Habitual Dislocation Research Articles

Surgical Treatment of Habitual Patella Dislocation with Genu Valgum

Habitual dislocation of patella is a rare disorder. Sometimes it is associated with angular deformity such as genu valgum. We experienced habitual patella dislocation associated with genu valgum that was treated with corrective osteotomy of distal femur and soft tissue realignment procedure including lateral release and medial reefing.

Patellaluxationen

Dislocation of the patella represents a frequent knee problem in childhood and adolescence. There are traumatic, recurrent, habitual and chronic forms. Many anatomical variations, which promote patellar dislocation, are known. The first traumatic dislocation is primarily treated conservatively with the exception of concomitant osteochondral fragments or very large soft tissue damage which justify surgical interventions. Recurrent, habitual and chronic dislocations are best cured surgically by vastus medialis advancement, reconstruction of the medial patellofemoral ligament, strengthening of the medial retinaculum together with a lateral release and by fixation of the patella using tendon grafts or medialisation of the insertion of the patellar ligament. To improve the femoropatellar groove by trochleoplasty is a different surgical concept. The long-term results following medialisation of the patellar ligament insertion or trochleoplasty are good with regards to patellar stability but mediocre in terms of avoiding degenerative changes in the patellofemoral joint.

Surgical treatment of recurrent habitual patellar dislocation associated with severe trochlear hypoplasia and generalized ligament laxity

Abstract Introduction Recurrent habitual patellar dislocation can be treated by soft tissue reconstruction or osteotomy or combination of both. However, no single surgical procedure can address the complex issue. We have successfully treated three patients (four knees) with trochlea hypoplasia and generalized ligament laxity with different surgical techniques. Patients and Methods From January 2001 to November 2008, four knees of three female patients were presented with recurrent habitual dislocation of the patella and generalized ligament laxity. Different surgical procedures were performed, including Insall proximal realignment in two knees, Roux-Goldthwait procedure in one knee, and combined trochleoplasty and tibial tubercle transfer in one knee. This article reports the functional and radiographic assessments at a mean follow-up of 3.4 years. Results The modified Cincinnati score increased from 74 ± 9 preoperatively to 88 ± 6 at latest follow-up; and the Kujala patellofemoral disorder score increased from 75 ± 10 to 86 ± 11. No recurrent dislocation occurred on all knees. Radiographic parameters improved, including congruence angle and axial linear patellar displacement. The sulcus angle improved in patient who underwent combined trochleoplasty and tibial tubercle transfer. Conclusions Surgical treatment for recurrent habitual dislocation of the patella varied according to the severity of the anatomical abnormality and the patellar stability assessed intraoperatively. In severe cases, combined trochleoplasty and tibia tubercle transfer is indicated to correct the recurrent dislocation of the patella. Proper patient selection and good surgical technique are the keys to success.

Electromyographic investigation of unstable patella before and after its realignment operation

Background:Patellar dislocations are either due to superolateral contracture of the soft tissue or imbalance of the power between the vastus medialis (VM) and the vastus lateralis (VL). The imbalance of muscle power as an etiology of patellar dislocation has not been studied. Hence, we studied the recurrent, habitual and permanent dislocations of the patella with an electromyogram (EMG) of the vastus medialis, vastus lateralis, and pes anserinus, before and after realignment operations, to document the muscle imbalance and effectiveness of the realignment operation.Materials and Methods:An electromyographic investigation was carried out on the vastus medialis and vastus lateralis in nine recurrent, 20 habitual, and 13 permanent dislocations of the patella, before and after their realignment operations. Pes anserinus transposition, which acted as a medial stabilizer of the patella, was also investigated with an EMG study, to understand its role on patellar stability at 0°, 30°, 60°, 90°, 120°, 150°, and full flexion of the knee. The age of the patients varied from nine to 30 (mean 15) years. There were 24 males and 18 females. Twenty-six patellar dislocations were on the right and 16 were on the left side.Results:Electromyographic pictures reveal subnormal activity of the vastus medialis in all types of dislocations and similar activities of the vastus lateralis in permanent and habitual dislocations recorded pre operatively, which recovered to almost normal values postoperatively, at the mean one-year follow-up. Pes anserinus, which was used for medial stabilization of the patella after its realignment, maintained normal EMG activity before and after the operation.Conclusion:This study is significant for understanding the imbalance of muscle activities in patients with an unstable patella, which can be rectified without recurrence after pes anserinus transposition.

Use of reciprocating rasp in articular eminectomy

We use a modified Al-Kayat and Bramley incision with extension through the temporalis fascia to allow adequate minectomy was first described by Myrhaug1 in 1951 for he treatment of habitual dislocation of the mandible. It s now a well established technique for recurrent disloation or subluxation and has been described for internal erangement.2 Baumstark et al. suggested that eminoplasty lone is sufficient for hypermobility cases,3 but if the disc equires decompression then eminectomy is better to reduce mpingement.4 Traditionally eminectomy is done using drills and chisels. ccess to the medial aspect of the eminence can be hazrdous because of the close proximity of the great vessels s they enter the base of the skull. For this reason we use micro reciprocator rasp (ConMed Linvatec, Largo, USA) s a saw attachment (Fig. 1). The smooth, rounded edge can e safely used deep in the infratemporal fossa to remove the uperomedial bone and achieve a good reduction of the entire minence without the risk of damaging vital structures. The elatively broad and flat working surface also prevents the isk of intracranial perforation. We have used this technique or a number of years and surgeons now familiar with the otal Biomet Microfixation TMJ replacement system (Biomet icrofixation—Europe, Dordrecht, The Netherlands) will be ware of a similar procedure they advise for preparation of he fossa.5

First-time patellar dislocation with resultant habitual dislocation two years later, which was not demonstrated on plain X-rays halfway: a case report

We present an instructive case of habitual left patellar dislocation in which the patella had appeared odd due to lateral tilt relative to contralateral side, but had been radiologically confirmed to be on the trochlea at 1 year prior to the referral. An 11-year-old girl presented to our hospital 2 years after the left patella had dislocated with a 'giving way' when cutting to the left. Our physical and radiological examinations confirmed that the left patella was laterally tilted in the patellar groove with the knee in extension but was dislocated in flexion beyond 45°. In spite of these findings, she had been untreated at the previous hospital since all plain X-rays, including a skyline patellar view, had failed to demonstrate the dislocation. Consequently, in addition to reconstruction of medial patellofemoral ligament, she had to undergo a lateral retinacular release, which might have been unnecessary if treated earlier. This case illustrates that first-time patellar dislocation can gradually lead to habitual dislocation subsequently, and that cautious physical examinations in regard to patella tracking are essential since radiological examinations do not always reveal the pathophysiology of patellar instability.

Effects of combined soft-tissue surgery on adaptability of the patellofemoral joint in treatment of habitual patellar dislocation in children

Objective To explore adaptability of the patellofemoral joint after combined soft-tissue surgery in treatment of habitual patellar dislocation at different age. Methods Seventy-three children with habitual patellar dislocation were retrospectively reviewed from 2000 to 2007. There were 24 males and 49 females, with a mean age of 7.1 years(ranged 3-15). The mean follow-up period was 38 months (ranged 25-98). There were 24 patients with 30 knees aged from 3 to 8 years in A group and 49 cases with 69 knees aged from 8 to 15 years in B group. The combined soft-tissue surgery procedure consists of lateral capsular release, medial retinacular tightening of the knee, vastus medialis muscle transfer to the patella, medial and distal transfer of the half patellar tendon. Patella axial and knee lateral X-ray examination were obtained.Femoral trochlear angle,patellar height changes, patellofemoral congruence angle and patellar tilt angle (Laurin angle) were measured to evaluate adaptability of the patellofemoral joint. Results The data of 73 cases were complete. At the last visit, no recurrence of patellar lateral dislocation was found and two cases had patella medial dislocation. Femoral trochlear angle improved from 150.1°±5.1° preoperatively to 144.3°±6.0° postoperatively (P ＜0.05) in A group, while similar changes had not found (P ＞ 0.05) in B group. There were no difference in A and B group in regard to patellar height, congruence angle and Laurin angle. Conclusion The combined soft-tissue surgery had effect on patellofemoral joint remodel in children with habitual patellar dislocation. These procedures can significantly promote development of the femoral condyle, decrease femoral trochlear angle and improve adaptability of the patellofemoral joint in children under the age of 8 years. But it had no obvious influence on older than 8-year-old children. Key words: Patellar dislocation; Knee joint; Surgical procedures, operative

Recessive multiple epiphyseal dysplasia (rMED) with homozygosity for C653S mutation in the DTDST gene - Phenotype, molecular diagnosis and surgical treatment of habitual dislocation of multilayered patella: Case report

BackgroundMultiple epiphyseal dysplasia (MED) is one of the more common generalised skeletal dysplasias. Due to its clinical heterogeneity diagnosis may be difficult. Mutations of at least six separate genes can cause MED. Joint deformities, joint pain and gait disorders are common symptoms.Case PresentationWe report on a 27-year-old male patient suffering from clinical symptoms of autosomal recessive MED with habitual dislocation of a multilayered patella on both sides, on the surgical treatment and on short-term clinical outcome. Clinical findings were: bilateral hip and knee pain, instability of femorotibial and patellofemoral joints with habitual patella dislocation on both sides, contractures of hip, elbow and second metacarpophalangeal joints. Main radiographic findings were: bilateral dislocated multilayered patella, dysplastic medial tibial plateaus, deformity of both femoral heads and osteoarthritis of the hip joints, and deformity of both radial heads. In the molecular genetic analysis, the DTDST mutation g.1984T > A (p.C653S) was found at the homozygote state. Carrier status was confirmed in the DNA of the patient's parents. The mutation could be considered to be the reason for the patient's disease. Surgical treatment of habitual patella dislocation with medialisation of the tibial tuberosity led to an excellent clinical outcome.ConclusionsThe knowledge of different phenotypes of skeletal dysplasias helps to select genes for genetic analysis. Compared to other DTDST mutations, this is a rather mild phenotype. Molecular diagnosis is important for genetic counselling and for an accurate prognosis. Even in case of a multilayered patella in MED, habitual patella dislocation could be managed successfully by medialisation of the tibial tuberosity.

Habitual dislocation of patella in knee disarticulation stump in a patient of congenital type I deficiency of tibia: a case report

The objective of this case report was to describe a patient who developed habitual dislocation of patella after knee disarticulation. Congenital deficiency of the tibia (tibial hemimelia, aplasia or dysplasia) is very rare, with an incidence of approximately 1 per 1 million live births. Knee disarticulation is preferred over transfemoral amputation for type I tibial deficiency. Most of the surgical techniques describe preservation of the patella and suturing of patellar tendon with cruciate ligaments. We present a case of a 14-year-old girl, who underwent disarticulation through the right knee as a primary procedure at age of 5 months for congenital type I tibia deficiency. At 13 years after the primary procedure, the patient developed painful flicking of the patella, which was diagnosed clinically as habitual (spontaneous) dislocation of the patella. In conclusion, type I tibia deficiency is associated with marked hypoplasia of the distal femur along with retardation of ossification of distal femoral epiphysis. This can later result in patellar dislocation. This could delay the rehabilitation of young amputees with knee disarticulation. It would be debatable and would need further evidence as to whether excision of the patella at the initial amputation may be more appropriate to prevent later incidence of dislocation.

Long-term efficacy of botulinum toxin type A for the treatment of habitual dislocation of the temporomandibular joint

Injection of botulinum toxin type A (BTX-A) into the lateral pterygoid muscles is a recently reported treatment for habitual dislocation of the temporomandibular joint (TMJ). We report five cases of dislocation in elderly patients with neurological or other severe systemic disease, and their successful treatment with one injection of BTX-A into the lateral pterygoid muscles. This is a relatively conservative option. Injection into the muscle is straightforward and can be done in outpatients with few complications. We recommend it as the first choice for patients with habitual dislocation and systemic or neurological diseases, particularly in the elderly.

Le instabilità abituali e permanenti di rotula nel bambino e nell’adolescente. Linee guida per un moderno trattamento

Patellofemoral disease in developmental age presents different clinical features: permanent dislocation, habitual dislocation, recurrent subluxation and patellar maltracking. The etiologic factors can be divided into skeletal abnormalities and soft tissue abnormalities. The Authors describe etiologic factors, clinical features, physiotherapic and surgical treatment.

Der Stellenwert der Sonographie in der Beurteilung von Instabilitäten des glenohumeralen Gelenkes

In a prospective study we evaluated diagnostic ultrasound investigation for shoulder instabilities. We measured the passive aptranslation In 150 healthy persons in relation to the dorsal glenoid as well as the inferior subluxation in relation to the acromion. After establishing normative datas we measured 23 patient with unidirectional instabilities and 34 with multidirectional instabilities. The humeral head position of a normal joint is 8 to 10 mm dorsally to the glenoid. In the control group the anterior translation of the dominant shoulder is significantly higher as in the nondominant shoulder (student-t-test; p less than 0.0045). Patients with anterior instabilities showed a significant increase of anterior translation in the injured shoulder (student-t-test; p less than 0.0001). In comparison with the control group there is a significant increase of downward subluxation in patients with multidirectional instabilities (chi 2 alpha less than 0.05). In habitual or voluntary dislocations the relation of the humeral head to the glenoid can be judged statically and dynamically. Secondary signs of dislocation (Hill-Sachs lesions, joint effusion) are evident.

Hip joint problems in patients with Down's syndrome

10 patients with Down's syndrome and hip disorders have been examined. Hip instability was present in 5 patients: habitual dislocations occurred in 2 patients, persistent subluxation was found in 2 patients and 1 patient had bilateral fixed hip dislocation. Hip instability usually occurs after the begin of walking and we suggest to perform regularly radiographic examinations on hip instability. Other hip disorders as slipped femoral capital epiphysis may be complicated by hip instability. Legg-Calvé-Perthes disease was found in 2 patients and slipped femoral capital epiphysis in 3 patients. 7 of the 10 patients underwent operative treatment. Subsequently a second or third operation was necessary in 2 patients because of an unexpected instability of the hip following the primary surgery. This was caused by the ligamentous laxity which is often found in Down's syndrome. An increased rate of infections is known in trisomy 21 and wound infections occurred in 2 of the 7 operated patients. Therefore we recommend to consider ligamentous laxity and susceptibility to infection in the treatment of hip disorders in Down's syndrome.

Computer tomography determination of the torsion angle of the humerus

A simple and easy method of CT-measurement of humeral torsion is proposed. This requires a transverse section of the proximal and distal epiphyses. The optimal site of cross-sectioning with reliable construction of the joint axis was determined in ten humeral bones. The variability of the angle was 2 to 3 degrees. Comparing CT-measurements in 50 humeri with anthropometry showed excellent correlation. Varation in humeral torsion on either side was approx. 50 degrees with the same mean value in right and left humeri of our specimens. Deviations in bone positioning within the gantry of up to 15 degrees in two different planes had little effect on the measurements. Habitual dislocation of the shoulder as well as assessment of postfractural malrotation of the humerus might be indications for measurement of humeral torsion.

Beidseitige habituelle Fibulaköpfchenluxation

Dislocation of the fibular head is rare. In most of the cases a trauma caused by sports activity, sometimes associated with a tibia fracture, is described. Only a few publications exist about habitual dislocation of the fibular head without history of trauma. This article reports a case of bilateral habitual anterolateral dislocation of the fibular head in a 17-year-old female. There was no information about a neurological or other disease and no sign of generalized ligamentous laxity. Because of marked symptoms with severe pain after each sensation of dislocation which appeared several times a day, the patient was treated by using a part of the biceps tendon for fixation of the reduced fibular head.

Die sonographische Bestimmung des Humerusretrotorsionswinkels

In patients with habitual dislocation of the shoulder and post-fracture malrotation the measurement of humeral torsion is important in preoperative diagnostics. An easy method of ultrasonic measurement of humeral torsion is proposed. The correlation with anthropometric, radiological and CT-measurement is good, what could be shown in 20 macerated humeri. In 111 patients with normal glenohumeral joints the average of humeral retrotorsion was 61 degrees. 86% had a torsion between 40 and 80 degrees.

Combined Proximal and Distal Realignment Procedures to Treat the Habitual Dislocation of the Patella in Adults

Background Habitual dislocation of the patella (HDP) is a rare condition. Many surgical procedures using proximal realignment have been reported to treat HDP in children, with around 80% satisfactory results. However, few articles have addressed the treatment of HDP associated with high-grade patellofemoral chondromalacia in adults. Hypothesis A combination of proximal and distal realignment procedures of the patella will reduce pain and increase function in adult patients with HDP. Study Design Case series; Level of evidence, 4. Methods Twelve patients with 13 symptomatic cases of HDP of the knee underwent surgical treatment that included lateral release, medial retinaculum advancement, and the anteromedial tibial tubercle transfer procedure. The average period between dislocation and surgery was 10.8 years. One patient had an additional procedure, an open-wedge varus corrective osteotomy of the distal femur, because of a 20° valgus deformity of the knee. The patellofemoral morphology study included routine and Merchant views of the knee and a computed tomography scan at full extension and at 30° flexion of the knee, before the operation and at follow-up. Any associated intra-articular pathologic findings during the surgical procedure were addressed. Patellofemoral function was evaluated with the Kujala functional score before surgery and at the time of the final follow-up. Results Chondromalacia of the patella over the medial facet and central ridge was grade III in 8 knees and grade IV in 5 knees. Corresponding chondral erosion of the lateral femoral condyle was noted in every knee. All patients were followed for an average period of 67.3 months (range, 25-103 months). The average preoperative Kujala functional score was 43.9 and the average postoperative score was 88.9 (P < .05). Radiographically, there was a statistically significant improvement in the congruence angle from 62.1° ± 15.0° preoperatively to —2.7° ± 9.8° postoperatively (P < .01) and in the lateral patellofemoral angle from —40.2° ± 9.3° preoperatively to 1.4° ± 7.0° postoperatively (P < .01). No patient has reported an episode of patellar dislocation after the surgical procedures. Conclusion Combined proximal and distal realignments of the patella effectively treat HDP in adults with associated high-grade patellofemoral chondromalacia.

Exacerbation of Habitual Dislocation of Ulnar Nerve by Concurrent Dislocation of Triceps Muscle: Complementary Role of Dynamic Ultrasonography to Electrodiagnosis

Exacerbation of Habitual Dislocation of Ulnar Nerve by Concurrent Dislocation of Triceps Muscle: Complementary Role of Dynamic Ultrasonography to Electrodiagnosis

The ‘four-in-one’ procedure for habitual dislocation of the patella in children

We describe our experience with the 'four-in-one' procedure for habitual dislocation of the patella in five children (six knees). All the patients presented with severe generalised ligamentous laxity and aplasia of the trochlear groove. All had a lateral release, proximal 'tube' realignment of the patella, semitendinosus tenodesis and transfer of the patellar tendon. The mean age at the time of the operation was 6.1 years (4.9 to 6.9), and the patients were followed up for a mean of 54.5 months (31 to 66). The clinical results were evaluated using the Kujala score. There has been no recurrence of dislocation. All the patients have returned to full activities and the parents and children were satisfied with the clinical results. The mean Kujala score was 95.3 (88 to 98). Two patients had marginal skin necrosis which healed after debridement and secondary closure. These early results in this small group have shown that the 'four-in-one' procedure is effective in the treatment of obligatory dislocation of the patella in children with severe ligamentous laxity and trochlear aplasia.

Treatment of Recurrent Anterior Dislocations of Shoulder by Laterjet-Bristow Operation: An Experience

Shoulder dislocation is common problem in orthopaedics. Management of recurrent shoulder dislocation is painstaking with different surgical procedures having varying outcomes. Laterjet-Bristow procedure provides stability and good functional outcome in Rowe scale and long term patient satisfaction. This is an observational prospective study carried out at two different tertiary care centers at Nepal and Pakistan using the same protocol. Habitual and pathological recurrent dislocations were excluded and all the recurrent dislocation of shoulder following initial traumatic anterior dislocation was included in this study. Standard Laterjet-Bristow operation was done and followed up for average of 27 months. Functional evaluation was done using Rowe score and graded as excellent, good, fair and poor. There were 12 men and 9 women with the mean ages of 23.4 years. At 12 months, 11 patients had fair result and seven patients had good result. At two years only three had fair result, 15 had good result and three patients had excellent result. Only three patients had poor result at one year while none had poor result at two year. The mean loss of external rotation in operated shoulder at one year was 24.33 degrees which decreased to 21.2 degrees at the end of second year. There was no restriction of external rotation in three patients at both yearly follow-ups while 18 patients had restriction in the range 10-30 degrees. Laterjet-Bristow can be the procedure of choice for surgical treatment of recurrent traumatic anterior dislocation and also as a salvage surgery for failed cases from other types of procedures. The only shortcoming of this procedure was some limitation in external rotation and minor loss in muscle power of that shoulder.