29 year old woman who is a daily wage worker presented to the outpatient department (OPD) with right anterior knee pain since 4 months. She felt a popping sensation in her right knee after slipping from the foot board of a bus while running to catch it 4 months ago. After this episode, she had severe pain and was unable to move her knee. She was then taken to a quack, after a local manipulation and massaging by him she was relieved of acute symptoms but had persistent knee swelling and mild knee pain. Patient returned to her daily activities the next day with minimal knee pain and difficulty in knee movements. She had similar episodes frequently (around 8) episodes since then, particularly during stair climbing, squatting and while boarding or trying to get down a running bus. The patient was evaluated in the OPD, she had severe anterior knee pain, tenderness over medial patellofemoral joint, a positive apprehension test, no hyperlaxity. Her Q-angle was 18°. Radiographs showed lateral patellar tilt, bony fragment in the medial patellofemoral joint, lateral patellar subluxation, Insall-Salvatti Index-0.91, sulcus angle 133°. Magnetic resonance imaging (MRI) showed effusion of knee joint with tear in the MPFL at the patellar attachment, osteochondral defect in the lateral patellar facet and an osteochondral fragment in the medial patellofemoral joint. Of note, she had no other knee surgeries performed to the same knee. An arthroscopy showed chondromalacia of patella, patellofemoral joint maltracking and an osteochondral fracture of lateral facet of patella [].\nThe patient was treated definitively with MPFL reconstruction by the technique described by us. Her pain resolved in 3 weeks, she returned to her daily routine in 6 weeks after surgery and at 24-month followup, Modified Crosby and Insall scale was good and Kujala score was 88.
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).