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Non-surgical and Invasive Options for Patella Instability

We speak to Consultant Knee Trauma Surgeon, Chinmay Gupte about patella instability: the causes, the signs and the treatments


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PM: What is patella instability?
CG: The patella, ‘glides’ over the femur during knee bending and straightening. Problems occur when this motion is not in a straight line or is causing increased pressure on the patella, which can result in pain and a sensation of instability. There are many potential causes, meaning that determining the correct treatment can be a challenge.

PM: How can you determine between patella related pain or instability?
CG: Classically, a patient will complain of pain in the front of the knee or under the patella. Patients may experience pain during exercise, going up or down stairs, squatting and getting up from a kneeling position. They may also feel the sensation that the patella is unstable and in danger of dislocating.

PM: What are the causes of patella instability?
CG: This can arise from an acute traumatic injury, caused by a direct blow or abnormal twisting movement, or from a chronic problem. Underlying causes include: bone problems such as knock knees (increased “Q angle”) or abnormal patella or femoral trochlea architecture (patellofemoral dysplasia), or patella ligament injury (medial patellofemoral ligament {MPFL} injury). Another very important contributing cause is poor muscle strength and conditioning of the buttock and thigh muscles.

PM: How is a diagnosis of patella instability made?
CG: This is done with a combination of a detailed history and a thorough knee examination. Sometimes imaging of the joint, in the form of radiographs, MRI scans and occasionally CT scans, are also required.

CT Scan


PM: What treatment is offered to acute cases?
CG: Immediate management involves reduction of the patella, aspiration of the knee joint (if there is a large swelling) and the use of a brace for comfort and to restrict movement. The underlying cause of the dislocation is determined and treatment planned, ranging from bracing to specialist physiotherapy and operation.

PM: Which non-operative options are available?
CG: Bracing can prevent further dislocation of the patella, but this must be balanced with over stiffening the knee and weakening muscles, due to prolonged bracing. Physiotherapy consists of initial swelling and pain management, followed by gradual bending of the knee and buttock, and quadriceps muscle strengthening exercises. In chronic cases, patella taping has been shown to be beneficial.

PM: If the MPFL is injured, can this be treated operatively?
CG: Yes it can and there are several procedures that can be done. Using an arthroscope, the tighter structures on the lateral aspect of the patella can be partially released to allow the patella to lie more medially. Alternatively, if the MPFL is badly injured and beyond repair, this can be reconstructed using the patient’s own tendons. The orthopaedic surgeon makes a decision as to whether one procedure is best or if a combination of procedures is required, based on clinical assessment and scan data.

PM: What are the causes of non-traumatic or chronic patella instability?
CG: These are slightly more complex and depend on the surgeon performing a thorough examination and imaging studies. Causes can include, the patella lying too high or too low in front of the femur, a mismatch in the shape of the undersurface of the patella and the front of the femur, a mal-alignment of the patella (in relation to the pull of the tendons it lies in) or even arthritis within the patellofemoral joint.

PM: How can these cases be treated?
CG: Treatment depends very much on the diagnosis. If the patella is lying too high or low, or in a misaligned Retraining and building the muscle around the patella with the help of physiotherapy is a vital treatment option position in relation to the pull of the tendons, to the tibial tubercle (to which the patella tendon attaches) it can be transposed to a more desirable position usually medially. If the problem is due to arthritis within the joint or a mismatch between the bone geometry, then a type of patella replacement can be performed.

PM: Is surgery the only option for chronic problems?
CG: Retraining and building the muscle around the patella with the help of physiotherapy is a vital treatment option. Surgery is usually offered to those patients who fail to make a satisfactory recovery using non-operative methods. As it is complex surgery, this should be performed by orthopaedic knee surgeons who have an interest and expertise in doing these types of procedures. 

*Original interview conducted by Mr Philip Pastides, Orthopaedic Registrar.


Keywords

patella instability, Mr Chinmay Gupte, Orthoapedics, Knee, knee trauma, chronic, non-traumatic, non-operative, mal-alignment



Issue
Number:
18
Title:
Orthopaedics: Non-surgical and operative solutions
Published:
November 2014
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Mr Chinmay Gupte

Consultant Knee Trauma Surgeon

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