The Classic: Total Tendon Transplant for Slipping Patella

Emil Hauser's 1938 Classic Article on recurrent dislocation of the patella includes a review of previous treatment methods and his own ideas about improving on them. His tibial tubercle transfer was widely accepted for many years because it was reasonable effective and easy to do. Unfortunately, the posterior and medial transfer of the tibial tubercle increased patellofemoral joint reaction forces and caused patellofemoral osteoarthritis in some patients. Procedures which move the insertion of the infrapatellar tendon anteriorly as well as medially, eg Maquet or Elmslie-Trillet operations, have supplanted Dr. Hauser's way of dealing with this problem, but his paper remains an important milestone. Emil Hauser was born in 1897 and died in 1982. He studied medicine at the University of Minnesota and graduated from that institution in 1922 with an MD degree. He received postgraduate training in surgery at the University of Minnesota and at the Mayo Clinic. Thereafter, he spent time at the Karolinska Institute in Stockholm studying orthopaedics. He earned an MS degree in orthopaedic surgery at the Mayo Clinic in 1927 and spent most of the rest of his working life in the Department of Orthopaedic Surgery at Northwestern University in Chicago. Henry H. Sherk, MD Deputy Editor for Classic Articles RECURRENT dislocations of the patella (slipping patella) may be divided, for clinical purposes, into three types: (1) congenital, which is a true anomaly; (2) traumatic, which is the result of severe injury; and (3) rachitic, which is secondary to a marked genu valgum. The anomalies that occur in the congenital type are not confined to the patella but frequently involve the patellar ligament and the lower end of the femur. The posterior surface, instead of having two equal joint surfaces to glide over the condyles of the femur, is irregular sometimes to the point of being almost wedge-shaped. The surface of the lateral condyle over which the patella glides is flattened and altered from the normal rounded shape, and since it is not fully developed the patella is likely to displace laterally. The patellar ligament is lengthened and the attachment to the tibia lies lateral to the normal attachment. The outer strands are much stronger, while the medial strands have become weakened through disuse, often to the point of atrophy and ultimate loss. The lengthening of the patellar ligament results in a high position of the patella in relation to the knee joint. The effect of this position on the function of the knee joint will be explained later. Congenital anomalies vary in severity, at times being so mild as not to cause any serious disturbance in function. Frequently both knees are involved; sometimes the one may give rise to recurrent dislocations, while the other, even though markedly deformed, carries out its function without any disability. The traumatic type of recurrent dislocation of the patella is relatively rare. It occurs as the result of severe injury which is practically always an indirect trauma. Most frequently it is the result of a forceful twist which brings the leg into abduction at the knee, with a resultant tear not only of the medial ligament of the knee but also of the entire medial fascia, so that the patella and patellar tendon are displaced laterally. Such a knee if permitted to heal with a gap in the fascia, particularly near the upper part of the patella, has a tendency to recurrent dislocation. A traumatic recurrent dislocation of the patella, if allowed to go untreated indefinitely, gives rise to secondary changes in the quadriceps muscle, in the lateral ligament, and in the patellar tendon, and ultimately in the patella itself. These changes are the result of altered use and a certain amount of disuse. The quadriceps muscle becomes weak and atrophic; the patellar tendon is lengthened and displaced laterally; the lateral fascia and capsule are shortened and markedly thickened. The shape of the patella is altered; it becomes wedge-shaped, the thinner part being toward the medial margin and the base toward the outer margin. A severe, neglected, traumatic recurring dislocation of the patella may ultimately reach the point where it becomes chronic, that is, the patella becomes constantly dislocated with nearly complete loss of function.Fig: Dr. Emil D. W. Hauser is shown. This image of Dr. Hauser is ©1983 by the Journal of Bone and Joint Surgery, Inc., and is reprinted with permission from Emil D. W. Hauser, MD: 1897-1982. J Bone Joint Surg Am. 1983;65:423.The rachitic type of slipping patella is associated with a primary anatomical change, namely, a genu valgum. That some other factor plays a rôle is evident, for not all patients with genu valgum are subject to recurrent dislocations of the patella; however, a severe genu valgum and a lengthened patellar ligament will explain a recurrent dislocation of the patella. In severe deformities the lateral condyle may be immaturely developed, particularly on its anterior surface, so that the patella can slide over to dislocate. REVIEW OF LITERATURE Prophylaxis and conservative treatment are not considered in this paper. Before presenting the new type of for slipping patella and its it is to the and as well as the of the of so that the which is to be and may be on the of have for of recurrent dislocation of the patella. The in that the has not will be to give a of however, in to give to and that has the methods have all and will be to anatomical The of are into (1) which are the (2) in which the fascia is (3) in which secondary are to the patella in which are to the patella in which the lower end of the is and in which the patellar ligament is the the so of the capsule and In the of this type of the medial of the capsule was and in to about a The was to the capsule and fascia and This was to be to so the patella was at its lateral margin the was to the patella and to it in the medial while the patella to the medial The was to was on the of the lateral fascia well the margin of the tendon the fascia and ligament on the medial the was through the fascia, the and and The was in a with the fascia not These methods not of the dislocation in a high of not the high position of the patella; not any of the lengthened patellar not the muscle of the quadriceps in a so that it can its in out normal function. The the by of a of the an was from the joint capsule on the medial and this was with the patella This was also with a of the It was in many to a lateral to the patella through the the of the patella an at the of the This was in by of a from the medial ligament not The for out this is to a of the medial the fascia, and the over the upper margin of the patella into the gap on the lateral not This was also by and This type of can be with a muscle type of includes the from the of the capsule to the with a of the medial capsule and a of the quadriceps This type of permitted in a of with the The patellar ligament is not shortened by this the patella not its normal this type of is not to the severe in which the patellar ligament on the since it not about a of the quadriceps the the ligament to at a marked from the patella to the The which the by the particularly by of was to the quadriceps by the tendon and the of the to the patella This was by and The of of the quadriceps was altered by the to this muscle In to the the was also to the quadriceps by it through the fascia of the The was also on to the patella in to the capsule and the insertion of the patellar ligament The muscle was the quadriceps tendon and into the medial In this way the as a to the patella and A of and tendon transfer from the outer to the has The of muscle was an to the weakened quadriceps and to the patella The to this from being a and to is that the forces that the patella are much the of all the that can be The results are The has because of the of not The of A of fascia or tendon was to the patella and to the medial condyle of the and have this with and it for and The from the lateral of the knee was over the patella and to the medial condyle This was also by other and The was the and to the medial of the tibia A of fascia was to the patella and both to the and the medial condyle A of fascia was through a in the patella and to the tibia to a new patellar ligament for a the patella from and it in the quadriceps tendon was on to the muscle by of a also a of the quadriceps of this is that namely, the lateral of the to the which even if in relatively or give way with resultant of the dislocation. it not the high position of the patella the lengthened patellar it not normal function of the quadriceps The of the lower end of the femur. the patella from slipping an was which permitted a of the leg and into normal position from and from was which lengthened the and on the quadriceps the patella from slipping the condyle was by of an The condyle was and an the upper end of the was and a tibial has not This type of tibial has with In of genu valgum it may be to out the by of a to the slipping of the patella have not always since the quadriceps in of the the quadriceps is shortened as a result of lengthening and this to of at the knee The and not be the of to the of the this is an for in which the slipping is to the of the It the joint. It not effect a of the patella and of the patellar ligament, and not the normal of the however, have with both methods The type of in the patellar The ligament was in the outer the and through a in the of the tibia of this was by The patellar ligament was from its insertion and to the condyle of the tibia by a of the time the was because it was the The fascia of the was which increased the on the quadriceps The of the patellar ligament has and and to the tibia the The entire ligament has and and at the time to a lower the A with its base at the insertion of the patellar ligament is from the medial of the knee to the lateral the patellar ligament and at the time an of the to the genu valgum. The patellar ligament has also by a A which the attachment of the patellar ligament has from the tibia and to slide medially, about a medial of the ligament of the medial capsule has in with patellar ligament In the congenital type of dislocated patella with in the lateral fascia and the will not be since not the quadriceps in to the The quadriceps to and to as an the the patellar ligament at an from the patella to the tibial The in this for a of time will to cause a of the tibia which will result in a of the of treatment to dislocation of the patella has to a from the patella in the condyle of the and have also for this not from the the tendency is toward some type of In one is a complete of the quadriceps with into the joint. a the of is out with a medial of the entire patellar insertion and not is to an the patella on both through the joint. the patella and the medial of patellar ligament are so that the quadriceps tendon into the This a gap on the lateral which into the joint. The patellar ligament is and with a The gap is allowed to In a the outer margin of the and both of the patellar tendon and a surface on the of the The muscle and tendon displaced and and the capsule was from the to the outer of the joint type of is to the patella and the patellar ligament and its insertion so that are a is in the of the capsule of the knee joint through which the patella and patellar ligament are The in the capsule is with The attachment of the patellar ligament is on to the and the patellar ligament and patella are to the capsule of the ligament and not The to are that and in the joint surface which the are the of a or is not and the position of the patella is not so as to a normal position for at the patella to normal muscle to the quadriceps muscle OF A The of a have in the to previous The of an for recurrent dislocation of the patella (1) the of (2) the of on the part of the (3) the of the of the knee the normal of the knee, the to the and the of by a review of the that have to the time that so has the by an that will both a of the anatomical changes and of normal function. In to the of an anatomical for all of recurrent it is to normal of the quadriceps muscle from its to its This includes the of the patella into its normal as well as the attachment of the patellar ligament to the patella so as to the of through it to the The patella be to its normal position with to its to the It is also important that the quadriceps tendon is not displaced but lies in the important of is the that the upper margin of the patella be over to the for it is that the is in the knee is to normal of the quadriceps muscle it is to have normal which if patellar ligament is it is to lower its insertion or to the of the quadriceps The about to be was years and has in of recurrent dislocation that has to since that the is the results have are in of which congenital The is to the most as well as to the of the congenital and traumatic the rachitic type with marked genu the of is the of the genu valgum by of a The of the to is as and not A is the upper lateral margin of the patella, the patella, and to the about the tubercle of the The is on both to the patella, the tendon, and the patellar The patellar ligament is to its A of about the attachment of the patellar ligament, is from the tibia by of the on three surfaces and an on the upper surface the The entire lateral of the patella is by the fascia to the The is the lateral of the tendon, well into the of the fascia lateral to the this fascia is to the capsule but the remains The patella can be The insertion of the patellar ligament is to the of the tibia and the patella lies in the normal position the this some of the quadriceps The is to two which are a is from the tibia in this by of the The attachment of the patellar ligament and its are in this and the is over the The is into the at the tibial of as to the medial of the patellar ligament to the The medial fascia is in the of the upper margin of the patella. It is not to the fascia to in the gap on the lateral The is The is by of a for from to The are at the end of this which the quadriceps muscle can be and with the leg The the knee can be and the quadriceps muscle allowed to is permitted A has and by of the Mayo Clinic without on the insertion of the patellar The has and has the of being a true type of which use and increased as well as being to both congenital and traumatic of dislocation. The of the all the as for a in of slipping patella. It of the anatomical which includes the of the quadriceps tendon, the patella, and the patellar ligament, so is a of in the quadriceps muscle It the position of the patella both in to the condyles and in relation to the the upper margin of the patella is in the so the has tendency to displace it laterally. The of the quadriceps muscle can be so that the is The of the patients will that have that the function has to that in some the has increased that of the other knee, and as by the that the knees at all Congenital of the knee, with and in the knee, a slipping patella. years of was to on of a weak knee which that since he with his knee, that out of in the knee and he This frequently and was by in the the years associated with in the He in many the He that in was any surgery that he was that be and that he have to with his disability. the years his to the the of a in the knee become and severe, and he to the knee with any degree of and of a and at the of His died of his was and he or a well was to into the in was for a The patellar was of the lower atrophy of the quadriceps with a in the of the as with the The patella was in a normal and was associated with A be over the knee it was and in and in one was was and of the knee a on the posterior surface of the patella which an The was congenital of the knee with and a in the knee, a slipping patella. The was A was the upper lateral margin of the patella and the patella to in the about the tubercle of the The was on both to the patella, the tendon, and the The patella was to be displaced laterally. The knee was through an on the medial about an and in The surface of the knee was for the posterior surface of the patella was and to be The patella was to a The posterior surface a which an with a but the attachment was so that it with a and The knee was The patellar ligament was to its the insertion of the ligament was by the of a of about which the attachment of the The entire lateral of the patella was by the fascia to the This was the lateral of the tendon into the of the fascia The patella be The insertion of the patellar ligament was to the medial of the and it was about its this point the was to two which The and the insertion of the patellar ligament so that both surfaces in with The over the with to the patellar ligament to the at a The medial fascia was in the upper margin of the patella by of so that this the of a The was and a posterior of was the the to it and the it normal and so the he of to the that the he was to he was permitted to he to with the of a and to the He all his on the The quadriceps was was He and one at a time the the he of the knee and normal of the The has for the his he with the is not the and he is to and without the tendency toward any or He has that the knee will give in of the that he always a of in to the knee from to the time of It is his that the knee is the other This is an of a severe congenital with a slipping patella and a disturbance in as well as an in the anatomical It is the type of in which the not be by any of the previous methods but it to the in an not only from an anatomical but from a as dislocation of the patella of congenital with in knee joint. D. years of was to on of in the knee, the result of on so that was to an of with the knee, but a of for the nearly as an of in the knee by a at the of previous to into the while a in a in the the knee and to was in the where an a in the was for a previous and was and on two changes in the knee with a The was and the patella displaced laterally; it to be in the was A was at the upper margin of the patella, its medial to the tubercle of the The was and the patella was the patella was to be displaced laterally. The knee was on the medial surface and a the of an was in was The tendon and the patellar ligament was the lateral of the patella, the fascia to the this was the of the tendon and into the lateral fascia of the the patella was so that it be the patella was and a was by of an from the tibia in the of its The was about to this and a about was The attachment of the patellar ligament and its in this The was over the The was into the of the tibial The was over the and from the patellar ligament to the of the The medial fascia was by at the upper margin of the patella. The was and a posterior was The to on the it was normal and on the was The was from the on to in a on and was on for was a has with the that the knee is the other, and that has any of much any slipping or has has in the of the it is and has as normal the patella being in a new This is an of a knee that a true which rise to of which the at the time of The may or may not have secondary to primary which was a congenital type of recurring dislocation of the patella. The anatomical changes with a in this The by of the in complete from all which to the of the of the of the slipping patella of the congenital genu valgum. W. years of for on of injury to the The of the was was about years of in knee while was and The knee was and was in from that time on the knee out and cause years previous to the and the knee over the of the was on for The knee has since and for the years the has many and to was with only this in the knee was practically and the knee was constantly of the knee was times the was that it was a while was but was the time of was a marked genu the knee was so that it was to the patella. was and the was to without and the use of was some and was over the of the The a loss of joint with of A was of (1) traumatic of the (2) of the (3) a slipping patella of the congenital and genu valgum. In of the severe a of the knee was but as the changes secondary to a slipping patella with of the knee, the to the loss of at the knee was and of the knee was The was the in this It the knee joint to the joint The was was a over the surface of the The of the and its as well as the out with a and The joint surface was to be in The was thinner was an of the in which was with a The joint was and the for of the dislocated patella was The knee on the The was and a was to of The and the In the was allowed to go the was and an to by was at the and the genu valgum was The was for without the of and The genu valgum only about of but this was and this point cause some The however, that was in the This the caused by a slipping patella over a of The recurrent dislocation of the patella in caused an of the knee with a of the a of over years a high degree of A and have In with the however, an to the by of a tendon was with a result to type of slipping patella. years of was to on of a dislocation of the knee which rise to severe, and of the He that years while he a with his leg and a severe, in his He that the patella was He was to without and was which about The patella to to normal that time however, he his knee the patella and at times he severe with a true dislocation of the and associated and and at years of he always was for the lower The patella was normal in and The knee was normal but was a dislocation of the patella toward the which was not It was to the patella only the knee was The dislocation time the knee was was atrophy of the quadriceps was the was The patella was through a lateral The fascia on the outer surface of the was divided, as the ligament and fascia lateral to the patella. These about in this and The was out the patella be displaced the knee the insertion of the patella was from its position on the lateral of the tibia to a point medial and to its position by of a The new attachment was with from the patellar ligament to the The medial ligament was shortened at the upper margin of the patella. The was and a was The to the but to normal on the and normal was The practically The and on the The with the of was and on the of the knee was He was from the on he was out his of The knee and its increased its was that of the other He and in the without in the He has since the in he without the of his to he was to a that time he has not only a but has also He has any about a any of This is an of a recurrent dislocation which become a dislocation. It a true traumatic type of slipping patella. The in and it is to of any other type of which be for the anatomical changes that in this A has and on a clinical recurrent dislocations of the patella into three types: (1) congenital, (2) traumatic, and (3) A of the anatomical changes in is The effect of the is in of altered function. The of of normal function is A review of all the previous methods of is into to the of This includes a complete review of the with A of type is on the of for a is which is in that it all the of (1) it of the (2) it gives the a of (3) it the it gives the knee a normal the to the is and the is The of the is in the for of the is are The has in use over a of and the results have