ROCK Form 5I: Surgery Form – PatellofemoralMalalignment/Instability

  1. Patellofemoral Pathology
  2. Chondrosis
  3. Maltracking
  4. Instability
  5. Risk Factors (select all that apply)
  6. Previous dislocations
  7. None
  8. Number of prior dislocations: ______
  9. Connective Tissue-related
  10. Ligamentous Laxity
  11. Beighton Score: ___/5 metrics….total score: ___/9
  12. Coronal Malalignment
  13. Genu Valgum
  14. Rotational Malalignment
  15. Femoral Anteversion
  16. External Tibial Torsion
  17. TT-TG Score: ______
  18. Patellar Lateralization
  19. Congruence angle: ______
  20. Lateral patellar tilt
  21. Lateral patellofemoral angle: ______
  22. Trochlear Dysplasia
  23. Sulcus angle: ______
  24. Patellar Dysplasia
  25. Wiberg Type
  26. A
  27. B
  28. C
  29. Lateral patellar tilt
  1. Surgical Treatment
  2. None
  3. Distal Realignment (select all that apply)
  4. Tibial Tubercle Osteotomy
  5. Isolated Medialization (Elmslie-Trillat)
  6. Isolated Anteriorization (Maquet)
  7. Anteromedialization (AMZ/Fulkerson)
  8. Galleazi (semi-tendinosistranspatellartenodesis)
  9. Roux-Goldthwaite (partial instertional patellar tendon transfer)
  10. Other: ______
  11. Proximal Realignment (select all that apply)
  12. Lateral Retinacular Procedure
  13. Lateral Release
  14. Open
  15. Arthroscopic
  16. Lateral Retinacular Z-lengthening/Interval Slide
  17. Medial Retinacular/MPFL Procedure
  18. VMO Advancement
  19. Medial retinacular reefing/imbrication
  20. MPFL reconstruction
  21. Graft type
  22. Autograft
  23. Quad tendon (soft-tissue only)
  24. Quad tendon w/ bone-block
  25. Adductor longus
  26. Hamstring
  27. Gracilis
  28. Single-strand
  29. Double-looped
  30. Semi-tendinosus
  31. Single-strand
  32. Double-looped
  33. Allograft
  34. Soft tissue
  35. Tibialis anterior
  36. Hamstring
  37. Semi-tendinosis only
  38. Gracilis
  39. Other: ______
  40. Achilles tendon w/ calcaneal bone-block
  41. Other: ______
  42. Patellar Fixation Technique
  43. Bony Tunnel(s)
  44. Tunnel Length
  45. Partial/blind patellar tunnel
  46. Complete/transverse patellar tunnel
  47. Tunnel Fixation Technique (select all that apply)
  48. Interference screw
  49. Docking technique (sutures tied over cortical bone bridge)
  50. Graft passed through tunnel, suture to itself
  51. Number of tunnels
  52. Single Tunnel
  53. Double Tunnels
  54. Suture anchor/implant fixation
  55. Type of anchor/implant(s): ______
  56. Number of points of fixation
  57. Single point of fixation
  58. Double point of fixation
  59. Graft sutured to periosteum
  60. Number of points of fixation
  61. Single point of fixation
  62. Double point of fixation
  63. Femoral Fixation Technique
  64. Bony Tunnel(s)
  65. Tunnel Length
  66. Partial/blind patellar tunnel
  67. Complete/transverse patellar tunnel
  68. Tunnel Fixation Technique (select all that apply)
  69. Interference screw
  70. Docking technique (sutures tied over cortical bone bridge)
  71. Graft passed through tunnel, suture to itself
  72. Number of tunnels
  73. Single Tunnel
  74. Double Tunnels
  75. Suture anchor/implant fixation
  76. Type of anchor/implant(s): ______
  77. Number of points of fixation
  78. Single point of fixation
  79. Double point of fixation
  80. Graft sutured to periosteum
  81. Number of points of fixation
  82. Single point of fixation
  83. Double point of fixation
  84. Other: ______