Surgery and non-surgical treatments for chronic knee cap dislocation and patella instability

Ross Hauser, MD

In this article, we will examine surgical and non-surgical options for patients with recurrent patellar instability or chronic kneecap dislocation.

Kneecap dislocation occurs when there is an impact injury to the knee significant enough to dislodge the kneecap. When this injury occurs there can be damage or complete disintegration of the medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL). When there is the complete destruction of the ligament(s), the patient will then decide if they will have a medial patellofemoral ligament and/or medial patellofemoral ligament and medial patellotibial ligament reconstruction surgery. But what if there is not complete ligament destruction? What if the ligaments are damaged or stretched, can they be repaired?

What we will discuss in this article are the various options for treatment:

Chronic patellar subluxation and dislocation

Many times people will reach out to us via email or phone call and they will tell us a story of an injury that they thought they recovered from only to have knee pain “show up,” one day. These stories go something like this:

I was in an accident years ago. My leg jammed into the floorboard. I first heard a popping sound and then felt intense pain. As I was able to walk on it and could “walk it off,” my doctor told me to watch for pain and then come in for an MRI. A couple of years passed, and my knee did not give me any problems. Then my knee started to hurt. Slowly a nagging pain developed with slightly increasing intensity as the weeks and months passed. 

Finally, I went to the doctor for an MRI. Impression: PATELLAR SUBLUXATION.

I was sent off to 6 x 2 a week physical therapy. After 12 sessions, I did not really get any help. Another doctor focused on the medial patellofemoral ligament (MPFL)  as my main pain was coming from the center or middle part of my knee. I was sent to another round of physical therapy, this time focusing on the patella. This helped more but not “all the way,” back. My doctor told me that to get all the way back, I should consider surgery. 

In this image, we see the lateral (sideways) tracking of the patella. In the left side panel, both patellae are seen with both knees bent at a 90-degree angle. In the right-side panel B the close-up. Because of this person’s patellae and knee (femoral-tibial joint) instability, he has lateral tracking patellae causing him pain.

Lateral tracking of the patella

The doctor’s textbook on patellar instability. You will understand patellar instability better if you understand it from your doctor’s perspective.

We are going to visit the National Library of Medicine online department and the September 2022 update of the publication Stat Pearls (1) for an overview of patellar instability. This chapter is a breakdown of current treatment ideas in dealing with patellar instability. Here is a summary, we have added parenthesis as brief explanatory notes:

“Patellar instability by definition is a disease where the patella bone pathologically disarticulates out from the patellofemoral joint (Your knee cap is dislocating and coming out of the groove). This most often involves multiple factors:

Overtime patients that have patellar instability can have debilitating pain, limitations in basic function, and long-term arthritis.” (You probably knew that already).”

Treatment guidelines: Nonoperative

These treatments work best with:

On Physical therapy, the treatment is described as: “Physical therapy should focus on closed chain exercises (an exercise such as a push-up where the furthest part of a limb remains stationary while you perform the exercise) and quadriceps strengthening. Core hip strengthening and gluteal muscle strengthening will improve external rotators of the hip, thus externally rotating the femur and decreasing the Q-angle. (The Q-Angle is the angle of the hip-to-knee typically pronounced in women because of childbearing).”

Gait abnormalities are obvious in patella instability. What the abnormalities mean and how to treat them is not so obvious.

An August 2022 paper from doctors in Austria published in the International Journal of Environmental Research and Public Health (16) suggests that “Identifying potential gait deviations in patellofemoral instability can help with the development of effective rehabilitation strategies.” However, it may not be as simple as it seems. Here is what the researchers said:

“Subjects with patellofemoral instability show decreased walking speed, stride length, and cadence. Some studies reported changes not only in knee kinematics (knee rotation with a fixed foot on the ground) and kinetics (knee rotation with a non-fixed foot) but also in hip and ankle kinematics and kinetics (fixed foot versus non-fixed foot). There is evidence that most subjects with patellofemoral instability walk with a quadriceps avoidance gait (this is walking to avoid pain or discomfort caused by the quadricep muscle tendons pulling on the patella) and show increased genu valgum posture (Knee Valgus deformity), but there is still great variability in the coping responses within individuals with patellofemoral instability.

The discrepancy (the variability) among the study results might underpin the fact that patellofemoral instability is a multifactorial problem, and subjects cope with the different underlying morphological as well as functional deficits using a variety of gait strategies, which makes the interpretation and understanding of the gait of subjects with patellofemoral instability a clinically challenging task.”

In other words, patella instability can cause or be in part caused by ankle problems, other knee problems, or hip problems. Each problem dictates a way in which the patient walks with compensation.

Patella dislocation surgery

From an email: It has been edited for clarity:

“I have subluxation of the left kneecap. Doctors are telling me that I should NOT have arthroscopic surgery to realign the kneecap, but rather, I should have a total knee replacement. For two years I have done, physical exercises, knee taping and bracing, and mistakenly done steroid injections. After easy walking (grocery shopping) for an hour or more, the knee is totally unstable and will not bear my weight without partially giving out and causing a lot of pain. I am overweight. I do eat healthy meals and am working on losing those extra pounds, but it is very difficult as my mobility is limited due to knee instability. I do not want a total knee replacement and my x-rays show some minimal damage to my knees. There is still a good gap between the bones in my knees, indicating a still good amount of cartilage.”

This guide of treatments now continues with the surgical aspects.

General indications for surgery:

The surgical options, which many of you may have already discussed with your orthopedic surgeon may include:

Long-term outcomes of patellar stabilization surgery in 51 active duty military personnel

A February 2022 from the Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, published in the Orthopaedic Journal of Sports Medicine (14)  examined the long-term outcomes of patellar stabilization surgery in 51 active duty military personnel.

Deciding on treatments

Many people get great benefits from conservative care and surgical repair of patella instability or chronic knee cap dislocations. For the majority, surgery can be very successful. These are typically the people we do not see at our center. Let’s point out here that if you have surgery that has failed, it will be very likely that moving forward you will need more surgery to fix the problem. Treatments such as conservative care and injection therapy will have limited success if screws and pins have been inserted or other radically anatomic changes have been made to the knee.

Surgery for a completely disintegrated ligament occurs with acute injury and dislocation.

What we are going to look at first is the injury that occurs when the knee suffers a blow that knocks the kneecap out of its groove. When this injury occurs almost always the medial patellofemoral ligament is completely ruptured. Ligaments connect bones to bones. The medial patellofemoral ligament connects the lower thigh bone to the back of the patella/kneecap. So it is easy to see when the kneecap is dislocated, this attachment snaps.

Treatment decisions:

The first treatment decision is obviously to get the kneecap back in place and secure it.

If this is your first kneecap dislocation, the decision to go to surgery will come with a degree of urgency. Surgeons believe that they only get one chance to perform a repair to your original ligament. After repeated dislocations, the original ligament cannot be surgically repaired, It must be reconstructed from a tendon or ligament that the surgeons get from somewhere else in your body.

In this October 2018 research, we see surgeons talking to surgeons in the medical journal Arthroscopy. (2) Let’s join the conversation:

The purpose of this research is to “clarify the discrepancy in surgical options and present evidence to treat patellar dislocation by evaluating which of the (surgical) techniques yields better improvement in stability and functional recovery for patellar dislocation.”

In this research, military and university researchers in South Korea shared with the international surgical community these findings:

Surgical treatment of the MPFL for acute patellar dislocation is not superior to conservative non-surgical treatment in restoring knee function and clinical outcomes

CONCLUSIONS:

The bottom line: Surgeons are reporting to surgeons that non-surgical technique is in fact just as good as surgery.

Medial patella-femoral ligament (MPFL) reconstruction and patellofemoral instability

A November 2022 paper published in the journal Knee surgery, Sports Traumatology, Arthroscopy (14) evaluated outcomes and the need for revision procedures following surgical treatment of patients with patellofemoral instability.

The researchers examined 138 knees from 116 patients who underwent patellofemoral instability surgery.

Results of research: At an average follow-up at 4.4 years, all patient-reported outcome scores measuring pain, function, and quality of life had significantly improved from pre-operative levels. No patellofemoral instability revision procedures were performed.

Acute Patella dislocation – Traditional non-surgical conservative care – Immobilization and rehab

Now we are going to get into even more controversy surrounding the treatment of patella dislocation. The conservative non-surgical treatment option. This is not to be confused with the non-surgical regenerative medicine option we will discuss below.

A well-cited paper from the Department of Orthopaedics, Southern California Permanente Medical Group was published in the journal Sports Health. What the doctors were looking for was to provide guidelines, A Treatment Algorithm for Primary Patellar Dislocations, (3) which was the title of their paper. Here is what they said:

“Surprisingly little evidence exists addressing the nonoperative treatment of the primary patellar dislocation. Contemporary treatment regimens range from immediate mobilization without a brace to cast immobilization in extension for 6 weeks.”

Here are some of the issues they came across:

Conclusion

It is clear from these two representative studies why acute patella dislocation usually becomes a situation of chronic patella dislocation

How to understand and better predict which patients were at greater risk of patella dislocation recurrence

In February 2022, researchers from Paracelsus Medical University in Salzburg, Austria published a paper in The American Journal of Sports Medicine (13) where they offered guidance to their fellow doctors on how to understand and better predict which patients were at greater risk of patella dislocation recurrence. The researchers assessed patients who had a previous lateral patellar dislocation at a minimum two-year follow-up and completion of a conservative care non-surgical treatment program.

Surgery for chronic patella dislocation – does this surgery help a 16-year-old athlete? Surgery judged ineffectively

Doctors in Germany at Münster University Hospital wrote in the journal BMC Musculoskeletal Disorders (4):

The goal then of their study was to evaluate the long-term results of combined arthroscopic medial reefing (reconstructive surgery of the supporting connective tissue of the patella) and lateral release (surgery to put the patella back into its correct position.)

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.

Why Do Patellofemoral Stabilization Procedures Fail?

Doctors in the United Kingdom said it more simply in their 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. (5)

Patellofemoral instability surgery success rates?

Highlights:

Physiotherapist Jenny Mcconnell wrote in the medical journal Manual Therapy (6) 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, clinical instability on postoperative examination, loss of knee flexion, wound complications, and pain.

Physical therapy after medial patellofemoral ligament reconstruction

Purpose: No consensus exists on rehabilitation programs after medial patellofemoral ligament reconstruction with or without tibial tuberosity osteotomy. To fill this knowledge void, researchers writing in November 2022 in the journal International Orthopaedics (15) examined the content and timeline of rehabilitation (weight-bearing, range of motion [ROM], and exercise therapy) and return to sport, as well as patient-reported outcomes after medial patellofemoral ligament reconstruction with or without tibial tuberosity osteotomy.

In their examination of previously reported research and case studies, the researchers found:

What are we seeing in this image?

We see that the patella sits in its groove in the knee and is held there by the tension created by the various pulling forces holding it there. Think of the tension on a trampoline. The tension is created by the force of the springs, cords, or ropes that keep the trampoline material tight with the frame. For the patella to remain in its groove, the forces that pull it to the left must be counterbalanced with the forces that pull it to the right, and the forces that pull it up must be counterbalanced with the forces that pull it down.

Instability can occur if the left side pull is stronger than the right side pulls because of ligament damage or other injuries to the right side structures. Instability can occur if the forces that pull the patella down are stronger than the forces that hold the patella up.

Like a trampoline, if one side of the tension is off or damaged, the trampoline will lose its tension, stability, and function.

Patella Movement

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

This is why, when addressing the problem of patella instability, we must address the whole knee, the right and light side to keep the proper tension, the up and down, to keep the proper tension and the patella in its groove.

A highly cited study in The American Journal of Sports Medicine from doctors at the University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine also suggests 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. (7)

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. (8)

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. (9) Of course to a doctor experienced in regenerating ligaments, all ligaments play an important role. In surgery, many times supportive tissue is discarded.

As we are discussing here, the problem of chronic dislocation is a problem of multiple weakened or damaged structures that pulls the knee cap out of place or the groove itself is damaged. In August 2021 doctors writing in the journal BioMed Central musculoskeletal disorders (10) wrote: “After first-time patellar dislocation, the dynamic position of the femur in relation to the tibia plays an important role in joint stability, because the medial stabilizer of the patella (the Medial Patellofemoral Ligament) is damaged or inefficient. The most important factor in controlling the rotational movement of the tibia in relation to the thigh are the hamstring muscles. . . . In patients with recurrent patellar dislocation, knee flexors strength is decreased significantly in both the unaffected and affected limbs. This may indicate a constitutional weakening of these muscles which can predispose to recurrent dislocations.”

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 on 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.

And if the surgery does not work?

This is a January 2021 study in the journal Knee Surgery, Sports Traumatology, Arthroscopy (11). It simply states: “Patients unable to return to play following medial patellofemoral ligament reconstructions demonstrate poor psychological readiness.” Let’s look a little closer at these findings:

“Medial patellofemoral ligament reconstruction is often indicated in athletes with lateral patellar instability to prevent recurrence and allow for a successful return to play. In this patient population, the ability to return to play is one of the most important clinical outcomes. The purpose of the current study was to analyze the characteristics of patients who were unable to return to play following medial patellofemoral ligament reconstruction.

A retrospective review of patients who underwent medial patellofemoral ligament reconstruction and subsequently did not return to play after a minimum of 12-months of follow-up was performed.”

Findings and conclusions:

The regenerative medicine option. Prolotherapy injections to pull the kneecap into place and keep it there.

In the research above you see that a first-time dislocation of the kneecap creates short and long-term problems of knee instability which leads to long-term problems of chronic patella subluxation or simply, chronic dislocation of the kneecap. This is also referred to as patellofemoral tracking syndrome. This is where the kneecap floats out of the groove on the femur (thigh bone) it is supposed to sit and glide up and down on.

As we have seen in the research above, this can equally affect an adolescent athlete as well as an older athlete. The kneecap is supposed to stay in the middle of the knee, in its groove. But because of past dislocations or advanced knee instability, the kneecap wanders to the sides. When this occurs not only is there a problem of the maltracking patella, but there is also a problem of accelerated wear and tear and the development of osteoarthritis. This can also lead to the problem of Patellofemoral Pain Syndrome.

Caring Medical Research on Prolotherapy treatments for patella disorders and knee instability

Our Caring Medical staff has published many research papers on using Prolotherapy for various musculoskeletal disorders. You can find that research on our Prolotherapy research page.

In 2014, we published in the journal Arthritis and Musculoskeletal Disorders our paper: Outcomes of Prolotherapy in Chondromalacia Patella Patients: Improvements in Pain Level and Function. (12) Below are the summary highlights.

Specifically, with Prolotherapy:

Return to activity and exercise

Prolotherapy had a notable effect on the potential for pain-free activity and exercise. After Prolotherapy, there was a substantial increase in the number of knees reported to have no pain or little pain upon activity from 22 knees (31.9%) to 67 knees (97.1%).

A decrease in the number of knees experiencing moderate pain was also observed from 24 knees (34.8%) to 4 knees (5.8%). Initially, 23 knees (33.3%) produced severe pain during activity, but no patient experienced severe pain after Prolotherapy. Overall, this reduction in pain during activity was statistically significant.

Similarly, upon exercise and before Prolotherapy, 42 knees (61.8%) of patients developed severe pain and 16 knees (23.5%) produced moderate pain.

After Prolotherapy, only 2 knees had severe pain upon exercise and 9 knees sustained moderate pain.

Fifty-nine knees (86.8%) had no pain or minimal pain during exercise after Prolotherapy compared to 10 knees (14.7%) without pain before Prolotherapy. The alleviation of pain upon exercise compared to the pain before Prolotherapy was also statistically significant.

At least 75% of Prolotherapy’s effect on pain relief lasted in 62 knees (89.9%) following treatment. Only 1 patient stated that pain relief from Prolotherapy did not last.

The results of this study confirm the findings of our previous study of 119 knees in 80 patients, in which more than 82% of patients showed improvements in walking ability, medication usage, athletic ability, anxiety, depression, and overall disability following Prolotherapy injections for unresolved knee pain. In that study, patients were provided Prolotherapy of 20–40 injections every 3 months and then evaluated at 15 months. As in this study, 96% of patients felt that Prolotherapy had improved life overall.

The results of this study suggest that Prolotherapy in the treatment of chondromalacia patella is associated with substantial gains in pain relief and functionality. As Prolotherapy is a simple, rapid, and low-morbidity option for use in the outpatient setting, it can be considered first-line conservative therapy for chondromalacia patella. The application of Prolotherapy to chondromalacia patella, a rheumatological disease in need of definitive therapy, warrants further investigation.

What are we seeing in this image?

Here we have the “sunrise” image of a before and after Prolotherapy treatment. The alignment and stability in this patient’s knees were greatly improved. She was able to run again. As with any medical technique, there are successes and failures. This treatment may work for you with varying degrees of success levels. This treatment may not work for you.

Patellofemoral Pain Syndrome Prolotherapy

 

What are we going to see in this video?

Ross Hauser, MD demonstrates a comprehensive Prolotherapy treatment for the knee in a patient with patellofemoral pain syndrome and poor patella tracking caused by knee instability. Because this patient is an avid hiker, frequently walking on uneven ground, the ligament attachments need to be treated along the lateral, and medial sides, as well as along the patellar tendon attachments. She has responded very well to Prolotherapy over the years, which has enabled her to be active. Otherwise, as the patient tells us, she would likely not be able to walk at all due to the various joint instability injuries that have occurred because of her hypermobility.

PRP and bone marrow aspirate or stem cells

Let’s remember that this is one patient and similar results will not be achieved in all patients.

In the caption of this image, we read: “Progression of patellar tendon healing with stem cells as evidenced by ultrasound. Pictures A and B show the patellar tendon at the start of the treatment. MRI revealed a 70% tear of the patellar tendon eight months later. This patient had one bone marrow treatment and several PRP treatments to resolve her tear.”

Summary and contact us. Can we help you?

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your knee cap problems and patella instability.  If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References:

1 Wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI. Patellar Instability. StatPearls [Internet]. 2022 Jan. [Google Scholar]
2 Lee DY, Park YJ, Song SY, Hwang SC, Park JS, Kang DG. Which Technique Is Better for Treating Patellar Dislocation? A Systematic Review and Meta-analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2018 Oct 6. [Google Scholar]
3 Jain NP, Khan N, Fithian DC. A Treatment Algorithm for Primary Patellar Dislocations. Sports Health. 2011;3(2):170-174. doi:10.1177/1941738111399237. [Google Scholar]
4 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]
5 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]
6 McConnell J. Management of a difficult knee problem. Man Ther. 2012 Jun 27. [Google Scholar]
7. 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]
8. 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]
9. 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]
10 Małecki K, Fabiś J, Flont P, Fabiś-Strobin A, Niedzielski K. Assessment of knee flexor muscles strength in patients with patellar instability and its clinical implications for the non-surgical treatment of patients after first patellar dislocation – pilot study. BMC Musculoskelet Disord. 2021 Aug 28;22(1):740.
11 Hurley ET, Markus DH, Mannino BJ, Gonzalez-Lomas G, Alaia MJ, Campbell KA, Jazrawi LM, Strauss EJ. Patients unable to return to play following medial patellofemoral ligament reconstructions demonstrate poor psychological readiness. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 Jan 20:1-5. [Google Scholar]
12 Hauser RA, Sprague IS. Outcomes of prolotherapy in chondromalacia patella patients: improvements in pain level and function. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2014 Jan;7:CMAMD-S13098. [Google Scholar]
13 Wierer G, Krabb N, Kaiser P, Ortmaier R, Schützenberger S, Schlumberger M, Hiller B, Ingruber F, Smekal V, Attal R, Seitlinger G. The Patellar Instability Probability Calculator: A Multivariate-Based Model to Predict the Individual Risk of Recurrent Lateral Patellar Dislocation. The American Journal of Sports Medicine. 2022 Jan 21:03635465211063176. [Google Scholar]
14 Žlak N, Kacin A, Martinčič D, Drobnič M. Age, body mass index, female gender, and patellofemoral cartilage degeneration predict worse patient outcome after patellofemoral instability surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2022 May 7:1-9. [Google Scholar]
15 Koshino Y, Taniguchi S, Kobayashi T, Samukawa M, Inoue M. Protocols of rehabilitation and return to sport, and clinical outcomes after medial patellofemoral ligament reconstruction with and without tibial tuberosity osteotomy: a systematic review. International Orthopaedics. 2022 Jun 15:1-2. [Google Scholar]
16 Habersack A, Kraus T, Kruse A, Regvar K, Maier M, Svehlik M. Gait Pathology in Subjects with Patellofemoral Instability: A Systematic Review. International Journal of Environmental Research and Public Health. 2022 Aug 23;19(17):10491. [Google Scholar]

This article was updated April 19, 2022

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