288 A. Horikawa et al. patellofemoral ligament or medial soft tissue reeﬁng for persistent subluxation of the patella despite a normal tibial tuberosity (14). However, some cases with knee joint stiffness were treated using medial reeﬁng. We used medial reeﬁng although the offset of the tuberosity from the trochlear groove had exceeded 18 mm. This may also have led to adhesion of the patellar tendon to surrounding tissues and subse- quent joint contracture. In addition, Verdonk et al. (1) pointed out that joint arthroﬁbrosis might be caused by the procedure of distal realignment in cases treated using trochleoplasty. Consequently, in the present case, combination of proximal realignment (medial reeﬁng without lateral release) and distal realignment (tibial transfer) might have increased patellofemoral joint pressure compared to either alone, and it might have led to arthroﬁbrosis during plaster immobilization. Trochleoplasty primarily affects the congruency of the patellofemoral joint. However, additional proximal and/or distal realignment should also be considered. Fulkerson (4) and Arendt et al. (15) emphasized that correction of dysplastic factors and realignment should be considered when mini- mally invasive surgery fails. According to our suc- cessful experience in the present case, although postoperative ﬁbrous adhesions should be avoided, one-stage surgery combining trochleoplasty, proxi- mal realignment, and distal realignment can be used as an effective treatment option for patients with recurrent patellar dislocation due to severe patellar malalignment and trochlear dysplasia. In summary, we have described a rare case with recurrent dislocation of the patella resulting from trochlear dysplasia of the femur and malalignment of the patella. This patient underwent surgical treat- ments including trochleoplasty and proximal and distal realignments. Postoperative ﬁbrous contracture occurred, but normal range of motion was obtained after arthroscopic release. Physical examination 2 years after surgery showed excellent clinical and radiological results, and the patient had no complaints of patellar dislocation. Declaration of interest: The authors report no conﬂicts of interest. The authors alone are responsible for the content and writing of the paper. References 1. Verdonk R, Jansegers E, Stiyts B. Trochleoplasty in dysplastic knee trochlea. Knee Surg Sports Traumatol Arthrosc. 2005; 13:529–33. 2. Donell ST, Joseph G, Hing CB, Marshall TJ. Modiﬁed Dejour trochleoplasty for severe dysplasia: operative technique and early clinical results. Knee. 2006;13:266–73. 3. Insall J, Bullough PG, Burstein AH. Proximal ‘tube’ realign- ment of the patella for chondromalacia patellae. Clin Orthop. 1979;144:63–9. 4. Fulkerson JP. Alternatives to patellofemoral arthroplasty. Clin Orthop. 2005;436:76–80. 5. Kobayashi A, Ou A. Condyloplasty of lateral epicondyle of the femur for patellar instability. Seikei-saigaigeka. (Orthop Surg Traumatol). 1994;37:49–57 (in Japanese). 6. Phillips BB. Recurrent dislocations. In: Canale ST, editor. Campbell’s operative orthopaedics. 10th ed. Philadelphia: Mosby; 2003. pp. 2377–448. 7. Bereiter H, Gautier E. Die Trochleaplastik als Chirurgische Therapie der Rezidivierenden Patellaluxation bei Trochlea- dysplasie. Arthroskopie. 1994;7:281–6. (in German). 8. Dejour H, Walch G, Neyret P, Adeleine P. Dysplasia of the femoral trochlea. Rev Chir Orthop. 1990;76:45–54. 9. Masse Y. Trochleoplasty. Restoration of the intercondylar groove in subluxations and dislocations of the patella. Rev Chir Orthop. 1978;64:3–17. 10. Schottle PB, Fucentese SF, Pﬁrrman C, Bereiter H, Romeo J. Trochleoplasty for patellar instability due to trochlear dyspla- sia. A minimum 2-year clinical and radiological follow-up of 19 knees. Acta Orthop. 2005;76:693–8. 11. Kuroda R, Kambic H, Valdevit A, Andrish J. Distribution of patellofemoral joint pressures after trochlear osteotomy. Knee Surg Sports Traumatol Arthrosc. 2002;12:33–7. 12. Koeter S, Pakvis D, Loon CJM, Kampen A. Trochlear osteotomy for patellar instability: satisfactory minimum 2-year results in patients with dysplasia of the trochlea. Knee Surg Sports Traumatol Arthrosc. 2007;15:228–32. 13. Ochi M. The importance of measurement for skyline view about the recurrent patella dislocation. Seikei-saigaigeka. (Orthop Surg Traumatol). 1994;37:19–27 (in Japanese). 14. Utting MR, Mulford JS, Eldridge JD. A prospective evaluation of trochleoplasty for the treatment of patellofemoral disloca- tion and instability. J Bone Joint Surg Br. 2008;90B:180–5. 15. Arendt EA, Fithian DC, Cohen C. Current concepts of lateral patella dislocation. Clin Sports Med. 2002;21:499–519.