Recurrent Dislocation of Patella/ Chronic Patellofemoral Instability

Chronic Patellofemoral instability can be a disabling condition. Female adolescents are the most common first time dislocators. The younger a patient is at the time of first dislocation and the more severe the dislocation, the greater is the risk of subsequent dislocation.
Common causes of Recurrent patellar dislocation are :
1. Increased Q angle
2. Trochlear dysplasia
3. Lax or deficient medial Patellofemoral ligament
4. High riding patella, or small patella
5. Increased knee valgus
6. Hyperextension of the knee

The vastus medialis obliquus and the medial patellofemoral ligament act together as a combined dynamic complex preventing lateral dislocation of patella.

Non-operative measures must be exhausted before offering a surgical option.
Physiotherapy is directed towards closed chain exercises and VMO strengthening, in close supervision of an Orthopedic surgeon.
Surgical options include the soft tissue procedures and bony procedures, depending upon the underlying pathology.
Skeletally immature patients are particularly demanding, as bony procedures should be avoided until maturity.
Soft tissue procedures include the MPFL reconstruction, Medial imbrication, Lateral retinacular release. Bony procedures include Trocheoplasty and Tibial tubercle osteotomy and re-alignment.

Key Points :
1. Outcome with MPFL reconstruction alone in patients with trochlea dysplasia may not be good.
2. There is no evidence that surgical stabilization of the patellofemoral joint decreases long term degenerative changes, despite improving short term stability.

Shoulder Dislocations

Shoulder dislocations commonly seen in young individuals occur as a result of direct or indirect impact over the shoulder joint. There are two broad types of dislocations described; based on the position of the Humeral head.
Anterior dislocations are more common. Posterior dislocation are a rare entity; often seen in epileptics. After an impact, the patient feels sudden give way in the shoulder joint followed by inability to move the upper limb. This is associated with pain which becomes worse with attempted movements.
The common scenario is a patient supporting his affected upper limb by the other hand.
Early of a shoulder dislocation is of paramount importance. If a shoulder dislocation is neglected, it may lose its vascularity and become necrotic.
Careful clinical assessment is required to confirm the type of dislocation.
The mechanism of reduction is to reverse the order of the deforming force.
In 90 percent of cases, a shoulder dislocation may be reduced without requiring any form of anesthesia. In some cases, a mild sedative helps reduce the patient's apprehension. Rarely an open reduction is required and particularly in patients presenting late to the clinic.
Patient's co-operation is of utmost importance.
Every shoulder dislocation has a risk of re-dislocation with similar or less severe impact. This happens due to laxity of tissue surrounding the shoulder joint.
After a dislocation has been reduced, the patient must be forewarned about this complication.
The risk of re-dislocation may be substantially reduced with supervised physiotherapy and avoidance of the precipitating forces.
In a fresh dislocation occurring in a young patient; after performing a closed reduction, the shoulder joint should be splinted for a period of 2-3 weeks. In elderly patients, early passive exercises are allowed for fear of causing stiffness of immobilization.
A patient with history of shoulder dislocation should be kept under close observation.
If there are lesions in the glenoid labrum (bankart's lesions) or the Humeral head (Hill Sach's and Reverse Hill Sach's lesions), sometimes an operative intervention may be required in patients presenting with recurrent dislocations or shoulder instability that interferes with daily routine activities.
The risk of dislocation reduces with increasing age.