16 year old with recurrent knee dislocation

[datapopp]

My daughter is a competative athlete and has had 2 Left patella dislocations within 6 months. First dislocation was treated with brace 4-6 weeks and PT 2x a week for 8 to 10 weeks. She just did it again. Her OS says she has a very shallow trochlea and a high Q Angle and recommends the Fulkerson Osteotomy. He says he could do a lateral release but it really is not for her type of problem and it will probably re-dislocate and we would end up doing the Fulkerson anyways.. Went to a second OS (did not tell him we were the for a second opinion) and he said he would recommend a Lateral release as it is better to start out conservative and see if it works, if it doesn't he would do a medial tightening, and if that did not work he would take part of the tendon from the hamsting and anchor the kneecap in place.

More info: I too was a competative athlete. My left knee dislocated when I was 15. It dislocates every couple of years I am now 47. It is not the sport as I have tried a variety...it is the knee. I do not want her to go through the same thing. I had a lateral release many years ago and it did nothing...but I am not her.

Her father and I want a surgery that will work...the first time. I do not understand how 2 OS can come back with so completely different operations for the same problem.

Any suggestions? Also any teen athletes on this board have a Fulkerson Osteotomy? Have a different procedure for the same problem? What was the outcome? Were you able to continue to compete??

Very confused any comments would be helpful. Thank You

[luckygrandma6]

I would recommend a Sports Brace when she is playing sports to keep this from happening. When my son was in Sports in High School he kept injuring his ankle. The doctor told him if he did it again he would be headed for surgery. He wore a Gel Cast Sports Brace when he played sports and didn't injure it again. Now he is 36 years old and last year he was playing softball and fell in a hole when he was jumping up to catch the ball. He seriously injured his knee and needed surgery. Now he wears a brace to keep from twisting it again. Once there has been an injury there is always a chance of injuring it again and for the rest of her life she will probably have to wear a brace if she wants to participate in sports.

[ATsoccergirl]

I work for an orthopedic surgeon as a physician extender, which is an athletic trainer working side by side with doctor. Based on your daughter's history and anatomy, I think that the Fulkerson's would really be her best option to prevent future dislocations. As the first OS said, a lateral release is not really going to help her and could make things worse. The lateral retinaculum has a purpose as a restraint to medial gliding of the patella. When the lateral release is done, is can sometimes increase the amount of patellar instability and can lead to further problems. A lateral release is a very imprecise procedure and the outcomes are unpredictable. I had a lateral release my junior year of high school, and although for the first couple of years it was fine, I eventually had to have my lateral retinaculum repaired, because the surgeon had done the release so poorly. I was considered the perfect candidate for the procedure, no structural problems, good alignment, my retinaculum has scarred down following a traumatic kneecap dislocation.

I can understand how you would be hesistant to consider such a major surgery, but you also want everything fixed in one go. Your daughter is also going to have to be okay with the decision as ultimately she is the one going to have to deal with the outcome for the rest of her life. Since your two opinions are pretty different, I would suggest seeking out a third opinion. Try to find someone with an extensive background in sports medicine. I would highly suggest seeking out an orthopedic surgeon at a large teaching hospital. I've been and referred people to both to local practices and teaching hospitals and the difference is huge. At a teaching hospital, you are not getting just one opinion but many at the same time. For my knee problems, I go to a University hospital that has a dedicated sports medicine center. I typically see a couple of the residents before being seen by my OS, then if necessary he can bring in a PT or ATC to consult. Teaching hospitals are typically more up to date on the newest techniques and procedures and are more likely to take on difficult cases. If you want, PM me your location I can help you find someone close to you.

In terms of bracing, long term bracing is never a good option. There also offer no guarantee that she will not dislocate again, even with the best braces. It is far better to correct the problem, if possible, and properly rehab than to rely on a brace. We hardly ever brace following injuries or surgery anymore, except in certain circumstances.

Also keep in mind, that she may eventually need surgery in the other knee if it were to become problematic as the structure should be the same on the right as it is on the left.

[luckygrandma6]

Sorry to disagree with you but I believe in "an ounce of prevention is worth a pound of cure" Anyone knows that once you have an injury there is an increased chance of injuring the same area again as that area will always be weaker. I'm not saying the problem should not be corrected first, but then after, while playing sports don't risk injuring the area again.
I have had 4 knee surgeries and have an overextention problem. My OS has not been able to diagnose the problem., not that he's even tried.The only thing that has been done for me is to wear a Donjoy Legand Brace to try to stabilize the knee. If it wasn't for the brace I wouldn't be able to walk at all.
I'm only suggesting she wear it while playing sports to prevent further injury. Believe me surgery after surgery is not the answer. I've had 4 surgeries to my knee and 2 on the back and still have problems. Once you have surgery you will always have problems as nothing is like the original. You mess with nature and nature strikes back.
My Orthopedic Surgeon and the many therapist I've been to have not been able to diagnose my problem so what would your suggestion be to get me through until they fix the problem.

[datapopp]

Thank You for your replies. She has been wearing a brace while playing sports since the first dislocation. She had the brace on (recommended by her PT) when the second dislocation occurred. That is why we are considering surgery as it is apparent for her that PT and bracing alone are not going to keep her knee in place. ATsoccergirl I will send you a pm and hopefully you will know some docs in our area.

[brianne]

The best thing is to take your daughter to see a Patella Femoral Specialist. Like your daughter I had recurrent knee dislocations and a shallow trochelar groove. I had a Fulkerson on both of my knees and it did nothing for the instability. Its likely that if your daughter has experienced full dislocations that her medial structures are torn or badly stretched.

A Lateral Release will do nothing for her dislocations. I would not even consider an OS who is even thinking about a Lateral Release at all. If your daughter is a competive athlete then you really cannot afford to have her knee made worse by incorrect surgery. I was far worse off after my Faulkerson then before.

A Patella Femoral Specialist is going to be your best option. They will be able to look at your daughter's situation and assess what the best treatment option would be. A regular OS is not a PF Specialist...not matter how good of a Doctor they are. Seeing a PF Specialist saved my knees. I could have avoided two painful and frustrating surgeries had I gone to a PF Specialist in the beginning. I did not because I did not think that my knees were "that bad" and I really trusted my local OS. Its a mistake that I made and I paid dearly for it.

Good luck with your daughter. The Knee Guru Website is a good source for finding surgeons.

Brianne

[kc1124]

I agree that a lateral release is not a good option. I have had quite a few on my left knee that were basically just a waste of time.

When I finally found my new OS, he said he would never do a lateral release as they do not "fix the problem". I agree with Brianne that finding a patella femoral specialist is a great idea. The patella femoral joint is very tricky and it is good to find a surgeon who is an expert in this area.

I am 7 weeks post-op from a Fulkeson/HTO and Trochleoplasty on my right knee. I am very pleased with how things are progressing to date. However, my procedure was not due to dislocations but was done for other reasons. Basically, this was my last option on a destroyed patella.

I hope everything works out for your daughter. Keep us posted.

Kat

[kimmyxs]

Like your daughter, I had reoccurant dislocations and used a brace. I avoided surgery like the plague. 2 years ago at the age of 47, I had a tramatic dislocation. My quads contracted in response and broke the patella. My lesson learned is that for some things surgery is a good solution (not a LR alone though). If taping, bracing and muscle strengthening works, I say go for it. On the other hand, the results of repeated dislocations are damaging to structures and the bones themselves. Either way, I would see a specialists. You don't want that damage, nor do you want your daughter to avoid some activities that she loves because they cause the patella to sublux or dislocate.

Good luck. Also please remember that the outcome of surgerys depend on the problem, the OS, the patient, and the PT. If all 4 are dedicated to recovery, usually the results are excellent.

[datapopp]

I looked up Patella femoral specialist and did not find anything directly under that. I am in San Diego so I saw a listing for Dr. William Bugbee and will try and schedule a 3rd opinion with him.

The hard part is I felt comfortable with the Fulkerson until I started reading posts on it. However, most of the posts are for adults > 35 which may have more difficulty healing than a teen on the other hand it makes me wonder why it is not recommended for more teens.

I talked to the OS who recommended it again today. I asked him if he had performed it before (he is very well known in San Diego and listed as one of the top 20 Doctors in the San Diego Medical Society and semi-retired he is only taking on friends and patients he has treated in the past.) He stated that the surgery is pretty straight forward he has performed it several times. However it is not one of those surgeries that a physician does 1000's of times and if they do you should not go there. It is recommended for people with high Q Angles, he said the x-factor was the shallow groove?? Should of asked what that meant. When I asked him how long till she could do gymnastics again...he said it all depended on her and the PT and the length of time it took her to build up her quads....6 mos to a year if she worked dilligently at it.

[brianne]

It is true that the Fulkerson is not going to be a procedure that an OS performs 1000's of times. However, a really top notch PF Specialist will perform many of them. While it is also a good procedure for a high Q angle, if your daughter has had full dislocations then it is likely that her medial structures are torn or badly stretched. This was the case for me. As far as the shallow groove, it is an added challenge in the reocover. For me I have a shallow groove, a high patella, and an inwardly twisted femur. So those three items were added challenges and unknowns in my surgeries. However, my OS is one of the top Patella Docs in the country and so he was able to come up with the best options to give me the best results. This is why the specialist is so important.

The Fulkerson is a long recovery. I am still just realizing what a long recovery it is as I had my original surgeries and never got the chance to fully rehab because I was in too much pain. I am 6 and 8 months out from my revisions and MPFL reconstructions and I still have a long way to go.

Brianne

[mhsflute07]

I had a variation of the Fulkerson on both of my knees when I was 16. I had been having dislocations for 5 years. At first I got by with physical therapy and bracing. But after awhile, my kneecaps dislocated with the braces. At that point I started looking into new OSes and surgical options. After multiple opinions I ended up traveling 7 hours away to have my surgeries done by a specialist. I had the surgery on my right knee first, then the left 7 weeks after that. While that was not a fun summer, it was worth it. At around 7 months post-op on the right, and 6 on the left, I was cleared to play tennis again.

I am now 3 years post-op. My left knee is great! However, I'm still having problems with my right knee and have had two subsequent surgeries on that knee. My knees are completely stable, but I have a lot pain behind my right kneecap and have some cartilage lesions. I have no way of knowing if the original surgery contributed in some way to the formation of these lesions, but regardless, I definitely do not regret having the surgeries. Knowing what I know today, I would still make the same decision to have the (variation of the fulkerson) surgery.

[kc1124]

Please know that there are many success stories on this board. As I said, I am 7 weeks post-op from my Fulkerson/HTO and Trochleoplasty and a few other procedures and am doing wonderfully. It was a major surgery, but with time, patience, and following the PT program, recovery does happen. It is a slow process. Recovery does not happen overnight, or in a few weeks or a few months. It takes time. I am anticipating at least a year for my full recovery. Granted everyone heals and recovers at different rates. I am a few months shy of my 44th birthday, fit and athletic, but I will be first to say that a teenager will probably have an easier time of it than some of us baby boomers.

I had a TTT on my left knee in 2004 and to date, it has been behaving. I do have limitations with the left knee, but that is due to many other and different major surgeries performed on that knee.

I believe that all good surgeons do not go into any surgery lightly. It is best to seek out a patella femoral specialist, but we cannot always do that as there may not be one in your area or your insurance may only cover certain surgeons in your insurance coverage area. To that end, there are also many capable and good surgeons out there who can perform this procedure well and successfully. I am lucky that I too have one of the most sought out surgeons in the country, but, he is located in my backyard.

I hope this is somewhat helpful. I will be happy to answer any more questions. Also, I was thinking about posting a pic from 2 days post-op after my surgery, but I did not know if you would want to look at that. I will have my son take a picture of my scar now and post later. I actually receive compliments on how "beautiful" the incision and scar are. I guess they are my body art.

Take care,
Kat

[Silkncardcrafts]

Hi there,

First of all 2 dislocations is not really that many. A lot of good knee surgeons won't operate in someone so young and until they have given conservative treatment at least 12 months. My knee surgeon wouldn't operate on my knees until I had tried conservative treatment for about a year with a specialised knee physio. It is imperative that your daughter goes to a physio that specialises in knees, especially patella problems.

I would try and avoid having any surgery until your daughter has exhausted all avenues conservatively, especially if she is a competitive athlete. Unless you go to a good knee physio you can waste a lot of time and money. Other things you may want to consider are orthotics, clinical pilates, mcconell taping, bracing and a regular gym program which involves a lot of work on an exercise bike.

If after exhausting all conservative treatment I would consider some surgery. My knee surgeon started with the least invasive and in the end had to do a trochleoplasty, a deepening of the groove as my trochlea were very shallow. It has made a massive difference to me already.

A lateral release can work well if done for the right reasons, so would not discount it. A lot depends on your daughter's anatomy. What is good for one isn't necessary good for the rest. Has your daughter had any CT scans and plain x-rays done ? These are the best types of scans to determine the best sort of treatment for your daughter.

Another thing you may want to consider is to see a good sports physician/doctor. They are most likely to have links with some top sports knee surgeons that specialise in patella problems.

I hope this helps.

[datapopp]

Great to hear some of the success stories, thank you. Yes and please post the pics.

My daughter had her MRI today and I am looking forward to picking up the report on Monday and seeing what it says.

My daughter has great quads...works out 8-15 hours a week (and has for many years), wore a brace and still dislcoated her knee 2x so I think for her this avenue will not solve the issue, though I wish it would. I am not sure that starting with the least invasive or on the other hand going in and doing a fulkerson osteotomy are the way to go. I will continue to get opinions until I feel comfortable with the option we choose.

Every time surgery is performed there are risks, every time you are put under general anesthesia there are risks, and every surgery causes scar tissues. I have been down that route myself and want to avoid it with her.

I did watch a video on the internet from Dr. Fulkerson where if possible he would prefer to do a (new?)mini-mpfl on a 15-20 year old rather than a full mpfl or fulkerson if there was a possibility for success . This seemed a better alternative to me. If she was a good candidate for it.

We will continue to get opinions from doctors until I feel comfortable and in the meantime...She is out of the straightleg brace and into a Breggs Pto though still on crutches. She is so very sad about missing her second season of sports...trained all summer again and back on the sidelines. She goes to every practice and sits afraid they will kick her off

[Silkncardcrafts]

Hi there,

Like your daughter, I was a competitive athlete but unfortunately have never been able to go back to playing sport. My situation has been complicated the fact that I have joint instabilities of my left ankle and both shoulders too. I hope that once I recover from my latest surgery that I will be able to go back to some kind of sport.

It is really important to understand whether your daughter will be able to go back to her chosen sport if she was to have surgery on her knee. That's why I think it would be wise to go and see a good sports physician/doctor that can refer you to a good sports knee surgeon, that specialises in patella problems. I guess this is one of the main reasons I would seriously exhaust all conservative treatments before considering surgery. I know your daughter is sad about missing another season, but is important to think about the long term future of her knee. It is hard at such a young age to really think about that. I never thought at the age of 34 I would have the start of osteoarthritis.

My knee surgeon firmly believes that MRI scans are a waste of time for patella instability. He said the best scans are in fact CT scans and plain x-rays. I would really encourage you to get some of these done. He is one of the best in his field and does a lot of research in this area too.

I hope this helps.