The patient was a 49-year-old Caucasian male with body mass index of 27 kg/m2. He complained about pain on his right knee in the last 8 months. The pain was gradually increased and still could be relieved by rest. He had the history of fixed lateral patellar dislocation since 25 years before. The dislocation happened after he got slipped and his right knee hit the floor with the body on top/kneeling. He came into the examination room with antalgic gait without any walking aid. He felt that his right knee was giving away while walking. There was no other trauma. There were no history of medical and surgical treatment, no family with the same symptom, and no routine sport activity.\nMuscle atrophy could be seen on the anterior compartment of the thigh, specifically on the lateral medial and intermedius muscle. We observed the atrophy of the thigh muscle from the anterior, lateral, and posterior view (). We found the patella was laterally dislocated. The knee range of motion was 0-120° in both passive and active movements. The patellar apprehension test was positive while the other special tests such as anterior and posterior drawer test, patellar tap test, joint line tenderness test, and Lachman test were all negative.\nOn the AP view of the radiographic imaging, we found neither varus nor valgus deformity of the knee and no sclerosis at the subchondral bone. However, whole mechanical axis radiology was not possible to be performed at the time of examination; therefore, we are lacking data such as femoral anteversion and Q angle. There was no sign of secondary osteoarthritis of the knee joint. From the lateral view, there was no sign of patella alta and patella baja, but on the skyline view, we could see that there was a lateral dislocation of the knee. The trochlear groove was relatively normal (). From the physical and X-ray examination, the patient was diagnosed as having chronically fixed lateral patella dislocation of the right knee.\nWe decided to perform extensive lateral release and right medial patellofemoral ligament reconstruction for this case. We performed incision on the lateral side of the knee joint until we reached the lateral capsule. We decided to release the lateral capsule and try to reduce the patella to be in the midline position. The patella was laterally fixed because of the tightened lateral vastus. We extended the incision and performed lateral release by cutting the fascia of the lateral vastus. After that, we tried again to reduce the patella but there was still resistance. We then cut the fascia of the medial vastus until the dislocated patella was fully released (). After we successfully reduced the patella, we performed semitendinosus tendon graft harvesting.\nA 3 cm oblique skin incision was made at the medial proximal tibial area, and the soft tissue was released. The semitendinosus tendon was harvested using a tendon stripper. We made a double-stranded graft by folding the semitendinosus tendon. The graft length was 160 mm, and the diameter of the ST tendon was 7 mm. After preparing the graft, 3 cm longitudinal skin incisions were made at the patellar and femoral natural footprints of the MPFL, and the soft tissue was peeled off so that the graft could pass through the soft tissue tunnel smoothly.\nA patellar tunnel was made at the one-third of the superior part of the patella from the medial side until it reached the lateral side. Subsequently, the graft was passed through the bone tunnel of the patella. After the endobutton (Smith & Nephew, Andover, MA) reached the lateral side, it was flipped to fixate the graft end.\nA femoral bone tunnel was constructed at the MPFL anatomical footprint, which is located at the Schottle point []. A 2.4 mm guide wire was inserted in the medial, ventral, and slightly proximal direction to avoid vessel and nerve injury. A 7 mm drill was used to create a bone tunnel. The depth of the bone tunnel was 80 mm until it reached the lateral cortex of the femur. We then sutured the graft end with ETHIBOND (Ethicon, Somerville, NJ) no. 2 and passed the graft through a medial side of the femur until the end of the tendon coming out from the lateral femoral side ().\nWe then drilled the lateral side of the distal femur and put a cancellous screw and washer with a diameter of 4.5 and a length of 65 mm just above the femoral tunnel. The end of the graft was sutured with ETHIBOND, and the ETHIBOND suture was then anchored to the cancellous screw and washer as the fixation of the patella to prevent it from redislocation ().\nThe soft tissue was then closed in layers. After that, we did confirmation X-ray to confirm the position of the inserted screw at the lateral side of the distal femur (). For the rehabilitation program, at first, the knee brace was applied to keep the knee in a full-extension position. The brace was used in this position up to three weeks; then, the knee flexion was increased to 20 degrees every week. After eight weeks postsurgery, the brace could be discharged and the patient could start active motion of the knee.
27 year old man who is a typist by profession presented with right anterior knee pain and frequent dislocations of the patella since four and a half months. To start with he fell down and twisted his knee while climbing down a staircase after which he had a patellar dislocation, the dislocation was self reduced with minimal knee manipulation. He later experienced 4 episodes of knee dislocations and consistent anterior knee pain. There was tenderness over medial patellofemoral joint, a positive apprehension test, no hyperlaxity and a Q angle of 12°. Radiographs showed lateral patellar tilt, lateral patellar subluxation, Insall-Salvatti Index-1, sulcus angle 142°. MRI showed effusion of knee joint with tear in the MPFL at the femoral attachment []. Of note, he had no other surgeries performed to the same knee. A preprocedure arthroscopy showed patellofemoral joint maltracking.\nThe patient was treated definitively with MPFL reconstruction by the technique described by us. He returned to work in 6 weeks, at 24-month follow up, Modified Crosby and Insall scale was excellent and Kujala score was 96.