Patellar Dislocation and Subluxation

Surgery for with Phase II Rehab

INDICATIONS

  • Surgery 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).

POSTOPERATIVE COURSE

  • 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 II EXERCISES

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

Once you have made progress adequate to begin discontinuing use of your brace, your caregiver will have you begin Phase II of your rehabilitation. This phase will help you gain even more flexibility in your knee to allow you to return to your previous daily and recreational activities. It is important that you do not force any exercise. Never continue an exercise that increases your pain or gives you the sensation that your knee is about to "pop out" or dislocate. Inform your physician, physical therapist or athletic trainer of any exercises that you need to discontinue, due to increasing either of these symptoms.

While completing these exercises, 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.

STRETCH - Quadriceps, Prone

  • Lie on your stomach on a firm surface, such as a bed or padded floor.

  • Bend your right / left knee and grasp your ankle. If you are unable to reach your ankle or pant leg, use a belt around your foot to lengthen your reach.

  • Gently pull your heel toward your buttocks. Your knee should not slide out to the side. You should feel a stretch in the front of your thigh and knee.

  • Hold this position for __________ seconds.

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

STRETCH – Hamstrings, Supine

  • Lie on your back. Loop a belt or towel over the ball of your right / left foot.

  • Straighten your right / left knee and slowly pull on the belt to raise your leg. Do not allow the right / left knee to bend. Keep your opposite leg flat on the floor.

  • Raise the leg until you feel a gentle stretch behind your right / left knee or thigh. Hold this position for __________ seconds.

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

STRETCH - Hamstrings, Doorway

  • Lie on your back with your right / left leg extended and resting on the wall and the opposite leg flat on the ground through the door. At first, position your bottom farther away from the wall.

  • Keep your right / left knee straight. If you feel a stretch behind your knee or thigh, hold this position for __________ seconds.

  • If you do not feel a stretch, scoot your bottom closer to the door, and hold __________ seconds.

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

STRETCH – Iliotibial Band

  • On the floor or bed, lie on your side so your right / left leg is on top. Bend your knee and grab your ankle.

  • Slowly bring your knee back so that your thigh is in line with your trunk. Keep your heel at your buttocks and gently arch your back so your head, shoulders and hips line up.

  • Slowly lower your leg so that your knee approaches the floor, until you feel a gentle stretch on the outside of your right / left thigh. If you do not feel a stretch and your knee will not fall farther, place the heel of your opposite foot on top of your knee and pull your thigh down farther.

  • Hold this stretch for __________ seconds.

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

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

These are some of the exercises you may progress to in your rehabilitation program. It is critical that you follow the instructions of your caregiver and not progress to these Phase II exercises until directed. You may continue with all Phase I strengthening exercises. Remember:

  • Strong muscles with good endurance tolerate stress better.

  • Do the exercises as initially prescribed by your caregiver. Progress slowly with each exercise, gradually increasing the number of repetitions and weight used under his or her guidance.

STRENGTH - Quadriceps, Short Arcs

  • Lie on your back. Place a __________ inch towel roll under your right / left knee, so that the knee bends slightly.

  • Raise only your lower leg by tightening the muscles in the front of your thigh. Do not allow your thigh to rise.

  • Hold this position for __________ seconds.

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

OPTIONAL ANKLE WEIGHTS: Begin with ____________________, but DO NOT exceed ____________________. Increase in 1 lb/0.5 kg increments.

STRENGTH - Hip Extensors, Bridge

  • Lie on your back on a firm surface. Bend your knees and place your feet flat on the floor.

  • Tighten your buttocks muscles and lift your bottom off the floor until your trunk is level with your thighs. You should feel the muscles in your buttocks and back of your thighs working. If you do not feel these muscles, slide your feet 1-2 inches further away from your buttocks.

  • Hold this position for __________ seconds.

  • Slowly lower your hips to the starting position and allow your buttock muscles relax completely before beginning the next repetition.

  • If this exercise is too easy, you may cross your arms over your chest.

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

STRENGTH - Quadriceps, Step-Ups

  • Use a thick book, step or step stool that is __________ inches tall.

  • Hold a wall or counter for balance only, not support.

  • Slowly step up with your right / left foot, keeping your knee in line with your hip and foot. Do not allow your knee to bend so far that you cannot see your toes.

  • Slowly unlock your knee and lower yourself to the starting position. Your muscles, not gravity, should lower you.

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

STRENGTH - Quadriceps, Wall Slides

Follow guidelines for form closely. Increased knee pain often results from poorly placed feet or knees.

  • Lean against a smooth wall or door and walk your feet out 18-24 inches. Place your feet hip width apart.

  • Slowly slide down the wall or door until your knees bend __________ degrees.* Keep your knees over your heels, not your toes, and in line with your hips, not falling to either side.

  • Hold for __________ seconds. Stand up to rest for __________ seconds in between each repetition.

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

* Your physician, physical therapist or athletic trainer will alter this angle based on your symptoms and progress.

STRENGTH - Quad/VMO, Isometric

  • Sit in a chair with your right / left knee slightly bent. With your fingertips, feel the VMO muscle just above the inside of your knee. The VMO is important in controlling the position of your kneecap.

  • Keeping your fingertips on this muscle. Without actually moving your leg, attempt to drive your knee down as if straightening your leg. You should feel your VMO tense. If you have a difficult time, you may wish to try the same exercise on your healthy knee first.

  • Tense this muscle as hard as you can without increasing any knee pain.

  • Hold for __________ seconds. Relax the muscles slowly and completely between each repetition.

Repeat __________ times. Complete exercise __________ times per day.