Patellar dislocation: Difference between revisions

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'''Original Editors '''- [[User:Jeremy Luytens|Jeremy Luytens]]


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== Definition/Description  ==
== Definition/Description  ==
A patellar dislocation is a severe acute injury where there is a shift of the patella, where the patella will leave the patellofemoral groove.  
A patellar dislocation occurs by a lateral shift of the [[patella]], leaving the trochlea groove of the femoral condyle. This mostly occurs as a disruption of the medial patellofemoral ligament.<ref name=":4">Frobell R, Cooper R, Morris H, Arendt, H. Acute knee injuries. In: Brukner P, Bahr R, Blair S, Cook J, Crossley K, McConnell J, McCrory P, Noakes T, Khan K. Clinical Sports Medicine: 4th edition. Sydney: McGraw-Hill. p.626-683.</ref>
 
It is important to make a differentiation between acute primary patellar dislocation, which accounts for 2-3%, and habitual dislocation for recommendations with varying treatment approaches. Primary (first-time) patellar dislocation is defined as a clinical entity that usually causes a traumatic disruption of the previously uninjured medial peripatellar structures [14,15,16].<br>One of the common findings related to acute, primary, traumatic patellar dislocations is hemarthrosis (bleeding into joint spaces) of the knee, caused by rupture of the medial restraints of the patella. [13]
 
<br>  


[[Image:336px-Patellaluxation ap 002.jpg|patella dislocation]]
[[Image:336px-Patellaluxation ap 002.jpg|patella dislocation]]
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== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


<br>The patellofemoral joint is the portion of the knee joint between the patella and the femoral condyles. The patellofemoral articulation totally depends on the function of the quadriceps. It increases the angle of pull of the patellar tendon, improving the mechanical advantage of the quadriceps in knee extension.<ref name="p1">D.L. Egmond, R. Schuitemaker. De knieregio. In: A.J.F. Mink, H.J. ter Veer, J.A.C.Th. Vorselaars. Extremiteiten manuele therapie in enge en ruime zin. 1e uitgave. Houten. Bohn Stafleu Van Loghum bv. 2006. p. 559 – 628 Level of evidence: D</ref><ref name="p1"/>  
The [[Patellofemoral Joint|patellofemoral joint]] makes part of the [[Knee|knee joint]]. The articular surfaces consist of the [[patella]] and the trochlear surface of the femoral condyles. The articular cartilage on the medial facet is thicker than on the lateral facet, with the lateral facet bigger than the medial.<ref name="p2">Matthijs O, Van Paridon-Edauw D, Winkel D. Hoofdstuk 2 knie. Manuele therapie van de perifere gewrichten. 1e uitgave. Houten. Bohn Stafleu Van Loghum bv. 2004. pp.220–235.</ref> It has an anterior projection on the lateral femoral condyle, lateral to the patellar groove. This prevents lateral dislocation of the [[patella]]. <ref name="p2" /><ref name="p5">Bijl GVD (Jr), De Graaf CG, De Ridder PA. In: Actief en passief bewegen in de gewrichten der extremiteiten. De tijdsstroom, 1975. p.126.</ref> The [[Patellofemoral Joint|patellofemoral]] articulation depends on the function of the quadriceps as it increases the angle of pull of the patellar tendon, improving the mechanical advantage of the quadriceps in knee extension.<ref name="p1">Egmond DL, Schuitemaker R. De knieregio. In: Mink AJF, Rer Veer HJ, Vorselaars JACTh. Extremiteiten manuele therapie in enge en ruime zin. 1e uitgave. Houten. Bohn Stafleu Van Loghum bv, 2006. p.559–628.</ref>  
 
<br>The suspension and movement of the patella is provided by passive and active stabilizers:<ref name="p1" />
* Passive stabilizers: [[Tensor Fascia Lata|Tensor fascia lata]], patellar ligament, knee capsule, patellofemoral ligament (medial and lateral), menisco patellar ligament (medial and lateral)
* Active: Quadriceps, patellar ligament, retinaculum


The articular surfaces consist of the patella and the trochlear surface of the femoral condyles. The articular cartilage on the medial facet is thicker than on the lateral facet, with the lateral facet bigger than the medial.<ref name="p2">Omer Matthijs, Didi van Paridon-Edauw, Dos winkel. Hoofdstuk 2 knie. Manuele therapie van de perifere gewrichten. 1e uitgave. Houten. Bohn Stafleu Van Loghum bv. 2004. p. 220 – 235 Level of evidence: D</ref>  
The medial patellofemoral ligament is the primary stabiliser (53-67%) against lateral displacement/dislocation of the patella. It is situated deep to the vastus lateralis muscle, ranging from the posterior aspect of the medial femoral condyle to the superomedial part of the patella, vastus medialis and quadriceps tendon.<ref name=":4" /><br>


The femoral condyles only project slightly in front of the shaft of the femur but project quite a distance posteriorly. The anterior aspects of both condyles are included in the articular area of the patella. The patellar articular surface is larger on the lateral femoral condyle than on the medial. There is an anterior projection on the lateral femoral condyle lateral to the patellar groove. This is the bony factor, which prevents lateral dislocation of the patella. The trochlea is on the anterior, distal end of the femur. The groove is continuous posteriorly with the intercondylar notch of the femur. The lateral facet is more prominent and has a greater radius.<ref name="p5">G.VD. Bijl Jr., C.G. De Graaf, P.A. De Ridder. “hoofdstuk”. Actief en passief bewegen in de gewrichten der extremiteiten. De tijdsstroom. 1975. p. 126 Level of evidence: A1</ref><ref name="p2"/>
== Epidemiology/Etiology  ==


<br>The suspension and movement of the patella is provided by passive and active stabilizers. <br>• Passive: fascia lata, ligamentum patellae, capsule of the knee, ligamentum patellofemorale medial and lateral and ligamentum meniscopatellare medial and lateral <br>• Active: the four heads of the quadriceps, ligamentum patellae and the retinacullum<ref name="p1" /><br>  
=== Epidemiology ===
The incidence of acute primary patellar dislocations are 2-3%.<ref name=":0">Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C. [http://journals.sagepub.com/doi/abs/10.1177/03635465000280040601 Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury.] Am J Sports Med 2000;28:472–479.</ref><ref name=":1">Kirsch MD, Fitzgerald SW, Friedman H, Rogers LF. [https://www.ajronline.org/doi/abs/10.2214/ajr.161.1.8517287 Transient lateral patellar dislocation: diagnosis with MR imaging.] AJR Am J Roentgenol 1993;161:109–113.</ref> Patellar dislocations are often associated with athletes<ref>Ficat RP, Hungerford DS. Disorders of the patello-femoral joint. Williams & Wilkins, 1977.</ref><ref name=":2">Hughston JC, Walsh WM, Puddu G. Patellar subluxation and dislocation. WB Saunders Company, 1984.</ref>, and is most common in females in the second decade of life.<ref name="p4">Meeusen R. Praktijkgids knieletsels. Cursus. Vrije Universiteit Brussel, 2011.</ref> Redislocation rates after conservative management are estimated between 15 and 44%.<ref name=":4" />


== Epidemiology /Etiology<br> ==
=== Aetiology ===
Primary patellar dislocation is defined as  traumatic disruption of the previously uninjured medial peripatellar structures.<ref name=":0" /><ref name=":1" /> It often results from a non-contact injury to the knee.


Athletics are often associated with patellar dislocation ( Ficat ’77, Hugston ’84 ). It is most common in females in the second decade of life.<ref name="p4">R. meeusen. 2011. Praktijkgids knieletsels. Cursus. Vrije universiteit brussel. Level of evidence: 5</ref>  
Predisposing factors include both morphological and functional patellofemoral disorders:<ref name="p4" /><ref name="p3">Skinner HB, Barrack RL, Bedmar MS, Clarson GD. Sports medicine. In: Reinhardt S, Nogueira I, Boyle PJ. Current diagnosis en treatment in orthopedics. 2nd edition. McGraw-Hill: United States of America, 2000. p.125–175.</ref><ref name="p7">Beeton KS. The knee. Manual therapy masterclass: the peripheral joints. Churchill Livingstone. Elsevier, 2003. p.54–55.</ref>
* Ligament laxity (can lead to atraumatic dislocations)<ref name=":4" />
* Reduced osseous constraint form the lateral femoral condyle
* Imbalance between stronger lateral tissues (e.g. lateral retinaculum and [[Vastus Lateralis|vastus lateralis]]), which are able to overcome weaker medial structures, especially the medial patellofemoral ligament and the distal [[Vastus Medialis|vastus medialis]]
* Biomechanical issues such as femoral and tibial rotation, and pes planus
* [[Patella alta]]
* Genu recurvatum
* Increased [[Q Angle|Q Angle]]
* Patellar hypermobility


Patellar dislocation most often result results from a non-contact injury to the knee. But apart from the traumatic component, it is also important to refer to the presence of predisposing morphological and functional patellofemoral disorders. Dominant predisposing factors need less trauma for dislocations, and vice versa.&nbsp;It’s etiology is regarder as multi-factorial, being associated with: reduced osseous constraint form the lateral femoral condyle; an imbalance between stronger lateral tissues, such as the lateral retinacullum and vastus lateralis, which are able to overcome weaker medial structures, especially the medial patellofemoral ligament and the distal vastus medialis; and finally biomechanical issues such as femoral and tibial rotation, and pes planus.
=== Mechanism of Injury ===
* Non-contract:  Twisting of the leg, with internal rotation of the [[femur]] on a fixed [[Foot Anatomy|foot]] and [[tibia]]
** Often associated with valgus stress (strong lateral force then dislocates the patella)<ref name=":2" />


The typical mechanism of injury is a twist of the leg, with the femur rotating internally on a fixed foot and tibia. Valgus stress is often associated with this rotating mechanism, thereby creating a strong laterally directed force, dislocating the patella ( Hugston ’84 ). A direct blow as well to the lateral side of the knee, producing a valgus stress, as to the medial side of the knee producing a direct dislocating force can also create this injury ( Fu ’90 ).<ref name="p3">Harry B. SKinner, Robert L. Barrack, Michael S. Bedmar, George D. Clarson et al. Sports medicine. In: Shelley Reinhardt, Isabel Nogueira, Peter J. Boyle. Current diagnosis en treatment in orthopedics. 2e edition. United states of America. McGraw-Hill. 2000. p. 125 – 175 Level of evidence: A2</ref>  
* Traumatic:  A direct blow to the knee (lateral or medial)<ref name="p3" />


A knee tape with a lateral reinforcement will reduce the movement of the patella so that can be used as prevention.<ref name="p4"/>  
== Clinical Presentation  ==
One of the common findings related to acute, primary, traumatic patellar dislocations is hemarthrosis of the knee, caused by rupture of the medial restraints of the patella.<ref>Tsai CH, Hsu CJ, Hung CH, Hsu HC. [https://josr-online.biomedcentral.com/articles/10.1186/1749-799X-7-21 Primary traumatic patellar dislocation.] Journal of orthopaedic surgery and research 2012;7(1):21.</ref> Medial swelling will also be prominent.<ref name="p4" /> Patellar dislocations often reduce spontaneously when the knee is extended.<ref name=":4" />


The patient will experience pain, instability of the knee and blocking of the knee after the trauma. After de dislocation there will be a swelling on the medial side of knee because on this side a lot of tissue will be hit.<ref name="p4" /><br>
Main complaints from the patient will include:<ref name="p4" />
* Pain
* Instability of the knee  
* Locking of the knee after the trauma


== Differential Diagnosis  ==
== Differential Diagnosis  ==
 
* Osteochondral fractures
A radiography to exclude osteochondral fractures and avulsion fractures, patellar apprehension test is also needed, where the patella will provide resistance,[[Patella tracking assessment]] .<ref name="p4" /><ref name="p6" /><ref name="p7">Karen S. Beeton. The knee. Manual therapy masterclass: the peripheral joints. Churchill Livingstone. Elsevier. 2003. p. 54 – 55 Level of evidence: A2</ref>
* Avulsion fractures
 
* [[Patellar Fractures|Patellar fracture]]
Research shows knee-specific scales yielded higher reliability coefficients and stronger validity than did general health instruments in Assessing Acute Patellar Dislocation. The Fulkerson and Lysholm scales were the only instruments to differentiate between patients with and without recurrent subluxations/dislocations. [34]<br>MRI is necessary to examine if the tendon is partially torn, for a complete tear a lateral X-ray might be sufficient due luxation of the patella. [17]
* [[Patellar tendon tear]]
<ref name="p4" /><ref name="p7" />


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
 
* [[X-Rays|X-rays]];  To exclude associated fractures (osteochondral, avulsion); subluxation will be seen on a lateral view
A patellar dislocation can be diagnosed by using a MRI, conventional X-rays and computed tomography scans for measurement of the tuberositas tibiae-trochlea groove distance. [18]
* [[CT Scans|CT]]:  To measure tuberosity tibia-trochlea groove distance
* [[MRI Scans|MRI]]:  To differentiate degree of tear; to rule out osteochondral fractures
** Indicated in young patients with primary dislocations<ref name=":4" />
<ref name=":3">Hohlweck J, Quack V, Arbab D, Spreckelsen C, Tingart M, Lüring C, Rath B. [https://europepmc.org/abstract/med/23963985 Diagnostic and therapeutic management of primary and recurrent patellar dislocations-analysis of a nationwide survey and the current literature.] Zeitschrift für Orthopädie und Unfallchirurgie 201;151(4):380-8.</ref>


== Outcome Measures  ==
== Outcome Measures  ==
* Fulkerson functional scale
* Lysholm knee scale
* [https://www.physio-pedia.com/Knee_Injury_and_Osteoarthritis_Outcome_Score Knee injury and osteoarthritis outcome score]
* [https://www.physio-pedia.com/Knee_outcome_survey Knee outcome survey]
* [https://www.physio-pedia.com/Lower_Extremity_Functional_Scale_%28LEFS%29 Lower extremity function scale]
* [https://www.physio-pedia.com/McGill_Pain_Questionnaire McGill pain questionnaire]
<ref>Paxton EW, Fithian DC, Lou Stone M, Silva P. [http://journals.sagepub.com/doi/abs/10.1177/03635465030310040201 The reliability and validity of knee-specific and general health instruments in assessing acute patellar dislocation outcomes.] The American journal of sports medicine 2003;31(4):487-92.</ref>


An increase in the Q-angle could lead to lateral patellar dislocation or increased lateral patellofemoral contact pressures. A Q-angle decrease may not shift the patella medially, but could increase the medial tibiofemoral contact pressure by increasing the varus orientation. (35)
== Physical Examination  ==
 
* History:<ref name=":4" />
<br>It is measured by drawing a line from the anterosuperior iliac spine to the centre of the patella, and a second line from the centre of the tibial tubercle to the centre of the patella. The angle where these lines intersect is regarded as the Q-angle. Traditionally, the Q-angle has been measured with subjects in supine, knee extended and with the quadriceps muscle relaxed. This is regarded as the ‘traditional’ or ‘conventional’ method of assessing Q-angle. (36)
** Instability (giving way) of the knee after jumping/twisting with severe onset of pain
 
** Feeling of moving/popping out
<br>In women, the Q angle should be less than 22 degrees. In men, the Q angle should be less than 18 degree. A typical Q angle is 12 degrees for men and 17 degrees for women. (37)
** Immediate swelling
 
* Observation:
== Examination  ==
** [[Patella alta]]
 
** Genu recurvatum
This is recommended to determine whether there are predisposing factors for dislocation, such as [[Patella alta]], genu recurvatum, increased [['Q' Angle]] and patellar hypermobility<ref name="p3" /><ref name="p4" /><ref name="p7" /><br>  
* Measure [[Q Angle|Q Angle]]
 
* Special tests:<ref name="p4" /><ref name="p7" />
== Medical Management <br>  ==
** Patella apprehension test
 
** Patella tracking assessment
Immediately after the trauma there is an immobilization in a cylinder cast for 6 weeks and medication, supplements like glucosamine and NSAID’s that could be used to keep the knee strong. If required arthroscopy with or without retinacular repair, surgical repair of the torn retinacullum or immediate patellar realignment.<ref name="p3" /><ref name="p6" /><ref name="p8">Pierre-paul Castelyn. “hoofdstuk”. Acute knee injuries, diagnostic and treatment managment proposals. Vub University press. 2001. p. 42-43 Level of evidence: A1</ref><br>
** Patellar hypermobility
 
Acute primary dislocations can be managed conservatively by immobilisation with a removable knee brace, posterior splint, a cylinder cast or by surgical treatment. [30]
 
A posterior splint might be the best therapeutic option because of the low redislocation rates and knee joint restrictions. However, this recommendation is based on only one small study with significant limitations. Further investigation with modern braces and standardisation of immobilisation time is needed to find the most appropriate conservative treatment for patellar luxation.
 
<br>Contemporary treatment regimens range from immediate mobilization without a brace to cast immobilization in extension for 6 weeks. In a patient who finds 6 weeks of immobilization unacceptable, a 3-week&nbsp;period of immobilization may be performed with the understanding that a higher redislocation rate may result. A 3-fold higher risk of redislocation was reported in those treated with immediate mobilization. [40]
 
== Physical Therapy Management <br>  ==
 
An important thing is the important task of the physiotherapist: Prevention. The physiotherapist has to increase the functions after an injury, but also has to prevent re-dislocation (in this way).
 
Conservative treatment have included:<ref name="p3" /><ref name="p4" /><ref name="p0">Smith TO., Davies L., Chester R., Clark A., Donell ST. CLinical outcomes of rehabilitation for patients following lateral patellar dislocation: a systematic review. Phystiotherapy. Volume 96. Issue 4. December 2010. p. 269 – 281 Level of evidence: 2a</ref><br>•&nbsp;[[Manual Therapy: Knee]] and [[Knee Mobilizations]] to improve the ROM of the knee <br>• [[Combination Therapy]]<br>• Strengthening exercises for quadriceps, hamstrings, adductors, muscles of the hip and lower abdomen. Important, is the use of closed kinetic chain exercises because of a greater number of advantages over the other forms of exercise.<br>• Stretching and flexibility training for hamstrings and quadriceps <br>• Proprioceptive exercises to improve the stability of the knee
 
Distal vastus medialis (VM) muscle strengthening doesn’t significantly improve functional outcomes compared to general quadriceps muscle strengthening following first-time patellar dislocation. [44] 
 
Bracing and re-education can play an important role in the treatment and prevention of patellar dislocation.<ref name="p9" />
 
Reassurance and behavioural modification is also commonly applied as preperation for exercises in therapy and thus to prevent redislocation of the patella. [45]<br>
 
Other than preferences for nonoperative treatment of primary patellar dislocations have been shown in previous studies [20,21,22], patients with habitual dislocations and patellofemoral symptoms seem to be benefited from reconstructive surgery [23,24]. High-level evidence supports nonoperative treatment for first-time lateral acute patellar dislocations. Surgical intervention is often indicated for recurrent dislocations [43]. However, according to studies [46], surgical treatment is associated with a higher risk of patellofemoral joint osteoarthritis. Therefore, it is of major importance to formulate one's management strategy patient oriented and to inform patients of the advantages and disadvantages of each management strategy when deciding.
 
<u>Non-operative treatment:</u>
 
Conservative treatment is still the most common treatment after primary dislocation of the patella. [25]<br>There is no statistically significant difference (p=0.091) between operatively and conservatively treated groups with regard to functional results. The same statistical outcome emerged when comparing incidences of re-dislocation (p=0.854), or other major patellar instabilities (p=0.856), between the groups. [26].<br>The results obtained should not promote a non-operative method on the basis of lower risk, but do support an individual approach based on precise diagnosis and defined criteria. [26].


Thus it appears that surgical and nonsurgical management of patellar dislocation tends to yield similar results in the skeletally mature and adolescents. Individual characteristics and goals should be taken into consideration when choosing an acute patellar dislocation treatment approach. Unless future studies show a more definitive benefit for surgical management, exercise and bracing should be considered initially. Exercise and bracing are less invasive and likely to be less expensive than surgery. [41]
== Medical Management    ==


Surgeon experience as well as individual patient values and preferences should primarily guide management. [42]
=== Conservative Management ===
Indication:
* Primary patellar dislocation<ref>Nikku R, Nietosvaara Y, Aalto K, Kallio PE. [https://www.tandfonline.com/doi/full/10.1080/17453670510041790 Operative treatment of primary patellar dislocation does not improve medium-term outcome: a 7-year follow-up report and risk analysis of 127 randomized patients.] Acta orthopaedica 2005;76(5):699-704.</ref><ref>Arendt EA, Fithian DC, Cohen E. [http://adrianokarpstein.lib.med.br/index.pl/CURRENT+CONCEPTS+OF+LATERAL+PATELLA+DISLOCATION+11914.pdf Current concepts of lateral patella dislocation.] Clinics in sports medicine 2002;21(3):499-519.</ref><ref>Buchner M, Baudendistel B, Sabo D, Schmitt H. [https://journals.lww.com/cjsportsmed/Abstract/2005/03000/Acute_Traumatic_Primary_Patellar_Dislocation_.5.aspx Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment.] Clinical Journal of Sport Medicine 2005;15(2):62-6.</ref>


Studies have shown taping resulted in a significantly better Lysholm score at 6 and 12 weeks post-dislocation (P=0.05), and also after 5-year follow-up (P=0.01). Knee function was better at 1-year follow-up. There were no cases of recurrent dislocation. [27]. 1B
In cases where the patella was not relocated spontaneously, it can be done under regional anaesthesia.<ref name=":4" /> Conservative management after reduction include:
* Immobilization for 6 weeks (cylinder cast/back slab/knee range of motion brace)<ref>Van Gemert JP, de Vree LM, Hessels RA, Gaakeer MI. [https://link.springer.com/article/10.1186/1865-1380-5-45 Patellar dislocation: cylinder cast, splint or brace? An evidence-based review of the literature.] International journal of emergency medicine 2012;5(1):45.</ref>
* Medication:
** Supplements like glucosamine and
** NSAID’s
Conservative treatment is the most common treatment after primary patellar dislocation.<ref name=":3" /><br>


Tape bandage immobilization seems superior to a cylinder cast even after 5 years. [27].
=== Surgical Management ===
Surgical management is done arthroscopically, with or without surgical repair of the torn retinaculum or immediate patellar realignment <ref name="p3" /><ref name="p8">Castelyn P. Acute knee injuries, diagnostic and treatment managment proposals. Vub University press, 2001. p.42-43.</ref>


<br><u>Surgical treatment:</u>
Indications:<ref>Fithian DC, Paxton EW, Cohen AB. [https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0030-1247149.pdf Indications in the treatment of patellar instability.] The journal of knee surgery 2004;17(01):47-56.</ref><ref>Koskinen SK, Rantanen JP, Nelimarkka OI, Kujala UM. [https://europepmc.org/abstract/med/9728716 Effect of Elmslie-Trillat and Roux-Goldthwait procedures on patellofemoral relationships and symptoms in patients with patellar dislocations]. The American journal of knee surgery 1998;11(3):167-73.</ref><ref>Stefancin JJ, Parker RD. [https://pdfs.semanticscholar.org/9d10/fa645beb96e99b4e5cfe57c6cd897750ad8f.pdf First-time traumatic patellar dislocation: a systematic review.] Clinical Orthopaedics and Related Research 2007;455:93-101.</ref>
* Recurrent/chronic dislocation<ref>Weber AE, Nathani A, Dines JS, Allen AA, Shubin-Stein BE, Arendt EA, Bedi A. [https://drbethshubinstein.com/wp-content/uploads/2016/11/An-Algorithmic-Approach-to-theManagement-of-Recurrent-Lateral-Patellar-Dislocation.pdf An algorithmic approach to the management of recurrent lateral patellar dislocation.] JBJS 2016;98(5):417-27.</ref>
* Patellofemoral symptoms
* Associated osteochondral fracture or major chondral injury
* Substantial disruption of the medial patellofemoral ligament)- vastus medialis obliquus-adductor mechanism
* Laterally subluxated patella on the plain Mercer-Merchant view with normal alignment on the contralateral knee
* Failed conservative management


Surgical intervention for first-time traumatic patellar dislocation is indicated in the following situations: <br>1) evidence on imaging or clinical examination of osteochondral fracture or major chondral injury; <br>2) palpable or MRI findings of substantial disruption of the MPFL (medial patellofemoral ligament)-VMO (vastus medialis obliquus)-adductor mechanism; <br>3) a patella laterally subluxated on the plain Mercer-Merchant view with normal alignment on the contralateral knee; <br>4) a patient fails to improve with nonoperative management especially in the presence of one or more predisposing factors to patellar dislocation; <br>5) subsequent redislocation [28]. Surgical stabilization significantly reduced the redislocation rate of primary traumatic patellar dislocation in a young adult population than those without surgical treatment, which was addressed in a prospective, randomized, controlled study [29].
Surgical stabilization significantly reduces the redislocation rate of primary traumatic patellar dislocation in the young adult population<ref>Sillanpää PJ, Mattila VM, Mäenpää H, Kiuru M, Visuri T, Pihlajamäki H. [https://www.grupodojoelho.com.br/img/uploads/revistas/1465312701-PF%20COM%20E%20SEM%20RECONSTRUCAO.pdf Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation: a prospective randomized study]. JBJS 2009;91(2):263-73.</ref>, but is associated with a higher risk of [[Patellofemoral Joint|patellofemoral joint]] [[osteoarthritis]].<ref>Smith TO, Song F, Donell ST, Hing CB. [https://www.researchgate.net/profile/Simon_Donell/publication/49755021_Operative_versus_non-operative_management_of_patellar_dislocation_A_meta-analysis/links/569ce84108ae8f8ddc708d5f/Operative-versus-non-operative-management-of-patellar-dislocation-A-meta-analysis.pdf Operative versus non-operative management of patellar dislocation. A meta-analysis]. Knee Surgery, Sports Traumatology, Arthroscopy 2011;19(6):988-98.</ref> Initial post-operative management consists of pain management, physiotherapy and [[cryotherapy]] .


<br>For surgical treatment, There are several surgical options that may be used to prevent patellar dislocation and subluxation. These procedures may be used alone or in a combination: <br>- Lateral release <br>- Medial patellofemoral ligament (MPFL) reconstruction / proximal realignment <br>- Distal realignment / anteromedialization (AMZ)  
==== Types of Surgery ====
* '''Lateral release''':  Release of tight lateral retinaculum to allow more medial tracking of the patella.  
** Indication: Mild patellar instability
* '''Medial patellofemoral ligament reconstruction / proximal realignment'''
** Balance the patellar tracking to more natural (medial) alignment
** Often done with a lateral release
** Indication:  Severe patellar instability
* '''Distal realignment / anteromedialisation'''
** Transferring of the tibial tubercle (where the patellar tendon attaches to the tibia). The bony attachment of the tendon is moved more medially to allow the patella to track normally 
** Used in conjunction with the lateral release and/or the medial patellofemoral ligament reconstruction.
** Indication:  Severe patellar instability
== Physiotherapy Management    ==
Goals:
* Improve function
* Prevent further dislocation:
** Taping:  Lateral reinforcement will reduce the movement of the patella (to prevent dislocation)<ref name="p4" />


<u>Lateral release</u>
Physiotherapy modalities include:<ref name="p4" /><ref name="p3" /><ref name="p0">Smith TO, Davies ., Chester R, Clark A, Donell ST. [https://www.sciencedirect.com/science/article/abs/pii/S0031940610000349 Clinical outcomes of rehabilitation for patients following lateral patellar dislocation: a systematic review.] Physiotherapy, 2010;96(4):269-81.</ref>
* Prevention of re-dislocation:
** Taping:  Lateral reinforcement will reduce the movement of the patella (to prevent dislocation)<ref name="p4" />
** Bracing
** Reassurance and behavioural modification<ref>Smith TO, Chester R, Clark A, Donell ST, Stephenson R. [https://s3.amazonaws.com/academia.edu.documents/40626632/A_national_survey_of_the_physiotherapy_m20151204-14943-105osyp.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1540789953&Signature=yNKlcm6EjIcfSBpbrZBCi2b6Jqs%3D&response-content-disposition=inline A national survey of the physiotherapy management of patients following first-time patellar dislocation.] Physiotherapy, 2011;97(4):327-38.</ref>  
* Improve range of motion:
** [[Manual Therapy: Knee|Manual therapy knee]] 
** [[Knee Mobilisations|Knee mobilisations]]


Release of tight lateral retinaculum (soft tissue) to allow patella to track more medially. This procedure is sometimes performed alone on patients with mild instability of the patella.
* [[Combination Therapy|Combination therapy]]
 
* Strengthening exercises:
<u>Medial patellofemoral ligament (MPFL) reconstruction</u>
** [[Quadriceps Muscle|Quadriceps]]<ref>Smith TO, Chester R, Cross J, Hunt N, Clark A, Donell ST. [https://www.sciencedirect.com/science/article/pii/S0968016015000654 Rehabilitation following first-time patellar dislocation: a randomised controlled trial of purported vastus medialis obliquus muscle versus general quadriceps strengthening exercises.] The Knee,2015;22(4):313-20.</ref>, [[hamstrings]], adductors, hip and lower abdomen and core muscles.
 
** [[Closed Chain Exercise|Closed kinetic chain exercises]] are recommended
A tightening of the MPFL or a reconstruction of this ligament can be used to balance the tracking of the patella to more natural (medial) alignment. This procedure is performed in patients with more severe patellar instability. A lateral release often is performed in conjunction with this procedure. (38)<br>After research 93% had good/exellent results using the Fulkerson’s functional knee score: Radiographic evaluation showed significant improvements in the congruence angle by an average of 20° (P= .0006), and in the lateral patellofemoral angle by an average of 10° (P&nbsp;= .0003). [32]
* [[Stretching]]:
 
** Improve flexibility of hamstrings and quadriceps
Conclusion: initial acute patellofemoral dislocations should be treated with immobilization and rehabilitation, as a majority of patients will do well without surgery. MRI is necessary to assess for osteochondral lesions, because they are associated with a poor prognosis if they are not addressed.
* [[Proprioception]]: Improve stability of the knee
 
* Weight bearing is usually started early in the case of patella dislocation or a fracture as the weight bearing line don't cross the patella.
Distal realignment / anteromedialization (AMZ)
== Resources   ==
 
This realignment procedure involves transferring the tibial tubercle (where the patellar tendon attaches to the tibia). The bony attachment of the tendon is moved more medially to allow the patella to track normally. This procedure is performed on patients with severe patellar instability and is used in conjunction with the lateral release and/or the MPFL reconstruction.
 
Following the operation you will be taken to the recovery room for observation. Once the effects of the anesthesia have worn off and your pain is under control you will be released. Initial treatment after surgery consists of pain management, physical therapy and cryotherapy (ice). (38)
 
== Key Research  ==
 
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
 
== Resources <br>  ==


{{#ev:youtube|TVTmz0zAsqA}}  
{{#ev:youtube|TVTmz0zAsqA}}  


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==
Primary acute patellofemoral dislocations should be managed conservatively with immobilization and rehabilitation, as the majority of these patients will do well without surgery. A MRI is necessary to assess for osteochondral lesions, as they are associated with a poor prognosis if not addressed. Surgical management would be considered in cases with recurrent dislocations, or when it is associated with patellofemoral symptoms.


add text here <br>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1FYSEY2m9I74sASm9QIBDuo</rss>
</div>
== References  ==
== References  ==


<references />  
<references />
 
13) Journal of otrhopaedic surgery and research.Primary traumatic patellar dislocation. Chun-Hao Tsai. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3511801 <br>14) Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med. 2000;28:472–479. [PubMed]<br>15) Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med. 2000;28:472–479. [PubMed]<br>16) Kirsch MD, Fitzgerald SW, Friedman H, Rogers LF. Transient lateral patellar dislocation: diagnosis with MR imaging. AJR Am J Roentgenol. 1993;161:109–113. [PubMed]<br>17) http://www.physio-pedia.com/Quadriceps_tendon_tear/Differential diagnosis<br>18) Hohlweck J., Diagnostic and therapeutic management of primary and recurrent patellar dislocations - analysis of a nationwide survey and the current literature. Zeitschrift für Orthopädie und Unfallchirurgie. 2013 Aug;151(4):380-8. [Pubmed]<br>19) Picture from: www.slideshare.net/bhavinj/mri-of-patellar-disorders (Bhavin Jankharia, Doctor at Jankharia Imaging, Mumbai, India)<br>20) Nikku R, Nietosvaara Y, Aalto K, Kallio PE. Operative treatment of primary patellar dislocation does not improve medium-term outcome: A 7-year follow-up report and risk analysis of 127 randomized patients. Acta Orthop. 2005;76:699–704. doi: 10.1080/17453670510041790. [PubMed] [Cross Ref] (level of evidence 1B)<br>21) Arendt EA, Fithian DC, Cohen E. Current concepts of lateral patella dislocation. Clin Sports Med. 2002;21:499–519. doi: 10.1016/S0278-5919(02)00031-5. [PubMed] [Cross Ref] (level of evidence 2C)<br>22) Buchner M, Baudendistel B, Sabo D, Schmitt H. Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment. Clin J Sport Med. 2005;15:62–66. doi: 10.1097/01.jsm.0000157315.10756.14. [PubMed] [Cross Ref] <br>(level of evidence 2B)<br>23) Fithian DC, Paxton EW, Cohen AB. Indications in the treatment of patellar instability. J Knee Surg. 2004;17:47–56. [PubMed] (level of evidence 2C)<br>24) Koskinen SK, Rantanen JP, Nelimarkka OI, Kujala UM. Effect of Elmslie-Trillat and Roux-Goldthwait procedures on patellofemoral relationships and symptoms in patients with patellar dislocations. Am J Knee Surg. 1998;11:167–173. [PubMed] (level of evidence 1C)<br>25) Hohlweck J., Diagnostic and therapeutic management of primary and recurrent patellar dislocations - analysis of a nationwide survey and the current literature. Zeitschrift für Orthopädie und Unfallchirurgie. 2013 Aug;151(4):380-8. [Pubmed] (level of evidence 4)<br>26) Apostolovic M., Vukomanovic B., Slavkovic N., Vuckovic V., Vukcevic M., Djuricic G., and Kocev N., Acute patellar dislocation in adolescents: operative versus nonoperative treatment. Int Orthop. 2011 Oct [PubMed] (level of evidence 2B)<br>27) Akkie Rood, Harm Boons, Joris Ploegmakers, William van der Stappen, Sander Koëter; Tape versus cast for non-operative treatment of primary patellar dislocation: a randomized controlled trial; Archives of Orthopaedic and Trauma Surgery; 2012 [PubMed] (level of evidence 1B)<br>28) Stefancin JJ, Parker RD. First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat Res. 2007;455:93–101. [PubMed] <br>(level of evidence 3A)<br>29) Sillanpaa PJ, Mattila VM, Maenpaa H, Kiuru M, Visuri T, Pihlajamaki H. Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. A prospective randomized study. J Bone Joint Surg Am. 2009;91:263–273. doi: 10.2106/JBJS.G.01449. [PubMed] [Cross Ref] (level of evidence 1B)<br>30) van Gemert et al.. Patellar dislocation: cylinder cast, splint or brace? An evidence-based review of the literature. International Journal of Emergency Medicine 2012 5.45<br>31) White BJ et al. Patellofemoral instability: bulletin of the NYU Hospital for Joint Diseases 2009; 67<br>32) David&nbsp;Drez, T.Bradley&nbsp;Edwards; Claude S.&nbsp;Williams: Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation ; March 2001; Arthroscopy: The Journal of Arthroscopic and Related Surgery (level of evidence 4)<br>33) Peter R.Miller, Roger M.Klein. Robert A. Teitge : Medial dislocation of the patella; August 1991,&nbsp;Volume 20; Issue 6;&nbsp;pp 429-431 <br>34) Elizabeth W. Paxton,&nbsp;Donald C. Fithian,&nbsp;Mary Lou Stone and&nbsp;Patricia Silva: The Reliability and Validity of Knee-Specific and General Health Instruments in Assessing Acute Patellar Dislocation Outcomes; July 2003<br>35) Mizuno, Y., Kumagai, M., Mattessich, S. M., Elias, J. J., Ramrattan, N., Cosgarea, A. J. and Chao, E. Y. S. (2001), Q-angle influences tibiofemoral and patellofemoral kinematics. J. Orthop. Res., 19:&nbsp;834–840. doi:&nbsp;10.1016/S0736-0266(01)00008-0 <br>36) Smith TO, The reliability and validity of the Q-angle: a systematic review , Knee Surg Sports Traumatol Arthrosc. 2008 Dec;16(12):1068-79. doi: 10.1007/s00167-008-0643-6. Epub 2008 Oct 8. <br>37) Emami MJ, Q-angle: an invaluable parameter for evaluation of anterior knee pain, Arch Iran Med. 2007 Jan;10(1):24-6. <br>38) http://ukhealthcare.uky.edu/uploadedFiles/UKHC-SportsMed-Medial-Patellofemoral-Lig-Recon.pdf<br>39) Chris S et al; Femoral Neuropathy due to patellar dislocation in a theatical and jazz dancer: a case report; Arch Phys Med Rehabil Vol 86, June 2005.<br>40 Neel P. Jain, MD, Najeeb Khan, MD, and Donald C. Fithian, MD; A Treatment Algorithm for Primary Patellar Dislocations ; Sports Health.&nbsp;2011 March
 
41) Fuller J., Hammil H., Prochinske K., Druall C., “Operative vs. Nonoperative Treatment after Acute Patellar Dislocation: Which is more Effective at Reducing Recurrence in Adolescents?”. Journal of Sport Rehabilitation, © 2017 Human Kinetics, Inc. [PubMed] (level of evidence 3A)
 
42) Khan M. and Miller B., Cochrane in CORR®: Surgical Versus Non-surgical Interventions for Treating Patellar Dislocation (Review). Clin Orthop Relat Res. 2016 Nov [Pubmed] (level of evidence 1A)<br>43) Weber A.E., Nathani A., Dines J.S., Allen A.A., Shuyin-Stein B.E., Arendt E.A., Bedi A., "An algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation." (review). J Bone Joint Surg Am. 2016 Mar [Pubmed] (level of evidence 1A)
 
44) Smith T., Cheste R., Cross J., Hunt N., Clark a., Donnel S., Rehabilitation following first-time patellar dislocation: a randomised controlled trial of purported vastus medialis obliquus muscle versus general quadriceps strengthening exercises. 2015 Elsevier. [Pubmed] (level of evidence 1B)
 
45) SMITH (Toby O.), CHESTER (Rachel), CLARK (Allan), DONELL (Simon T.), STEPHENSON (Richard). A national survey of the physiotherapy management of patients following first-time patellar dislocation, in ''Physiotherapy'', 2011, vol. 97, nr. 4, p. 327–338. [Online] http://www.sciencedirect.com.myezproxy.vub.ac.be/science/article/pii/S0031940611000265?via%3Dihub (Level of evidence: 2b)
 
46) SMITH (Toby O.), SONG (Fujian), DONELL (Simon T.), HING (Caroline B.). Operative versus non-operative management of patellar dislocation. A meta-analysis, in ''Knee Surgery, Sports Tramatology, Arthroscopy'', 2011, vol. 19, nr. 6, p. 988-998. [Online] https://link-springer-com.myezproxy.vub.ac.be/article/10.1007%2Fs00167-010-1355-2 (Level of evidence: 3a)


[[Category:Injury]] [[Category:Knee_Injuries]] [[Category:Knee]] [[Category:Bones]] [[Category:Sports_Injuries]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Injury]]  
[[Category:Knee_Injuries]]  
[[Category:Knee]]  
[[Category:Bones]]  
[[Category:Sports_Injuries]]  
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]  
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Primary Contact]]
[[Category:Sports Medicine]]
[[Category:Acute Care]]
[[Category:Conditions]]
[[Category:Bone - Conditions]]
[[Category:Paediatrics]]
[[Category:Paediatrics - Conditions]]
[[Category:Paediatrics - Conditions]]
[[Category:Knee - Conditions]]

Latest revision as of 18:27, 9 January 2024

Original Editors - Jeremy Luytens

Top Contributors - Jeremy Luytens, Kim Jackson, Leana Louw, Laura Verhasselt, Ruben Vellemans, Zefyrin Hoornaert, Admin, Evan Thomas, WikiSysop, Anneleen Blok, Nupur Smit Shah, Oyemi Sillo, Daphne Jackson, 127.0.0.1, Wanda van Niekerk, Rachael Lowe, Matt Huey, Sehriban Ozmen, Naomi O'Reilly, Karen Wilson and Claire Knott

Definition/Description[edit | edit source]

A patellar dislocation occurs by a lateral shift of the patella, leaving the trochlea groove of the femoral condyle. This mostly occurs as a disruption of the medial patellofemoral ligament.[1]

patella dislocation

Clinically Relevant Anatomy[edit | edit source]

The patellofemoral joint makes part of the knee joint. The articular surfaces consist of the patella and the trochlear surface of the femoral condyles. The articular cartilage on the medial facet is thicker than on the lateral facet, with the lateral facet bigger than the medial.[2] It has an anterior projection on the lateral femoral condyle, lateral to the patellar groove. This prevents lateral dislocation of the patella. [2][3] The patellofemoral articulation depends on the function of the quadriceps as it increases the angle of pull of the patellar tendon, improving the mechanical advantage of the quadriceps in knee extension.[4]


The suspension and movement of the patella is provided by passive and active stabilizers:[4]

  • Passive stabilizers: Tensor fascia lata, patellar ligament, knee capsule, patellofemoral ligament (medial and lateral), menisco patellar ligament (medial and lateral)
  • Active: Quadriceps, patellar ligament, retinaculum

The medial patellofemoral ligament is the primary stabiliser (53-67%) against lateral displacement/dislocation of the patella. It is situated deep to the vastus lateralis muscle, ranging from the posterior aspect of the medial femoral condyle to the superomedial part of the patella, vastus medialis and quadriceps tendon.[1]

Epidemiology/Etiology[edit | edit source]

Epidemiology[edit | edit source]

The incidence of acute primary patellar dislocations are 2-3%.[5][6] Patellar dislocations are often associated with athletes[7][8], and is most common in females in the second decade of life.[9] Redislocation rates after conservative management are estimated between 15 and 44%.[1]

Aetiology[edit | edit source]

Primary patellar dislocation is defined as traumatic disruption of the previously uninjured medial peripatellar structures.[5][6] It often results from a non-contact injury to the knee.

Predisposing factors include both morphological and functional patellofemoral disorders:[9][10][11]

  • Ligament laxity (can lead to atraumatic dislocations)[1]
  • Reduced osseous constraint form the lateral femoral condyle
  • Imbalance between stronger lateral tissues (e.g. lateral retinaculum and vastus lateralis), which are able to overcome weaker medial structures, especially the medial patellofemoral ligament and the distal vastus medialis
  • Biomechanical issues such as femoral and tibial rotation, and pes planus
  • Patella alta
  • Genu recurvatum
  • Increased Q Angle
  • Patellar hypermobility

Mechanism of Injury[edit | edit source]

  • Non-contract: Twisting of the leg, with internal rotation of the femur on a fixed foot and tibia
    • Often associated with valgus stress (strong lateral force then dislocates the patella)[8]
  • Traumatic: A direct blow to the knee (lateral or medial)[10]

Clinical Presentation[edit | edit source]

One of the common findings related to acute, primary, traumatic patellar dislocations is hemarthrosis of the knee, caused by rupture of the medial restraints of the patella.[12] Medial swelling will also be prominent.[9] Patellar dislocations often reduce spontaneously when the knee is extended.[1]

Main complaints from the patient will include:[9]

  • Pain
  • Instability of the knee
  • Locking of the knee after the trauma

Differential Diagnosis[edit | edit source]

[9][11]

Diagnostic Procedures[edit | edit source]

  • X-rays; To exclude associated fractures (osteochondral, avulsion); subluxation will be seen on a lateral view
  • CT: To measure tuberosity tibia-trochlea groove distance
  • MRI: To differentiate degree of tear; to rule out osteochondral fractures
    • Indicated in young patients with primary dislocations[1]

[13]

Outcome Measures[edit | edit source]

[14]

Physical Examination[edit | edit source]

  • History:[1]
    • Instability (giving way) of the knee after jumping/twisting with severe onset of pain
    • Feeling of moving/popping out
    • Immediate swelling
  • Observation:
  • Measure Q Angle
  • Special tests:[9][11]
    • Patella apprehension test
    • Patella tracking assessment
    • Patellar hypermobility

Medical Management[edit | edit source]

Conservative Management[edit | edit source]

Indication:

In cases where the patella was not relocated spontaneously, it can be done under regional anaesthesia.[1] Conservative management after reduction include:

  • Immobilization for 6 weeks (cylinder cast/back slab/knee range of motion brace)[18]
  • Medication:
    • Supplements like glucosamine and
    • NSAID’s

Conservative treatment is the most common treatment after primary patellar dislocation.[13]

Surgical Management[edit | edit source]

Surgical management is done arthroscopically, with or without surgical repair of the torn retinaculum or immediate patellar realignment [10][19]

Indications:[20][21][22]

  • Recurrent/chronic dislocation[23]
  • Patellofemoral symptoms
  • Associated osteochondral fracture or major chondral injury
  • Substantial disruption of the medial patellofemoral ligament)- vastus medialis obliquus-adductor mechanism
  • Laterally subluxated patella on the plain Mercer-Merchant view with normal alignment on the contralateral knee
  • Failed conservative management

Surgical stabilization significantly reduces the redislocation rate of primary traumatic patellar dislocation in the young adult population[24], but is associated with a higher risk of patellofemoral joint osteoarthritis.[25] Initial post-operative management consists of pain management, physiotherapy and cryotherapy .

Types of Surgery[edit | edit source]

  • Lateral release: Release of tight lateral retinaculum to allow more medial tracking of the patella.
    • Indication: Mild patellar instability
  • Medial patellofemoral ligament reconstruction / proximal realignment
    • Balance the patellar tracking to more natural (medial) alignment
    • Often done with a lateral release
    • Indication: Severe patellar instability
  • Distal realignment / anteromedialisation
    • Transferring of the tibial tubercle (where the patellar tendon attaches to the tibia). The bony attachment of the tendon is moved more medially to allow the patella to track normally
    • Used in conjunction with the lateral release and/or the medial patellofemoral ligament reconstruction.
    • Indication: Severe patellar instability

Physiotherapy Management[edit | edit source]

Goals:

  • Improve function
  • Prevent further dislocation:
    • Taping: Lateral reinforcement will reduce the movement of the patella (to prevent dislocation)[9]

Physiotherapy modalities include:[9][10][26]

  • Prevention of re-dislocation:
    • Taping: Lateral reinforcement will reduce the movement of the patella (to prevent dislocation)[9]
    • Bracing
    • Reassurance and behavioural modification[27]
  • Improve range of motion:

Resources[edit | edit source]

Clinical Bottom Line[edit | edit source]

Primary acute patellofemoral dislocations should be managed conservatively with immobilization and rehabilitation, as the majority of these patients will do well without surgery. A MRI is necessary to assess for osteochondral lesions, as they are associated with a poor prognosis if not addressed. Surgical management would be considered in cases with recurrent dislocations, or when it is associated with patellofemoral symptoms.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Frobell R, Cooper R, Morris H, Arendt, H. Acute knee injuries. In: Brukner P, Bahr R, Blair S, Cook J, Crossley K, McConnell J, McCrory P, Noakes T, Khan K. Clinical Sports Medicine: 4th edition. Sydney: McGraw-Hill. p.626-683.
  2. ↑ 2.0 2.1 Matthijs O, Van Paridon-Edauw D, Winkel D. Hoofdstuk 2 knie. Manuele therapie van de perifere gewrichten. 1e uitgave. Houten. Bohn Stafleu Van Loghum bv. 2004. pp.220–235.
  3. ↑ Bijl GVD (Jr), De Graaf CG, De Ridder PA. In: Actief en passief bewegen in de gewrichten der extremiteiten. De tijdsstroom, 1975. p.126.
  4. ↑ 4.0 4.1 Egmond DL, Schuitemaker R. De knieregio. In: Mink AJF, Rer Veer HJ, Vorselaars JACTh. Extremiteiten manuele therapie in enge en ruime zin. 1e uitgave. Houten. Bohn Stafleu Van Loghum bv, 2006. p.559–628.
  5. ↑ 5.0 5.1 Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med 2000;28:472–479.
  6. ↑ 6.0 6.1 Kirsch MD, Fitzgerald SW, Friedman H, Rogers LF. Transient lateral patellar dislocation: diagnosis with MR imaging. AJR Am J Roentgenol 1993;161:109–113.
  7. ↑ Ficat RP, Hungerford DS. Disorders of the patello-femoral joint. Williams & Wilkins, 1977.
  8. ↑ 8.0 8.1 Hughston JC, Walsh WM, Puddu G. Patellar subluxation and dislocation. WB Saunders Company, 1984.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Meeusen R. Praktijkgids knieletsels. Cursus. Vrije Universiteit Brussel, 2011.
  10. ↑ 10.0 10.1 10.2 10.3 Skinner HB, Barrack RL, Bedmar MS, Clarson GD. Sports medicine. In: Reinhardt S, Nogueira I, Boyle PJ. Current diagnosis en treatment in orthopedics. 2nd edition. McGraw-Hill: United States of America, 2000. p.125–175.
  11. ↑ 11.0 11.1 11.2 Beeton KS. The knee. Manual therapy masterclass: the peripheral joints. Churchill Livingstone. Elsevier, 2003. p.54–55.
  12. ↑ Tsai CH, Hsu CJ, Hung CH, Hsu HC. Primary traumatic patellar dislocation. Journal of orthopaedic surgery and research 2012;7(1):21.
  13. ↑ 13.0 13.1 Hohlweck J, Quack V, Arbab D, Spreckelsen C, Tingart M, Lüring C, Rath B. Diagnostic and therapeutic management of primary and recurrent patellar dislocations-analysis of a nationwide survey and the current literature. Zeitschrift für Orthopädie und Unfallchirurgie 201;151(4):380-8.
  14. ↑ Paxton EW, Fithian DC, Lou Stone M, Silva P. The reliability and validity of knee-specific and general health instruments in assessing acute patellar dislocation outcomes. The American journal of sports medicine 2003;31(4):487-92.
  15. ↑ Nikku R, Nietosvaara Y, Aalto K, Kallio PE. Operative treatment of primary patellar dislocation does not improve medium-term outcome: a 7-year follow-up report and risk analysis of 127 randomized patients. Acta orthopaedica 2005;76(5):699-704.
  16. ↑ Arendt EA, Fithian DC, Cohen E. Current concepts of lateral patella dislocation. Clinics in sports medicine 2002;21(3):499-519.
  17. ↑ Buchner M, Baudendistel B, Sabo D, Schmitt H. Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment. Clinical Journal of Sport Medicine 2005;15(2):62-6.
  18. ↑ Van Gemert JP, de Vree LM, Hessels RA, Gaakeer MI. Patellar dislocation: cylinder cast, splint or brace? An evidence-based review of the literature. International journal of emergency medicine 2012;5(1):45.
  19. ↑ Castelyn P. Acute knee injuries, diagnostic and treatment managment proposals. Vub University press, 2001. p.42-43.
  20. ↑ Fithian DC, Paxton EW, Cohen AB. Indications in the treatment of patellar instability. The journal of knee surgery 2004;17(01):47-56.
  21. ↑ Koskinen SK, Rantanen JP, Nelimarkka OI, Kujala UM. Effect of Elmslie-Trillat and Roux-Goldthwait procedures on patellofemoral relationships and symptoms in patients with patellar dislocations. The American journal of knee surgery 1998;11(3):167-73.
  22. ↑ Stefancin JJ, Parker RD. First-time traumatic patellar dislocation: a systematic review. Clinical Orthopaedics and Related Research 2007;455:93-101.
  23. ↑ Weber AE, Nathani A, Dines JS, Allen AA, Shubin-Stein BE, Arendt EA, Bedi A. An algorithmic approach to the management of recurrent lateral patellar dislocation. JBJS 2016;98(5):417-27.
  24. ↑ Sillanpää PJ, Mattila VM, Mäenpää H, Kiuru M, Visuri T, Pihlajamäki H. Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation: a prospective randomized study. JBJS 2009;91(2):263-73.
  25. ↑ Smith TO, Song F, Donell ST, Hing CB. Operative versus non-operative management of patellar dislocation. A meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy 2011;19(6):988-98.
  26. ↑ Smith TO, Davies ., Chester R, Clark A, Donell ST. Clinical outcomes of rehabilitation for patients following lateral patellar dislocation: a systematic review. Physiotherapy, 2010;96(4):269-81.
  27. ↑ Smith TO, Chester R, Clark A, Donell ST, Stephenson R. A national survey of the physiotherapy management of patients following first-time patellar dislocation. Physiotherapy, 2011;97(4):327-38.
  28. ↑ Smith TO, Chester R, Cross J, Hunt N, Clark A, Donell ST. Rehabilitation following first-time patellar dislocation: a randomised controlled trial of purported vastus medialis obliquus muscle versus general quadriceps strengthening exercises. The Knee,2015;22(4):313-20.
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