Management of Patellofemoral Instability (AANA25)-Evolving Concepts in Management of Patellofemoral Instability

Video Transcription

Video Summary

This instructional course lecture on femoral/patellofemoral instability brings together an expert panel to discuss soft-tissue stabilization, trochlear dysplasia and trochleoplasty, tibial tubercle osteotomy (TTO), and patellofemoral cartilage restoration.<br /><br />Soft-tissue stabilization focuses on reconstruction rather than repair: MPFL/“medial patellofemoral complex” laxity is described as the common denominator in most instability cases, while repair has a high failure rate except in rare acute avulsion scenarios. Surgeons debate MPFL vs MQTFL vs hybrid techniques, but the panel emphasizes outcomes are similar if reconstruction is anatomic, with correct femoral insertion, appropriate patellar fixation (avoiding large tunnels to reduce fracture risk), and careful graft tensioning (often set around 30–60° flexion to avoid over-constraint). Allograft and autograft are considered equivalent in this extra-articular ligament.<br /><br />Trochlear dysplasia is presented as the dominant risk factor for recurrent instability and a contributor to early patellofemoral arthritis. Modern groove-deepening trochleoplasty (thin- or thick-flap) is argued to have durable stability, high satisfaction, return-to-sport potential, and possibly cartilage preservation; key indications are high-grade dysplasia with a prominent “bump” and maltracking (e.g., jumping J sign). MRI-based assessment and a simplified classification are advocated to avoid missed high-grade dysplasia.<br /><br />For TTO, speakers stress that TTTG alone should not dictate surgery because it may reflect dysplasia, rotation, or groove medialization. TTO remains valuable to unload cartilage (anteromedialization/anteriorization), treat severe patella alta via distalization, and address select salvage problems, often combined with stabilization and/or cartilage restoration.<br /><br />Cartilage restoration (OCA vs ACI) depends on whether pathology involves subchondral bone; both can help but patellofemoral results lag behind tibiofemoral outcomes, and offloading procedures (often TTO, sometimes trochleoplasty) are important. The Q&A highlights ongoing controversy on “subcritical” risk factors and whether to do extensive bony correction after first-time dislocation with osteochondral fracture.

Asset Caption

Laith M. Jazrawi, M.D. | James Lee Pace, M.D. | David Dejour, M.D. | Seth L. Sherman, M.D., FAANA | Abigail L. Campbell, M.D.

Keywords

femoral instability

patellofemoral instability

MPFL reconstruction

medial quadriceps tendon-femoral ligament (MQTFL)

trochlear dysplasia

trochleoplasty

tibial tubercle osteotomy (TTO)

patella alta distalization

patellofemoral cartilage restoration

osteochondral allograft (OCA)

autologous chondrocyte implantation (ACI)