The aim of this study was to evaluate the functional and clinical outcome following medial patello-femoral ligament reconstruction using autogenous hamstring tendon grafts for patellar instability. Over a 4 year period the senior author operated on 35 patients for lateral instability of the patella. The predominant initiating event was a sporting injury. Each patient had either failed conservative management including physiotherapy, or failed surgical management including tibial tuberosity transfer. Post-operatively, all patients were allowed full flexion and extension. Sporting activity was restricted until 4-6 months post-operatively. Patients were evaluated clinically and functionally. The Fulkerson score was utilised pre- and post-operatively. The minimum follow-up was 6 months, the mean follow-up was 20 months. There were 18 males and 17 females. The mean age was 24.6 years. The mean pre-operative Fulkerson score was 59.3 (range 6-100). The mean post-operative Fulkerson score was 83.6 (range 25-100), the mean improvement was 24.3. 24 patients returned to sporting activities. The main complications were one patient with a patella fracture that was stabilised with internal fixation, one patient requiring exploration and reinforcing the ligament which had attenuated. Both patients finally had a good clinical outcome. Our study has shown that symptomatic lateral instability of the patella can be effectively treated with a medial patello-femoral ligament reconstruction and result in overall good clinical and functional outcome. We would recommend this technique

Aim. We report the results of a modified Fulkerson technique of antero-medialisation of the tibial tubercle, combined with microfracture or abrasion arthroplasty in patients under 60 with patello-femoral osteoarthritis. Methods. All patients operated between September 1992 and October 2007 were reviewed by an independent observer in clinic or by postal questionnaire, using the Oxford Knee Score, Melbourne Patella Score and a Satisfaction Score. Only patients with Outerbridge Grade 3-4 osteoarthritis of the patello-femoral joint were included. They were assessed pre-operatively with plain x-rays, MRI scans (as well as tracking scans in the last 10 years) and arthroscopically. All patients with tracking scans showed lateral subluxation of the patella. The surgical procedure was a modification of Fulkerson's tibial tubercle osteotomy, with an advancement of 1-1.5cms and a medialisation of 1.5cms. The exposed bone of the patella and trochlea was drilled in the early cases and in the later cases an arthroscopic microfracture or abrasion using a power burr was carried out. Results. Between September 1992 and October 2007, 103 procedures were carried out in 84 patients, 19 patients having staged bilateral procedures. The mean follow-up was 84 months (range 24-204 months). The mean age was 45 (range 26-59) and the female to male ratio was 7.6:1. 70 patients were reviewed (follow-up rate of 82%). The mean Oxford Knee Score was 18.5 pre-operatively (range 3-32) and 34.3 post-operatively (range 11-47). The Melbourne Patella Score was 9.6 pre-operatively (range 3-30) and 20 post-operatively (range 11-30). Patient Satisfaction Scores were excellent (54%), good (29%), fair (8.5%) and poor (8.5%). 4 knees in 3 patients were converted to a patello-femoral arthroplasty, giving a 10 year survival rate of 96.1%. Conclusion. This procedure offers an alternative to patello-femoral arthroplasty for younger patients with isolated patello-femoral arthritis

We performed an advancement and medial transfer of the tibial tuberosity based on Fulkerson's principle to treat intractable anterior knee pain associated with patellofemoral maltracking diagnosed by dynamic MRI. Between January 1998 and July 2000 twenty-two patients had 28 knees operated for anterior knee pain. There were 4 men and 18 women with a mean age of 28 years (range 18-41). Indications for surgery were [a] failure to improve after six months of physiotherapy and [b] patellofemoral maltracking evident in dynamic MRI. Mean follow-up was for 37 months (23 – 42). Knee instability score modified by Fulkerson was employed for objective and subjective assessment. Objectively 22 (79%) knees achieved good to excellent results. Four knees (14%) had fair, and two (7%) had poor results. Excellent and very good results were seen in 20 knees. These patients were a younger age group (mean age 21 years) and had minimal degeneration (grade I-II) of the patellofemoral joints. Two patients achieved good results. One of them had moderate (grade III) and one minimal (II) arthritis. Three knees with fair results had advanced (grade IV or V) and one had moderate (grade III) arthritis. Out of two patients who had a poor result, one had advanced degeneration (grade V) that later required a patellofemoral joint resurfacing. The other was a 24 year old woman with grade II changes. She was treated by the pain therapy team. Anterior displacement of the tuberosity in the presented study was kept to 5 mm to avoid the possible complications of wound break down. The overall length and depth of the osteotomy was also reduced to minimise risk of fracture and commence early mobilisation. Based on our results there is a strong case of justification for Anteromedialisation of tibial tuberosity using a smaller length of osteotomy and lesser degree of anteriorisation in carefully selected patients with Patellofemoral arthralgia associated with maltracking patella

This study is a prospective analysis of clinical outcome in 201 consecutive patients treated with medial patellofemoral ligament reconstruction using an autologous semitendinosus graft between October 2005 and January 2011. Patients received pre and post-operative clinical evaluation, radiological assessment and outcome scoring systems. 193 patients (92 male, 119 female) underwent 211 procedures, with mean age 26 (16–49) and follow-up 16 months (6–42 months). Indications were atraumatic recurrent patella dislocation (68%), traumatic recurrent dislocation (22.8%), instability (5%), single dislocation (2.7%) and anterior knee pain (1.4%). Trochlea dysplasia was moderate in 57% and mild in 35%. There have been no recurrent dislocations/ subluxations. 10 patients have required further surgery. The mean pre-op Kujala Scores were 55 (SE 5.21) and post-op scores improved to mean 82 (31–100) (SE 1.18)(p < 0.001). This improvement and significance is mirrored with Oxford (27 to 41), WOMAC (76 to 93), Fulkerson (53 to 83), IKDC (46 to 75), Tegner (4.1 to 5.3) and SF12 (38 to 51) scores (p < 0.005). 93% of patients were satisfied with their operation. History of prior realignment surgery was associated with significantly worse outcomes compared to patients where MPFL reconstruction was their first realignment procedure (p < 0.05). This series is the largest reported in the literature for any technique of MPFL surgery. This technique allows for objective intra-operative evaluation of the required graft tension to optimise patella tracking

To assess the clinical outcomes of patients undergoing ACI in the patellofemoral joint. Level of evidence. Therapeutic study, Level II-1 (prospective cohort study). In a prospective study to determine the clinical effectiveness of autologous chondrocyte implantation 130 patients reached a minimum follow up of two years (range, 2–9 years, average 56.5 months) after treatment involving the patellofemoral articulation. There were 77 men (59%) and 53 women (41%) with an average age of 37.5 years (range, 15-57years). The treatment groups included I) isolated patella, n = 14; II) isolated trochlea, n = 15; III) patella plus trochlea, n = 5; IV) weight bearing condyle plus patella n = 19; V) weight bearing condyle plus trochlea, n = 52; VI) weight bearing condyle plus patella plus trochlea n = 25. The average surface area per patella, n = 63, was 4.72 cm2 and per trochlea, n = 98, was 5.8cm2. The average resurfacing per knee, n = 130, was 11.03cm2. This prospective outcome study demonstrated a significant postoperative improvement in quality of life as measured by the SF-36; WOMAC, Knee Society Score, modified Cincinnati Score and a patient satisfaction survey. There were 16 failures (12%) as a result of a patella or trochlea failure. Eighty percent of patients rated their outcomes as good or excellent, 18% rated outcome as fair, and 2% rated outcome as poor. ACI is effective in the patellofemoral joint and specifically is a complementary intervention for those patients that will predictably do poorly with an isolated Fulkerson Tibial Tubercle osteotomy