic analysis of patella tilt”. Journal of Bone and Joint Surgery. British Volume5 (1993): 822-826.
14. Seil R., et al. “Reliability and interobserver variability in radiological patellar height ratios”. Knee Surgery, Sports Traumatology, Arthroscopy 4 (2000): 231-236.
15. Dejour H., et al. “Dysplasia of the femoral trochlea”. Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur1 (1990): 45-54.
16. Bensahel H., et al. “The unstable patella in children”. Journal of Pediatric Orthopaedics4 (2000): 265-270.
17. Kumar A., et al. “Functional evaluation of the modified Elmslie-Trillat procedure for patello-femoral dysfunction”. Knee 4 (2001): 287-292.
18. Kujala UM., et al. “Scoring of patellofemoral disorders”. Arthroscopy2 (1993): 159-163.
19. Justis EJ. “Muscle contractures”. In: Allens E, Crenshaw AH (eds) Campbell’s operative orthopaedics. C.V Mosby, St. Louis, MO (1980): 2383-2385.
20. Alvarez EV., et al. “Quadriceps myofibrosis. A complication of intramuscular injections”. Journal of Bone and Joint Surgery. American Volume1 (1980): 58-60.
21. Dennis RW. “Knee pain in children and adolescents”. In: Dennis RW, Mercer R (eds) ART and pratice of children’s orthopaedics. Raven, New York (1993): 220-255.
22. Mukherjee PK and Das AK. “Injection fibrosis in the quadriceps femoris muscle in children”. Journal of Bone and Joint Surgery. American Volume3 (1980): 453-456.
23. Sharrard WJW. “Developmental contracture of the quadripceps”. In: Sharrard WJW (ed) Paediatric orthopaedics and fracture. Blackwell, Oxford (1979): 877-880.
24. Ghanem I., et al. “Congenital dislocation of the patella. Part I: pathologic anatomy”. Journal of Pediatric Orthopaedics 6 (2000): 812-816.
25. Cotta H. “Zur Therapie der habitullen patellaren Luxation”. Archiv fur Orthopadische und Unfall-Chirurgie 51 (1959): 256-271.
26. Drez DJ., et al. “Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation”. Arthroscopy3 (2001): 298-306.
27. Abraham E., et al. “Insall proximal realignment for disorders of the patella”. Clinical Orthopaedics and Related Research 248 (1989): 61-65.
28. Fulkerson JP. “Anteromedialization of the tibia tuberosity for patellofemoral malalignment”. Clinical Orthopaedics and Related Research 177 (1983): 176-181.
29. Galeazzi R. “Nuove applicazioni del trapianto muscolare e tendineo”. Archivio di Ortopedia 38 (1922): 315-323.
30. Deie M., et al. “Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children”. Journal of Bone and Joint Surgery. British Volume6 (2003): 887-890.
31. Hinton RY and Sharma KM. “Acute and recurrent patellar instability in the young athlete”. Orthopedic Clinics of North America 3 (2003): 385-396.
32. Stanitski CL. “Management of patellar instability”. Journal of Pediatric Orthopaedics 3 (1995): 279-280.
33. West F. “Recurrent dislocation of the patella in adult, end result of patellectomy with quadriceps plasty”. Journal of Bone and Joint Surgery. American Volume 40-A.2 (1958): 386-394.
34. Lieb FJ and Perry J. “Quadriceps function: an anatomical and mechanical study using amputated limbs”. Journal of Bone and Joint Surgery. American Volume 50-A.8 (1968): 1535-1548.
35. Andrish J. “The management of recurrent patellar dislocation”. Orthopedic Clinics of North America 3 (2008): 313-327.
36. Moyad TF. “Modified Galeazzi technique for recurrent patellar dislocation in children”. Orthopedics 4 (2006): 302.
37. Hall JE., et al. “Semitendinosus tenodesis for recurrent subluxation or dislocation of the patella”. Clinical Orthopaedics and Related Research 144 (1979): 31-35.
38. Letts RM., et al. “Semitendinosus tenodesis for repair of recurrent dislocation of the patella in children”. Journal of Pediatric Orthopaedics 6 (1999): 742-747.
39. Hall JE., et al. “Semitendinosus tenodesis for recurrent subluxation or dislocation of the patella”. Clinical Orthopaedics and Related Research 144(1979): 31-35.
40. Marsh JS., et al. “Treatment of recurrent patellar instability with a modification of the Roux-Goldthwait technique”. Journal of Pediatric Orthopaedics 4 (2006): 461-465.
41. Dutkowsky JP. “Cerebral palsy”. In: Allens E, Crenshaw AH, editors. Campbell’s operative orthopaedics. C.V Mosby: St Louis, MO (1980): 3934-3935.