Thank you very much. It's a big honor to speak to you all and provide a kind of a pediatric orthopedic perspective in some of these difficult cases. I'll just begin by thinking about the terms we use, you know, habitual patellar dislocation is not one of my favorite terms because it reminds me of like habitual, shoulder, behavioral, so what should we be calling it? But then also a reminder for everybody to check out the patellofemoral courses that are online at the Patellofemoral Foundation website. There's some great updated courses there that are good modules to go through. These terms really, when I first back and start to find where do people start talking about habitual dislocation, I go back to this old Pediatric Orthopedic Journal article in JB Jessen, 72, Dr. Carol, John Hall, who's a famous pediatric orthopedic spine surgeon when he was at Toronto. He says these are recurrent, they're spontaneous, but they can be, they may be congenital. They might be habitual. They might be recurrent. And a lot of times in the literature, when you go back and look historically, all these terms were used interchangeably. So it's hard to kind of know what you're talking about. But another interesting thing about this old paper was how they talked about the high-riding patella. They talked about the ligamentous laxity, hypoplasia of the condyle, medial angulation of the pole of the quadriceps, contracture of the lateral patella. All things were talked about today were being discussed by the pedi-orthopods in Toronto, sick kids in 72. I like to use obligatory patella dislocation instead of habitual, but in literature you'll see congenital. You also see this referred as quadricep fibrosis. So I'm going to call it, I'm going to talk today, basically I'm going to use the term obligatory patella dislocation inflection. You can see, as the case that Dr. Arndt showed, you can see there's terrible J signs that are really obligatory dislocation and extension as well. We will see in our pediatric clinic fixed lateral patella dislocations that just stick in the gutter in extension and flexion. And in the pediatric clinic, we'll see kids with skeletal dysplasia, now patella syndrome, Marfan's, Ehlers-Danlos, CP, Down syndrome. So we'll be talking about obligatory patella dislocation inflection. Basically every single time the knees flex, the patella dislocates. In extension, it's reduced, it dislocates inflection. So there's another case, similar case. Notice she's using her other leg to kind of provide a little bit more extension force. Every time she extends, it's centered anteriorly. Every time she flexes, it dislocates in the gutter. So what would happen if you just did an MPFL in this situation and you kept it in the front of the patella in the front of the trochlea? As you flex, it would just stop or it would just rip out your MPFL. So you have to recognize this pattern and have a plan. And so the plan begins with a massive lateral release and lengthening. And you're going to do, and traditionally we'll do this down all the way to the tibial tubercle. And then we're going to release the vastus lateralis tendon. So a quad tendon release, later it'll be lengthened. And to do this, you have to remove the vastus lateralis tendon from the patella and from the adjacent quad. Then later in the case, you can reattach the vastus lateralis in a lengthened position. And that will relieve that dislocation inflection about 60, 70% of the time in my hands. And if it's not released after that, then you might have to lengthen the quad. I prefer this Z lengthening because you remove the more lateral force from the lateral patella and then you can lengthen the quad there. But also a VY lengthening has been reported in many textbooks. Here's an old Dr. Andrisch paper from 2007 that really shows the diagram nicely. Look at the picture on the right here. You can see this massive opening on the lateral side. You can see the lengthening of the vastus lateralis tendon. This tendon used to be all the way down at the patella. So again, you really got to assess your knee, your patella tracking after you've done your vastus lateralis lengthening. And if you still are unable to keep the patella located anteriorly after that, you need to consider lengthening the quad. So here's the quad, the vastus lateralis completely isolated from the quad. And then in this case, we needed to have to do a formal Z lengthening as well. Here's the vastus lateralis again. Here it is. We haven't done MPFL surgery yet. We've just released the quad and now the patella is tracking anteriorly without a pull medially. We've described this in arthroscopy techniques in 2021 if you want to go kind of a step-by-step look. And so our usual treatment plan going in this is to like what we talk about after we can get the patella to be located in the anteriorly inflection. We'll then go on to an MPFL reconstruction and in some cases we'll need distal realignment. Let's see if this is a short clip, see if it's going to work. So here's a case of obligatory dislocation inflection. Dr. Dejour is having a heart attack looking at the trochlea. Here we've done doing a lateral lengthening here. We're going to go on. Now we're going to remove the vastus lateralis, removing the vastus lateralis here. And we're going to lengthen that later. I just want to show the range of motion. This is what I really wanted to show you. See we got to about 90 degrees. The patella is trying to dislocate. So that's a little bit too much of a pull, too much deforming force to rely on your medial structure. So that's what leads me to go on and do the remainder of the quad in a lengthened position. Here's a case, an eight-year-old with obligatory patella dislocation, strong family history. And they're post-op four years later on the bottom. You can see the trochlea looks a little better. So it had the quad lengthening and the MPFL surgery. Does the trochlea, in pediatrics, I do think if you can get to the kids under age 10, the trochlea can develop and become deeper, and a number of small studies have shown that. Here's a case that came to my clinic for a two-year post-op the other day. Here's the pre-op, a classic obligatory patella dislocation and extension. And here he was last week. He had both of his knees done. He just doesn't have a, he doesn't have an extensor leg. What I like about this little lateral video is you can almost see the extensive lateral release that had been done, and you can see my little lateral lengthening there. Another kid, this kid obviously has severe valgus. He had a medically treated hypophosphatidymic recurrence, again, obligatory dislocation. So we elected to use implant-mediated guided growth first, correct the malalignment, then perform our quad lengthening and MPFL surgeries in a sequential way, and this child's done very well. Last case, one of the worst cases I've taken care of was, look at how posterior this patella is. So it's a fixed lateral patella dislocation in a 10-year-old, and we did our, we got the patella anterior, hypoplastic patella, MPFL, MQTFL, quad lengthening, vasus lateralis lengthening. We even transposed the patella tendon medially. Here's where it used to be. The patella tendon would be, was way over by the fibula, and we moved it medially, and you can see at two years, the patella in this scuttle dysplasia patient is in an anterior position. So I love all this discussion today. It's really important to think about this, Dr. Sherman said, what's in your toolbox and to really recognize these patterns and apply them to the individual patient as needed. So thank you very much.

pediatric orthopedics

patellar dislocation

terminology

treatment options

ligamentous laxity