Case Report

Knee Surg Relat Res 2011;23(3):177-179

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pISSN 2234-0726 eISSN 2234-2451

Knee Surgery & Related Research

Surgical Treatment of Habitual Patella Dislocation with

Genu Valgum
Ji Hoon Kwak, MD, Jae Ang Sim, MD, Nam Ki Kim, MD and Beom Koo Lee, MD
Department of Orthopedics, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea

Habitual dislocation of patella is a rare disorder. Sometimes it is associated with angular deformity such as genu valgum. We experienced habitual
patella dislocation associated with genu valgum that was treated with corrective osteotomy of distal femur and soft tissue realignment procedure
including lateral release and medial reefing.
Key words: Habitual patella dislocation, Genu valgum, Distal femoral osteotomy.

Habitual patellar dislocation is a rare condition where the patella

dislocates during flexion and relocates during extension unlike
chronic patellar dislocation that occurs during both flexion and
extension of the knee, and it usually presents without pain or
swelling.
A variety of surgical techniques have been introduced for the
treatment of habitual dislocation of the patella with genu valgum.
Among them, osteotomy combined with proximal soft tissue
realignment procedures including lateral release and medial
reefing has been commonly performed. It has been known that
significant treatment results can be obtained with combined
procedures, not with a single procedure.
We here report a case of habitual dislocation of the patella
with genu valgum treated with a corrective osteotomy of the
distal femur combined with lateral release and medial reefing.
Received October 22, 2009; Revised December 15, 2009;
Accepted June 13, 2011.
Correspondence to: Beom Koo Lee, MD.
Department of Orthopedics, Gil Medical Center, Gachon University of
Medicine and Science, 1198 Guwol-dong, Namdong-gu, Incheon 405760, Korea.
Tel: +82-32-460-3384, Fax: +82-32-468-5437
Email: jihoon1976@[Link]

This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License ([Link]
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Copyright 2011. THE KOREAN KNEE SOCIETY

The clinical and radiological outcomes of the treatment were

satisfactory.

Case Report
A 23-year-old man visited our institution due to lateral
dislocation of the left knee in flexion and instability that had
persisted for 7 years (Fig. 1). The patient had a history of femoral
growth plate fracture treated conservatively at 13 years of age. In
the physical examination, the apprehension test was positive. In
the radiographic examination, the congruence angle, sulcus angle,
Q-angle, and Insall-salvati Ratio was 44.17o, 152o, 18o, and 1.15,
respectively. The tibiofemoral angle measured from the weightbearing radiograph was 16o, indicating genu valgum deformity,
and hypoplasia of the lateral femoral condyle of the left knee was
observed. A skyline view of the knee showed lateral dislocation
of the patella. Arthroscopic examination revealed the hypoplasia
of the lateral femoral condyle, Outerbridge grade II cartilage
damage on the lateral articular surface, and contracture of the
lateral retinaculum and vastus lateralis. Patellar dislocation during
flexion was confirmed with arthroscopy. A lateral retinacular
release and an open-wedge distal fermoral varus osteotomy were
followed by additional procedures including lateral release and
medial reefing because dislocation was still present after the
osteotomy. About 2 cm of the medial retinaculum was reefed
because it was excessively elongated. When lateral dislocation of
the patella in flexion was no longer observed, a bone graft was
inserted into the osteotomy site. Gradual flexion exercises were
started postoperatively. Complete flexion was obtained at the

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178 Kwak et al. Habitual Patella Dislocation with Genu Valgum

Fig. 1. Patella is dislocated when the knee is

flexed and reduced in extension.

angle, Q-angle, and Insall-salvati ratio was 15.75o, 152o, 2.3o, and
1.03, respectively. The tibiofemoral angle was corrected to 4o of
valgus on the weight-bearing radiograph. Dislocation did not
recur at 27 months after surgery. No limitation of joint motion
was noted. The apprehension test for recurrent dislocation was
negative (Fig. 2). The Kujala score1) was 96, indicating excellent
clinical results.

Discussion

Fig. 2. (A) Two year after surgery, normal patella-femoral alignment was
achieved. (B) Distal femoral varus osteotomy was performed.

3rd postoperative week. Weight bearing was gradually permitted

and complete weight bearing was allowed at the 3rd postoperative
month.
On the postoperative radiograph, the congruence angle, sulcus

The causes of habitual patellar dislocation include contracture

and fibrosis of the quadriceps femoris, vastus lateralis, and lateral
retinaculum, abnormal iliotibial band attachment, repeated
intramuscular injections into the thigh, patella alta due to the
abnormal position of an elongated patellar tendon, systemic
ligament laxity, dysplastic lateral femoral condyle, and genu
valgum2-4).
A variety of surgical techniques have been introduced for the
treatment of habitual dislocation of the patella. However, it has
been known that combined procedures, not one single procedure,
should be performed to achieve relatively satisfying treatment
results.
Hnevkovsky et al.4) attributed habitual patellar dislocation to
contracture of the quadriceps femoris and introduced a technique
to lengthen the muscle with the use of a lateral retinacular release
and quadricepsplasty, which did not bring about complete
flexion in their patients. In our patient, genu valgum and lateral
femoral condyle hypoplasia following a growth plate fracture
were thought as the cause of the dislocation. A quadricepsplasty
was considered unnecessary because he had no contracture of
the quadriceps femoris. However, lateral retinacular release alone
was not sufficient to achieve joint reduction.
Realignment procedures can be performed additionally to
reduce the joint. They are broadly classified into proximal and

Knee Surg Relat Res, Vol. 23, No. 3, Sep. 2011

distal realignment procedures or bone and soft tissue realignment

procedures. Proximal soft tissue realignment procedures
including lateral release and medial reefing and distal realignment
procedures are commonly used in adults. In particular, distal
realignment procedures are limited to adult patients with 20o
of Q-angle because they could result in premature growth plate
closure in children with open growth plates.
Proximal realignment is the most effective treatment for
reduction of patellar dislocation. However, vastus medialis
advancement can cause an increase in pressure on the knee,
which eventually results in patellofemoral arthritis. Recently,
medial patellofemoral ligament reconstruction using
semitendinosus or gracillis tendon is recommended5).
Although the patients medial retinaculum was extensively
elongated, it was thick enough to be reefed and sutured.
Therefore, a reconstruction using a medial patellofemoral
ligament allograft was not considered necessary and the
reduction was maintained at the follow-up examination.
Appropriate surgical treatment methods for habitual dislocation
of the patella with genu valgum still remain controversial. Gao et
al.6) reported that flexion contracture of the quadriceps muscle
was the cause of lateral dislocation of the patella in children and
the sustained contracture also resulted in genu valgum. A release
of quadriceps femoris contracture can be effective in correcting
genu valgum in children who have hypoplasia of the lateral
femoral condyle due to growth plate damage7). Still, the ideal age
for the treatment has yet to be established.
In adults, if genu valgum deformity remains after realignment
due to the unstable patella, symptoms may also persist. Coventry8) reported that femoral supracondylar varus osteotomy
should be performed in patients with 12o of symptomatic genu
valgum or with 10o of tilt of the articular surface. Healy et al.9)
recommended to perform corrective osteotomy of the distal
femur for 15o of genu valgum. Shen et al.10) suggested proximal
soft tissue realignment and distal femoral osteotomy and
anteromedial tibial tubercle transfer to treat genum valgum with
20o of femorotibial angle. The femorotibial angle was 16o in our
patient. Therefore, we thought proximal soft tissue realignment
alone was not sufficient to realign the patella and performed
a femoral supracondylar osteotomy in addition. Femoral
supracondylar osteotomy for genu valgum can be performed
using an open or closed technique, but the latter has been
associated with postoperative joint stiffness7). Considering that
the risk of joint stiffness would be high in our patient because of
the complex procedures including lateral retinacular release and

179

medial reefing, we used an open osteotomy technique and took

care not to damage the joint capsule during surgery.
We believe that clinical improvement of habitual dislocation
of the patella can be obtained with correction of soft tissue
imbalance and contracture and realignment of the patellofemoral
and tibiofemoral joints. In particular, soft tissue procedures
should be followed by bony procedures including femoral
supracondylar osteotomy in cases of habitual dislocation of the
patella with genu valgum.

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