Dislocation > Treatments
Proximal realignment for patients with recurrent kneecap
dislocation may be performed and helpful in preventing
further kneecap dislocations. During a proximal realignment,
your surgeon reinforces, oversews, or cuts some of the
attachments above the kneecap to improve the kneecap's
ability to track better in its groove. This, hopefully,
prevent further dislocations.
| Preparing for Surgery
The decisions you make and the actions you take before
your surgery can be every bit as important as the procedure
itself in giving you the best possibility of a healthy
recovery. Most insurance companies require a second
opinion before agreeing to reimburse a patient for a
surgical procedure. Getting a second opinion from a
surgeon who is as qualified as the surgeon who gave
the initial diagnosis is advisable in any case.
to your return home from the hospital, make sure you
have received any equipment you will need when you get
home from the hospital. This may include a knee brace,
crutches, walker, ice packs or coolers, or household
items to make movement around the house easier. You
should receive prescriptions for any of these from your
doctor before you go home from the hospital.
the potential risks and benefits of the surgery, and
ask your surgeon any questions that will help you better
understand the procedure. It can also help to talk to
someone else who has undergone the same surgery.
physical problems or changes in your overall health,
such as a fever or infection, should be reported to
your surgeon, and you should notify your surgeon of
any new medications you are taking.
the use of any anti-inflammatory medicine, especially
aspirin, a week prior to surgery, to prevent excessive
bleeding during the procedure.
reduce the risk of infection, improve healing, and decrease
complications, try to quit smoking or decrese the amount
you smoke. In general, smokers have a higher overall
infection and complication rate.
possible, practice walking with your crutches in case
you need to use them after surgery.
sure the orthopedist performing the surgery is board-certified,
which can be determined by calling the American Board
of Orthopaedic Surgery at 919-929-7103.
to ask the doctor
to take to the hospital
Prior to surgery, you may be instructed to go to the
hospital for pre-admission testing a few days before
surgery. A nurse will review your medical history and
provide you with all the preoperative instructions you
need.You will be asked about your past medical history,
given a complete physical exam and undergo the appropriate
routine blood and urine tests and diagnostic studies
(e.g. X-rays and electrocardiogram). If you are taking
any medications, you will receive instructions about
which medications to take and the appropriate dosing
prior to your surgery. At most medical centers, you
will go to "patient admissions" to check in
for your surgery. There may be separate areas for ambulatory
outpatients (patients who go home the same day after
surgery) and for overnight inpatient surgery check-in.
Be sure to ask your doctor or one of his assistants
about this. After you have checked in to the hospital,
you will go to a holding area where the final preparations
are made. The mandatory paperwork is completed and your
knee area may be shaved (this is not always necessary).
You will be asked to change into a hospital gown and,
if necessary, to remove all of your jewelry, watches,
dentures, and glasses. You will have the opportunity
to speak with your orthopedic surgeon or one of his
assistants, and meet the anesthesiologist or anesthetist
(a nurse who has done graduate training to provide anesthesia
under the supervision of an anesthesiologist). Then,
you will walk or ride on a stretcher to the operating
room. Unless requested, most patients are not sedated
until they go into the operating room. Here are some
important steps to remember for the day of your surgery:
will probably be told not to eat or drink anything after
midnight on the night before your surgery. This will
reduce the risk of vomiting while you are under general
your surgery is going to be an outpatient procedure,
arrange for someone to drive you home when you are released,
as the anesthetic and pain medications may make you
your surgery is going to be an inpatient overnight stay
procedure, pack a bag for yourself that contains toiletries,
underwear, personal phone numbers you may need, and
any other items you would like to have during your hospital
a loose pair of pants or other clothing that will fit
comfortably over your knee bandage when you leave the
it easy. Keeping a good frame of mind can help ease
any nerves or anxiety about undergoing surgery. Distractions
such as reading, watching television, chatting with
visitors, or talking on the telephone can also help.
to take to the hospital
A proximal realignment procedure to repair a dislocated
kneecap usually takes about one-and-a-half to two hours.
During a proximal realignment, your surgeon reinforces,
oversews, or transfers some of the attachments above
the kneecap to improve the kneecap's ability to track
better in its groove. This, hopefully, prevents further
anesthesia is typically used in this surgery, though
in some cases a spinal or epidural anesthetic is used.
You can expect to be given a sedative in the operating
room before the anesthesiologist administers the anesthesia
to put you to sleep.
anesthesia is administered, the surgical team sterilizes
the leg with antibacterial solution and places clean
drapes around the site of the operation.
four to six inch linear incision is made above and over
your kneecap. The incision is deepened to expose the
underlying quadriceps tendon, which attaches to the
kneecap and helps the knee extend.
inner (medial) portion of the quadriceps tendon is cut
and used to increase the inner pull on the kneecap to
balance the forces on the kneecap. This helps prevent
the kneecap from subluxating or dislocating. The inner
quadriceps tendon is reinforced, oversewn, or moved
to improve the kneecap's ability to track in its groove.
a lateral release is also performed to augment the proximal
incision is closed, a sterile dressing is placed over
the wound, and a knee immobilizer or cast is placed
to knee movement. You will then be taken to the recovery
After a proximal realignment precedure, you will be
transported to the recovery room where you will be closely
observed for one to two hours while the immediate effects
of the anesthesia wear off. After surgery, you will
experience some pain. Adequate pain medications will
be prescribed for you. You will be given oral, IV (intravenous),
or intramuscular pain medications when you ask for them.
In some cases, you will be given an IV patient-controlled
analgesia (PCA) device, which delivers pain medications
in safe amounts when you push a button. Your knee will
be bandaged and may have ice on it. There will likely
be pain, and you can expect to be given pain medication
as needed. Be sure to ask for medication as soon as
you feel pain coming on, because pain medication works
best on pain that is building rather than on pain that
is already present. The nurses will not give you more
than your doctor has prescribed and what is considered
to be safe. You should try to move your hips, feet,
and ankles while you are in the recovery room to improve
circulation. Your temperature, blood pressure, and heartbeat
will be monitored by a nurse, who, with the assistance
of the doctor, will determine when you are ready to
leave the hospital or, if necessary, be admitted for
an overnight stay. Depending on the type of procedure
performed and your surgeon's preference, you may or
may not be allowed to bear any weight on your operative
leg. Even if you are allowed to bear some weight on
your operative leg, you will probably have to use crutches
or a walker for a period of time. After surgery, your
physician will give you specific instructions about
how much weight you can bear on your operative leg.
Occasionally, a proximal realignment precedure is an
outpatient procedure. However, it is not uncommon for
patients to spend one to two days in the hospital.
| Post-op in Hospital
Because pain is relative and subjective, it is difficult
to predict how much pain a given patient will feel after
surgery. Staying overnight in the hospital allows your
surgeon, anesthesiologist and nurses to carefully monitor
your condition and control your pain. Some doctors may
prescribe physical therapy after surgery to teach you
how to walk and perform activities with the aid of crutches
or a walker while following weight bearing restrictions.
After surgery, you will experience some pain. Adequate
pain medications will be prescribed for you. You will
be given oral, IV (intravenous), or intramuscular pain
medications when you ask for them. In some cases, you
will be given an IV patient-controlled analgesia (PCA)
device, which delivers pain medications in safe amounts
when you push a button. Be sure to ask for pain medication
as soon as you feel pain coming on, because pain medication
works best on pain that is building rather than on pain
that is already present. The nurses will not give you
more than your doctor has prescribed and what is considered
safe. You will be given instructions about caring for
your knee at home and schedule a follow-up appointment.
You will also be given a prescription for oral pain
medications. You will be unable to drive a car, so be
sure to have arranged a ride home.
You will likely feel pain or discomfort for one to
two weeks, and you will be given oral pain medications
as needed. A prescription-strength pain medication is
usually prescribed and should be taken as directed on
the bottle. There may be some minor drainage on the
dressing since fluid may have accumulated during the
surgery. If you are not in a cast and are able to see
your dressing, do not be alarmed to see some bloody
drainage on your dressing over the first 24 to 48 hours.
Here is what you can expect and how you can cope after
a proximal realignment procedure:
knee will be swollen for several weeks. The incision
is usually from four to six inches long and takes a
few months to heal completely.
external sutures or staples are in place, they should
be removed approximately two to three weeks after surgery.
should usually continue with the ice for at least 24
to 72 hours, and if you are not in a cast, remove the
dressing as instructed by your physician. Icing your
knee as much as possible during the first two days after
surgery will help reduce pain and swelling. Ice therapy
is most effective in the first 24 to 48 hours.
much as possible, you should keep your knee elevated
above heart level to reduce swelling and pain. It often
helps to sleep with pillows or blankets under your ankle.
bathe and keep your cast or knee immobilizer and wound
dry. Do not shower or take a bath until your surgeon
tells you it is safe to do so. Once you can, put your
leg in a plastic bag and tie it around the top of your
leg to keep your cast or knee immobilizer and wound
or a cane may be needed for four to six weeks following
two or three days after surgery, you may experience
a low-grade fever of up to 101. Your physician may suggest
acetaminophen, coughing, and deep breathing to get over
this. This is common and should not alarm you.
on your pain threshold, you may be able to return to
work in three to four days. If your job requires heavy
lifting or other heavy activity, you may have to miss
work for up to two months.
to call the doctor after surgery
Physicians usually suggest you rest your knee for four
to six weeks while the kneecap's soft-tissue reconstruction
heals. You should not start aggressive rehab with weight-bearing
exercising until instructed to do so by your surgeon.
Your physician and physical therapist can help design
a custom rehab program that is best for you. You will
start slowly with range of motion exercises, and then
proceed to strengthening exercises. Patients usually
do stretching and strengthening exercises for a minimum
of three days a week. The workouts should focus on the
knee for at least thirty minutes and be combined with
a knee-friendly cardiovascular workout. Physical therapy
after a tibial tubercle osteotomy with distal realignment
surgery follows a general pattern. Most people can begin
stretching the muscles and tendons around the kneecap
after about four weeks. Your knee is generally strong
enough to handle mild stretching and slow movements.
Working to restore early range of motion is important.
It usually takes about six weeks for the soft-tissue
reconstruction to heal enough for you to begin more
rigorous strengthening exercises. When stretching, try
to avoid bending your knee past 90 degrees, which is
roughly the knee angle when sitting in a chair with
your feet flat on the floor. Rehabilitation progresses
into strengthening exercises that focus on the quadriceps
and hamstrings - the main stabilizing muscles for your
knee. Physicians suggest you gradually increase the
amount of weight as your leg muscles get stronger. Strengthening
exercises require dedication because results often take
months and pain may occur. Once the muscles of your
injured leg are about as strong as the uninjured leg,
the focus of rehab turns to increasing your coordination.
After about six to 12 weeks of rehab, physical therapy
may become activity-oriented as you regain the ability
to perform complicated movements, using stationary bikes,
elliptical machines, and cross-country skiing machines.
It may take up to six months of rehabilitation to return
to activities at full strength. Physicians usually suggest
that you continue strength training even after your
kneecap has been rehabilitated. Have your physician
periodically check your kneecap for strength and proper
strengthening exercises: Kneecap (patella) injuries
Your main prevention goal following kneecap dislocation
should be to strengthen your quadriceps and hamstring
muscles so they are stronger than before the dislocation.
You should try to feel comfortable that your leg muscles
are powerful enough to snugly keep your kneecap in a
normal alignment. Physicians usually suggest that you
wear your knee sleeve during any activities that may
stress your knee. The knee sleeve by itself may improve
the tracking of your kneecap, however, to prevent kneecap
dislocations, your rehab exercises are ultimately more
important than bracing. Making the strengthening exercises
you learned in rehab part of your regular conditioning
routine is the best way to prevent future kneecap dislocations.
Like any dislocated joint, once the first dislocation
occurs, less force may provoke subsequent dislocations.
You will have to rely much more on muscle strength to
hold your kneecap in a normal position after a dislocation.
Depending on the severity of your dislocation and the
success of your rehab program, your physician may recommend
that you avoid contact sports or risky, high-speed activities.
In general, your kneecap can become healthy and stable
after a dislocation, but you may need to be cautious
of activities that could result in accidental collisions
or falls. Besides the knee sleeve, consider wearing
sturdy kneepads designed for crashes during activities
like in-line skating and padded knee braces during contact
sports. Your physician can recommend the best types
of protective gear for your knees. You may know some
people who seem able to pop their joint in and out of
place painlessly. This should be avoided at all costs.
The more your kneecap is popped out of place, the greater
your chances of arthritis and the higher your risk of
re-injury during activities.