Surgery and non-surgical treatments for patellar instability

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, MMS, PA-C

In this article, we will examine surgical and non-surgical options for the patient with recurrent patellar instability.

If you have questions about our patellar instability treatment options and would like us to review your case, reach out to the Caring Medical staff.

Patellofemoral subluxation is one of the most common knee problems seen. The kneecap is not tracking properly (staying in the groove in the femur), and often times tracks laterally (wanders to the side). Sometimes recurrent knee cap instability may require surgical intervention as suggested by structural anatomical defects, i.e., underdeveloped bones especially in children in adolescents.

Knee instability from wear and tear injuries, which is the focus of this article,  increase tibial tubercle–trochlear groove distance (the kneecapPatellar tracking disorder is floating away from the joint), and insufficiencies in the medial retinacular structures (medial patellar retinaculum tendon damage).

Again, traditional medicine likes to treat this condition with surgery.

Patellofemoral instability surgery – knee surgery to stabilize the kneecap

Doctors in Germany at Münster University Hospital wrote in the journal BMC musculoskeletal disorders June 24, 2017 that:

The average age of the patients at the time of surgery was 16 and comprised of adolescent athletes. The youngest patient in the study was 9. The patients were followed for about 5 – 15 years post surgery.

The surgery is more of a threat

The University of Chicago Medicine & Biological Sciences researchers have published findings in The Orthopedic clinics of North America which they suggest that while patellar instability is a common injury that can result in significant limitations of activity and long-term arthritis, the surgery is more of a threat.

There is a high risk of recurrence in patients and operative management is often indicated. Advances in the understanding of patellofemoral anatomy, such as knowledge about the medial patellofemoral ligament, tibial tubercle-trochlear groove distance, and trochlear dysplasia may allow improved surgical management of patellar instability.

However, techniques such as medial patellofemoral ligament reconstruction are technically demanding and may result in significant complication. The role of trochleoplasty remains unclear.(2)

3 things the body does to stabilize joints

Why Do Patellofemoral Stabilization Procedures Fail?

Doctors in the United Kingdom said it more simply in their March 2017 paper published in the Sports medicine and arthroscopy review. They asked Why Do Patellofemoral Stabilization Procedures Fail?

In recent years, surgical interventions for patellofemoral joint instability have gained popularity, possibly revitalized by the recent advances in our understanding of patellofemoral joint instability and the introduction of a number of new surgical procedures. This rise in surgical intervention has brought about various complications.(3)

Patellofemoral instability surgery success rates?

Patellofemoral Pain Syndrome Prolotherapy

Highlights:

Physiotherapist Jenny Mcconnell wrote in the medical journal Manual Therapy that:

Some cases of patellofemoral instability are difficult to manage and, in fact, some treatments can make the patient feel worse. Frequently, the patient often bounces from practitioner to practitioner, physiotherapist to surgeon, seeking some relief of symptoms. However, their underlying source of pain is not well understood, so treatment can aggravate the symptoms.

Doctors have put a lot of emphasis on medial patellofemoral ligament (MPFL) reconstruction for the treatment of recurrent patellar dislocations/subluxations. Numerous techniques have been reported; however, there is no consensus regarding optimal reconstruction and in one paper a total of 164 complications occurred in 26% of patients. Side effects included patellar fracture, failures, and clinical instability on postoperative examination, loss of knee flexion, wound complications, and pain.(4)

Patellofemoral instability – not addressing the whole knee leads to surgical complications

A highly cited study in the The American journal of sports medicine from doctors at the University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine also suggest that patients with  medial patellofemoral ligament reconstruction without additional stabilizing treatments suffered from a high rate of continued problems including 5% who continued with recurrent dislocations.(5)

In the March 2016 issue of Arthroscopy, university and researchers in Rome working with the Harvard Medical School found conflicting evidence for the use of Medial Patellofemoral Ligament Reconstruction combined With Bony Procedures (bone reshaping) for Patellar Instability. Enough so that they were unable to identify an absolute indication for this type of surgery.(6)

This supports research from the Mayo Clinic published in the American Journal of Sports Medicine that says when you have multiple knee ligament damages – such as in degenerative wear and tear or acute injury – the medial patellofemoral ligament plays a very insignificant role in knee instability and does not even need to be addressed. (7Of course to a doctor experienced in regenerating ligaments, all ligaments play an important role. In surgery, many times supportive tissue is discarded.

Athletes with pain often feel there is no other choice but a surgical procedure, even a drastic one

Athletes with pain often feel there is no other choice but surgical procedures, even drastic ones. A good example of drastic surgery is the recommendation to surgically remove the patella in order to remove the pain. This sometimes does relieve the pain, but at a significant cost to the body. The strength to extend the knee is reduced by about 30 percent, and the force exerted in the knee is increased.

There are a host of other risks associated with surgery. The patient must realize that with each procedure and each shaving or cutting of tissue, NSAID (non-steroidal anti-inflammatory drug) prescription, or cortisone shot, the odds of developing long-term arthritis are greatly increased. The key to keeping the knee strong is to stimulate the area to heal, not to cover up the pain with a cortisone shot or NSAID. Even worse is to eliminate the painful area by shaving or cutting. This just delays the pain for a few years until the remaining tissue becomes degenerated. The best approach for the athlete is to stimulate the area to heal.

Prolotherapy Treatment for Patellofemoral Pain Syndrome

With Patellofemoral Pain Syndrome, the patella should be tracking in the groove in the femur, but oftentimes tracks laterally. A sunrise view X-Ray will show how the patella is tracking. An examination by the physician that includes moving the knee will reveal the tracking of the patella. Strengthening the vastus medialis may be helpful, but often that alone will not resolve the Patellofemoral Pain Syndrome.

Prolotherapy injections to the medial side of the patella, to strengthen the attachment of the vastus medialis to the patella, will pull the patella into the groove.

Exercises, such as cycling, would be encouraged as well, because they will help to strengthen the vastus medialis. Prolotherapy along with vastus medialis strengthening will get rid of the pain and speed up the process to normalize the patellar tracking. Prolotherapy for patellofemoral pain syndrome gets people back to running, jumping, playing tennis, or doing their favorite activities very quickly.

If you have questions about patellar instability treatment options, get help and information from our Caring Medical staff

References for this article
1
Schorn D, Yang-Strathoff S, Gosheger G, Vogler T, Klingebiel S, Rickert C, Andreou D, Liem D. Long-term outcomes after combined arthroscopic medial reefing and lateral release in patients with recurrent patellar instability–a retrospective analysis. BMC musculoskeletal disorders. 2017 Jun 24;18(1):277. [Google Scholar]

2. Koh JL, Stewart C. Patellar instability.Orthop Clin North Am. 2015 Jan;46(1):147-57. doi: 10.1016/j.ocl.2014.09.011. [Google Scholar]

3 Caplan N, Nassar I, Anand B, Kader DF. Why Do Patellofemoral Stabilization Procedures Fail? Keys to Success. Sports Med Arthrosc. 2017 Mar;25(1):e1-e7. [Google Scholar]

4. McConnell J. Management of a difficult knee problem. Man Ther. 2012 Jun 27. [Google Scholar]

5. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A Systematic Review of Complications and Failures Associated With Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation. Am J Sports Med. 2012 Jun 7. [Google Scholar]

6. Longo UG, Berton A, Salvatore G, Migliorini F, Ciuffreda M, Nazarian A, Denaro V. Medial Patellofemoral Ligament Reconstruction Combined With Bony Procedures for Patellar Instability: Current Indications, Outcomes, and Complications. Arthroscopy. 2016 Mar 28. pii: S0749-8063(16)00043-8. [Google Scholar]

7. Allen BJ, Krych AJ, Engasser W, Levy BA, Stuart MJ, Collins MS, Dahm DL. Medial patellofemoral ligament tears in the setting of multiligament knee injuries rarely cause patellar instability. Am J Sports Med. 2015 Jun;43(6):1386-90. doi: 10.1177/0363546515576902. Epub 2015 Mar 25. [Google Scholar]

 

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