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  • Improper tracking of patella in trochlear groove 
  • Caused by tight lateral retinaculum
    • leads to excessive lateral tilt without excessive patellar mobility
  • Miserable Triad
    • is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. They include:
      • femoral anteversion
      • genu valgum
      • external tibial torsion / pronated feet
  • Presentation
    • pain with stair climbing
    • theatre sign (pain with sitting for long periods of time)
  • Physical exam
    • pain with compression of patella and moderate lateral facet tenderness
    • inability to evert the lateral edge of the patella
  • Radiographs
    • patellar tilt in lateral direction
  • Nonoperative
    • NSAIDS, activity modification, and therapy
      • indications
        • mainstay of treatment and should be done for extensive period of time
      • technique
        • therapy should emphasize vastus medialis strengthening and closed chain short arc quadriceps exercises 
  • Operative
    • arthroscopic lateral release 
      • indications
        • objective evidence of lateral tilting (neutral or negative tilt)   
        • pain refractory to extensive rehabilitation
        • inability to evert the lateral edge of the patella
        • ideal candidate has no symptoms of instability
        • medial patellar glide of less than one quadrant
        • lateral patellar glide of less than three quadrants
    • patellar realignment surgery 
      • Maquet (tubercle anteriorization)
        • indicated only for distal pole lesions
        • only elevate 1 cm or else risk of skin necrosis
      • Elmslie-Trillat (medialization)
        • indicated only for instability with lateral translation (not isolated lateral tilt)
        • avoid if medial patellar facet arthrosis
      • Fulkerson alignment surgery (tubercle anteriorization and medialization) 
        • indications (controversial)
          • lateral and distal pole lesions 
          • increased Q angle
        • contraindications
          • superior medial arthrosis (scope before you perform the surgery)
          • skeletal immaturity
  • Arthroscopic lateral release 
    • technique
      • viewing through superior portal will show medial facet does not articulate with trochlea at 40 degrees of knee flexion
      • be sure adequate hemostasis is obtained
      • postoperatively the patella should be able to be passively tilted 80°
    • complications
      • persistent or worsened pain
      • patellar instability with medial translation

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