Evolving Concepts in Management of Patellofemoral Instability (2025 Annual Meeting)-Evolving Concepts in Management of Patellofemoral Instability

Video Transcription

Video Summary

The instructional course reviews modern management of patellofemoral (patellar) instability, emphasizing that instability reflects underlying anatomic risk factors (trochlear dysplasia, patella alta, malalignment/rotation, valgus) plus laxity of the medial patellofemoral complex.

<strong>Medial soft-tissue stabilization:</strong> Faculty largely favor reconstruction over repair; isolated repair has high failure except rare acute avulsion cases. MPFL vs MQTFL vs hybrid techniques generally yield similar clinical outcomes when performed anatomically with appropriate graft positioning and tensioning. Key technical priorities are accurate femoral and patellar attachment sites, avoiding patellar fracture (minimize large patellar tunnels; consider anchors), and avoiding over-constraint by tensioning with the patella engaged in the trochlea (often ~30–60° flexion). Allograft and autograft perform similarly.

<strong>Trochlear dysplasia and trochleoplasty:</strong> Trochlear dysplasia is presented as the dominant risk factor for recurrent dislocation and a contributor to early cartilage damage/arthritis. The speakers argue modern trochleoplasty is evidence-supported (not “Wild West”), with high satisfaction, durable stability, and acceptable arthritis rates in long-term series. Indications focus on high-grade dysplasia, particularly a prominent “bump” and maltracking (jumping J sign). MRI-based quantification and newer classification concepts are advocated to avoid missing high-grade disease. Trochleoplasty aims to remove the bump, reorient the groove, and modestly deepen it while preserving cartilage.

<strong>Tibial tubercle osteotomy (TTO):</strong> TTO is positioned as most useful for cartilage unloading (anteromedialization/anteriorization) and for significant patella alta distalization, not simply for TTTG >20. Elevated TTTG may reflect dysplasia/rotation rather than true tubercle lateralization.

<strong>Cartilage restoration:</strong> Patellofemoral cartilage surgery is challenging; two main options are osteochondral allograft (for structural bone involvement) and ACI (large surface defects, usually combined with unloading TTO). Outcomes are generally inferior to tibiofemoral lesions; BMI, lesion size/chronicity, and age worsen results.

Panel discussion highlights variability in constructs, the need to individualize “subcritical” risk factors, and debate about how aggressively to treat first-time dislocators with major osteochondral injury.

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

patellofemoral instability

medial patellofemoral ligament (MPFL) reconstruction

medial quadriceps tendon–femoral ligament (MQTFL)

trochlear dysplasia

trochleoplasty

patella alta

tibial tubercle osteotomy (TTO)

TT-TG distance

patellofemoral maltracking (J sign)

cartilage restoration (ACI, osteochondral allograft)

anatomic risk factors and surgical decision-making