Patellofemoral Realignment

What is Patellofemoral Realignment?

Patellofemoral realignment is a surgical procedure performed to treat symptomatic patellofemoral instability that does not respond to nonsurgical treatment measures.

The knee can be divided into three compartments: patellofemoral, medial, and lateral compartment. The patellofemoral compartment is the compartment in the front of the knee between the kneecap (patella) and the thigh bone (femur). The medial compartment is the area on the inside portion of the knee, and the lateral compartment is the area on the outside portion of the knee joint. In a normal knee, the patella is positioned within a groove at the bottom of the thigh bone. Patellofemoral instability occurs when the patella moves either partially (subluxation) or completely (dislocation) out of the trochlear groove causing abnormal tracking. This malalignment can damage the underlying soft structures such as muscles and ligaments that hold the knee in place.
 
Patellofemoral realignment surgery helps to return the patella to a normal tracking path by realigning the kneecap in the groove and decreasing the Q angle to improve knee alignment.

Anatomy of the Patella

The patella is a small piece of bone in front of the knee that slides up and down the groove in the femur bone during bending and stretching movements. The ligaments on the inner and outer sides of the patella hold it in the femoral groove and avoid dislocation of the patella from the groove.

Indications for Patellofemoral Realignment

Some of the indications for patellofemoral realignment include:

• Patellar subluxation: Partial separation of the kneecap from its supporting structures
• Patellar dislocation: Complete separation of the kneecap from the supporting structures
• Patellar maltracking: Malpositioning of the patella within the trochlear groove
• Anatomical defect: Flat feet or fallen arches and congenital abnormalities in the shape of the patella bone can cause misalignment of the knee joint.
• Abnormal Q angle: The high Q angle (angle between the hips and knees) often results in maltracking of the patella such as in knock knees.
• Improper muscle balance: Weak quadriceps (anterior thigh muscles) can lead to abnormal tracking of the patella.
• Patellofemoral arthritis: Patellofemoral arthritis occurs when there is a loss of the articular cartilage on the back of the kneecap. This can eventually lead to abnormal tracking of the patella.

Preparation for Patellofemoral Realignment

Preoperative preparation for patellofemoral realignment will involve the following steps:

• A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
• You will be asked if you have allergies to medications, anesthesia, or latex.
• You should inform your doctor of any medications, vitamins, or supplements that you are taking.
• You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
• You should refrain from alcohol or tobacco at least 24 hours prior to surgery.
• You should not consume any solids or liquids at least 8 hours prior to surgery.
• Arrange for someone to drive you home as you will not be able to drive yourself post surgery.
• A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Patellofemoral Realignment

Patellar realignment surgery is broadly classified into proximal re-alignment procedures and distal re-alignment procedures.

• Proximal re-alignment procedures: During this procedure, structures that limit the movements on the outside of the patella are lengthened or ligaments on the inside of the patella are shortened.
• Distal re-alignment procedures: During this procedure, the Q angle is decreased by moving the tibial tubercle towards the inner side of the knee.

The surgery is performed under sterile conditions in the operating room under spinal or general anesthesia. A larger incision is made over the front of the knee. After visualizing the type and severity of the injury, your surgeon decides on the appropriate surgical correction for it.

• A lateral retinacular release may be performed, where your surgeon releases or cuts the tight ligaments on the lateral side (outside) of the patella, enabling it to slide more easily in the femoral groove. Your surgeon may also perform a procedure to realign the quadriceps mechanism by tightening the tendons on the inside or medial side of the knee. 
• If the misalignment is severe, tibial tubercle transfer (TTT) will be performed. This procedure involves removal of a section of bone where the patellar tendon attaches to the tibia. The bony section is then shifted and properly realigned with the patella and reattached to the tibia with two screws.
• MPFL reconstruction with graft is another surgery employed for severe patellofemoral instability. This procedure involves fixing a brand new ligament from the medial aspect of the thighbone into the medial aspect of the kneecap. This enhances the medial pull on the kneecap in the earliest phases of knee flexion and guides the kneecap successfully into the trochlear groove.

Once the malalignment is repaired and confirmed, the incisions are closed with sutures and sterile dressings applied.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after patellofemoral realignment will involve the following steps:

• You will be transferred to the recovery area to be monitored until you are awake from the anesthesia.
• Your nurse will monitor your blood oxygen level and other vital signs as you recover.
• You may notice some pain, swelling, and discomfort in the knee area. Pain and anti-inflammatory medications are provided as needed.
• Medications will also be prescribed as needed for symptoms associated with anesthesia, such as vomiting and nausea.
• Antibiotics are prescribed to address the risk of surgery-related infection.
• Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
• You will be placed on crutches for the first few weeks with instructions on restricted weight-bearing. You are encouraged to walk with assistance as frequently as possible to prevent blood clots.
• Use of a continuous passive motion machine (CPM) at home is advised during the first few weeks to aid in constant movement of the knee joint under a controlled range of motion.
• You are advised to keep your leg elevated while resting to prevent swelling and pain.
• Refrain from smoking as it can negatively affect the healing process.
• Eating a healthy diet rich in vitamin D is strongly advised to promote healing and a faster recovery.
• Refrain from strenuous activities and lifting heavy weights for the first couple of months. Gradual increase in activities over a period of time is recommended.
• An individualized physical therapy protocol is designed to help strengthen your knee muscles and optimize knee function.
• You will be able to resume your normal activities in a couple of months; however, return to sports may take 6 months or more.
• A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications of Patellofemoral Realignment

Patellofemoral realignment is relatively a safe procedure; however, as with any surgical procedure, it does carry some risks and complications, including:

• Persistent pain
• Blood clots
• Infection
• Bleeding
• Injury to nerves and blood vessels
• Loss of ability to extend the knee
• Recurrent dislocations or subluxations
• Arthrofibrosis (thick fibrous material around the joint)
• The need for revision surgery