Proximal and distal realignment procedures are surgical treatments performed for patellar instability, a situation where the kneecap (patella) dislocates or shifts from its normal position. These procedures are designed to realign the patella, enhance its stability, and minimize the likelihood of future dislocations. Here’s an overview of both proximal and distal realignment techniques:Here’s an overview of both proximal and distal realignment techniques:

Proximal Realignment

Proximal realignment involves the modification of the structures close to the superior aspect of the patella. This typically involves:

1.     Medial Patellofemoral Ligament (MPFL) Reconstruction: The MPFL play a crucial role in the stabilization of the patella. Reconstruction entails using a graft, which may be sourced from the patient’s hamstring tendon, to reconstruct or reinforce the defective ligament.

2.     Lateral Release: This involves releasing the tight lateral retinaculum, a structure on the outer side of the knee, that may assist in decreasing pulling forces on the patella laterally.

3.     Medial Imbrication: To bring the patella back to the center, the medial soft tissues are pulled more tightly.

Distal Realignment

Distal realignment involves changing the position of the tibial tubercle, the bony prominence on the tibia where the patellar tendon inserts. This typically involves:

1.     Tibial Tubercle Transfer (Osteotomy): This technique requires the excision and transfer of the tibial tubercle to shift the patellar tendon and enhance the patella’s glide. Types of osteotomies include:

·        Medialization (Elmslie-Trillat Procedure): Rotating the tubercle inwards towards the inner aspect of the knee.

·        Anteromedialization (Fulkerson Procedure): Relocating the tubercle both anteriorly and medially to decrease the amount of patellar tilting and increase the patellar glide.

2.     Tubercle Distalization: Tibial tubercle transfer in cases where the patella is located higher than normal (patella alta).

Indications for Surgery

Surgical intervention is typically considered for patients who have:Surgical intervention is typically considered for patients who have:

·        Recurrent patellar dislocations.

·        Chronic patellar instability.

·        Persistent pain and disability even with non-surgical interventions such as physiotherapy, splinting or avoiding certain activities.

Postoperative Rehabilitation

Rehabilitation is crucial for a successful outcome and involves:Rehabilitation is crucial for a successful outcome and involves:

·        Immobilization: Application of a brace or splint at the beginning to support the knee.

·        Physical Therapy: Slow advancement of range of motion exercises, strengthening, and proprioceptive training.

·        Return to Activity: Gradual return to sports and high-impact activities depending on the patient’s progress and the stability of the patella.

Risks and Complications

As with any surgical procedure, there are risks, including:As with any surgical procedure, there are risks, including:

·        Infection

·        Blood clots

·        Stiffness or limited range of motion

·        Pain or discomfort

·        Persistent subluxation or dislocation


The majority of patients who undergo proximal or distal realignment surgery have improved stability, decreased pain, and enhanced knee function. However, the particular result may depend on certain factors including the amount of preoperative instability, the particular surgical procedure performed and the compliance with postoperative physiotherapy.


Both proximal and distal realignment procedures are successful surgical interventions for the treatment of patellar instability. The decision between using proximal or distal techniques depends on the etiology of the instability, the patient’s anatomy, and the surgeon’s judgement. Both methods are used to realign the structures, enhance the knee’s functionality and prevent recurrent dislocations.