Top

Current Reviews in Musculoskeletal Medicine

Published in:

01-02-2021 | Patella Dislocation | Non-Operative Management of Anterior Knee Pain (M Fredericson and T Besier, Section Editors)

Acute Patellofemoral Dislocation: Controversial Decision-Making

Authors: Joseph M. Rund, Betina B. Hinckel, Seth L. Sherman

Published in: Current Reviews in Musculoskeletal Medicine | Issue 1/2021

Abstract

Purpose of Review

The topic of acute patella dislocations is controversial. Discussions revolve around which individuals need early surgery, identification of risk factors, and rehabilitation protocol. The purpose of this review is to discuss the current recommendations for non-operative and/or operative management of first-time dislocators.

Recent Findings

Recent studies have made it clear that not all patellar dislocations are the same, not all patients do well with conservative treatment, and risk stratification can identify individuals at high risk of recurrence who would benefit from early surgical intervention. Risk factors that have been identified include younger age, skeletally immature, contralateral instability, trochlear dysplasia, patella alta, increased tibial tubercle-trochlear groove distance, and increased patella tilt. The PAPI (Pediatric and Adolescent Patellar Instability) RCT study and JUPITER (Justifying Patellar Instability Treatment by Early Results) prospective cohort study have been carefully developed, are under way, and will provide further guidance.

Summary

In summary, the management of acute patellar dislocations is evolving. Surgery for patients with osteochondral loose bodies should include fixation as well as soft tissue stabilization. The standard of care for patients with an acute patellar dislocation without osteochondral loose bodies or fracture is non-operative treatment. However, imaging for all first-time dislocators is indicated to stratify risks and determine risk profile. If an individual is at high risk, soft tissue stabilization may be considered. Still, most patients will be treated non-operatively.

Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32(5):1114–21. https://doi.org/10.1177/0363546503260788.CrossRefPubMed

Stanitski CL, Paletta GA Jr. Articular cartilage injury with acute patellar dislocation in adolescents. Arthroscopic and radiographic correlation. Am J Sports Med. 1998;26(1):52–5. https://doi.org/10.1177/03635465980260012501.CrossRefPubMed

• Sherman SL. Editorial commentary: Risk stratification is the new “standard of care” following first-time patellar dislocation. Arthroscopy. 2019;35(8):2482–3. https://doi.org/10.1016/j.arthro.2019.05.039Comments on high recurrent instability rates and low levels of return to unlimited activity following non-operative treatment. Discussed the development of risk stratification models and early surgical stabilization in high-risk individuals. Advocated for counseling patients regarding risk of recurrence.CrossRefPubMed

Sherman SL, Plackis AC, Nuelle CW. Patellofemoral anatomy and biomechanics. Clin Sports Med. 2014;33(3):389–401. https://doi.org/10.1016/j.csm.2014.03.008.CrossRefPubMed

Aglietti P, Insall JN, Cerulli G. Patellar pain and incongruence. I: Measurements of incongruence. Clin Orthop Relat Res. 1983;176:217–24.

Simmons E Jr, Cameron JC. Patella alta and recurrent dislocation of the patella. Clin Orthop Relat Res. 1992;274:265–9.

Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc. 1994;2(1):19–26.CrossRef

Balcarek P, Jung K, Frosch KH, Sturmer KM. Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete. Am J Sports Med. 2011;39(8):1756–61. https://doi.org/10.1177/0363546511404883.CrossRefPubMed

Selfe J, Callaghan M, Witvrouw E, Richards J, Dey MP, Sutton C, et al. Targeted interventions for patellofemoral pain syndrome (TIPPS): classification of clinical subgroups. BMJ Open. 2013;3(9):e003795. https://doi.org/10.1136/bmjopen-2013-003795.CrossRefPubMedPubMedCentral

10.

•• Magnussen RA, Verlage M, Stock E, Zurek L, Flanigan DC, Tompkins M, et al. Primary patellar dislocations without surgical stabilization or recurrence: how well are these patients really doing? Knee Surg Sports Traumatol Arthrosc. 2017;25(8):2352–6. https://doi.org/10.1007/s00167-015-3716-3Reports on patients undergoing non-operative treatment for primary lateral patellar dislocations. At 3 year follow-up, 73.1% reported no further dislocation events. Only 26.4% of the patients without further dislocations reported they were able to return to desired sport activities without limitations.CrossRefPubMed

11.

Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg Am. 2008;90(3):463–70. https://doi.org/10.2106/JBJS.G.00072.CrossRefPubMed

12.

Seeley M, Bowman KF, Walsh C, Sabb BJ, Vanderhave KL. Magnetic resonance imaging of acute patellar dislocation in children: patterns of injury and risk factors for recurrence. J Pediatr Orthop. 2012;32(2):145–55. https://doi.org/10.1097/BPO.0b013e3182471ac2.CrossRefPubMed

13.

Balcarek P, Oberthur S, Hopfensitz S, Frosch S, Walde TA, Wachowski MM, et al. Which patellae are likely to redislocate? Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2308–14. https://doi.org/10.1007/s00167-013-2650-5.CrossRef

14.

• Jaquith BP, Parikh SN. Predictors of recurrent patellar instability in children and adolescents after first-time dislocation. J Pediatr Orthop. 2017;37(7):484–90. https://doi.org/10.1097/BPO.0000000000000674Reports on risk factors in patients with first-time patellofemoral dislocations. 34.7% had a dislocation recurrence. Trochlear dysplasia, skeletal immaturity, CDI> 1.45, and a history of contralateral patellar dislocation were all significant risk factors for recurrence.CrossRefPubMed

15.

Lewallen L, McIntosh A, Dahm D. First-time patellofemoral dislocation: risk factors for recurrent instability. J Knee Surg. 2015;28(4):303–9. https://doi.org/10.1055/s-0034-1398373.CrossRefPubMed

16.

• Nwachukwu BU, So C, Schairer WW, Shubin-Stein BE, Strickland SM, Green DW, et al. Economic decision model for first-time traumatic patellar dislocations in adolescents. Am J Sports Med. 2017;45(10):2267–75. https://doi.org/10.1177/0363546517703347Compares nonoperative treatment only, surgery for recurrent dislocations, and immediate surgery through a cost-effectiveness model. Nonoperative treatment only was the least costly but also the least effective. Concluded that immediate surgery and delayed surgical treatment are both cost-effective treatment options.CrossRefPubMed

17.

•• Pagliazzi G, Napoli F, Previtali D, Filardo G, Zaffagnini S, Candrian C. A meta-analysis of surgical versus nonsurgical treatment of primary patella dislocation. Arthroscopy. 2019;35(8):2469–81. https://doi.org/10.1016/j.arthro.2019.03.047A meta-analysis of RCTs which compares outcomes after surgery versus nonsurgical treatment in the management of primary lateral patellar dislocation. The redislocation rate was higher with the nonsurgical approach. More favorable clincial outcomes were found with the surgical approach up to 6 years. However at a longer follow-up, the results were similar for surgical and nonsurgical treatment.CrossRefPubMed

18.

Askenberger M, Arendt EA, Ekstrom W, Voss U, Finnbogason T, Janarv PM. Medial patellofemoral ligament injuries in children with first-time lateral patellar dislocations: a magnetic resonance imaging and arthroscopic study. Am J Sports Med. 2016;44(1):152–8. https://doi.org/10.1177/0363546515611661.CrossRefPubMed

19.

Mountney J, Senavongse W, Amis AA, Thomas NP. Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction. J Bone Joint Surg Br. 2005;87(1):36–40.CrossRef

20.

Christiansen SE, Jakobsen BW, Lund B, Lind M. Isolated repair of the medial patellofemoral ligament in primary dislocation of the patella: a prospective randomized study. Arthroscopy. 2008;24(8):881–7. https://doi.org/10.1016/j.arthro.2008.03.012.CrossRefPubMed

21.

Sillanpaa P, Mattila VM, Iivonen T, Visuri T, Pihlajamaki H. Incidence and risk factors of acute traumatic primary patellar dislocation. Med Sci Sports Exerc. 2008;40(4):606–11. https://doi.org/10.1249/MSS.0b013e318160740f.CrossRefPubMed

22.

Bitar AC, Demange MK, D'Elia CO, Camanho GL. Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med. 2012;40(1):114–22. https://doi.org/10.1177/0363546511423742.CrossRefPubMed

23.

• Liu JN, Steinhaus ME, Kalbian IL, Post WR, Green DW, Strickland SM, et al. Patellar instability management: a survey of the International Patellofemoral Study Group. Am J Sports Med. 2017:363546517732045. https://doi.org/10.1177/0363546517732045Surveys active members of the International Petallofemoral Study Group to discover a conensus on patellofemoral instability treatment controversies. Conlusions were nonoperative management is the current standard of care for first-time dislocations, patellar instability should be addressed concurrently if immediate surgery indicated, and recurrent instability should be treated surgically.

24.

• Hevesi M, Heidenreich MJ, Camp CL, Hewett TE, Stuart MJ, Dahm DL, et al. The recurrent instability of the patella score: a statistically based model for prediction of long-term recurrence risk after first-time dislocation. Arthroscopy. 2019;35(2):537–43. https://doi.org/10.1016/j.arthro.2018.09.017Describes a developed multivariate, statistically derived scoring system utilizing age, skeletal maturity, trochlear dysplasia, and TT-TG/PL ratio. The scoring system determines percent risk of recurrent instability at 5 years and stratifies individuals into risk categories. Possesses significant potential clinical utility for determining individuals at high risk for recurrent instability.CrossRefPubMed

25.

Farr J, Covell DJ, Lattermann C. Cartilage lesions in patellofemoral dislocations: incidents/locations/when to treat. Sports Med Arthrosc. 2012;20(3):181–6. https://doi.org/10.1097/JSA.0b013e318259bc40.CrossRefPubMedPubMedCentral

26.

•• Stein B. Pediatric and Adolescent Patellar Instability (PAPI). https://clinicaltrials.gov/ct2/show/NCT02333825. Accessed April 16 2020. Provides the study description for a multi-center, RCT which is ongoing. Discusses its purpose which is to determine if patients age 25 and younger who undergo MPFL reconstruction have lower rates of recurrent instability compared to those treated non-operatively.

27.

• Koh JL, Parikh S, Stein BS. Conducting a Multicenter Trial: Learning from the JUPITER (Justifying Patellar Instability Treatment by Early Results) Experience. In: Musahl V, Karlsson J, Hirschmann MT, Ayeni OR, Marx RG, Koh JL et al., editors. Basic methods handbook for clinical orthopaedic research: a practical guide and case based research approach. Berlin, Heidelberg: Springer Berlin Heidelberg; 2019. p. 415–25. Discusses the JUPITER study, a hypothesis-driven, multi-center, multi-armed, prospective cohort study developed to obtain sufficient subjects to better describe clinical characteristics and predictors of clinical outcomes in the young patellar instability population. Also discusses how a multicenter trial can be divided into several stages. Provides specific recommendations regarding the conduct of orthopedic multicenter trials.

28.

•• Bishop ME, Brady JM, Ling D, Parikh S, Stein BES. Descriptive epidemiology study of the justifying patellar instability treatment by early results (JUPITER) cohort. Orthop J Sports Med. 2019;7(3_suppl):2325967119S00046. https://doi.org/10.1177/2325967119s00046Provides preliminary descriptive analysis of patient demographics and clinical features for the initially enrolled patients in the JUPITER study. Almost 60% of first time dislocators were indicated for nonsurgical management while only 13% of recurrent dislocators were indicated for non-operative management. KOOS QOL scores were significantly lower in individuals who experienced more than one redislocation.CrossRefPubMedCentral

29.

Respizzi S, Cavallin R. First patellar dislocation: from conservative treatment to return to sport. Joints. 2014;2(3):141–5.CrossRef

Title: Acute Patellofemoral Dislocation: Controversial Decision-Making
Authors: Joseph M. Rund
Betina B. Hinckel
Seth L. Sherman
Publication date: 01-02-2021
Publisher: Springer US
Keyword: Patella Dislocation
Published in: Current Reviews in Musculoskeletal Medicine / Issue 1/2021
Electronic ISSN: 1935-9748
DOI: https://doi.org/10.1007/s12178-020-09687-z

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Acute Patellofemoral Dislocation: Controversial Decision-Making

Abstract

Purpose of Review

Recent Findings

Summary

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 1/2021

Patient Education in Orthopedics: the Role of Information Design and User Experience

Three-Dimensional Printing in Orthopedics: from the Basics to Surgical Applications

Graft Options in Hip Labral Reconstruction

The Evidence Behind Weighted Ball Throwing Programs for the Baseball Player: Do They Work and Are They Safe?

Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptom State of Outcome Measures Relating to Shoulder Pathology and Surgery: a Systematic Review

Femoral Stem Cementation in Hip Arthroplasty: The Know-How of a “Lost” Art