What is the recommended treatment for a patient with transient patella dislocation, bone contusion, and a tibial tuberosity trochlear groove of 13mm?

Treatment of Transient Patella Dislocation with Bone Contusion and Tibial Tuberosity Trochlear Groove 13mm

For a patient with transient patella dislocation, bone contusion, and a tibial tuberosity trochlear groove (TT-TG) distance of 13mm, surgical intervention with tibial tuberosity transfer is recommended as the definitive treatment to prevent recurrent dislocations and improve long-term outcomes. 1, 2

Initial Assessment and Conservative Management

• Radiographs should be the first imaging modality, including anteroposterior, lateral, and patellofemoral views to assess patellar alignment and potential fractures 1
• MRI is necessary to evaluate bone contusions, cartilage damage, and soft tissue injuries, particularly the medial patellofemoral ligament (MPFL) which is almost always injured in acute patellar dislocations 1, 3
• Initial conservative management includes:
  • Relative rest and activity modification to reduce loading of damaged structures 1
  • Cryotherapy for 10-minute periods for acute pain relief 1
  • Short-term NSAIDs for pain management 1
  • Eccentric strengthening exercises focusing on quadriceps to improve patellar stability 1

Surgical Decision-Making

• A TT-TG distance of 13mm is considered excessive (normal is <10mm) and is a significant risk factor for recurrent dislocations 2
• The presence of bone contusion indicates significant trauma and increases risk of cartilage damage 3
• Surgical intervention is indicated when:
  • TT-TG distance exceeds 10mm 2
  • There is evidence of bone or cartilage injury 1, 3
  • Risk of recurrent dislocation is high 4

Recommended Surgical Approach

• Tibial tuberosity transfer is the procedure of choice for patients with increased TT-TG distance 5, 2
• The procedure should include:
  • Medial transfer of the tibial tuberosity to correct the excessive TT-TG distance 2
  • Lateral release to reduce lateral patellar tilt and tracking issues 2
  • Consideration of MPFL reconstruction if there is evidence of significant medial soft tissue damage 5

Expected Outcomes and Benefits

• Surgical intervention significantly reduces the risk of recurrent dislocations compared to non-surgical management 4
• Studies show that tibial tuberosity transfer can reduce recurrent dislocation rates to as low as 15.2% compared to higher rates with conservative management 2
• The mean post-operative TT-TG distance after tibial tuberosity transfer is typically reduced to approximately 8.9mm from pre-operative values 2
• Improved patient-reported outcomes can be expected, with mean Kujala scores of 88 following surgery 2

Post-Surgical Rehabilitation

• Progressive rehabilitation focusing on quadriceps strengthening and patellar stabilization exercises 1
• Regular radiographic follow-up to assess patellar alignment and healing of the tibial tuberosity transfer 1
• Monitoring for potential complications including recurrent instability, pain, or patellofemoral arthritis 1

Important Considerations and Caveats

• Timing of surgery should be within the first 24 hours if possible to reduce local and systemic complications 1
• If there are associated severe injuries or the patient is unstable, a delayed approach with temporary stabilization followed by definitive surgery once the patient is stable may be necessary 1
• The surgical approach should be tailored based on specific anatomical factors, including trochlear dysplasia, patella alta, and patellar tilt, which may require additional procedures 5
• While some surgeons may consider isolated lateral release for patients with minimal TT-TG distance abnormalities, this is not appropriate for a patient with a 13mm TT-TG distance 2