Surgical Management of Habitual Patellar Dislocation: Quadricepsplasty, Medial Plication, and Baguette Molle.

Background: Fixed and habitual (obligatory) dislocation of the patella is caused by externally rotated and shortened quadriceps mechanisms. Many surgical techniques have been described to treat this condition, yet there is insufficient evidence favoring one over another. A combination of procedures is recommended to restore proper patellar tracking.

Indications: The quadricepsplasty with medial plication and Baguette Molle is indicated in skeletally immature patients with a misaligned extensor mechanism causing habitual patellar dislocation.

Technique description: A lateral approach to the femur is performed, followed by dissection down to the iliotibial band fascia. The fascia is opened, and the vastus lateralis is dissected from the posterior iliotibial band fascia, exposing the femur. Distal-to-proximal release of the vastus lateralis is performed until fully released. The incision extends distally toward the tibial tuberosity, opening the lateral retinaculum and capsule. Full-thickness flaps are developed on each side of the tibial tuberosity. The apophysis of the tuberosity is sharply dissected and transposed medially within a trough in the tibial periosteum ("Baguette Molle") and then secured with interrupted nonabsorbable sutures. Medial plication is performed through a longitudinal incision parallel to the patella's long axis. Nonabsorbable sutures are used to plicate the flap, ensuring appropriate tension. On-table assessment of patellar tracking is carried out throughout the procedure.

Results: The patient undergoes a standard postoperative admission lasting 2 to 3 days, primarily focusing on pain management and facilitating early range of motion. A perioperative epidural catheter is inserted to ensure effective pain control and aid in early mobilization. Additionally, patients are introduced to a continuous passive motion device, dedicating 3 to 5 hours per day to mobilize the affected limb at a 45° angle on postoperative day 1, gradually progressing to full range by postoperative day 3. Subsequently, a protective weightbearing status is recommended for 4 to 6 weeks with unrestricted range of motion. Follow-up appointments are scheduled at 6 weeks, 12 weeks, 6 months, and annually thereafter until growth cessation to monitor for any potential growth disturbances.

Discussion/conclusion: Quadricepsplasty with medial plication and the Baguette Molle technique is a reproducible and effective procedure for treating habitual patellar dislocation in skeletally immature patients, with satisfactory short-term outcomes.

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