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When do you advise patients to have reconstructive surgery for chronically dislocating kneecaps?

A recent study from St. Luois Children's Hospital has shed some new light on this topic. They found that the longer the condition went on before surgery, the more likely results would be less than optimal. They also reported that younger children had better outcomes. Those particular outcomes have led the surgeon to recommend patellofemoral reconstruction after only 2 subluxation or dislocation episodes -- rather than waiting until the child has had many more than that months to years after the first episode. But before surgery, the usual first-line of treatment for this problem is conservative (nonoperative) care. Rehab under the supervision of a physical therapist is essential. Only when dislocations continue after attempts to realign the joint with manual therapy, postural alignment, and exercises to improve neuromuscular control is reconstructive surgery advised. The stabilization procedure varies from patient-to-patient. Age, skeletal maturity, and etiology (cause) are important factors in the decision-making process. The surgeon also performs an arthroscopic exam before doing surgery in order to find out what the patellofemoral joint looks like inside. Any unknown or previously unseen problems with the soft tissue structures and joint surface are identified. The surgeon may perform a lateral release (cuts the soft tissue along the outside edge of the patella) with or without retensioning the medial soft tissue (changing the tension on the other side of the patella closest to the other knee). Other options include an osteotomy (the surgeon removes a wedge of bone to change knee alignment), repair of any damaged patellar ligaments, or a patellar tendon transfer (changes the angle of pull on the patella). The work may be done from above or below the knee to create the stability needed based on the cause of the problem. In some cases, the patella is reshaped by doing a patellar shaving procedure. Any loose pieces of bone or cartilage found in the joint are removed as well. Many patients end up having more than one thing done during the same surgery -- this is referred to as combined procedures. Would fewer operative steps be required if the surgery were done sooner? That's unknown and would be the topic of another interesting research project!

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