Patellar Dislocation and Subluxation

Surgery for with Phase I Rehab

INDICATIONS

  • ExitCare ImageSurgery is advised to remove loose fragments of bone or cartilage in the knee, if present. If the surgery is for the patient's first knee dislocation, then surgery to prevent future dislocations is usually not advised.

  • If the patient has had multiple previous knee dislocations, or pain remains despite rehabilitation, surgery may be recommended. Surgery on people with recurring patellar dislocations may be completed with or without the presence of loose fragments in the joint.

  • Patients who play sports that require pivoting, cutting, or jumping are sometimes, though not commonly, recommended for surgery after their first kneecap dislocation.

  • Surgery is often performed after the knee has regained its full range of motion and control of the thigh muscles (typically 3 or more weeks after injury). Surgery may be performed earlier, if loose fragments are present.

  • Surgery is performed to prevent further dislocations.

  • The purpose of patellar dislocation surgery is to restore a normal tracking of the kneecap in the trochlea and/or to remove loose fragments that are present in the joint.

  • Healing and rehabilitation prior to returning to sports typically lasts 3 to 9 months (depending on the type of surgery and rehabilitation).

REASONS NOT TO OPERATE

  • Normal tracking of the kneecap.

  • Inability or unwillingness to complete the rehabilitation program.

  • Infection of the knee (current or previous; not an absolute reason not to operate).

  • Skeletal immaturity (not fully grown yet; not an absolute reason not to operate).

  • Severe knee or kneecap arthritis.

RISKS AND COMPLICATIONS

  • Infection, bleeding, or injury to nerves (numbness, weakness, paralysis) of the knee, leg, and foot. (Some numbness, temporary or permanent, on the outer part of the upper leg is not uncommon.)

  • Swelling or continued pain of the knee.

  • Rupture or stretching out of the repair, causing recurring kneecap dislocation.

  • Kneecap dislocation or subluxation, inward.

  • Knee stiffness (loss of knee motion) or weakness.

  • Recurring dislocation or subluxation of the kneecap.

  • Pain, from the screw used to hold the bone.

  • Clot in the veins of the calf or thigh (deep venous thrombosis, phlebitis) that may break off in the bloodstream and go to the lungs (pulmonary embolus) or brain (causing a stroke).

  • Reflex sympathetic dystrophy (severe pain).

  • Inability of the bone to heal (nonunion).

  • Inability to remove all the loose fragments in the knee.

TECHNIQUE

Many different surgical techniques exist for patellar dislocation. The procedure depends on the goal of the surgery. Different techniques include the following:

  • Lateral release procedures involve the soft tissues (tendons, ligaments, and muscles). These procedures often include cutting the ligament-like tissue (retinaculum) on the outer side of the knee, to release tension on the kneecap. This may or may not include tightening the tissues on the inner knee, to pull the kneecap back towards the trochlea. These procedures may be performed through an incision near the joint (arthroscopically), and you go home the same day as surgery (outpatient basis).

  • Tibial tubercle transfer surgery is performed below the kneecap. These procedures involve cutting the tibia (shinbone) at the tibial tubercle, where the patellar tendon attaches, and moving it inward. These procedures help the quadriceps (thigh muscle) to pull in a straight line, reducing the angle and tendency for the kneecap to dislocate (tibial tubercle transfer). These procedures may be performed arthrocopically and require a 1 to 2-day stay in the hospital. When the bone is cut and moved, it is held with screws. After surgery, a brace or cast is often advised, for 2 to 8 weeks. The screws used to hold the bone usually do not need to be removed, unless they bother you.

  • Other procedures include rerouting tendon or ligament tissue, to keep the kneecap from dislocating (usually for growing children).

AFTER THE PROCEDURE

  • Keep the wound clean and dry for 10 to 14 days after surgery.

  • To reduce inflammation, ice your knee for 20 minutes every 2 to 3 hours, for the first 1 to 2 weeks after surgery.

  • You will be given pain medicines by your caregiver. Take only as directed.

  • You may be given a knee brace or cast after surgery.

  • Rehabilitation exercises after patella-stabilizing surgery are important for reducing knee swelling, regaining strength, and regaining a full range of motion. Check with your surgeon or physical therapist for the exact exercises to perform. Often a graduated program (increasing gradually) is specified.

RETURN TO SPORTS

Return to sports occurs when your caregiver or therapist gives you permission to do so. Return to sports is usually allowed once you have no pain, a full range of motion, muscle strength, and endurance. If a tibial transfer has been performed, the bone must be completely healed. Healing and rehabilitation usually takes 4 to 6 months.

SEEK MEDICAL CARE IF:

  • You experience pain, numbness, or coldness in the foot and ankle.

  • Blue, gray, or dark color appears in the toenails.

  • You develop increased pain, swelling, redness, drainage of fluids, or bleeding in the affected area.

  • Signs of infection develop (headache, muscle aches, dizziness, a general ill feeling with fever).

  • New, unexplained symptoms develop. (Drugs used in treatment may produce side effects.)

EXERCISES

PHASE I EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Patellar Dislocation and Subluxation, Surgery For Phase I

People who have a chronic or repeated history of patellar dislocations and/or subluxations may be treated with surgery. Immediately after surgery, your caregiver will likely restrain your knee in a brace or cast. This will keep your knee straight, allowing the surgically repaired tissues a better chance to heal. It is extremely important to adhere to the recommendations of your physician, physical therapist or athletic trainer when advancing the flexibility in your knee. Being too aggressive too soon can damage healing tissues. When you have shown adequate progressions in your healing, you will begin bending and straightening your knee. This will be controlled by wearing a hinged brace, with limited motion, while you exercise. The following are some of the exercises your caregiver may have you begin. While completing them, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

ExitCare Image RANGE OF MOTION - Knee Flexion and Extension, Active-Assisted

  • Sit on the edge of a table or chair with your thighs firmly supported. It may be helpful to place a folded towel under the end of your right / left thigh.

  • Flexion (bending): Place the ankle of your healthy leg on top of the other ankle. Use your healthy leg to gently bend your right / left knee until you feel a mild tension across the top of your knee.

  • Hold for __________ seconds.

  • Extension (straightening): Switch your ankles so your right / left leg is on top. Use your healthy leg to straighten your right / left knee until you feel a mild tension on the backside of your knee.

  • Hold for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image RANGE OF MOTION - Knee Flexion, Active

  • Lie on your back with both knees straight. (If this causes back discomfort, bend your opposite knee, placing your foot flat on the floor.)

  • Slowly slide your heel back toward your buttocks until you feel a gentle stretch in the front of your knee or thigh.

  • Hold for __________ seconds. Slowly slide your heel back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH - Knee Flexion, Supine

  • Lie on the floor with your right / left heel and foot lightly touching the wall. (Place both feet on the wall if you do not use a door frame.)

  • Without using any effort, allow gravity to slide your foot down the wall slowly until you feel a gentle stretch in the front of your right / left knee.

  • Hold this stretch for __________ seconds. Then return the leg to the starting position, using your healthy leg for help, if needed.

Repeat __________ times. Complete this stretch __________ times per day.

STRENGTHENING EXERCISES - Patellar Dislocation and Subluxation, Surgery For Phase I

These exercises may help you when beginning to rehabilitate your injury. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Increase the resistance and repetitions only as guided by your caregiver.

ExitCare Image STRENGTH - Quadriceps, Isometrics

  • Lie on your back with your right / left leg extended and your opposite knee bent.

  • Gradually tense the muscles in the front of your right / left thigh. You should see either your knee cap slide up toward your hip or increased dimpling just above the knee. This motion will push the back of the knee down toward the floor, mat, or bed on which you are lying.

  • Hold the muscle as tight as you can, without increasing your pain, for __________ seconds.

  • Relax the muscles slowly and completely between each repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Quadriceps, Straight Leg Raises

Quality counts! Watch for signs that the quadriceps muscle is working, to be sure you are strengthening the correct muscles and not "cheating" by substituting with healthier muscles.

  • Lay on your back with your right / left leg extended and your opposite knee bent.

  • Tense the muscles in the front of your right / left thigh. You should see either your knee cap slide up or increased dimpling just above the knee. Your thigh may even shake a bit.

  • Tighten these muscles even more and raise your leg 4 to 6 inches off the floor. Hold for __________ seconds.

  • Keeping these muscles tense, lower your leg.

  • Relax the muscles slowly and completely in between each repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Hip Abductors, Straight Leg Raises

Be aware of your form throughout the entire exercise, so that you exercise the correct muscles. Poor form means that you are not strengthening the correct muscles.

  • Lie on your side so that your head, shoulders, knee and hip line up. You may bend your lower knee to help maintain your balance. Your right / left leg should be on top.

  • Roll your hips slightly forward, so that your hips are stacked directly over each other and your right / left knee is facing forward.

  • Lift your top leg up 4-6 inches, leading with your heel. Be sure that your foot does not drift forward or that your knee does not roll toward the ceiling.

  • Hold this position for __________ seconds. You should feel the muscles in your outer hip lifting. (You may not notice this until your leg begins to tire.)

  • Slowly lower your leg to the starting position. Allow the muscles to fully relax before beginning the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Hip Extensors, Straight Leg Raises

  • Lie on your stomach on a firm surface.

  • Tense the muscles in your buttocks to lift your right / left leg about 4 inches. If you cannot lift your leg this high without arching your back, place a pillow under your hips.

  • Keep your knee straight. Hold __________ seconds.

  • Slowly lower your leg to the starting position and allow it to relax completely before starting the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.