Dr. Alfred Tylla, M.D., is a highly qualified specialist in knee surgery in Schwarzenbruck who has earned an outstanding reputation thanks to his extensive expertise and many years of experience. He has made a name for himself with a particular focus on preserving the knee joint and is the ideal specialist for patients with knee problems. He possesses in-depth knowledge in the treatment of cartilage, meniscus, and patella injuries, as well as in sports orthopedics. Dr. Tylla’s areas of treatment include regenerative cartilage and joint surgery, the treatment of meniscus tears, ligament injuries, patellar instability, leg alignment abnormalities, and mild cartilage damage. He also specializes in complex combined procedures on the knee joint and the management of complex trauma cases.
The Knee Center at Rummelsberg Hospital, led by Dr. Tylla, was certified by the German Knee Society in 2019 as the first specialized clinic in the Nuremberg metropolitan region. This distinction confirms the high quality of care and the center’s outstanding medical services, which are recognized far beyond the region. Dr. Tylla began his career in Rummelsberg in 2015 as a senior attending physician in the Department of Trauma, Shoulder, and Reconstructive Surgery, Sports Medicine, and Sports Traumatology. His passion for the knee joint and his focus on joint preservation have contributed significantly to the center’s outstanding reputation.
Rummelsberg Hospital, located in the municipality of Schwarzenbruck, is known for its modern medical care and serves as an academic teaching hospital for Friedrich-Alexander University Erlangen-Nuremberg. The hospital is one of the most modern facilities in the Nuremberg-Fürth-Erlangen metropolitan region and plays a central role in the region’s healthcare system. With nearly one hundred physicians and approximately 500 employees, it treats nearly 10,000 inpatients and 20,000 outpatients annually. The certified knee center, headed by Dr. Tylla, is synonymous with medical care of the highest standard, based on the latest scientific findings. At least six hundred complex procedures are performed here annually, far exceeding minimum requirements and ensuring the highest quality.
Dr. Tylla’s expertise is particularly evident in reconstruction and joint preservation, which often allows him to avoid the use of prostheses. As a certified ATLS (Advanced Trauma Life Support) provider, he is able to treat trauma according to international standards, thereby offering a high level of safety for his patients. His ability to make quick and precise diagnoses under pressure makes him a reliable emergency physician. As Senior Attending Physician in the Knee Preservation and Sports Orthopedics Section, Dr. Tylla has extensive knowledge in the treatment of meniscus injuries, cruciate ligament problems, and cartilage damage. His certification as a specialist in trauma surgery and orthopedics, along with his expertise in minimally invasive surgical techniques, makes him the ideal specialist for arthroscopy. This minimally invasive technique allows for procedures with minimal scarring and a rapid recovery.
In addition to his clinical work, Dr. Tylla serves as the Executive Senior Physician at the Clinic for Trauma, Shoulder, and Reconstructive Surgery, Sports Medicine, and Sports Traumatology, and holds numerous additional qualifications, including in radiological diagnostics. He is well-connected and actively participates in various professional societies, such as the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy and the German Society for Arthroscopy and Joint Surgery (AGA). Through his regular publications, he stays up to date on the latest medical research and contributes to the advancement of knee surgery. The editorial team of the Leading Medicine Guide spoke with Dr. Tylla to learn more about patellar dislocation and the associated diagnostic and surgical techniques.
Patellar dislocation, also known as a dislocated kneecap, is a common orthopedic injury in which the kneecap slips out of its normal position in the knee joint. This injury can be caused by sudden trauma, such as a fall or a direct impact, or by chronic instability of the knee joint. Symptoms range from severe pain and swelling to a visible deformity of the knee. The diagnosis and treatment of patellar dislocation require a thorough clinical examination and often the use of advanced imaging techniques. Innovative techniques such as digital volume tomography and specialized surgical procedures offer promising ways to restore stability to the knee joint and prevent long-term damage.
Among the most common causes are traumatic injuries such as a strong direct blow to the knee, a sudden change of direction, or a twisting motion of the leg.
“Patients who have experienced patellar dislocation—where the kneecap has slipped out of place or become dislocated—experience severe pain. One trigger for the kneecap to slip out of place can be, for example, excessive rotation while the leg is extended. In most cases, however, patients have already been complaining of pain in the front of the knee for some time. When the kneecap pops out for the first time, an emergency physician usually needs to be called to reduce the kneecap. People with a dislocated kneecap cannot walk, except for those who have experienced dislocation multiple times and are able to realign it themselves. In addition, there are so-called subluxations—in these cases, the kneecap does not slide properly in its groove, meaning that the articular surfaces of the bones remain partially in contact but are no longer fully aligned in their normal position relative to one another. This results in the kneecap not being properly guided. “These types of dislocations are recurrent,” explains Dr. Tylla at the beginning of our conversation.
“There are several methods for making a diagnosis. Compared to conventional X-rays, which provide only two-dimensional images, digital volume tomography (DVT) offers a three-dimensional representation of the knee’s anatomical structures. This enables a more comprehensive and accurate analysis of bone and soft tissue structures, which is particularly important for determining the exact position of the dislocated patella as well as any associated injuries to ligaments, menisci, or cartilage. DVT can therefore provide more detailed information that is of great importance for planning and carrying out treatment. Compared to computed tomography (CT), DVT offers the advantage of lower radiation exposure while providing higher image quality. This reduces health risks for the patient, which is particularly important in cases of repeated examinations or for young patients. At our Knee Center, DVT is performed with the patient standing, allowing us to assess the hip, knee, and ankle joints in relation to one another. When this procedure was first introduced, we were only the third center in all of Europe to offer it. Since then, several more centers have recognized the benefits of this procedure. One key advantage is the ability to identify changes in muscular structures that may affect the patella. Hip rotations, which are visible in the full-body image, can also be a cause of dislocation. “This is because the imaging takes place during the active phase of standing, when the patella is under load, unlike with a CT scan, which is performed while the patient is lying down in a relaxed position,” Dr. Tylla explains.
The three-dimensional data enable surgeons to create individualized surgical plans that take into account the patient’s specific needs and anatomical conditions. This increases the accuracy of the procedures and reduces the risk of postoperative complications. Abnormalities such as a high patella (patella alta)—in which the kneecap is positioned higher than normal—or misalignments of the leg axis, such as bowlegs or knock-knees, are particularly common. These deformities are often associated with increased instability of the knee joint and can lead to patellar dislocation. By analyzing these deformities, the treating physician can determine whether and to what extent correction is necessary during surgery.
Accurate Diagnosis Through Deformity Analysis
“Deformity analysis is a structured procedure in which specific angles are precisely measured at the knee joint, as well as at the hip and ankle joints, to identify the cause of patellar dislocation. In the past, when the kneecap was dislocated, the approach was simply to try to pull it back into place somehow, suture it, and stabilize it. Today, we try not only to treat the kneecap itself but also to examine the groove in which the kneecap glides. In doing so, we examine whether it is properly formed, whether it might be in the wrong position, or whether the direction of tension in the lower leg is perhaps incorrect. And with deformity analysis, we have the advantage of being able to determine several clearly defined angles and distances and measure everything precisely. This analysis includes the digital volume tomography (DVT) explained earlier, as well as MRI (magnetic resonance imaging), i.e., MRI scans. “This allows us to see, for example, how high the kneecap is in relation to the cartilaginous attachment in the upper lower leg,” explains Dr. Tylla, adding details about the diagnostic process:
“When the patient is sitting in front of me, I first conduct a standard clinical history. I ask how often the kneecap has dislocated, whether there have been any associated injuries on the opposite side, or whether the patient has previously experienced a dislocated kneecap. It’s important to take a full-leg standing X-ray to determine the alignment, since even bowlegs can lead to dislocation. Only once all parameters are known can the surgeon decide what needs to be addressed first and how to plan the next steps. “There is no standard surgical procedure for patellar dislocation. Only a functional examination combined with diagnostic testing provides the complete picture, based on which a decision is made on how best to help the patient.”
Various reconstructive procedures are used to treat patellar dislocations, depending on the cause of the dislocation, the patient’s anatomical characteristics, and other individual factors.
“What we do very frequently is stabilize the ligamentous apparatus, since we have many young patients and also those with muscle weakness, which can lead to a tear of the MPFL (medial patellofemoral ligament), a central ligament that stabilizes the patella and protects against lateral dislocations. MPFL reconstruction aims to restore or reinforce the ligament to improve the stability of the patella. It is also possible that the thigh is twisted, causing this misalignment to lead to patellar dislocation. We see this very frequently during deformity analysis: the thigh is rotated too far inward. In such cases, the direction of rotation must be corrected using an osteotomy (a surgical procedure in which a bone is cut or a piece of bone is removed). We use what are called rotation markers to precisely mark the misalignment, which allows us to align the leg with millimeter precision. Sometimes the direction of pull on the kneecap also needs to be adjusted. “It’s always very important to do the ‘homework’ before any procedure. This means that the cause of the patellar dislocation must be precisely identified in order to determine the optimal treatment method,” explains Dr. Tylla.
The introduction and further development of minimally invasive techniques have brought significant benefits to patients with patellar dislocations, both in terms of postoperative recovery and the overall treatment outcome.
A key advantage of minimally invasive techniques lies in the reduction of surgical trauma. Compared to traditional open procedures, minimally invasive surgeries are performed through smaller incisions, resulting in less soft-tissue damage. This enables patients to recover more quickly and reduces postoperative pain. The reduced trauma to surrounding tissues often results in a shorter rehabilitation period and allows patients to mobilize sooner and return to normal activities.
“For example, we can perform MPSL tendon plasty (medial patellofemoral tendon plasty) using a minimally invasive technique. In this case, the longest incision is 2 cm. The overall outcome for the patient is positive. The surgery takes only 30–60 minutes; the patient can be discharged from the hospital after 1–2 days and regains mobility quickly. It’s also important to note that in tendon plasty, the tendon is statically fixed in older patients, while younger patients who are still growing receive a dynamic plasty. “In this procedure, we stabilize the patella using a tendon attachment from a muscle. This muscle then pulls the patella back into the proper groove, preventing further dislocation,” explains Dr. Tylla.
Another important aspect of minimally invasive procedures is the aesthetic component. Smaller skin incisions mean smaller scars, which are more cosmetically appealing and less distressing for patients.
Significant advances in the surgical treatment of patellar dislocations are expected in the coming years, which could considerably improve the range of treatment options. “Personally, I think there’s still a lot to come, especially when it comes to artificial intelligence. This would be beneficial in the case of the knee joint, given its complexity and the many degrees of freedom involved. The fact is that we correct axes in the frontal view; we correct rotations, sometimes in conjunction with axial corrections. However, we do not yet have a 100% clear picture of how this ultimately affects ligament tension and musculature. In this regard, a lot will change—for example, with the help of AI (artificial intelligence), we’ll be able to identify, even before surgery and also intraoperatively, where we can best intervene and what consequences this will have for the patient when walking, jumping, and performing rotational movements. “At the moment, we only have static imaging, and it’s only after the procedure, based on gait analyses, that we see what has changed in the patient,” said Dr. Tylla.
Through a thorough analysis of the patient’s anatomical conditions using preoperative deformity analysis, surgeons can identify the exact cause of patellar dislocation and plan the best possible surgical strategy. However, this procedure is not used everywhere.
“Unfortunately, we very often see patients who have been undergoing unsuccessful treatment for far too long. They are often simply advised by their treating physician or physical therapist to build muscle strength to better protect the knee. But the patients simply cannot do this because they are in too much pain. As a result, they often fall into a vicious cycle: they gain weight, experience psychological stress, which worsens their condition, and are thus unable to fully participate in daily life. Furthermore, we see that these patients develop severe osteoarthritis behind the kneecap at the age of just 40 or 45, which in some cases may lead to the need for a knee replacement. This should be avoided as much as possible, especially at a young age, since young people with a prosthesis generally aren’t satisfied with it given their active lifestyles. “My approach has always been to prioritize knee joint preservation,” explains Dr. Tylla, who, along with his team at Rummelsberg Hospital, performs approximately 700 knee surgeries per year. Dr. Tylla adds: “The number of knee dislocations has increased significantly. That doesn’t mean every patient whose kneecap has popped out needs surgery. Of course, there are also conservative treatment options. However, if a patient has suffered multiple dislocations, surgery must definitely be considered.” Therefore, preoperative deformity analysis is an indispensable step in the treatment process for patellar dislocations, helping to accurately understand each patient’s individual situation and develop the best possible surgical strategy for stabilizing and restoring knee function.
“In the future, minimally invasive techniques will certainly play an even greater role. As far as deformity analysis is concerned, it is still very labor-intensive at this point, and many results depend on the orthopedic surgeon’s interpretation. I hope that, with the help of artificial intelligence, we’ll have a more mobile approach with dynamic gait analysis recordings. This would also make it easier to recognize that when we perform an axial correction, it will affect the patient not only while standing but also, for example, during sports,” says Dr. Tylla, describing his vision for the future. We then turn to the currently very topical issue of hospital centralization. This development is currently being strongly promoted by the Federal Ministry of Health, which advocates that patients should only be treated at facilities where there are sufficiently high case volumes for the specific surgery required, in order to ensure the highest possible level of expertise and experience. Dr. Tylla comments on this:
“It’s certainly important to specialize, but hospitals must also be accessible to patients. Many years ago, I specialized in knee treatment, particularly with regard to knee misalignments and axial corrections. And when you perform such procedures hundreds of times a year, it’s naturally quite different from doing them only a few times a year. That’s where experience comes into play—the frequency of these procedures leads to shorter operating times, fewer complications, and fewer infections. Unfortunately, however, there is a lack of broad knowledge needed to guide patients to the right specialist. Patients who try to do their own research online usually have difficulty finding exactly the right specialist. How do patients learn about their treatment options? Here, the Leading Medicine Guide definitely offers a valuable and important platform to facilitate the search for the right specialist, especially when it comes to knee preservation. “Because that should always be the primary goal,” emphasizes Dr. Tylla, who concludes by offering some tips on prevention:
“Anyone who wants to protect their knee should focus on maintaining good muscle tone, especially in the thigh area. You should also always train the inner thigh muscles, because they are the primary stabilizers for the kneecap. This also applies to patients who have undergone knee surgery. For them, the real work begins then. To this end, we’ve developed and posted online follow-up treatment plans here at Rummelsburg Hospital, specifically to start isometric exercises early on and stabilize precisely the muscle groups that are crucial for the kneecap. This way, every patient can actively do something at home to prevent muscle loss!”
Thank you very much, Dr. Tylla, for this fascinating insight into the treatment of the kneecap!
