Patellofemoral instability is a broad and complex area of knee surgery. It is characterised
clinically by recurrent patellar dislocations with an association of many different
underlying anatomical pathologies that can predispose patients to the condition. These
can include a tear of the medial patellofemoral ligament (MPFL), trochlear dysplasia
and an increased tibial tubercle – trochlear groove distance (TT-TG). Assessing for
lower limb rotational malalignment of the femur and tibia is also important in the
evaluation of patellofemoral instability. A meticulous and detailed clinical assessment
coupled with radiological investigations allow the clinician to identify the exact
causative pathology which can often be multifactorial in some patients. It can also
be associated with generalised hyperligamentous laxity and other co-morbidities including
connective tissue disorders (i.e. Marfan’s syndrome, Ehlers-Danlos syndrome) which
also have multisystem manifestations. A degree of supratentorial overlay is also present
in some patients which can further complicate the clinical assessment and indeed should
be factored into the decision-making process when considering the optimal choice of
treatment. In these patients, a variable degree of catastrophizing of symptoms may
be apparent and the clinician’s consultation should be prudent to this. It should
be noted that undertaking patellar stabilisation surgery for the symptom of anterior
knee pain alone and in the absence of true patellofemoral instability yields notoriously
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