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SECTION I: SYMPOSIUM: Papers Presented at the 2006 Meeting of the Knee Society

The Classic: Recurrent Dislocation of the Patella: Operative Treatment*

Roux, César

Section Editor(s): Laskin, Richard S MD, Guest Editor

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Clinical Orthopaedics and Related Research: November 2006 - Volume 452 - Issue - p 17-20
doi: 10.1097/01.blo.0000238832.88304.0e
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César Roux, born March 23, 1857 at Mont-la-Ville, died December 21, 1934, in Lausanne. Roux was educated in the Lausanne schools and persued medical studies in Berne from 1874-1880. After one year of study in Vienna, Prague and Halle, he became first assistant at Kocher's Clinic and L'Hôpital de L'lle. In 1883, he began a medical practice in Lausanne. He rapidly achieved a reputation of an extremely skillful surgeon. In 1887, he was asked to become the physician in charge of one of the 2 surgical services at the regional hospital in Lausanne, and in 1890, Roux was given a title of Extraordinary Professor and in 1893, Ordinary Professor of Surgery. Roux knew how to incite students to observe and think. His fiery medical, professorial and scientific activities lasted almost 40 years. He was a commander of the French Légion d'Honneur and Doctor Honoris Causa Degree of the University of Paris in 1929.

Roux's name is closely linked to important progress in modern surgery, especially in the treatment of typhlitis, an affliction that Roux named more pertinently appendicitis. His operative methods represent important innovations (thoracoplasty in pulmonary tuberculosis, esophagojejunogastrostomosis in esophageal stenosis, posterior gastroenterostomy in Y-manner in gastric carcinoma, etc). There is practically no surgical intervention that Roux has not modified technically in an original manner. A great number of new instruments and apparatuses are attributed to him. In his later years, Roux was particularly interested in the goiter problem.

J.C.P.

The classic authors recommended prevention of a recurrence after reduction of a dislocated patella by the use of appropriate bandages, more or less effective, the most common one being the laced knee brace. Most modern works do not even mention the non-reduced dislocation, or they regard it as a minimal disability. Which seems to prove that the entity is rather rare, that those who suffer from it very often do not seek surgical counsel, or finally that the consequent functional orders are rather insignificant. But one must distinguish: it is true that in the lateral type, for example, that a fixed dislocation, although it is frequent, produces minimal patient discomfort to a point of refusal to consult a physician or even wear a bandage. We have all seen occasionally one or more cases of a patella resting on the lateral femoral condyle where the patient would not even mention this anomaly. The thigh is slightly atrophied. No disability is apparent in the gait. For these cases, reduction is more or less easy but at the slightest motion the patella immediately resumes its place in the outer aspect of the condyle.

It is totally different for an individual suffering from recurrent dislocation proper in which the bone usually is in its normal position but easily displaces frequently after a false motion, a particular muscular contraction, etc. In this case, each new displacement is an accident, predicted and little apprehended it is true, but repeated at any time (usually at the same time the patient thinks he has set his balance) which very soon pushes the patient in a total loss of confidence in certain exercises with his leg. This can be easily understood if one remembers that, for a dislocation to be produced or not by a given motion, a few millimeters of excursion is all that is necessary.

In order to compare the insignificant functional disorders of the non-reduced dislocation in relation to the more severe ones of the recurrent dislocation, we have found it worthwhile to present the following case report of a young girl treated by us last spring.

Fanny Lavanchy, 13 years old, entered the hospital on May 21, 1887; her mother wanted her healed from the sequelae of an old accident even if surgery was required. She gave Mr. Hansen, the intern on the service, the following history.

In 1881, fleeing from her father who wanted to beat her, the young girl jumped from the top of a 15 step staircase and landed on her feet, then flat on her back and was unable to get up; she denies having felt any special knee pain. The two tibio-tarsal articulations were swollen and painful, the left knee was markedly swollen, red and hot during the 15 days that she was in bed before “mege” was used. During the next 3 months, the child was crawling on all fours.

At this time Dr. P. was consulted at C. He treated the swollen knee which appeared to be the only problem with an elastic bandage, which was very painful; he discovered that the patella was freely mobile on the lateral aspect of the lateral femoral condyle during gait or during simple quadriceps contraction.

The status on May 23rd. A young, red-haired girl, non-anemic with remarkable musculature, with no other anomaly than her left knee slightly prominent. The left thigh like the leg appeared to be slightly smaller than the right side; muscles were well developed. At rest, there seems to be nothing abnormal with the knee; but when the reclining child contracts the quadriceps or attempts to elevate the heel above the bed, the patella subluxes laterally: there is a complete dislocation, that is, the inner aspect of the bone touches the lateral aspect of the lateral femoral condyle. More medially, one can feel the intercondylar notch and notice that the aponeurotic expansion of the quadriceps on the inner side of the patella does not get taut when the child contracts the thigh muscles.

After repetitive exercises, one can see the outline of the muscle bundle of the vastus lateralis, which is prominent and pulls the patella laterally by its superolateral quadrant. Medial to this ridge, there is a fairly deep depression near the patellar insertion.

There is no doubt that this is a complete dislocation of the patella, laterally, with rupture of the internal patellar aponeurosis, with the dislocation recurring constantly under the influence of the vastus lateralis traction.

When the child bends the knee gently, the patella remains in place up to maximum normal flexion and loses its normal position when the child has to reextend the leg. A similar event happens when the child walks very gently. By slightly turning the end of the foot inside, which she does most of the time, she avoids little accidents which inevitably happen when she is hurried or when she initiates ambulation by a vigorous contraction of the quadriceps. If the patella is displaced at the beginning of a flexion motion, the child may achieve a range of motion without great difficulty with the bone dislocated; if the range of motion has attained a certain point before contraction of the vastus lateralis, the patella will not pass the edge of the condyle no matter how energetic the muscle contraction is and the flexion will be achieved without incident.

A dislocation occurs, it is obvious, when the quadriceps contraction surprises the patella before its two superior half-facettes arrive in contrast with the anterior aspect of the condyles or are engaged in the intercondylar notch. As long as the two inferior half-facettes of the bone touch the condyles by their antero-superior part and when the patella barely touches the condyle by its tranvserse crest only, the contraction of the vastus lateralis immediately pulls it out of the condyle but when the superior half-facettes are against and between the condyles, any traction superiorly and laterally will place the bone more intimately against the femur and will be incapable of driving it beyond the edge of the lateral femoral condyle.

One can understand that it is difficult for this patient to define her precise limitation and she has been many times taken by surprise by the dislocation. She has lost confidence in her leg and can not trust the leg to ambulate fast, go down stairs and especially run unless her leg is stiffened ahead of time.

If the child climbs the stairs slowly, there will not be a dislocation. When she squats gently, everything remains in place until she is erect; if she hastens, motion will begin with a dislocation which will persist throughout the range of motion and the patella will resume its position when the muscles relax. Young L. states that she has more difficulty getting up in the second case than in the first case.

In summary, despite the little artifact in the foot posture, she has been unable to avoid the surprise caused by each dislocation at a time she would like to depend on her leg. She also has developed a habit of dislocating the patella at the beginning of the motion so that she could benefit from being accustomed to inveterate lateral dislocation.

She has a frank limp and rapidly deforms her left shoe.

She really does not mind avoiding the positions which would reduce the number of patellar accidents produced inadvertently. Obstinate like a boy and incapable of obedience, she runs, jumps, climbs the vineyard walls, descends the stairs hastily despite the numerous falls which she incurs daily.

Furthermore we have noted, on many occasions, that there were hyperextension motions (probably passive) in her knee associated with sharp pains in the popliteal fossa.

During the few months after the original accident, the dislocations were relatively rare; later on, they would become more and more frequent. The child falls a minimum of 3 or 4 times a day frequently going down stairs, once carrying a baby in her arms. This is what led her mother to request a cure at any price since she can not stand the persistent anguish of a possible serious fall.

It was obvious for us that this was not an inveterate dislocation that a patient may have without complaing, but rather an habitual dislocation for which something had to be done and we were led to chose between a containing apparatus or an operation.

One could attempt to maintain the patella in place by means of a laced bandage or a similar apparatus; but the outcome is very relative and, even with a laced bandage, the child still had the dislocation and the constant renewal of this apparatus because of growth could be very costly. We also worried that the parents, because of their education, may not have the necessary persistence and, losing faith in our art, would abandon the patient and her deformity. The mother, particularly, did not have any confidence in this type of treatment because, at the beginning of the illness, she had seen the patella displace under the tightest bandages.

From the operative standpoint one could consider transforming the habitual dislocation into a non-reduced one and fix the patella on the outer part of the lateral femoral condyle; this would have been worse than a bandage; on the other hand, we could attempt a restitution ad integrum and this is what we accomplished very successfully by the following operation.

To fix the patella to its normal position by suturing the torn aponeurosis; to exclude temporarily the perturbing action of the vastus lateralis; to assure a good result by displacing medially the insertion of the patellar ligament: this was the triple goal of our operative plan.

On the morning of May the 26th, in the presence of Dr. Francillon and with the help of Mr. Hansen, the child, coming out of her bath, is put to sleep with ether; the leg, shaved, scrubbed with sublime 1 for 1,000, is placed through a hole in the middle of a large operative sheet soaked in sublime that covers the entire patient and the operating table. A rubber band is applied at the root of the limb.

An incision a (Fig. 2, not shown) measuring 9.0 cm, convex above and outside, at 1.5 cm from the edge of the patella c, crosses the entire thickness of the vastus lateralis muscle, the fibers of which will not be able to operate their traction on the superio-lateral quadrant of this bone. The superior part of the incision leads to the external aspect of the bursa under the quadriceps which is left intact while somewhat inferiorly it is partically impossible to leave intact the articular capsule intimately adherent on the deep portion of the muscle as it spreads over a few millimeters. Pending the end of the operation, in order to attain definitive hemostasis, a fine sponge soaked in sublime 1 per 1,000 is sutured in the wound.

A second 15.0 cm incision b, longitudinal, begins above the patella extending medial to it, the patellar tendon and its insertion. In its superior portion, this incision is limited to the skin only and allows retrieval of the lateral aponeurosis of the patella which is found extensively torn as may be expected. A few fibrous fascides, spread apart like rake teeth, assure the means of continuity. The edges of the tear are freshened and a strong interrupted catgut contention suture followed by a running less strong simple suture on the edges of the aponeurosis are made. The patella is thus fixed in its normal position.

To accomplish the displacement of the patellar tendon, the inferior aspect of the incision penetrates to the bone; the skin only is retracted laterally to the lateral edge of the patellar tendon along which an incision x′′′, paralled to the first, also down to bone, somewhat like a subcutaneous incision. By means of a wide thin Macewen osteotome, the patellar tendon d is detached from the tibia, sparing at its inferior extremity the continuity with the thick and rich periosteum which will assure its nutrition and guarantee exact coaptation. Then within the first incision is elevated the periosteum of the tibia from which is resected a triangle xxx′ with a narrow 1.0 cm base turned above near the articular cartilage. From this denuded subperiosteal surface the patellar tendon is slid and fixed with two steel nails going through the skin and placed one above the other at a 1.5 cm distance. To avoid retraction of the internal border the advanced ligament is sutured with two large catguts through the tibial periosteum.

The operation, considerably shorter and simpler than this description, has ended.

The two wounds are rapidly washed with sublime which is not left in contact with the tissues more than a few seconds; the larger superficial wound is closed without drainage; the first deeper incision received a small drain through a special lateral aperture. After completing hemostasis, Girard's suture is done with a sublimized silk.

Compressive bandage made with a layer of iodoform gauze (prepared with sublime), a cushion of sublimized sawdust and a nonimpermeable ordinary cotton. The limb is placed in a splint. The postoperative course is simple. The maximum temperature is 37.8 the night of the third day.

After 2 24-hour periods, the drain is removed as well as all the sutures as is the rule. A new dressing, similar to the original one, is applied.

On June 1, after 6 days, healing by first intention is noted.

On the fifth of June, the knee is carried through fine motions of flexion and extension to avoid articular stiffness, this exercise is repeated every day. On the 15th of June the splint is removed but the patient is told to be strictly immobile; two days later, she tried to run around the room.

On the 18th day of June, she was allowed a short walk every day.

On July 10th, there was minimal pain around the nails, which have disappeared under the skin and are covered with a small crust. They are removed without difficulty on the 12th with an anatomical forcep. Since the beginning of the month, the child walks all day. She still limps when she thinks that she is alone. When observed she walks perfectly, the patella remaining in place.

On July 22nd, a slight difference in thickness between the legs is noted. The left thigh and calf are respectively 1.0 cm and 1/2 cm less on the left than the right. Active motions of flexion and extension are the same on both sides. The left patella maintains its normal position when the patient contracts vigorously the thigh muscles in extension. It is as difficult to displace laterally the patella on the left as it is on the right. When the muscles are relaxed, one can move the left patella left to right and vice-versa as on the right side. At the level of the supero-lateral scar, one can feel the contraction of the vastus lateralis perfectly reestablished without sign of a hiatus in the scar. The internal scar, free in its superior two-thirds is slightly adherent in its inferior extremity without depression. The sewed aponeurosis may be felt vigorously taut in active forced extension. The superior nail wound is closed without adhesions; the inferior is not completely closed. When compared with the right side, one can feel at the attachment of the patellar tendon a slight subcutaneous fairly resistant bulge, accounting for the proliferative process of the point of transplantation.

Gait is absolutely normal; the tendency to turn the foot inward is completely gone, without progression to the reverse attitude. The young girl seems to be afraid to ambulate rapidly.

Today, a total correction has been obtained and the mother of young L. is astonished that the sutures have held since she thought that a recurrence would occur considering the child's vigorous use of her leg.

The members of the Vaudoise Medical Society as well as those of the “Suisse Romande Medical Society” have been able to control the anatomical and functional result, excellent in all aspects.

If one operative success does not by itself justify the surgeon's intervention, it seems that in this case the indication was formal. The only point that seems debatable is the necessity for such a complete operation. Were one or two phases of the operation sufficient? We do not think so, and if we were faced with the same situation, we would act the same way, even if it seemed excessive.

Displacing the patellar tendon only would not have been adequate; the same applies to the simple division of the vastus lateralis that eventually reconstitutes itself. In the first case, traction of the vastus lateralis would have easily displaced the patella over the lateral condyle.

The mere suture of the torn aponeurosis would have carried a better prognosis provided that the unrestrained action of the vastus lateralis had not distracted the freshly scarred suture line. The prolonged immobilization necessary in this case would have had some inconveniences.

If we had to choose between 3 possible combinations of 2 phase procedures, we would be quite embarassed; it seems that the aponeurotic suture associated with transplantation of the tendon attachment seems preferable and one would hope that the muscle would not disturb our calculations.

The contraction of this part of the quadriceps was obviously the main (occasional) factor in the patellar migration and it seemed natural to suppress it temporarily since the functional recovery of this muscle is almost a certainty. It is necessary to reestablish continuity in the torn aponeurosis which is the real anatomical cause of the recurrent dislocation. Finally, the displacement of the tendon medially seems to have corrected the inward position of the foot, changed the contraction direction of the vastus lateralis, diminished the prominence of the knee, and given the critical stability which prevents the patella from abnormal tracking when it is in equilibrium on its transverse crest or ready to go beyond the edge of the condyle.

The operation has been described with some length but in reality it takes minimal time; it is easy to perform; for a Listerian, there is no morbidity and the contemplated result justifies fully the surgeon's labor and the operative risks.

© 2006 Lippincott Williams & Wilkins, Inc.