Patellar instability: will my patella dislocate again?

PURPOSE OF REVIEW: The incidence of patellar instability in pediatric patients ranges is 50-100 in 100,000 patients per year. Risk of recurrent dislocations however has been cited from 8.6% to 88% depending on individual patient factors. This manuscript highlights the demographical, historical, and anatomic factors associated with recurrent patellar instability following a first-time patella dislocation in the pediatric population. RECENT FINDINGS: In recent years, various studies have focused on identifying risk factors for recurrent patellar instability following a primary patellar dislocation. A mix of patient factors, including age of first dislocation, patella alta, elevated tibial tubercle to trochlear groove and trochlear dysplasia have all been noted in the literature, which have helped to develop various scoring tools to predict recurrent dislocation following nonoperative treatment. SUMMARY: Risk of recurrent patellar instability in patients who have previously suffered a patellar dislocation can be due to many factors. These risk factors should be used and applied to a variety of risk scores in order to provide physicians and healthcare providers with a tool to counsel patients and families on their patellar redislocation risk and help guide further management.

Predictive Scoring for Recurrent Patellar Instability After a First-time Patellar Dislocation.

PURPOSE: Patellofemoral instability is a common acute knee injury seen in the pediatric population. First-time patellar dislocations usually undergo conservative management, but ~15% to 80% of patients experience recurrent instability. This study aims to develop a prediction model using radiographic parameters of the patellofemoral joint seen on computed tomography scans in different degrees of knee flexion, to determine the risk of recurrence after the first episode of patellofemoral instability. METHODS: A 12-year retrospective case-control study was performed. All patients in a single institution aged 18 years or younger who had a computed tomography patellar tracking scan performed for patellar instability were included. Predictors included in the score were determined through backward logistic regression and compared using receiver operating characteristic curve analysis. RESULTS: This study revealed that recurrent dislocation in first-time patellofemoral dislocation could be accurately predicted using the prediction score that consisted of age, tibial tubercle-trochlear groove distance and congruence angle at 10- and 20-degree flexion. The sensitivity of the score was 100% and specificity was 73.3%. Three diagnostic zones were identified and used to categorize patients into low-, intermediate-, and high-probability groups. CONCLUSION: This study presented a scoring system that incorporated radiographic knee kinematics in the risk assessment for recurrent patellofemoral instability for patient stratification. The scoring system could guide the decision for early surgical intervention after the first-episode patellofemoral dislocation for patients at high risk of recurrent patellofemoral dislocation.

Implementation of a Prehospital Patella Dislocation Reduction Protocol.

Introduction: Acute patella dislocations account for up to 3% of all knee injuries. Prehospital care of patella dislocation often includes knee immobilization and pain management, but in the wilderness environment patella reductions are often performed by basic life support providers. Given the potential benefits of early reduction, the perceived low risk of harm and precedent with which the procedure can be performed, patella reduction was added to the EMT scope of practice in New York State. Our objective is to characterize the mechanism of patella related injuries and describe the success rate and complications experienced with the addition of a prehospital patella reduction protocol.Methods: This was a retrospective review of a voluntary, preexisting, quality assurance database of cases in which a patella reduction was attempted between October 1, 2016 and June 30, 2018.Results: 90 patients underwent an attempt at patella reduction at one of 52 EMS agencies during the study period. The most common mechanism was a sports-related injury. Patella reduction was successful 83/90 (92.2%). Median pain score was reduced from 10 to 2. There were no reported complications.Conclusion: While a convenience sample, our results provide preliminary evidence that patella reduction can be performed by EMS providers with infrequent complication and offers significant pain relief.

Scoring system for optimal management of acute traumatic patellar dislocation: A multicenter study.

BACKGROUND: In first-time acute traumatic patellar dislocations, numerous anatomic and clinical factors are complicatedly associated and should be comprehensively considered for the optimal management of conservative or surgical intervention. The purpose of this study was to establish a scoring system, using a concept that is not complicated and easily used in clinic. METHODS: Of 131 first-time acute traumatic patellar dislocations, 81 patients (51 females, 30 males) with an average age of 19.6 (95%CI, 17.5-21.6) years and an average follow-up duration of 17.1 (95% CI, 12.3-21.9) months, who underwent conservative treatment after first-time dislocations, were reviewed. Based on the odds ratios applying logistic regression analysis, the scoring system was established. RESULTS: The scoring system (total: 10 points) had simple composition of age <20 (2 points), sports injury (1 points), hemarthrosis (1 points), and image findings of a bony fragment (3 points), lateral shift of the patella (1 points), and trochlear dysplasia (2 points). A threshold score of 6.5 was determined using the area under receiver operating characteristic curve of 0.893 (p < 0.0001). In logistic regression analysis, a score of ≥7 was shown to be a dominant factor for recurrence (OR = 27.1, p < 0.0001). Furthermore, the association between the score and recurrence risk was as follows: a score of ≤4 = low risk (1/21 cases, 5%); a score of 5-7 = medium risk (13/27 cases, 48%); a score of ≥8 = high risk (30/33 cases, 91%). CONCLUSIONS: Based on the simple scoring system, patients who scored ≥8 were considered suitable for surgical treatment because of the high rate of recurrence, whereas those who scored ≤4 were considered suitable for conservative treatment because of the low rate of recurrence.

Surgical treatment is better than non-surgical treatment for primary patellar dislocation: a meta-analysis of randomized controlled trials.

BACKGROUND: At present, the best treatment for primary patellar dislocation (PPD) has not been unified. Moreover, meta-analyses comparing the non-surgical and surgical treatments of PPD are lacking. Thus, we aimed to compare the clinical efficacy of surgical or non-surgical treatment of PPD. METHODS: Randomized controlled studies of surgical and non-surgical treatments of PPD from 1966 to 2018 were retrieved from the following databases: PubMed, EMBASE, Cochrane Library, Wanfang Database, China Knowledge Network, Google Scholar, and Weipu Database. We screened for literature that met the inclusion criteria and extracted useful data for our meta-analysis. RESULTS: Nine studies, involving 492 patients, met the inclusion criteria and were analyzed in this study. The recurrence rate of patellar dislocation in the surgical group was lower than that in the non-surgical group (P = 0.04]). Subgroup analysis according to the follow-up time showed that the Kujala score (P < 0.001) and lower recurrence rate of dislocation (P = 0.05) than the non-surgical group in the short term. Subgroup analysis according to surgical year showed that the surgical group get higher Kujala score (P < 0.001) and lower recurrence rate of dislocation (P = 0.01) than the non-surgical group in recent years. CONCLUSION: Surgical treatment can provide better clinical results in a short period of time, and patients may achieve good results within 10 years owing to the advances in surgical techniques and instruments. Thus, we recommend surgical treatment as the preferred treatment for primary patellar dislocation.

Pediatric patellar dislocation.

Acute patellar dislocation affects approximately 1:1000 healthy children 9-15 years of age, and up to 50% are at risk for recurrent dislocations. In adults the condition is associated with long-term complications, such as osteoarthritis and impairment of knee function. However, literature describing the outcome in a pediatric population is sparse. The present review article evaluates the long-term effects on knee function and cartilage quality after traumatic patellar dislocation in childhood, and also to evaluate the reliability of two clinical tests of medio-lateral knee position, in healthy children.

Surgical versus conservative treatment for first patellofemoral dislocations: a meta-analysis of clinical trials.

INTRODUCTION: The first approach for acute patellar dislocation is still a debated topic. The purpose of the present study was to perform a meta-analysis evaluating the outcomes of the surgical approach compared to the conservative treatments for primary acute patellar dislocation. We hypothesize that a prompt surgical treatment may lead to better outcomes in terms of re-dislocations and quality of life. METHODS: This meta-analysis was performed according to the PRISMA guidelines. All the prospective clinical trials comparing surgical and conservative treatment for first acute patellofemoral dislocation were included in this study. For the methodological quality assessment, the PEDro appraisal score was adopted. For the risk of publication bias, the funnel plot was performed. The statistical analysis was performed using the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen). RESULTS: The funnel plot detected a low risk of publication bias. According to the PEDro score, the methodological quality assessment was good. Data from 654 patients were collected, undergoing a mean of 53.8 ± 48.4 month follow-up. A total of 311 patients (17.66 ± 4.1 years old) were analyzed in the surgery group and 291 patients (19.25 ± 4.5 years old) in the conservative ones. The mean Kujala score resulted in greater favor of the surgery group (MD: 9.99%; P = 0.006). The analysis of the comparison of re-dislocations resulted in favor of the surgery group (OR: 0.41; P < 0.0001). The analysis of the comparison of persistent joint instability resulted in favor of the surgery group (OR: 0.41; P < 0.0001). CONCLUSIONS: Data from the present study encourage a prompt surgical approach for the first patellofemoral dislocation.

A Meta-analysis of Surgical Versus Nonsurgical Treatment of Primary Patella Dislocation.

PURPOSE: To compare outcomes after surgery versus nonsurgical treatment in the management of primary lateral patellar dislocation (LPD) through a meta-analysis of randomized controlled trials (RCTs) in terms of redislocation rate and clinical outcome, investigating both short-term (<6 years) functional recovery and overall benefit over time (>6 years). METHODS: A systematic search of the literature was performed in November 2018. Risk of bias and quality of evidence were evaluated according to the Cochrane guidelines. RCTs investigating differences between surgery and nonsurgical treatment in primary LPD were included. The outcomes evaluated were redislocation rate, reinterventions, and Kujala score at short-, mid-, and long-term follow-up, with subanalyses for the pediatric population. RESULTS: We included 510 patients from 10 RCTs in the meta-analysis. Redislocation rate was 0.40 (0.25 to 0.66; P < .001) and 0.58 (0.29 to 1.15; P = .12) at the short- and mid-term follow-ups, respectively, and the risk ratio for the need for further operations at 6 to 9 months' follow-up was 0.14 (0.02 to 1.03; P = .05), all favoring surgery. Concerning the Kujala score, an advantage of the surgical approach of 10.2 points (1.6 to 18.7; P = .02) at short-term follow-up was seen, whereas long-term follow-up results were similar between the groups. The subanalysis of the pediatric population at heterogeneous follow-up confirmed a lower risk of recurrence in surgery, with a risk ratio of 0.60 (0.26 to 1.37; P = .22), although not significant. CONCLUSION: The literature documents a low number of high-level trials. The meta-analysis of RCTs underlined that the redislocation rate is higher with the nonsurgical approach compared with the surgical one. Moreover, when looking at the clinical outcome, more favorable findings were found with the surgical approach up to 6 years, whereas results seems to be similar at a longer follow-up after either surgical or nonsurgical treatment of primary LPD. LEVEL OF EVIDENCE: II, meta-analysis of level I and level II randomized clinical trials.

Which Technique Is Better for Treating Patellar Dislocation? A Systematic Review and Meta-analysis.

PURPOSE: To clarify the discrepancy in surgical options and present evidence to treat patellar dislocation by evaluating which of the techniques yields better improvement in stability and functional recovery for patellar dislocation. METHODS: The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus electronic databases were searched for relevant articles comparing the outcomes of medial patellofemoral ligament (MPFL) treatment published up until August 2017. Data searching, extraction, analysis, and quality assessment were performed based on The Cochrane Collaboration guidelines. Clinical outcomes were evaluated using various outcome values in various techniques. For results with high heterogeneity, 95% prediction intervals (PIs) were also investigated. RESULTS: Eleven clinical studies were investigated. In patients with primary patellar dislocation, there were no significant differences in all evaluated outcomes between the conservative and surgical treatment groups. For patients with recurrent patellar dislocation, MPFL reconstruction was associated with a favorable Kujala score (mean difference, -8.91; 95% confidence interval, -14.05 to -3.77; I2 = 94%; 95% PI, -9.64 to -8.1) and Lysholm score (mean difference, -13.51; 95% confidence interval, -21.35 to -5.68; I2 = 96%; 95% PI, -14.86 to -12.16) when compared with soft tissue realignment surgery. CONCLUSIONS: Although surgical treatment of the MPFL for primary patellar dislocation is not superior to conservative treatment in restoring knee function and clinical outcomes, MPFL reconstruction is associated with more favorable clinical outcomes compared with medial soft tissue realignment surgery in patients with recurrent patellar dislocation. Double-bundle MPFL reconstruction seems to provide more favorable outcomes than single-bundle MPFL reconstruction, but this finding should be interpreted with caution because the evidence levels were low and were from only a few studies. LEVEL OF EVIDENCE: Level III, meta-analysis.

Evaluation of the utility of teaching joint relocations using cadaveric specimens.

BACKGROUND: Like other procedural skills, the ability to relocate a joint is an important aspect of junior doctor education. Changes in the approach to teaching and learning from the traditional apprenticeship-style model have made the teaching of practical skills more difficult logistically. Workshops utilising cadaveric specimens offer a solution to this problem. METHODS: One hundred forty-six fourth year medical students were randomly divided into 5 groups. Each group received a different teaching intervention based on ankle, patella and hip relocation. The interventions consisted of online learning modules, instructional cards and workshops using skeleton models and cadaveric dislocation models. Following the intervention students were given a test containing multiple choice and true/false style questions. A 13-item 5-point Likert scale questionnaire was also delivered before and after the intervention. The data was analysed using one-way analysis of variance (ANOVA) and the Bonferroni post-hoc test. RESULTS: Compared to the instructional cards group, the other 4 groups showed a 10.8-19.2% improvement in total test score (p < 0.01) and an 18.4-25.3% improvement in self-reported understanding and confidence in performing joint relocations (P < 0.01). There was no significant difference in total test scores between groups exposed to cadaveric instruction on the relocation of one-, two- or all three- joints, nor any significant difference between all the cadaveric dislocation groups and the group receiving instruction on the skeleton model. CONCLUSION: The results of the present study suggest that workshops utilising cadaveric dislocation models are effective in teaching joint relocation. In addition, the finding that lower fidelity models may be of equal utility may provide institutions with flexibility of delivery needed to meet financial and resource constraints.

Operative Versus Nonoperative Treatment After Acute Patellar Dislocation: Which Is More Effective at Reducing Recurrence in Adolescents?

Clinical Scenario: Acute patellar dislocations during adolescence often lead to future patellar instability. Two common treatment options include nonoperative treatment or operative repair of injured structures. Focused Clinical Question: In adolescents with acute patellar dislocation, how does operative stabilization compare with nonoperative treatment for reducing dislocation recurrence? Summary of Key Findings: Three studies were included: 2 randomized controlled trials and 1 nonrandomized study. All studies compared operative and nonoperative treatment outcomes in adolescents who experienced an acute patellar dislocation. Each study included nonoperative treatment such as patellar bracing and quadriceps strengthening. The operative treatments utilized in each study included lateral retinacular release and medial retinacular repair. All 3 of the studies included a follow-up of at least 6 years. Two of the studies concluded there to be no significant difference between treatment groups regarding redislocation rate, pain, and function. The third study reported a lower redislocation rate following operative treatment. Clinical Bottom Line: Reviewed evidence suggests that outcomes are similar when comparing operative and nonoperative treatment approaches with little agreement as to which is the optimal plan of action. Strength of Recommendation: One level II randomized controlled trial and a level III nonrandomized study suggest that patellar dislocation recurrence rates are similar among operative and nonoperative treatment approaches, while another level II randomized controlled trial suggests that an operative approach is superior.

Treatment of Primary Acute Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature.

PURPOSE: The aim of this study was to evaluate clinical outcomes, rate of redislocation, and complications after conservative or surgical procedures used to treat primary acute patellar dislocation. METHODS: A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patella," "dislocation," "treatment," "acute," "primary" was performed. The following data were extracted: demographics, chondral defects and soft tissue lesions, outcome measurements, type of management, recurrence of instability, and complications. RESULTS: A total of 2134 knees in 2086 patients were included, with an average age at dislocation of 20.3 years. The average Kujula score was 75.6 for patients treated conservatively and 88.7 for patients undergoing surgical treatment in the short-medium follow-up (less than 5 years); the average Kujula score was 87.5 for patients treated conservatively and 86.6 for patients undergoing surgical treatment in the long-term follow-up (more than 5 years). The rate of recurrence was significantly lower in the surgical group (25%) than in the conservative group (36.4%). The overall complication rate was 6.5% (29 of 441 knees) in the surgical management group. No complications were reported for patients treated conservatively. CONCLUSIONS: Surgical treatment of primary acute patellar dislocation leads to significantly lower rate of redislocation and provides better short-medium clinical outcomes, whereas in the long-term follow-up, results of patients treated conservatively were as good as those of surgical patients. Further randomized controlled trials, describing anatomical abnormalities and soft-tissue integrity that may influence the choice of treatment, are needed. LEVEL OF EVIDENCE: Systematic review, level IV.

Primary patellar dislocations without surgical stabilization or recurrence: how well are these patients really doing?

PURPOSE: While a significant research has gone into identifying patients at highest risk of recurrence following primary patellar dislocation, there has been little work exploring the outcomes of patients who do not have a recurrent patellar dislocation. We hypothesize that patients without recurrent dislocation episodes will exhibit significantly higher KOOSs than those who suffer recurrent dislocations, but lower scores than published age-matched normative data. METHODS: A retrospective review of patients with nonoperatively treated primary lateral patellar dislocations was carried out, and patients were contacted at a mean of 3.4 years (range 1.3-5.5 years) post-injury. Information regarding subsequent treatment and recurrent dislocations along with patient-reported outcome scores and activity level was collected. RESULTS: One hundred and eleven patients (29.8 %) of 373 eligible patients agreed to study participation, seven of whom were excluded because they underwent subsequent patellar stabilization surgery on the index knee. Seventy-six patients (73.1 %) reported no further dislocation events, and the mean KOOS subscales at follow-up were: symptoms-80.2 ± 18.8, pain-81.8 ± 16.2, ADL-88.7 ± 15.9, sport/recreation-72.1 ± 24.4, and QOL-63.9 ± 23.8 at a mean follow-up of 3.3 years (range 1.3-5.5 years). No significant differences in any of the KOOS subscales were noted between these patients and the group that reported recurrent patellar dislocations. Only 26.4 % of the patients without further dislocations reported they were able to return to desired sport activities without limitations following their dislocation. CONCLUSION: Patients who do not report recurrent patellar dislocations following nonoperative treatment of primary patellar dislocations are in many cases limited by this injury 3 years following the initial dislocation event. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Management of patellar problems in skeletally mature patients with nail-patella syndrome.

PURPOSE: Nail-patella syndrome (NPS) or hereditary onychoosteodysplasia is a rare autosomal dominant disease, characterized by a tetrad of findings, which include fingernail abnormalities, hypoplasia of the patellae, radial head dislocation and prominent iliac horns. Most of the literature on the treatment of patellar problems in NPS concerns paediatric patients, and there is no standard treatment algorithm for adult patients. METHODS: We reviewed the charts of skeletally mature patients with NPS who presented to our clinic. We reviewed the presenting complaints, the physical examination findings and the radiographic imaging. RESULTS: We identified seven skeletally mature patients with NPS who presented with patellofemoral complaints. Their symptoms were instability, pain, or a combination of the two. Examination and imaging revealed a wide range of severity but included patellar instability and patellar arthritis. In our series, milder forms of the disease were treated with non-operative measures, but the majority of our patients required surgery including medial patellofemoral ligament reconstruction, tibial tuberosity transposition, patellofemoral and total knee arthroplasty. At midterm follow-up, most patients had good results. CONCLUSION: Nail-patella syndrome has a wide range of presentations and severity in skeletally mature patients. Knee surgeons should be familiar with the spectrum of clinical presentation and the range of treatment options available in order to provide optimum treatment for patients with this disorder. LEVEL OF EVIDENCE: IV.

Predictors of Recurrent Patellar Instability in Children and Adolescents After First-time Dislocation.

BACKGROUND: Patellar dislocations are one of the most common knee injuries in children and adolescents and are challenging to treat. Recurrence rates are relatively high and many patients have functional limitations, even in the absence of a recurrent instability episode. The purpose of this study was to examine the risk factors in patients with first-time patellofemoral dislocations to develop a prediction model of recurrence. METHODS: A single institution retrospective review of all patients with a first-time patellofemoral dislocation from 2002 to 2013 was performed. Demographic risk factors (age, sex, laterality, mechanism of injury, and history of contralateral patellar dislocation) and radiographic risk factors (increased patella height, trochlear dysplasia, and skeletal immaturity) were examined. Patella height was measured using Caton-Deschamps index (CDI). Trochlear dysplasia was assessed using the 2-grade Dejour classification and skeletal immaturity was assessed based on the distal femur and proximal tibia physis (open, closing, or closed). RESULTS: In total, 266 knees in 250 patients were included in the study. Of these, 222 (83.5%) were treated nonoperatively and 44 (16.5%) were treated surgically. Of the knees treated nonoperatively, 77 (34.7%) had a recurrence. Significant risk factors for recurrence on univariate analysis were age 14 years and below, history of contralateral patellar dislocation, trochlear dysplasia, skeletal immaturity, and a CDI>1.45. Multivariate analysis was performed and trochlear dysplasia and skeletal immaturity were the most significant factors with odds ratios of 3.56 and 2.23, respectively. The presence of all 4 multivariate risk factors (CDI>1.45, history of contralateral patellar dislocation, trochlear dysplasia, and skeletal immaturity) had a predicted risk of recurrence of 88%. The presence of any 3 risk factors had a predicted risk of about 75% and the presence of any 2 risk factors had a predicted risk of about 55%. CONCLUSIONS: Trochlear dysplasia, skeletal immaturity, CDI>1.45, and a history of contralateral patellar dislocation were all significant risk factors for recurrence in patients with first-time patellar dislocations. A predictive model for calculation of recurrence risk was developed for any combination of the different risk factors. This information is useful when counseling patients and their families after first-time patellar dislocation about prognosis and potential outcomes. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Management of traumatic patellar dislocation in a regional hospital in Hong Kong.

INTRODUCTION: The role of surgery for acute patellar dislocation without osteochondral fracture is controversial. The aim of this study was to report the short-term results of management of patellar dislocation in our institute. METHODS: Patients who were seen in our institution with patella dislocation from January 2011 to April 2014 were managed according to a standardised management algorithm. Pretreatment and 1-year post-treatment International Knee Documentation Committee score, Tegner activity level scale score, and presence of apprehension sign were analysed. RESULTS: A total of 41 patients were studied of whom 20 were first-time dislocators and 21 were recurrent dislocators. Among the first-time dislocators, there was a significant difference between patients who received conservative treatment versus surgical management. The conservative treatment group had a 33% recurrent dislocation rate, whereas there were no recurrent dislocations in the surgery group. There was no difference in Tegner activity level scale score or apprehension sign before and 1 year after treatment, however. Among the recurrent dislocators, there was a significant difference between those who received conservative treatment and those who underwent surgery. The recurrent dislocation rate was 71% in the conservative treatment group versus 0% in the surgery group. There was also significant improvement in International Knee Documentation Committee score from 67.7 to 80.0 (P=0.02), and of apprehension sign from 62% to 0% (P<0.01). CONCLUSIONS: A management algorithm for patellar dislocation is described. Surgery is preferable to conservative treatment in patients who have recurrent patellar dislocation, and may also be preferable for those who have an acute dislocation.

[Conservative treatment of congenital patellar dislocation]. / Konservative Therapie bei kongenitaler Patellaluxation.

This article presents the rare case of a boy who was born in our hospital with valgus deformity and external rotation of the right lower leg because of congenital patellar dislocation. In the case presented a stable repositioning of the patella could be achieved by redressment with a plaster cast and leg brace. During a 4-year follow-up there were no tendencies towards dislocation during the clinical examination and no dislocation events were documented. In selected cases an attempt at conservative repositioning and retention treatment appears to be worthwhile before surgical treatment is indicated.

[Patellar instability : diagnosis and treatment]. / Instabilité rotulienne : diagnostic et traitement.

The aim of this paper is to present recent advances in surgical management of patellar instability. Several anatomical factors were reported to promote instability. We propose to classify them in two groups. Extra articular factors are valgus and torsion deformity. Articular factors include trochlea and patella dysplasia, tibial tubercle lateralization and medial patellofemoral ligament (MPFL) insufficiency. Acute patellar dislocations are treated conservatively, with exception for osteochondral and MPFL avulsion fractures that require acute reinsertion. Surgery is considered for recurrent instability. As we aim for a correction of all contributing elements, we prefer a two stages approach. Extra articular factors are treated first by osteotomy, followed by articular factors after 4-6 months. This allows separate rehabilitation protocols.

L'objectif de cet article est de détailler les progrès dans la prise en charge chirurgicale de l'instabilité rotulienne. Différents facteurs anatomiques favorisent cette instabilité. Nous proposons de les classer en deux groupes : facteurs extra-articulaires (valgus et troubles de torsion) et articulaires (dysplasies trochléenne et rotulienne, latéralisation de la tubérosité tibiale antérieure, insuffisance du ligament patello-fémoral médial (MPFL)). Le premier épisode de luxation est traité conservativement, à l'exception des fractures-avulsions ostéochondrales et du MPFL qui nécessitent une réinsertion en aigu. L'instabilité rotulienne récidivante est traitée chirurgicalement. Nous proposons une correction en deux étapes, avec un intervalle de 4-6 mois, de l'ensemble des facteurs identifiés, d'abord extra-articulaires puis articulaires.

Six-year outcome after non-surgical versus surgical treatment of acute primary patellar dislocation in adolescents: a prospective randomized trial.

PURPOSE: There is only one prospective randomized trial on acute primary patellar dislocation in adolescents comparing the long-term outcome after conservative versus operative procedures. Therefore, the long-term outcome, patellar redislocation rate, and functional outcome after conservative versus operative procedures were investigated in a prospective randomized study. METHODS: Initially, 36 patients with acute primary patellar dislocation were prospectively randomized to conservative (n = 20) versus operative procedures (n = 16) and 30 of them (83%), 15/20 with conservative and 15/16 with operative procedures, were reached for a follow-up interview 6 years after primary procedure. RESULTS: Baseline and clinical parameters were similar in the two groups. The prevalence of patellar redislocation rate at 3 and 6 years after primary procedure was higher in the conservative group (7/20, 35%, 3 years and 11/15, 73%, 6 years) versus in the operative group (0/16, 0%, 3 years and 5/15, 33%, 6 years) (p = 0.02). The knee function was slightly better 6 years after primary treatment in the operative group than in the conservative group. Most patients in both groups had excellent or good knee function at 6-year follow-up, but four patients (4/15, 27%) in conservative group and two patients (2/15, 13%) in operative group had poor knee function at 6-year follow-up. Four patients in conservative group (4/15, 27%) and two patients in the operative group (2/15, 13%) were unsatisfied with the procedure at 6-year follow-up. CONCLUSIONS: In conclusion, the results suggest that both conservative and operative procedures are feasible options for treatment of acute primary patellar dislocation in adolescents. A new finding with clinical relevance in the present work is a significantly higher redislocation rate in conservative group compared to operative group after 6-year follow-up in acute primary patellar dislocation in adolescents. LEVEL OF EVIDENCE: II.

Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review.

PURPOSE: The goal of this study was to perform a comparative review to determine whether there is a significant difference in the rate of repeat dislocation and clinical outcome between surgical and conservative management of acute patellar dislocation in children and adolescents. METHODS: A systematic review of the MEDLINE database was performed. English-language clinical outcome studies with a primary outcome/treatment specific to acute patella dislocation in a paediatric population were included. Eleven studies met inclusion criteria; Chi-square analysis, independent t tests and weighted mean pooled cohort statistics were performed where appropriate. RESULTS: A total of 470 conservatively managed and 157 operatively treated knees were included. Conservatively managed patients were on average 17.0 years and had a mean follow-up of 3.9 years; surgically managed patients were on average 16.1 years and had a mean follow-up of 4.7 years. Conservatively managed knees had a 31% rate of recurrent dislocation rate compared to 22% in surgical knees (p = 0.04). Trochlear dysplasia and skeletal immaturity confer greater risk for recurrent instability. Surgical treatment may provide clinically important quality of life and sporting benefit. CONCLUSIONS: Surgical treatment of first time patella dislocation in children and adolescents is associated with a lower risk of recurrent dislocation and higher health-related quality of life and sporting function. There is a paucity of evidence on MPFL reconstruction for first time traumatic patella dislocation in this population. LEVEL OF EVIDENCE: IV.