Indications in the Treatment of Patellar Instability

Recent developments in patellar instability have focused on the passive restraints against mediolateral patellar motion. Viewed from this perspective, muscle alignment is considered secondary because, although muscle forces are important, their ability to cause or prevent patellar dislocation depends on passive stability or the lack thereof. In the normal knee, the patella seats quickly in the trochlea in early flexion, so that the ligamentous restraints are important only near full extension. In the unstable patellofemoral joint, the trochlea frequently is deficient and patella alta often exists. In such cases, the ligaments assume a greater role in preventing excessive lateral patellar displacement. The most pressing questions at the moment are: 1) which of the anatomical abnormalities must be corrected, alone or in combination, to prevent further patellar instability; and 2) what is the relative risk of corrective procedures compared to the natural history or competing surgical approaches? These questions must be addressed by clinical trials. Only a minority of patients who experience patellar dislocation will redislocate the patella, and surgical treatment does not always yield results that are superior to conservative care. Treatment recommendations should be based on an individual's risk of recurrent dislocation, pain, and disability, a thorough understanding of his or her anatomy, and clear treatment objectives. Lateral release has no role in the treatment of a hyperlax patellofemoral joint, as it adds additional laxity to a system that is already unstable. If surgery is performed, current evidence suggests techniques aimed at repair or reconstruction of the passive retinacular restraints are as effective as more extensive procedures at preventing subsequent dislocations. Among the latter procedures, realignment procedures use active muscle forces to help seat the patella in the femoral groove; however, biomechanical costs are associated with this approach and superior results have not been demonstrated with distal and combined realignments compared with more limited proximal procedures.