INFORMATION & PROTOCOLS
Many people (7 people out of every 10) will suffer some discomfort around their kneecap or patella during normal activity or exercise. Often, these symptoms are troublesome but not debilitating and in many cases will be resolved by physiotherapy and muscle retraining.
In a small group of people however maltracking or malalignment of their patella upon the femur will cause high pressure areas and the possibility of accelerated wear changes due to the “bad fit” of their patella on the femur.
Most commonly, this “bad fit” is due to the patella situated far too laterally (on the outside aspect of) the femur.
Realignment of the patella aims to address this maltracking problem and restore the patella back into the normal position on the centre part of the femur. By performing this procedure, it is hoped to lessen the immediate discomfort of the under surface of the patella and reduce some of the long-term changes that may occur due to patella malpositioning.
Patients who have lateral maltracking will be diagnosed by a mixture of clinical examination, x-rays and dynamic MR scanning. Dynamic MR scanning allows an active picture to be built up regarding the movement of the patella during knee function. It also provides an indication and picture of the cartilage on the under surface of the patella and any subsequent damage that may have been sustained.
You will be called to the hospital prior to your operation for assessment of your physical health. This ensures that you are fit and medically well to undergo surgery and there will be no problems with the administration of anaesthetic or other treatments. Samples of blood and urine are taken and the heart and lungs are assessed and checked to ensure all is well.
Please ensure that any x-rays or scans taken of the knee or chest are brought with you to the hospital on the day of surgery. These are essential for the planning and execution of your knee surgery.
You will also see a physiotherapist, who will assess your knee and gait and tell you what to expect post surgery. Your will be fitted for a lightweight detachable brace. You will take this home with you. It is very important that you bring this into hospital with you and that it goes down with you to the operating theatre.
Prior to surgery, you will undergo some preoperative assessment checks to ensure that you are fit and healthy for the operative procedure.
Prior to the operation you will be seen by myself and the anaesthetist and at that point any further queries or questions may be addressed to myself or my anaesthetist.
At operation I shall perform an arthroscopy to inspect the under surface of the patella and confirm patella maltracking. If technical aspects allow, I routinely record a DVD of the procedure for the patient’s understanding and information.
The whole knee is inspected including the under surface of the patella to include the main tibia, femoral joint and all ligament structures.
An internal release of some of the tight tendons is then undertaken and then through a small incision on the front part of the knee, the attachment of the patellar tendon to the tibial bone is moved sideways, most commonly to the inner aspect of the tibia and re-attached with two small stainless steel screws.
The position of the patella following this realignment procedure is then confirmed using the arthroscope. The skin incisions are then closed if the alignment is found to be satisfactory.
POST OPERATIVE PROGRESS
Following surgery the wounds of the knee are dressed and subsequently a lightweight detachable brace is worn for 3 weeks to allow the bone to fully heal at the site of re-attachment.
During the immediate post operative recovery, you will receive physiotherapy guidance in learning to walk with the brace and use of crutches as required. Whilst resting, sleeping and stationery activities, the brace may be removed for comfort. However during walking and weightbearing activities the brace should be retained to support the knee.
Your physiotherapist will instruct you in activities to strengthen the muscles of the thigh and in minimal (maximum 40º) knee bending exercises. You will be shown how to put the brace on and off.
To prevent any bloods clot forming in the back of the calf, intermittent compression bootees will be worn in the immediate post operative stage. X-rays will be taken on the day following surgery to ensure that the fixation of the moved bone fragment is satisfactory.
Week 3 onwards
At the end of the third week I will review the surgery in outpatients. At that point intensive physiotherapy will be commenced and you will gradually be weaned from the brace. These exercises are aimed at increasing knee flexion and further strengthening the muscles of the thigh, particularly on the inner aspect of the leg, to improve patella tracking.
Following the three week appointment physiotherapy is commenced and I would under normal circumstances review patients at a further eight weeks. The outcome is dependant upon the degree of damage that has been sustained to the under surface of the patella.
Realignment of the patella where there has not been a great deal of damage to the under side of the surface of the patella prior to the operation, is successful in diminishing the symptoms of kneecap pain.
Where there has been significant damage to the surface of the patella as a result of lateral maltracking in the past, realignment may not fully remove all the symptoms of discomfort arising from the patella and therefore patients may still suffer some occasional symptoms on stair climbing and deep bending exercises.
Occasionally patients will suffer some intermittent symptoms from the presence of the two small screws inserted at surgery. If this is the case removal of screws may be undertaken as a very simple day case procedure several months after the patella realignment.
Although the discomfort of patella maltracking may be largely settled, it is often expected that the patient’s knees will continue to “click” or “crack” on deep bending exercises. Research has shown that this is a natural function of the kneecap and does not necessarily indicate further significant damage.
HELP AND ADVICE
Should you have any queries regarding patella realignment surgery or be concerned as regards pain or swelling in the post operative period following discharge, please feel free to contact the personnel on any of the numbers listed below:
Nursing Unit 2 02380 775544 Ext. 2372
Physiotherapy Department 02380 775544 Ext. 2348
Bernice Allison, PA to Professor Barrett 02380 776877
Aimee Dibden, Secretary to Professor Barrett