Patellofemoral Instability in Active Adolescents

 

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Abstract

Patellofemoral instability is a common problem in the adolescent population. Patellar stability depends on a dynamic interplay between bony and soft tissue restraints. Several pathoanatomical factors increase the likelihood of patellar instability: patella alta, trochlear dysplasia, malalignment, and deficient proximal medial restraints. Treatment for first-time patella dislocations is typically nonoperative and includes bracing, early range of motion, and physical therapy. The only absolute indication for early surgery is a large osteochondral fragment that can be fixed. Surgical stabilization is indicated for chronic patellar instability and includes both proximal and distal realignment options. Medial patellofemoral ligament reconstruction is the treatment of choice in most adolescent patients with patella instability. Distal bony realignment procedures are reserved for skeletally mature adolescents.

• References

• 1 Nietosvaara Y, Aalto K, Kallio PE. Acute patellar dislocation in children: incidence and associated osteochondral fractures. J Pediatr Orthop 1994; 14 (4) 513-515
  CrossrefPubMedGoogle Scholar
• 2 Waterman BR, Belmont Jr PJ, Owens BD. Patellar dislocation in the United States: role of sex, age, race, and athletic participation. J Knee Surg 2012; 25 (1) 51-57
  Article in Thieme ConnectPubMedGoogle Scholar
• 3 Fithian DC, Paxton EW, Stone ML , et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med 2004; 32 (5) 1114-1121
  CrossrefPubMedGoogle Scholar
• 4 Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med 2000; 28 (4) 472-479
  PubMedGoogle Scholar
• 5 Hawkins RJ, Bell RH, Anisette G. Acute patellar dislocations. The natural history. Am J Sports Med 1986; 14 (2) 117-120
  CrossrefPubMedGoogle Scholar
• 6 Colvin AC, West RV. Patellar instability. J Bone Joint Surg Am 2008; 90 (12) 2751-2762
  CrossrefPubMedGoogle Scholar
• 7 Boden BP, Pearsall AW, Garrett Jr WE, Feagin Jr JA. Patellofemoral Instability: Evaluation and Management. J Am Acad Orthop Surg 1997; 5 (1) 47-57
  PubMedGoogle Scholar
• 8 Seeley MA, Knesek M, Vanderhave KL. Osteochondral injury after acute patellar dislocation in children and adolescents. J Pediatr Orthop 2013; 33 (5) 511-518
  CrossrefPubMedGoogle Scholar
• 9 Gardner E, O'Rahilly R. The early development of the knee joint in staged human embryos. J Anat 1968; 102 (Pt 2) 289-299
  PubMedGoogle Scholar
• 10 Hinton RY, Sharma KM. Acute and recurrent patellar instability in the young athlete. Orthop Clin North Am 2003; 34 (3) 385-396
  CrossrefPubMedGoogle Scholar
• 11 Ogden JA. Radiology of postnatal skeletal development. X. Patella and tibial tuberosity. Skeletal Radiol 1984; 11 (4) 246-257
  CrossrefPubMedGoogle Scholar
• 12 Stanitski CL. Articular hypermobility and chondral injury in patients with acute patellar dislocation. Am J Sports Med 1995; 23 (2) 146-150
  CrossrefPubMedGoogle Scholar
• 13 Fithian DC, Neyret P, Servien E. Patellar instability: the Lyon experience. Curr Orthop Pract 2008; 19 (3) 328-338
  CrossrefPubMedGoogle Scholar
• 14 Shea KG, Nilsson K, Belzer J. Patellar dislocation in skeletally immature athletes. Oper Tech Sports Med 2006; 14 (3) 188-196
  CrossrefPubMedGoogle Scholar
• 15 Kepler CK, Bogner EA, Hammoud S, Malcolmson G, Potter HG, Green DW. Zone of injury of the medial patellofemoral ligament after acute patellar dislocation in children and adolescents. Am J Sports Med 2011; 39 (7) 1444-1449
  CrossrefPubMedGoogle Scholar
• 16 Nelitz M, Dornacher D, Dreyhaupt J, Reichel H, Lippacher S. The relation of the distal femoral physis and the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2011; 19 (12) 2067-2071
  CrossrefPubMedGoogle Scholar
• 17 Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am 1979; 61 (1) 56-62
  PubMedGoogle Scholar
• 18 Feller JA, Feagin Jr JA, Garrett Jr WE. The medial patellofemoral ligament revisited: an anatomical study. Knee Surg Sports Traumatol Arthrosc 1993; 1 (3-4) 184-186
  CrossrefPubMedGoogle Scholar
• 19 Kang HJ, Wang F, Chen BC, Su YL, Zhang ZC, Yan CB. Functional bundles of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2010; 18 (11) 1511-1516
  CrossrefPubMedGoogle Scholar
• 20 Conlan T, Garth Jr WP, Lemons JE. Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 1993; 75 (5) 682-693
  CrossrefPubMedGoogle Scholar
• 21 Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998; 26 (1) 59-65
  PubMedGoogle Scholar
• 22 Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM. Medial soft tissue restraints in lateral patellar instability and repair. Clin Orthop Relat Res 1998; (349) 174-182
  PubMedGoogle Scholar
• 23 Hennrikus W, Pylawka T. Patellofemoral instability in skeletally immature athletes. J Bone Joint Surg Am 2013; 95 (2) 176-183
  CrossrefPubMedGoogle Scholar
• 24 Farahmand F, Naghi Tahmasbi M, Amis A. The contribution of the medial retinaculum and quadriceps muscles to patellar lateral stability—an in-vitro study. Knee 2004; 11 (2) 89-94
  CrossrefPubMedGoogle Scholar
• 25 Goh JC, Lee PY, Bose K. A cadaver study of the function of the oblique part of vastus medialis. J Bone Joint Surg Br 1995; 77 (2) 225-231
  PubMedGoogle Scholar
• 26 Beasley LS, Vidal AF. Traumatic patellar dislocation in children and adolescents: treatment update and literature review. Curr Opin Pediatr 2004; 16 (1) 29-36
  CrossrefPubMedGoogle Scholar
• 27 Insall J, Goldberg V, Salvati E. Recurrent dislocation and the high-riding patella. Clin Orthop Relat Res 1972; 88 (88) 67-69
  CrossrefPubMedGoogle Scholar
• 28 Geenen E, Molenaers G, Martens M. Patella alta in patellofemoral instability. Acta Orthop Belg 1989; 55 (3) 387-393
  PubMedGoogle Scholar
• 29 Larsen E, Lauridsen F. Conservative treatment of patellar dislocations. Influence of evident factors on the tendency to redislocation and the therapeutic result. Clin Orthop Relat Res 1982; (171) 131-136
  PubMedGoogle Scholar
• 30 Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 1994; 2 (1) 19-26
  CrossrefPubMedGoogle Scholar
• 31 Köhlitz T, Scheffler S, Jung T , et al. Prevalence and patterns of anatomical risk factors in patients after patellar dislocation: a case control study using MRI. Eur Radiol 2013; 23 (4) 1067-1074
  Google Scholar
• 32 Balcarek P, Jung K, Frosch KH, Stürmer KM. Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete. Am J Sports Med 2011; 39 (8) 1756-1761
  CrossrefPubMedGoogle Scholar
• 33 Pennock AT, Alam M, Bastrom T. Variation in tibial tubercle-trochlear groove measurement as a function of age, sex, size, and patellar instability. Am J Sports Med 2014; 42 (2) 389-393
  CrossrefPubMedGoogle Scholar
• 34 Dickens AJ, Morrell NT, Doering A, Tandberg D, Treme G. Tibial tubercle-trochlear groove distance: defining normal in a pediatric population. J Bone Joint Surg Am 2014; 96 (4) 318-324
  CrossrefPubMedGoogle Scholar
• 35 Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg Am 2008; 90 (3) 463-470
  CrossrefPubMedGoogle Scholar
• 36 Lewallen LW, McIntosh AL, Dahm DL. Predictors of recurrent instability after acute patellofemoral dislocation in pediatric and adolescent patients. Am J Sports Med 2013; 41 (3) 575-581
  CrossrefPubMedGoogle Scholar
• 37 Nikku R, Nietosvaara Y, Aalto K, Kallio PE. Operative treatment of primary patellar dislocation does not improve medium-term outcome: a 7-year follow-up report and risk analysis of 127 randomized patients. Acta Orthop 2005; 76 (5) 699-704
  CrossrefPubMedGoogle Scholar
• 38 Abbasi D, May MM, Wall EJ, Chan G, Parikh SN. MRI findings in adolescent patients with acute traumatic knee hemarthrosis. J Pediatr Orthop 2012; 32 (8) 760-764
  CrossrefPubMedGoogle Scholar
• 39 Reider B, Marshall JL, Warren RF. Clinical characteristics of patellar disorders in young athletes. Am J Sports Med 1981; 9 (4) 270-274
  CrossrefPubMedGoogle Scholar
• 40 Stanitski CL, Paletta Jr GA. Articular cartilage injury with acute patellar dislocation in adolescents. Arthroscopic and radiographic correlation. Am J Sports Med 1998; 26 (1) 52-55
  PubMedGoogle Scholar
• 41 Seeley M, Bowman KF, Walsh C, Sabb BJ, Vanderhave KL. Magnetic resonance imaging of acute patellar dislocation in children: patterns of injury and risk factors for recurrence. J Pediatr Orthop 2012; 32 (2) 145-155
  CrossrefPubMedGoogle Scholar
• 42 Felus J, Kowalczyk B. Age-related differences in medial patellofemoral ligament injury patterns in traumatic patellar dislocation: case series of 50 surgically treated children and adolescents. Am J Sports Med 2012; 40 (10) 2357-2364
  CrossrefPubMedGoogle Scholar
• 43 Felus J, Kowalczyk B, Lejman T. Sonographic evaluation of the injuries after traumatic patellar dislocation in adolescents. J Pediatr Orthop 2008; 28 (4) 397-402
  CrossrefPubMedGoogle Scholar
• 44 Vavken P, Wimmer MD, Camathias C, Quidde J, Valderrabano V, Pagenstert G. Treating patella instability in skeletally immature patients. Arthroscopy 2013; 29 (8) 1410-1422
  CrossrefPubMedGoogle Scholar
• 45 Buchner M, Baudendistel B, Sabo D, Schmitt H. Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment. Clin J Sport Med 2005; 15 (2) 62-66
  CrossrefPubMedGoogle Scholar
• 46 Garth Jr WP, Pomphrey Jr M, Merrill K. Functional treatment of patellar dislocation in an athletic population. Am J Sports Med 1996; 24 (6) 785-791
  CrossrefPubMedGoogle Scholar
• 47 Sillanpää PJ, Mattila VM, Mäenpää H, Kiuru M, Visuri T, Pihlajamäki H. Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. A prospective randomized study. J Bone Joint Surg Am 2009; 91 (2) 263-273
  CrossrefPubMedGoogle Scholar
• 48 Christiansen SE, Jakobsen BW, Lund B, Lind M. Isolated repair of the medial patellofemoral ligament in primary dislocation of the patella: a prospective randomized study. Arthroscopy 2008; 24 (8) 881-887
  CrossrefPubMedGoogle Scholar
• 49 Järvinen M. Acute patellar dislocation—closed or operative treatment?. Acta Orthop Scand 1997; 68 (5) 415-418
  CrossrefPubMedGoogle Scholar
• 50 Hensler D, Sillanpaa PJ, Schoettle PB. Medial patellofemoral ligament: anatomy, injury and treatment in the adolescent knee. Curr Opin Pediatr 2014; 26 (1) 70-78
  CrossrefPubMedGoogle Scholar
• 51 Cash JD, Hughston JC. Treatment of acute patellar dislocation. Am J Sports Med 1988; 16 (3) 244-249
  CrossrefPubMedGoogle Scholar
• 52 Mäenpää H, Lehto MU. Patellar dislocation. The long-term results of nonoperative management in 100 patients. Am J Sports Med 1997; 25 (2) 213-217
  CrossrefPubMedGoogle Scholar
• 53 Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP. Anatomy and biomechanics of the medial patellofemoral ligament. Knee 2003; 10 (3) 215-220
  CrossrefPubMedGoogle Scholar
• 54 Cherf J, Paulos LE. Bracing for patellar instability. Clin Sports Med 1990; 9 (4) 813-821
  PubMedGoogle Scholar
• 55 Gigante A, Pasquinelli FM, Paladini P, Ulisse S, Greco F. The effects of patellar taping on patellofemoral incongruence. A computed tomography study. Am J Sports Med 2001; 29 (1) 88-92
  PubMedGoogle Scholar
• 56 Cowan SM, Bennell KL, Hodges PW. Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome. Clin J Sport Med 2002; 12 (6) 339-347
  CrossrefPubMedGoogle Scholar
• 57 McConnell J. Rehabilitation and nonoperative treatment of patellar instability. Sports Med Arthrosc Rev 2007; 15 (2) 95-104
  CrossrefPubMedGoogle Scholar
• 58 Willis RB, Firth G. Traumatic patellar dislocation: loose bodies and the MPFL. J Pediatr Orthop 2012; 32 (Suppl. 01) S47-S51
  CrossrefPubMedGoogle Scholar
• 59 Luhmann SJ, Schoenecker PL, Dobbs MB, Gordon JE. Arthroscopic findings at the time of patellar realignment surgery in adolescents. J Pediatr Orthop 2007; 27 (5) 493-498
  CrossrefPubMedGoogle Scholar
• 60 Walsh SJ, Boyle MJ, Morganti V. Large osteochondral fractures of the lateral femoral condyle in the adolescent: outcome of bioabsorbable pin fixation. J Bone Joint Surg Am 2008; 90 (7) 1473-1478
  CrossrefPubMedGoogle Scholar
• 61 Hinton RY. Primary, Traumatic Patella Dislocation: Operative Indications. September/October 2010 Sports Medicine Update; American Orthopaedic Surgery Sports Medicine Society (AOSSM):p. 2–6
  Google Scholar
• 62 Hinton RY, Sharma KM. Patellar instability in childhood and adolescence. In: Insall JN, Scott WN, , eds. Surgery of the Knee. 4th ed. London: Churchill Livingstone; 2006
  Google Scholar
• 63 Andrish J. The management of recurrent patellar dislocation. Orthop Clin North Am 2008; 39 (3) 313-327 , vi
  CrossrefPubMedGoogle Scholar
• 64 Smith TO, Davies L, O'Driscoll ML, Donell ST. An evaluation of the clinical tests and outcome measures used to assess patellar instability. Knee 2008; 15 (4) 255-262
  CrossrefPubMedGoogle Scholar
• 65 Ahmad CS, McCarthy M, Gomez JA, Shubin Stein BE. The moving patellar apprehension test for lateral patellar instability. Am J Sports Med 2009; 37 (4) 791-796
  CrossrefPubMedGoogle Scholar
• 66 Fithian DC, Paxton EW, Cohen AB. Indications in the treatment of patellar instability. J Knee Surg 2004; 17 (1) 47-56
  Article in Thieme ConnectPubMedGoogle Scholar
• 67 Crosby EB, Insall J. Recurrent dislocation of the patella. Relation of treatment to osteoarthritis. J Bone Joint Surg Am 1976; 58 (1) 9-13
  CrossrefPubMedGoogle Scholar
• 68 Nomura E, Inoue M. Cartilage lesions of the patella in recurrent patellar dislocation. Am J Sports Med 2004; 32 (2) 498-502
  CrossrefPubMedGoogle Scholar
• 69 Insall J, Bullough PG, Burstein AH. Proximal “tube” realignment of the patella for chondromalacia patellae. Clin Orthop Relat Res 1979; (144) 63-69
  PubMedGoogle Scholar
• 70 Redziniak DE, Diduch DR, Mihalko WM , et al. Patellar instability. J Bone Joint Surg Am 2009; 91 (9) 2264-2275
  PubMedGoogle Scholar
• 71 Halbrecht JL. Arthroscopic patella realignment: an all-inside technique. Arthroscopy 2001; 17 (9) 940-945
  CrossrefPubMedGoogle Scholar
• 72 Ali S, Bhatti A. Arthroscopic proximal realignment of the patella for recurrent instability: report of a new surgical technique with 1 to 7 years of follow-up. Arthroscopy 2007; 23 (3) 305-311
  CrossrefPubMedGoogle Scholar
• 73 Nam EK, Karzel RP. Mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation: a medium-term follow-up. Am J Sports Med 2005; 33 (2) 220-230
  CrossrefPubMedGoogle Scholar
• 74 Shelbourne KD, Urch SE, Gray T. Results of medial retinacular imbrication in patients with unilateral patellar dislocation. J Knee Surg 2012; 25 (5) 391-396
  Article in Thieme ConnectPubMedGoogle Scholar
• 75 Miller JR, Adamson GJ, Pink MM, Fraipont MJ, Durand Jr P. Arthroscopically assisted medial reefing without routine lateral release for patellar instability. Am J Sports Med 2007; 35 (4) 622-629
  CrossrefPubMedGoogle Scholar
• 76 Boddula MR, Adamson GJ, Pink MM. Medial reefing without lateral release for recurrent patellar instability: midterm and long-term outcomes. Am J Sports Med 2014; 42 (1) 216-224
  CrossrefPubMedGoogle Scholar
• 77 Hartmann F, Dietz SO, Rommens PM, Gercek E. Long-term outcome after operative treatment of traumatic patellar dislocation in adolescents. J Orthop Trauma 2014; 28 (3) 173-180
  CrossrefPubMedGoogle Scholar
• 78 Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2012; 40 (8) 1916-1923
  CrossrefPubMedGoogle Scholar
• 79 Arendt E, Lind M, van der Merew W. Indications for MPFL reconstruction after patellar dislocation. ISAKOS Newsl 2009; 13: 29-31
  PubMedGoogle Scholar
• 80 Ahmad CS, Brown GD, Stein BS. The docking technique for medial patellofemoral ligament reconstruction: surgical technique and clinical outcome. Am J Sports Med 2009; 37 (10) 2021-2027
  CrossrefPubMedGoogle Scholar
• 81 Schottle PB, Romero J, Schmeling A, Weiler A. Technical note: anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft. Arch Orthop Trauma Surg 2008; 128 (5) 479-484
  CrossrefPubMedGoogle Scholar
• 82 Schöttle PB, Hensler D, Imhoff AB. Anatomical double-bundle MPFL reconstruction with an aperture fixation. Knee Surg Sports Traumatol Arthrosc 2010; 18 (2) 147-151
  CrossrefPubMedGoogle Scholar
• 83 Shubin Stein BE, Ahmad CS. The management of patellar instability in the skeletally immature patient. Oper Tech Orthop 2007; 17 (4) 250-256
  CrossrefPubMedGoogle Scholar
• 84 Nelitz M, Dreyhaupt J, Reichel H, Woelfle J, Lippacher S. Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents with open growth plates: surgical technique and clinical outcome. Am J Sports Med 2013; 41 (1) 58-63
  CrossrefPubMedGoogle Scholar
• 85 Schöttle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 2007; 35 (5) 801-804
  CrossrefPubMedGoogle Scholar
• 86 Bollier M, Fulkerson J, Cosgarea A, Tanaka M. Technical failure of medial patellofemoral ligament reconstruction. Arthroscopy 2011; 27 (8) 1153-1159
  CrossrefPubMedGoogle Scholar
• 87 Sanchis-Alfonso V. Guidelines for medial patellofemoral ligament reconstruction in chronic lateral patellar instability. J Am Acad Orthop Surg 2014; 22 (3) 175-182
  CrossrefPubMedGoogle Scholar
• 88 Nelitz M, Reichel H, Dornacher D, Lippacher S. Anatomical reconstruction of the medial patellofemoral ligament in children with open growth-plates. Arch Orthop Trauma Surg 2012; 132 (11) 1647-1651
  CrossrefPubMedGoogle Scholar
• 89 Deie M, Ochi M, Sumen Y, Yasumoto M, Kobayashi K, Kimura H. Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children. J Bone Joint Surg Br 2003; 85 (6) 887-890
  PubMedGoogle Scholar
• 90 Noyes FR, Albright JC. Reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon. Arthroscopy 2006; 22 (8) 904.e1-904.e7
  PubMedGoogle Scholar
• 91 Sillanpää PJ, Mäenpää HM, Mattila VM, Visuri T, Pihlajamäki H. A mini-invasive adductor magnus tendon transfer technique for medial patellofemoral ligament reconstruction: a technical note. Knee Surg Sports Traumatol Arthrosc 2009; 17 (5) 508-512
  CrossrefPubMedGoogle Scholar
• 92 Gomes JE. Comparison between a static and a dynamic technique for medial patellofemoral ligament reconstruction. Arthroscopy 2008; 24 (4) 430-435
  CrossrefPubMedGoogle Scholar
• 93 Adams D, Agel J, Arendt E. Medial patella ligament reconstruction, a Prospective cohort. AOSSM Annual Meeting; 2010; Abstract 9086
  PubMedGoogle Scholar
• 94 Oliva F, Ronga M, Longo UG, Testa V, Capasso G, Maffulli N. The 3-in-1 procedure for recurrent dislocation of the patella in skeletally immature children and adolescents. Am J Sports Med 2009; 37 (9) 1814-1820
  CrossrefPubMedGoogle Scholar
• 95 Moyad TF, Blakemore L. Modified Galeazzi technique for recurrent patellar dislocation in children. Orthopedics 2006; 29 (4) 302-304
  PubMedGoogle Scholar
• 96 Baker RH, Carroll N, Dewar FP, Hall JE. The semitendinosus tenodesis for recurrent dislocation of the patella. J Bone Joint Surg Br 1972; 54 (1) 103-109
  PubMedGoogle Scholar
• 97 Aulisa AG, Falciglia F, Giordano M, Savignoni P, Guzzanti V. Galeazzi's modified technique for recurrent patella dislocation in skeletally immature patients. J Orthop Sci 2012; 17 (2) 148-155
  CrossrefPubMedGoogle Scholar
• 98 Grannatt K, Heyworth BE, Ogunwole O, Micheli LJ, Kocher MS. Galeazzi semitendinosus tenodesis for patellofemoral instability in skeletally immature patients. J Pediatr Orthop 2012; 32 (6) 621-625
  CrossrefPubMedGoogle Scholar
• 99 Fondren FB, Goldner JL, Bassett III FH. Recurrent dislocation of the patella treated by the modified Roux-Goldthwait procedure. A prospective study of forty-seven knees. J Bone Joint Surg Am 1985; 67 (7) 993-1005
  PubMedGoogle Scholar
• 100 Marsh JS, Daigneault JP, Sethi P, Polzhofer GK. Treatment of recurrent patellar instability with a modification of the Roux-Goldthwait technique. J Pediatr Orthop 2006; 26 (4) 461-465
  CrossrefPubMedGoogle Scholar
• 101 Luhmann SJ, O'Donnell JC, Fuhrhop S. Outcomes after patellar realignment surgery for recurrent patellar instability dislocations: a minimum 3-year follow-up study of children and adolescents. J Pediatr Orthop 2011; 31 (1) 65-71
  CrossrefPubMedGoogle Scholar
• 102 Benoit B, Laflamme GY, Laflamme GH, Rouleau D, Delisle J, Morin B. Long-term outcome of surgically-treated habitual patellar dislocation in children with coexistent patella alta. Minimum follow-up of 11 years. J Bone Joint Surg Br 2007; 89 (9) 1172-1177
  PubMedGoogle Scholar
• 103 Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med 1990; 18 (5) 490-496 , discussion 496–497
  CrossrefPubMedGoogle Scholar