Patella Instability

Tibial Tubercle (Fulkerson) Osteotomy & Medial Patellofemoral Ligament (MPFL) Reconstruction.

Indication and Procedure Description

This procedure is indicated for those patients who have recurrent episodes of patella dislocation. The procedure is considered after multiple episodes where the patella dislocates with minimal activity. The Fulkerson procedure is also occasionally indicated for those patients who have patellofemoral (anterior) knee pain and arthritis. The Fulkerson procedure involves moving the bony attachment of the patella tendon on the tibia to a more medial (inner) and anterior (forward) position, combined with releasing the tight tissues on the lateral (outside) aspect of the patella. This allows the patella to run in a more normal position, thereby preventing lateral dislocation. The bony portion of the patella tendon attachment of the tibia is called the tibial tubercle. Once this has been moved, it is securely re-attached with two screws.

In patients that don’t have pre-existing malalignment of their patella, a reconstruction of the Medial Patellofemoral Ligament (MPFL) may be sufficient to stabilize the patella from recurrent patella dislocation. This reconstruction is typically performed with arthroscopic assistance using two small incisions to pass a tendon graft made up of the patients own hamstring tendon or an allograft (cadaver) tendon.

In certain cases, both of these techniques are combined to provide the patient with the best result and lowest chance of recurrent patella dislocation.

Pre-operative Preparation

X-rays will be obtained peri-operatively. It will also include a skyline X-ray of the patella to assess its location with respect to the knee. Occasionally CT scans are also obtained to allow a better determination of the degree of dislocation and bony anatomy.

Hospital Stay

On the day of surgery, the limb will be marked. The procedure requires a general anesthetic and is supplemented by a nerve block which will control the pain post-operatively.

Following the procedure, the knee will initially be held straight in a brace. Physiotherapy is begun immediately to help with mobilization. The patient is encouraged to weight bear as tolerated through the leg. A brace will be used post-operative to allow the bone and/or ligament to heal, but in most cases the patient will be able to bear weight with the brace locked straight.

Most patients are discharged on the same day as surgery, but occasionally patients are kept overnight and sent home on the day after surgery.

Post-Operative Care

Knee brace. A knee brace is generally required for approximately six weeks. It will be removed for exercises in this time. It will be removed permanently once the patient can comfortably straight leg raise and adequate healing has occurred.

Weight bearing. The patient may be partial weight bearing for the first two weeks and then transition to weight bearing as tolerated for the next first four weeks. This will require crutches generally for this time to protect the osteotomy or graft.

Exercises

Physiotherapy is commenced early with the emphasis on static quadriceps and hamstring work to maintain muscle bulk. Early work is also directed at mobility of the patella to prevent tethering and scarring of the soft tissues around the patella.

Range of motion exercises are also begun early with the aim of having 90° of bend by four to six weeks. The remaining motion will be obtained over the next 2-6 weeks.

It is expected that fast walking can be commenced by two months and a return to running and sporting activities by four to six months’ post-surgery.