ORIGINAL ARTICLE
Treatment of Recurrent Patellar Instability With a
Modification of the Roux-Goldthwait Technique
James S. Marsh, MD, John P. Daigneault, MD, Paul Sethi, MD, and Gert K. Polzhofer, MD
Abstract: Recurrent instability of the patella may be a significant
disability in the childhood and adolescent population. Numerous
surgical procedures to address this instability have been described,
with variable outcome. This has led to considerable confusion in the
literature as to how to treat patellofemoral problems in children. This
study retrospectively reviews 30 knees in 20 patients with chronic
recurrent patellar instability who were treated with a modified Roux-
Goldthwait technique including the release of contracted lateral
structures by a single surgeon over a 13-year period, with an average
of 6.2 years follow-up. By Insalls criteria,17 26 knees had an
excellent result, 3 good result, and 1 fair result. Ten patients
evaluated using a dynamometer showed that strength achieved in the
operated leg was greater than 90% in 8 patients and greater than 80%
in 2 patients. Here, we report upon a single operation to treat patellar
instability performed in the pediatric population with consistently
excellent results.
Key Words: recurrent patellar instability, modified Roux-
Goldthwait procedure, adolescents
(J Pediatr Orthop 2006;26:461Y465)
P atellar subluxation and dislocation are well-documented
causes of chronic knee pain and instability in the pediatric
and adolescent population. It is considered highly associated
with chondral and osteochondral lesions of the patellofemoral
joint.21 Patients present with giving-way, popping, or frank
dislocation, requiring reduction manually. The etiology of
patellar instability requires a thorough physical and radio-
graphic examination of the patient because the causes may
include genu valgum, genu recurvatum, patella alta, patellar
dysplasias, trauma, femoral anteversion, external tibial torsion,
ligamentous laxity, congenital abnormalities, and syndromes
such as nail-patella (Fig. 1) and Down syndromes.3,25,31 The
optimal treatment in this patient population, as well as
immediately after traumatic patellar dislocation,3 is nonoper-
ative, but when physical therapy and/or bracing fails, surgical
repair is indicated.7
Several different operative reconstructive procedures
are suggested in the literature, indicating that no single
procedure is predominant.1,3,7,14 Part of this owes to a lack of
uniform definition of the problem, when treating malalign-
From the Klinik Dr Guth Hamburg, Germany.
None of the authors received financial support for this study.
Reprints: Dr Gert K Polzhofer, MD, Kuchelweg 3, 22605 Hamburg, Germany.
E-mail: polzhofer@web.de.
J Pediatr Orthop & Volume 26, Number 4, July/August 2006
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ment, maltracking, or actual instability.23 As well, no clear
indications for realignment had been reported until in 2003
when Kobayashi et al18 set up a 3-dimensional computed
tomography classification. Further, various articles, in addi-
tion to lumping together the diagnostic entities, cite multiple
procedures within the same article for treatment of these
problems, making an analysis of the literature extremely
confusing, something already mentioned back in 2003 by
Hinton et al.15 Stanitski27 has advocated the following: (1)
releasing an abnormal tethering vector, (2) providing a
balance to the medial vector, (3) aligning the quadriceps
patellar-tibial mechanism, and (4) a combination of the
above. In the skeletal immature patient, transfer of the tibial
tubercle must be avoided, if possible, to prevent premature
physeal closure and subsequent development of genu
recurvatum. This leaves soft tissue procedures to address
the above problems in this patient population. In this study,
we report upon a single operative technique performed by a
single surgeon in children and adolescents for treatment of
recurrent instability (dislocation) only.
METHODS
Thirty-four knees were operated on in 24 patients and
reviewed retrospectively. All procedures were performed by
the first author. There were 10 males and 14 females (male/
female ratio, 1:1.4). Age range was from 3 to 18 years with a
mean of 14.2 years. The follow-up average was 6.2 years with a
range of 2 to 13 years. The preoperative diagnoses included
ligamentous laxity (10), nail-patella syndrome (8), patella
alta (7), malrotation (5), genu recurvatum (5), genu valgum
(5) (Q-angle greater than 20 degrees), trauma (1), and Down
syndrome (1) (Table 1). All patients presented with a history
of pain and chronic recurrent patellar dislocation (Fig. 2).
The abnormal Q-angle was defined following Insalls
criteria.17 The patellar reticular tightness was assessed, and
radiographs were obtained for assessment of patellar tilt,
patellar tracking, patella alta, and various radiographic
parameters as noted below. Vastus medialis obliquus
strength and thigh girth were assessed as well using a Kin-
Com dynamometer (Chattanooga Group, Hixson, TN).
All patients had a modified Roux-Goldthwait procedure
performed in the sense that as a modification, an additional
release of the contracted structures lateral to the extensor
mechanism was performed: following the Roux-Goldthwait
technique, the patellar tendon was split longitudinally, and its
lateral half detached from the tibial tuberosity. The detached
lateral half of the tendon was transferred distally beneath its
intact medial half. There, the split tendon was sutured to soft
tissues on the medial side of the tibia, if possible to the
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Marsh et al J Pediatr Orthop & Volume 26, Number 4, July/August 2006

FIGURE 2. Ligamentous laxity with lateral dislocation of

patella preoperatively.

because otherwise, too many variables, such as sex, age, side

operated on, preoperative diagnoses, etc, the sample size
FIGURE 1. Patella dislocation due to nail-patella deformity.
would have been too small for valid statistical analysis.

RESULTS
insertion of the sartorius muscle (Fig. 3). We tried to avoid too Four knees in 4 patients were lost to follow-up, giving
much distalization so that the medial half of the patellar 30 knees in 20 patients for evaluation: 10 patients presenting
tendon would relax. We also arranged the lateral half in a way with patellar instability on one side (group 1) and 10 patients
that the vector forces to be transmitted through the tendon
halves align the extensor mechanism in the axis of the femoral
shaft. Postoperatively, all patients were immobilized for
4 weeks in a knee immobilizer, had protected immobilization
for additional 2 weeks, with physical therapy beginning
between the 4th and 6th week. All patients required 8 to
12 weeks of postoperative physical therapy. Patients were
asked to return for reevaluation in which the clinical and
radiographic parameters were reassessed. In those patients
who had a single knee procedure performed, isokinetic
strength testing with a Kin-Com dynamometer was accom-
plished on both the operated and nonoperative legs for
comparison of strength. We analyzed the data descriptively

TABLE 1. Preoperative Diagnoses. All Patients Presenting with

History of Pain and Chronic Recurrent Patellar Dislocation

FIGURE 3. Modified Roux-Goldthwait Technique: patellar

tendon split and transferred medially onto the tibial insertion
of the sartorius muscle (1); modification of the classical
Roux-Goldthwait operation by adding a lateral release
(2); and medial half of patellar tendon (3).

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J Pediatr Orthop & Volume 26, Number 4, July/August 2006
TABLE 2. Postoperative Results of 30 Procedures in 20
Patients Following the Q-angle Definition by Install (14- as
Normal, Above 20- as Abnormal)
with patellar instability on both sides (group 2). By Insalls
criteria17 considering a Q-angle of 14 degrees as normal and
above 20 degrees as abnormal, there were 26 excellent results
(Q-angle of 14 degrees; 8 in group 1 and 18 in group 2), 3 good
results (Q-angle 12-16 degrees; 1 in group 1 and 2 in group 2),
and 1 fair result (Q-angle of 18 degrees, group 1)17 (Table 2).
The improved radiographic results for 20 randomly selected
knees of both groups (10 of group 1 and 10 of group 2; t test,
n = 20) including sulcus/congruence angle and lateral patellar
deviation/angle are shown below (Table 3). The fair result
occurred in a Down syndrome patient, who had recurrent
dislocation requiring reoperation. The good result occurred in
2 patients, one of them having bilateral patellar instability on
the basis of extreme ligamentous laxity that probably fell into
the category of a collagen disorder that, at this point, remains
undiagnosed. The 10 patients presenting with patellar
instability on one side (group 1) evaluated by Kin-Com
dynamometer showed that strength achieved in the operated
leg was greater than 90% in 8 patients (80%) and greater than
80% in 2 patients (20%) (Fig. 4).
DISCUSSION
Studies of patellar instability in the skeletally immature
population are rare, and the indications for the different
procedures are not well documented. Females seem to be
more likely to present with patellar-tracking problems,
whereas males are more likely to have knee extensor
mechanism problems.4 The Roux-Goldthwait procedure,
initially described by Roux24 in 1888 and subsequently
TABLE 3. Averaged Radiographic Results of the Modified
Roux-Goldthwait Procedure in 20 Knees (t test, n = 20)
Preoperative Postoperative
Sulcus angle (degrees) 138 134
Congruence angle (degrees) 15.7 j5.3
Lateral patellar deviation (mm) 6.5 0 G0.001
Lateral patellar angle (degrees) 7 16.7
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Treatment of Recurrent Patellar Instability
reported upon by Goldthwait11 in 1895 has been studied
extensively and stood the test of time with successful results
and a low rate of complications. The transfer of the tibial
tubercle described by Trillat et al,28 with subsequent
modifications by Maquet,19 and more recently, Fulkerson9
have reports with good to excellent results in the 85% to 90%
range. These transfer procedures, however, are not generally
applicable to the skeletally immature population.
Vahasarja et al29 examined lateral release alone, lateral
release with medial reefing, and the Roux-Goldthwait proce-
dures in an effort to address specific indication for specific
procedures. In their study of 57 operations, they concluded that
a lateral release was the choice operation for patellar tilt alone, a
lateral release, and medial reefing was choice for tilt and
subluxation, and that subluxation alone was best treated with a
Roux-Goldthwait procedure. Of the 57 knees in their study,
only 3 were treated with a Roux primarily. Thirteen of the
remaining 54 knees, required reoperation, 10 of which
subsequently underwent a Roux-Goldthwait.
In 1985, Fondren et al8 had specifically examined the
results of the Roux-Goldthwait procedure in response to the
complications that resulted from the Hauser procedure. They
achieved good to excellent results in 91% of their subjects. Nine
patients in this study were 14 years old and younger, and all had
a good to excellent result. They reported no cases of recurrent
dislocations and a zero incidence of epiphyseal injury. Their
recommendations of Goldthwait procedure were for patients
who have chronic recurrent painful dislocation and giving-way
with symptoms and signs suggesting a deficiency of the medial
capsular structures or an abnormal Q-angle.
Various tendon transfers to the extensor mechanism
have been suggested by Baker, Lexer, Lange, and Hall. The
report of Hall et al13 suggested using a semitendinosus
tenodesis graft. The patients of Hall et al13 had a mean age of
14.5 years and yielded a 63% good to excellent results. We do
not routinely use these procedures at our institution.
Chrisman et al5 compared the Hauser and Roux-
Goldthwait procedures. In his review of 87 knees, there were
10 Roux-Goldthwait procedures performed on patients who
were 15 years old or younger. One of those 10 had a reported
failure, consistent with his 93% satisfactory results when
compared with 72% satisfactory with the Hauser procedure.
Hughston and Walsh16 reported a 71% good to excellent
outcome (with 90% of athletes returning to normal competi-
tion) while using a proximal and distal soft tissue procedure.
Although of different etiology, the surgical treatment of
congenital patellar dislocation consists of soft tissue release
and reefing coupled with patellar tendon transfer. Gao et al10
demonstrated an 87.8% satisfactory result, and Gordon and
Schoenecker,12 who transferred the entire patellar tendon,
claims all patients had a marked increase in activity tolerance
and relief of pain.
Beals and Buehler2 reported creating a femoral sulcus
P in children with severe trochlear dysplasia in 6 patients, who
V all had underlying chromosomal abnormalities; with his
G0.001 method, there were no recurrent dislocations.
Vahasarja et al30 subsequently reported on 40 adoles-
G0.001 cent knees, which underwent lateral release, medial combi-
nation, and vastus medialis obliquus advancement. This more
463
Marsh et al
FIGURE 4. Kin-Com dynamometer showing an achieved strength in the operated leg of 95% when compared to the healthy
leg as a control.
recent report is a deviation from previous recommendations
made in the Journal of Pediatric Orthopaedics, first by using
one operation for all cases. Certainly, these cases were
performed before his records were published, but
in retrospect, this individual operation was at least equal
(82.5 G/E), if not having a better outcome than the 70.5 G/E
reported with his previous records.
Deie et al6 reported a technique involving transfer of
the tendon of the semitendinosus to the patella using the
posterior third of the femoral insertion of the medial collateral
ligament as a pulley which led to no recurrent patellar
dislocations after surgery. Hypermobility and patella alta
were not fully correctable with this technique.
Recently, it seems that the primary stabilizing role of
the mediopatellofemoral ligament in the unaffected knee and
its lesion as an essential key factor for patella instability is
more and more emphasized.1,15,22,26 The trend turns form
nonanatomic extensor mechanism reconstructions toward
more anatomic procedures based on using a pulley of the
semitendinosus tendon around the posterior one third of the
medial collateral ligament.26 As to reconstruct the medio
patellofemoral ligament, even artificial ligaments have been
successfully used.20
Fithian et al7 also stated recently that, although conser-
vative treatment is still the first choice, if surgery is per-
formed, the aim should be to repair or reconstruct the passive
retinacular restraints.
In our study, we now review 34 knees in 24 patients who
presented with chronic recurrent patellar instability. They
were all treated with the same modified Roux-Goldthwait
procedure by a single surgeon over a 13-year period and an
average of 6.2 years of follow-up. Four patients were lost to
follow-up, and the balance ,10 patients with patellar instability
on one side (group 1) and 10 patients with patellar instability
on both sides (group 2), returned for clinical assessment of
pain, stability, and range of motion. By Insalls criteria,17 26
patients had an excellent result (Q-angle of 14 degrees; 8 in
464
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J Pediatr Orthop & Volume 26, Number 4, July/August 2006
group 1 and 18 in group 2), 3 good (1 in group 1 and 2 in group
2) and 1 fair result (group 1). Those 10 patients evaluated by
Kin-Com dynamometer showed that strength achieved in the
operated leg was greater than 90% in 8 patients and greater
than 80% in 2 patients.
Numerous surgical procedures to address this instability
have been described with variable outcome before and
unfortunately, many studies have lumped all types of patellar
instability together and report performing a single operation,
whereas other studies have reported performing multiple
procedures for a single diagnostic entity. This has led to con-
siderable confusion in the literature as to how to treat patello-
femoral problems. To further complicate matters, many
studies have been performed in adults, and these procedures
are being applied to children.
By reporting upon a single operation, a modified Roux-
Goldthwait procedure with additional release of the con-
tracted lateral structures, to treat one entity of the different
causes/clinical signs of patellofemoral problems in childhood
and adolescence, namely chronic recurrent patellar instability,
we were able to achieve excellent results in the pediatric
population. We hope thereby to help in making up ones
decision on how to treat one spectrum of the field of the
so called Bpatellofemoral problems[ in childhood and
adolescence.
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