Dr. Brian Feeley and Dr. Drew Lansdown talk about patellar instability. They see it all the time in clinic, but it's one of the harder problems in sports medicine to sort out. They cover what happens when the kneecap dislocates and who does well without surgery. They also explain Dr. Dejour's "à la carte" approach, where the surgeon picks which problems in the leg to correct. And they discuss a new randomized trial from Norway on MPFL reconstruction.
Patellar Instability: One Surgery, Two, or Three?
Dr. Brian Feeley and Dr. Drew Lansdown talk about patellar instability. They see it all the time in clinic, but it's one of the harder problems in sports medicine to sort out. They cover what happens when the kneecap dislocates and who does well without surgery. They also explain Dr. Dejour's "à la carte" approach, where the surgeon picks which problems in the leg to correct. And they discuss a new randomized trial from Norway on MPFL reconstruction.
In this episode:
-The Norwegian trial. Patients aged 12–30 with at least two dislocations were randomized to MPFL reconstruction or to arthroscopy plus rehab. At 3 years, the rehab group was about 5.8 times more likely to still be unstable (AJSM 2026).
-What happens in a dislocation. The kneecap almost always slips toward the outside. This can come from a direct hit or from a planting and twisting move, much like an ACL injury.
-Putting it back in. Straightening the knee usually lets the kneecap slide back into place. Brian has a story about a mattress-jumping sleepover.
-What tears. The medial patellofemoral ligament (MPFL), which normally holds the kneecap in place, is stretched or torn. Some patients also chip bone or damage cartilage.
-First-time dislocations. When the anatomy is normal, rehab usually works. Most athletes return in about 6 to 8 weeks. Patrick Mahomes returned in about 3.
-Bad luck or anatomy. Features that raise the risk include a rotated hip, a flat groove (trochlear dysplasia), a high-riding kneecap, a patellar tendon that attaches too far to the outside, a rotated lower leg, and being knock-kneed.
-Don't treat the X-ray or MRI. Surgeons don't operate on a knee that has never been unstable, even if it looks abnormal. A kneecap that "sits to the side" on an MRI means little, because the knee is straight during the scan.
-Measurements aren't perfect. Surgeons may not get the same result when they measure the same knee twice, or when two surgeons measure it.
-The à la carte approach:
MPFL reconstruction for almost everyone.
Tibial tubercle osteotomy (moving where the patellar tendon attaches) when the pull on the kneecap is off.
Trochleoplasty (deepening the groove) only occasionally.
Femoral derotation osteotomy for severe rotation.
For borderline anatomy, MPFL reconstruction alone works about 95% of the time.
-Recovery and outcomes. The first 6 weeks after an osteotomy are hard. Patients who are doing well at 6 months tend to still be doing well 10 to 15 years later. The knee doesn't have to be anatomically perfect, just good enough.
-A reminder. Most pain at the front of the knee is not instability. It usually gets better by improving how you do squats and lunges.
Hosts: Brian Feeley, MD, and Drew Lansdown, MD (UCSF)
Reference:
Straume-Næsheim TM, Randsborg PH, Nilsgård TL, Årøen A. Medial patellofemoral ligament reconstruction vs nonoperative treatment for recurrent lateral patellar dislocation: three-year results from a randomized controlled trial. Am J Sports Med. 2026;54(4).
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This podcast is for educational purposes and is not medical advice.