Patella Stabilisation Surgical Procedures
Surgical Correction to Prevent Kneecap Dislocation and Restore Stability back in the knee.
Patella stabilisation surgery addresses issues with the kneecap’s alignment and stability, helping to restore proper knee function. The patella plays a key role in allowing smooth knee movement by enhancing the power of the quadriceps muscle. However, instability—caused by trauma, congenital issues, or weakened ligaments can lead to dislocations, subluxations, or chronic pain.
The goal of this surgery is to reposition and secure the patella for pain-free, stable movement and the surgical approach Dr Liddell uses during your procedure will depend on the cause and severity of your condition.
In the following sections, we will delve into the various surgical treatment options to correct problems with the alignment and stability of the patella (kneecap).
MEDIAL PATELLOFEMORAL LIGAMENT (MPFL) RECONSTRUCTION
The medial patellofemoral ligament (MPFL) is a critical structure in your knee that helps keep the patella (kneecap) properly aligned within the femoral groove (on top of the thigh bone). The MPFL prevents the kneecap from shifting or dislocating to the outside of the knee, especially during movement. This ligament acts like an elastic band, providing stability to the kneecap while allowing the knee to bend and extend smoothly.
An MPFL injury usually occurs when the kneecap is forced out of place, often as a result of a traumatic event. Sports that involve sudden pivoting movements, such as football, basketball, netball, and tennis, are common culprits of MPFL tears. The injury can also be caused by underlying knee abnormalities or muscle imbalances that make the knee more prone to dislocation.
MPFL reconstruction is a surgical procedure designed to stabilise your kneecap (patella) and prevent it from dislocating or moving out of place.
The procedure involves reconstructing the damaged ligament using a graft (tendon tissue), which helps restore stability to your knee.
Here’s what you can expect during MPFL reconstruction:
- Anaesthesia: You will be under general anaesthesia for the procedure, meaning you’ll be fully asleep.
- Graft Selection and Harvesting: Dr Liddell will make a small incision near your knee. The graft used to reconstruct the MPFL is typically taken from a nearby tendon in your leg. In some cases, a graft from your quadriceps tendon may be used instead. The graft is carefully prepared and sized to ensure it fits perfectly in your knee.
- Placement of the Graft: Once the graft is prepared, it is positioned in the knee using precise techniques to ensure the correct tension and alignment. A small hole is made in your kneecap (patella) and femur (thigh bone) to secure the graft in place. Special instruments are used to ensure the graft doesn’t overstretch during movement.
- Tension and Fixation: The graft is secured with the knee in a bent position, ensuring the correct tension to control the kneecap’s movement. It’s important that the new ligament has the right amount of tension to prevent future dislocations.
- Final Check and Wound Closure: After securing the graft, Dr Liddell will check your knee’s range of motion to ensure everything is functioning properly. The incision is then closed with sutures, and the procedure is complete.
The entire procedure typically takes around 60 to 90 minutes, and most patients stay in the hospital for one night before going home.
- Hospital Stay: After surgery, you will stay in the hospital for one night. During this time, your pain will be monitored, and a physiotherapist will help you begin the early stages of rehabilitation, including teaching you how to walk with crutches. An X-ray will be taken to ensure the graft, and any fixation devices are in the correct position.
- Pain Relief: Your knee will be injected with local anaesthetic during surgery, but once it wears off, you may experience more discomfort. It’s important to take your pain medication as directed to manage this. Start with regular paracetamol (2 tablets every 6 hours). Stronger medications such as Panadeine Forte, Tramadol, or Endone may also be prescribed, and they can be taken in combination with paracetamol. If you’ve been prescribed anti-inflammatory medications, take them with food and stop if you experience indigestion or nausea.
- Dressings and Wound Care: Small waterproof dressings will cover your incisions, allowing you to shower. These can be removed after 4 to 5 days. If the cuts are healed and dry, they can be left uncovered, or you may use a simple bandage if they are still moist.
- Using a Knee Brace and Crutches: You will need to wear a knee brace for 3 to 6 weeks while walking. This helps protect the new ligament and prevent further injury. You’ll be able to place weight on the leg as tolerated, but crutches will be used for the first few days. Avoid climbing stairs, squatting, and stretching your leg until the tendon has healed properly.
- Post-Op Appointment: You will have a follow-up appointment with Dr Liddell around two weeks after surgery to assess your progress and discuss the next steps in your recovery.
Here’s a general timeline for recovery after MPFL reconstruction:
- Hospital Stay: 1 night
- Return to Work: You’ll likely need 3 to 4 weeks off work, depending on the nature of your job.
- Physiotherapy: Physiotherapy starts immediately after surgery and will continue throughout your recovery.
- Movement Restrictions: Avoid climbing stairs, squatting, or stretching the leg until the tendon heals.
- Knee Brace: Use the knee brace for 3 to 6 weeks to stabilise the knee during walking.
- Weight Bearing: You will be able to bear weight as tolerated with crutches for approximately 6 weeks.
- Return to Normal Activities: Most patients can return to regular activities and sports 5 to 7 months after surgery.
If you’ve experienced frequent kneecap dislocations or significant instability, MPFL reconstruction may be recommended.
TIBIAL TUBERCLE OSTEOTOMY (TTO)
Tibial Tubercle Osteotomy (TTO) is the surgical procedure used to treat patellar instability or misalignment, particularly in patients who experience recurrent dislocations or chronic knee pain due to improper patella tracking. The tibial tubercle is the bony prominence on the front of your shinbone (tibia), where the patellar tendon attaches. In patients with patellar instability or misalignment, this bony prominence may need to be repositioned to improve the alignment of the kneecap (patella) and ensure it tracks properly within the groove at the end of the thigh bone (femur).
A Tibial Tubercle Osteotomy is typically recommended for patients who experience:
- Recurrent Patellar Dislocations: If your kneecap frequently slips out of place, TTO can help by realigning the patella and reducing the risk of future dislocations.
- Patella Maltracking: If the kneecap doesn’t move smoothly within its groove on the femur, TTO can improve its alignment and reduce pain and instability.
- Chronic Knee Pain: Patients who suffer from ongoing knee pain due to patellar misalignment or instability may benefit from TTO as part of a broader treatment plan.
- Structural Abnormalities: Some patients have a naturally high-riding patella (patella alta) or a shallow trochlear groove, which can lead to instability. TTO helps to correct these structural issues by repositioning the tibial tubercle.
Here’s what you can expect during a Tibial Tubercle Osteotomy:
- Anaesthesia: TTO is performed under general anaesthesia, so you will be fully asleep during the procedure.
- Incision and Bone Realignment: Dr Liddell will make an incision at the front of your knee to access the tibial tubercle. The tibial tubercle is then carefully cut and repositioned to improve the alignment of the patella. By shifting the tibial tubercle, the attachment point of the patellar tendon is moved, which helps the kneecap track more smoothly in its groove.
- Securing the Tubercle: Once the tibial tubercle has been repositioned, it is secured in place using small metal screws or plates. These devices help ensure the bone heals in the correct position.
- Final Check and Wound Closure: Dr Liddell will check the knee’s range of motion and patellar tracking to ensure proper alignment. The incision is then closed with sutures, and the procedure is complete.
The entire surgery typically takes around 60 to 90 minutes.
- Hospital Stay: You will likely stay in the hospital for one night after the procedure. During this time, your pain will be managed, and a physiotherapist will begin your rehabilitation, including teaching you how to walk with crutches.
- Pain Management: Your knee will be injected with local anaesthetic during surgery to help manage post-operative pain. Once the anaesthetic wears off, you may experience discomfort, which can be managed with medications such as paracetamol, Panadeine Forte, or stronger pain relievers like Tramadol or Endone. You may also be prescribed anti-inflammatory medications, which should be taken with food.
- Dressings and Wound Care: Small waterproof dressings will cover your incision, allowing you to shower. These can be removed after 4 to 5 days. If the cuts are healed and dry, they can be left uncovered, or a bandage may be used if still moist.
- Using a Knee Brace and Crutches: A knee brace is usually required for 4 to 6 weeks to stabilise the knee and protect the realigned tibial tubercle during healing. Crutches will be used to assist with walking during the first few days, and you can begin weight-bearing as tolerated. It’s important to avoid high-impact activities, such as climbing stairs or squatting, until the knee has healed.
Here’s an outline of what you can expect during your recovery from a Tibial Tubercle Osteotomy:
- Hospital Stay: 1 night
- Return to Work: You will likely need 3 to 4 weeks off work, depending on your occupation.
- Physiotherapy: A structured physiotherapy program will begin shortly after surgery to restore strength and range of motion.
- Movement Restrictions: Avoid high-impact activities such as squatting, climbing stairs, and running for several months.
- Knee Brace: You will need to wear a knee brace for 4 to 6 weeks to protect the surgical site.
- Return to Normal Activities: Most patients can gradually return to regular activities and sports 4 to 6 months after surgery, depending on the rate of healing and rehabilitation progress.
TTO is often performed in combination with other procedures, such as Medial Patellofemoral Ligament (MPFL) reconstruction, to restore proper function to the knee and prevent future dislocations.
LATERAL RELEASE
Lateral release is a surgical procedure designed to correct patellar (kneecap) misalignment and relieve pain caused by excessive pressure on the outer side of the knee. The procedure involves releasing or cutting the tight lateral retinaculum, a band of fibrous tissue that pulls the kneecap towards the outside of the knee. By loosening this tissue, the patella can track more centrally within the femoral groove, improving knee function and reducing discomfort. Lateral release is typically recommended for patients who experience patellar instability, mal-tracking, or pain due to a tight lateral structure in the knee.
A lateral release may be recommended for patients with the following conditions:
- Patellar Mal-tracking: When the kneecap doesn’t move properly within the femoral groove, lateral release can help improve alignment.
- Patellar Tilt: Some patients have a kneecap that tilts outward due to tightness in the lateral retinaculum, causing pain and instability. Lateral release can help correct this issue.
- Lateral Knee Pain: Pain on the outer side of the knee, particularly during activities such as walking, running, or climbing stairs, may be caused by lateral tightness. Lateral release may alleviate this pain by balancing the forces around the kneecap.
- Failure of Non-Surgical Treatments: If physiotherapy, bracing, or other non-surgical treatments have not been effective in relieving symptoms of patellar mal-tracking or lateral knee pain, lateral release may be considered as an option.
Here’s what you can expect during lateral release surgery:
- Anaesthesia: The procedure is typically performed under general anaesthesia, ensuring you are fully asleep. In some cases, regional anaesthesia may be used.
- Arthroscopic Approach: Dr Liddell commonly performs a lateral release arthroscopically, meaning small incisions are made around the knee, and a camera (arthroscope) is inserted to guide him during the procedure. This minimally invasive approach may support a faster recovery compared to traditional methods.
- Releasing the Lateral Retinaculum: Through these small incisions, the lateral retinaculum is carefully cut or released to reduce the lateral pull on the kneecap. This allows the kneecap to move more freely and track correctly within the femoral groove.
- Checking Patellar Tracking: Once the release is complete, Dr Liddell will ensure the kneecap is properly aligned and tracking smoothly throughout the knee’s range of motion.
- Wound Closure: The small incisions are closed with sutures, and the knee is bandaged.
The entire procedure typically takes less than an hour.
This minimally invasive procedure can help correct patellar maltracking and alleviate pain caused by excessive lateral pressure on the knee. By releasing the tight structures on the outer side of the knee, the procedure can restore proper alignment and improve overall knee function.
- Hospital Stay: Most patients can go home the same day as the surgery. For some patients however, an overnight stay may be required for pain management.
- Pain Relief: You may experience some discomfort after the anaesthetic wears off. Pain medication, including paracetamol and stronger options like Tramadol or Endone, may be prescribed. Anti-inflammatory medications may also help manage swelling and discomfort.
- Dressings and Wound Care: Small waterproof dressings will cover the incisions, allowing you to shower. These dressings can typically be removed after 4 to 5 days. If the incisions are dry and healed, they can be left uncovered.
- Using Crutches and a Knee Brace: While a knee brace is not always required after lateral release surgery, crutches may be needed for a few days to reduce strain on the knee while walking. Dr Liddell will provide specific instructions based on your recovery needs.
Here’s what to expect during recovery:
- Return to Work: Depending on the nature of your job, you may need 1 to 2 weeks off work to recover.
- Physiotherapy: Physiotherapy typically begins shortly after surgery to help restore strength, flexibility, and range of motion. It will also focus on retraining the muscles around the knee to support proper patellar tracking.
- Weight Bearing: You can usually begin weight-bearing as tolerated soon after surgery however, you should avoid high-impact activities like running or squatting until the knee has healed.
- Return to Normal Activities: Most patients can return to their normal activities within 6 to 12 weeks, although full recovery may take longer, especially if other procedures were performed alongside the lateral release procedure.
Lateral release can be an effective surgical option for selected patients with persistent kneecap pain or instability caused by tight lateral structures. While it is often performed in conjunction with other procedures to optimise patellar alignment, careful assessment is essential to determine whether this approach is appropriate for your specific condition. If you’re experiencing ongoing knee discomfort or instability, Dr Liddell can assess your knee mechanics and discuss whether a lateral release may form part of your personalised treatment plan.
TROCHLEOPLASTY
A Trochleoplasty is the surgical procedure used to correct a shallow or flat trochlear groove in your knee. The trochlear groove is the natural depression in the femur (thigh bone) where the kneecap (patella) sits and moves during knee flexion and extension. In some patients, the trochlear groove may be too shallow or abnormally shaped, causing the kneecap to dislocate or move out of place (patellar instability). A Trochleoplasty reshapes this groove to allow the patella to track properly, reducing the risk of future dislocations and improving knee stability.
A Trochleoplasty is typically recommended for patients who experience:
- Recurrent Patellar Dislocations: If the kneecap repeatedly dislocates, especially due to a shallow trochlear groove, trochleoplasty may be needed to correct the underlying issue.
- Chronic Patellar Instability: Patients who suffer from long-term patellar instability and have not responded to non-surgical treatments, such as physiotherapy or bracing, may benefit from this surgery.
- Congenital or Developmental Abnormalities: Some individuals are born with or develop a shallow trochlear groove, which leads to ongoing issues with patellar tracking and stability. Trochleoplasty helps reshape the groove to match the patella’s movement.
- Failure of Other Surgical Procedures: In cases where previous surgeries to stabilise the patella (e.g., MPFL reconstruction or lateral release) have not resolved the problem, trochleoplasty may be considered to address the shape of the trochlear groove.
Here’s what you can expect during trochleoplasty surgery:
- Anaesthesia: The procedure is performed under general anaesthesia, meaning you will be fully asleep during the surgery.
- Incision and Access: Dr Liddell will make an incision over the front of your knee to access the trochlear groove. Once the knee joint is exposed, he will evaluate the shape of the groove to determine the necessary corrections.
- Reshaping the Trochlear Groove: The shallow or abnormally shaped groove is carefully reshaped to create a deeper, more defined path for the patella to sit and move. This is done using specialised tools to remove a small amount of bone from the femur, creating a new, properly shaped groove.By reshaping the groove, the kneecap can more likely track properly, reducing the risk of future dislocations and improving overall knee function
- Stabilising the Patella: Once the groove is reshaped, the patella is repositioned to ensure it tracks correctly within the groove. For some patients, additional procedures such as MPFL reconstruction or tibial tubercle osteotomy may also be performed to further stabilise the patella.
- Wound Closure: After the reshaping is complete and the patella is in its proper position, the incision is closed with sutures, and your knee is bandaged.
The entire procedure typically takes around 90 to 120 minutes, depending on the complexity of the requirements.
- Hospital Stay: You will likely stay in the hospital for one or two nights following the procedure. During this time, your pain will be managed, and you will begin the early stages of rehabilitation with the assistance of a physiotherapist.
- Pain Management: Post-operative pain is common but can be managed with prescribed pain medications such as paracetamol, Tramadol, or stronger medications like Endone. Dr Liddell may also prescribe anti-inflammatory medications to help reduce swelling.
- Dressings and Wound Care: Waterproof dressings will cover your incisions, allowing you to shower. These dressings can typically be removed after 4 to 5 days. If the incisions are healed and dry, they can be left uncovered or covered with a bandage if needed.
- Using a Knee Brace and Crutches: A knee brace will likely be required for 4 to 6 weeks to protect the surgical site and keep your knee stable during healing. Crutches will also be used for the first few days to weeks, depending on your weight-bearing tolerance. You will gradually increase weight-bearing as guided by Dr Liddell and the physiotherapy team.
Recovery from trochleoplasty is a gradual process, here’s what you can expect:
- Hospital Stay: 1 to 2 nights
- Return to Work: Depending on your job, you may need 4 to 6 weeks off work to recover.
- Physiotherapy: Physiotherapy will begin shortly after surgery to help restore range of motion and strengthen the muscles around your knee. This is crucial for ensuring proper patellar tracking and preventing future instability.
- Movement Restrictions: Avoid high-impact activities, such as running, squatting, and jumping, for several months. Dr Liddell will advise you on when it is safe to gradually return to these activities.
- Knee Brace: You will need to wear a knee brace for 4 to 6 weeks to stabilise the knee while it heals.
- Return to Normal Activities: Most patients can return to daily activities and light exercise within 3 to 6 months, although full recovery and return to sports may take 6 to 12 months.
Trochleoplasty may be considered in cases of severe patellar instability where the shape of the trochlear groove contributes to ongoing dislocations or functional limitations. By reshaping the groove to better accommodate the patella, this procedure aims to improve stability and reduce the risk of future episodes. Dr Liddell will carefully assess your knee anatomy, symptoms, and imaging to determine whether a trochleoplasty is suitable as part of your overall treatment plan.