A 50-year-old woman presented with iatrogenic habitual dislocation of left patella from childhood and pain from past 3 years. She recalled a childhood surgery over middle third of left thigh (incision and drainage). Few years after the surgery, she started noticing the giving way of patella and lived for 38 years without much disability. She was carrying out her daily activities without much pain or symptoms, but she was never symptom free during this period.\nPhysical examination did not reveal general joint laxity or malalignment of the lower extremity. There was a healed surgical scar over middle and lower third lateral aspect of the left thigh. Although the patella was in the femoral trochlear groove in extension, it dislocated laterally with 25 degrees of knee flexion. She complained slight discomfort by an apprehension test, but was not very painful even when dislocated. The passive lateral patellar tilt test was negative since the soft tissue attachment to the lateral border of the patella was diffusely stiff and tight. Radiological examination revealed evidence of patella alta as defined by Insall and Salvati,[] and Q angle was 18 degrees. Clinically and radiologically (Grade III Kellgren and Lawrence classification[]) tricompartmental degenerative knee arthritis was appreciated []. Preoperative Kujala score[] was 49.\nWith patient in supine position under epidural anesthesia, an anterior midline knee incision was used with paramedian arthrotomy. The lateral retinaculum was thickened while the medial retinaculum was thinned. The lateral tether is released by dividing the fibrous adhesions, which extended along the lateral intermuscular septum. The lateral patellar retinaculum and the synovium were divided and vastus lateralis was detached from the quadriceps tendon, leaving a rim of tendon for suturing.\nDue to shortening of the extensor mechanism, the patella could not be reduced. Quadriceps tendon was lengthened using V Y plasty at aponeurotic junction. Tracking was augmented with MPFL reconstruction using semi-tendinosus tendon and patellar end was fixed with 2.8 mm FASTak titanium anchor on the medial border of patella and over near isometric point on medial epicondyle of femur, which was checked under fluoroscopy. Patellar maltracking was persistent and so, it was decided to proceed with medial and distal transfer of tibial tuberosity.\nA long-leg hinged knee brace was applied with the knee in 20° of flexion and partial weight bearing with crutches for four weeks was advised, during which the patient was encouraged to do vigorous static quadriceps strengthening exercises. Knee mobilization and full weight bearing was started after four weeks. Initially patient had extensor lag of 15 degrees as she was immobilized in flexion. But after vigorous quadriceps exercises, patient improved without any extensor lag.\nAt final followup two years postoperatively, the patient was pain-free. There was no evidence of patellar maltracking or instability on detailed physical examination. Radiographs showed well reduced patella in both lateral, anteroposterior view and skyline view []. The patient's kujala knee society score 89 [] and range of motion was 0° to 90° on the left side []. Quadriceps strength was rated 4 (MRC grade).
18 year old male, a basketball player presented with right anterior knee pain and frequent subluxations and dislocation of the patella since 5 months. To start with he fell down and twisted his knee while playing basketball for which he visited an orthopedician and was diagnosed to have right patella dislocation that was treated by immobilization in a cylindrical cast for 4 weeks. He returned to sports after the primary episode but experienced frequent anterior knee pain and multiple episodes of patellar subluxations and dislocations that is, 6 episodes of frank dislocations while playing which were reduced by his coach. The patient was evaluated in the OPD, he had severe anterior knee pain, tenderness over medial patellofemoral joint, a positive apprehension test, no hyperlaxity and a Q-angle of 14°. Radiographs showed lateral patellar tilt [], lateral patellar subluxation, Insall-Salvatti Index-1, sulcus angle 140°. MRI showed effusion of knee joint with tear in the MPFL at the patellar attachment []. Of note, he had no other frank knee injuries or surgeries performed on the same knee. A preprocedure arthroscopy showed patellofemoral joint maltracking but no chondromalacia of patella.\nThe patient was treated definitively with MPFL reconstruction by the technique described by us. He returned to practice in 3 months and professional sports in 4 months, at 24-month followup, Modified Crosby and Insall scale was excellent and Kujala score was 98.