I have a unique case that I am wanting to get input on from other clinicians: 

I have a 70 year old female who had a knee replacement (hinged knee) in Jan of 2024.  She had PT at another clinic and reports good recovery post surgery.  In December 2024 she sustained an avulsion fracture to the inferior pole of the patella.  The ortho immobilized her in extension for 5 weeks and then she began PT to regain strength at another clinic.  She never lost the ability to fully extend the knee actively, however the patella on the involved side rests significantly higher than the uninvolved side. She also has a persistent quad lag with SLR that has not improved even as the MMT tested strength of the quads has shown improvement.   She came to me last fall with her primary complaint being the knee will buckle and cause her to fall where she will have to catch herself with an AD or furniture.  I have treated her for over 50 visits working on strengthening of the knee extensors, hips, static balance, dynamic balance and functional strength/balance (i.e. step ups unsupported).  Her strength and her level of function have improved however she still will have occasional knee buckling averaging 2x per week, placing her at a high risk of falling.  The MOI for the buckling varies, sometimes planted and twisting, sometimes standing in place, sometimes while walking.  

My question is has anyone treated something similar and can offer some additional ideas to incorporate?  Would there be any benefit from dry needling the surrounding homeostatics, and/or femoral n. distribution? 

Thank you all in advanced for any insights,

Dan