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Surgery: Patellar Dislocation

MPFL reconstruction for recurrent patellar dislocation: surgical technique, detailed postoperative course and return to sport. Dr. Priano, Milan.

Medial patellofemoral ligament reconstruction for patellar instability

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Surgical Techniques

Medial Patellofemoral Ligament Reconstruction (MPFL)

Reconstruction of the main medial patellar stabiliser with a tendon graft. Position and fixation are selected to restore function; in growing patients the technique must protect the growth plates.

When it is used

Recurrent patellar dislocations (2 or more episodes), first episode with associated osteochondral lesion, persistent patellar instability despite rehabilitation.

Recovery

Hinged brace in the first weeks, with progressive unlocking as instructed. Rehabilitation over several months. Return to sport is based on clinical and functional criteria, not on the calendar alone.

Tibial Tuberosity Transfer (TTT)

Repositioning of the patellar tendon insertion to address selected anatomical factors, such as patella alta or lateralisation of the tubercle. It may accompany MPFL reconstruction; Q angle alone does not establish the indication.

When it is used

Selected cases assessed according to anatomy and skeletal maturity. An open proximal tibial physis is an important restriction and normally a contraindication; any near-closure cases require specialist assessment of remaining growth. This is not a standard procedure for a skeletally immature child.

Recovery

Longer protected weight bearing than isolated MPFL reconstruction. Longer rehabilitation and later return to sport: combined procedures change the whole pathway.

Trochleoplasty

Reshaping of the femoral trochlea to create a deeper groove that stably accommodates the patella. Reserved for selected cases with severe trochlear dysplasia.

When it is used

Instability with severe trochlear dysplasia in carefully selected cases. Trochlear shape, cartilage, skeletal maturity and remaining growth matter; reports in adolescents approaching maturity do not justify extending the procedure to all children with open physes.

Recovery

Prolonged non-weight bearing period. Careful rehabilitation and later return to sport.

Postoperative Overview

The surgical approach to recurrent patellar dislocation is personalised based on each patient's predisposing anatomical factors. MPFL reconstruction alone is sufficient in most cases; bony procedures are added only when necessary. Success depends largely on postoperative rehabilitation, focused on global quadriceps recovery, hip strength, neuromuscular control, proprioception and movement quality. The pathway described below is indicative and personalised; combined procedures (TTT, trochleoplasty) change timing, weight bearing and progression.

Recovery Pathway (indicative)

Note: This is an indicative pathway, personalised after surgery. Some elements are relatively stable (goal of the procedure, approximate hospital stay, presence of a cast or brace); others depend on the individual case (weight bearing, range of motion, imaging, sport, hardware removal, follow-up intervals) and on the surgical technique chosen.

  1. Hospital stay

    Usually one night in hospital. Arthroscopy-assisted or mini-open surgery. Discharge with a hinged brace locked in extension.

  2. First weeks

    First weeks: brace locked in extension for walking, ice and rest with the leg elevated. Early start of isometric quadriceps exercises and passive patellar mobilization. Brace unlocking and ROM progression are orientative (usually gradual over the first weeks) and are decided by the surgeon according to the technique and any combined procedures.

  3. Second month

    Brace removal and transition to full weight bearing when indicated. Rehabilitation focused on global quadriceps recovery, hip strength, proprioception and neuromuscular control, with progressive ROM recovery.

  4. Third month

    Progressive muscle strengthening, closed kinetic chain exercises, cycling and swimming. Light jogging is reintroduced when pain, swelling, strength and control allow.

  5. Return to sport

    Indicative pathway: running and sport-specific exercises in the middle months, then gradual return to sport. Return is not decided by the calendar but by clinical and functional criteria: no effusion, full and pain-free ROM, strength recovery compared with the healthy side, good single-leg control, quality of hops and change of direction, psychological confidence. The 9-month reference (longer with combined bony procedures) remains an orientative, cautious indication, not a single requirement. A knee brace on return to sport is proposed in selected cases, not as a universal standard.

  6. Follow-up

    Scheduled clinical follow-ups during the first year. No routine MRI is performed to assess the neoligament: imaging is requested only if clinically indicated. Functional assessment before return to sport.

Possible Complications

Possible: stiffness (limited by early rehabilitation), recurrence of instability, residual anterior pain, hardware irritation (rare, removal if needed).

For parents

Patellar Dislocation: condition information page

Causes, diagnosis, conservative options and when surgery is considered.

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