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Sports Medicine

Patella subluxation treatment & surgery

02/12/2008

Question:

I have had bilateral subluxating patellas since age 11. I just turned 26 years old. I have had lateral release surgery on both at age 14 and it didn’t help at all. At age 18 I had a patella realignment surgery on my right knee. Eight years later it has popped out twice and I remember my surgeon at the time said that only one person he has operated on has had it fail and he was a physically handicapped man and that a dog ran into him and popped it out. I guess I’m a statistic for that surgery failing also. I have not seen him now for 8 years. My knees have approximately subluxated around 500 times together in my lifetime. My left one did just 2 weeks ago. They both track laterally and sit tilted. I feel as though I have arthritis beginning which I was warned about because of all the trauma my knees have encountered at a young age. I have been told I am too young for knee replacements. What age will surgeons replace knees? I have to alter my lifestyle because of this and it’s always in the back of my mind. I know that a woman has a tendency over a man to have this problem because of the way we are shaped. My knee just pops out while I am walking without any warning and it scares me and is embarrassing if others are around because people don’t understand what has happened. I didn’t know if you knew of any new surgeries for my condition or have any suggestions. As you can tell I am desperate at this point. I’ve worn all kind of braces but my knee doesn’t fit in them properly to begin with. I’m scared I will tear something or completely dislocate one of them (my right one did at age 17). My husband and I are thinking about starting a family but I read that pregnancy softens and loosens your ligaments. Is this true for the knee joints also? My ligaments are lax enough and I’m scared if one goes out while I’m pregnant I could injury myself or my baby. Any feedback from you would be so greatly appreciated.

Answer:

Given the severity of your symptoms, including the fact your patellar subluxation episodes occur during such low-demand activities as walking, you may wish to consider getting another surgical opinion, ideally from an orthopedic surgeon who has a lot of experience with people who have recurrent patellar subluxation and dislocation. If you are loose-jointed (hypermobile), unfortunately the long-term success rates for stabilization-type surgeries are not as good as for people who are not hypermobile. An orthopedist specializing in Sports Medicine would be more likely to have experience with patellar disorders compared to a general orthopedist. In addition to your local phone book listings, to find an orthopedist in your area, consider visiting the website for the American Orthopaedic Society for Sports Medicine (AOSSM): www.sportsmed.org/tabs/Index.aspx

 

There is also the website for the American Academy of Orthopaedic Surgeons (AAOS): aaos.org/

Although you mentioned your knees didn't properly fit into the knee braces you've tried, there should be a brace design to fit/help you, which may require that you obtain custom-fitted or custom-fabricated patellar stabilization braces as could be provided by a Certified Orthotist (practitioner who specializes in making and providing braces which are best for a person's needs).

Patellar taping, which is typically performed and taught to patients by Physical Therapists, would certainly also be worth considering, unless you've already tried this technique.

If part of the reason for your recurrent patellar subluxation episodes is due to muscular tightness and/or weakness - not only in your thighs but also your "core"/hip as well as lower legs, a Physical Therapist can guide and assist you regarding an optimal therapeutic exercise program.

If pain is a significant issue, this needs to be well-controlled for maximum strength and function, which may be achieved by icing and other physical treatments, as well as by topical and/or oral and/or injectable medications.

If your feet tend to hyperpronate, this could be one of a number of "structural" factors predisposing you to patellar subluxation, and such factors need to be identified and treated as aggressively as possible.

Since knee replacements have a finite (10-15 years, depending on body weight, activity level, and other factors) lifespan, this irreversible treatment option is best reserved as a last resort, when all other options have been exhausted. Knee replacements certainly can be performed at younger ages, including in children, but again other options should first be exhausted.

It is true that the more times a patella subluxes or dislocates, the greater the chance of developing arthritis.

To predict how your knees may do if you were to become pregnant, ideally it would be best for the above options - including possible medication options - to be fully pursued/tried beforehand. However, since the cause for your continuing symptoms may not just be due to lax ligaments, it is not a certainty that pregnancy would make your symptoms worse. Such a prediction would need to be based on the specific cause(s) of your symptoms and their response to these additional treatment options, and should be discussed in detail with your physician, and/or with whomever you decide to consult.

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Response by:

Brian L Bowyer, MD Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University