Acute patellar dislocation--closed or operative treatment?

Non-surgical treatment for acute patellar dislocation with special emphasis on the MPFL injury patterns

PURPOSE

The objective of present study was to propose a new classification for acute MPFL injury, which can help choose optimal treatment method for certain injury type.

METHODS

Eighty-five patients with acute patellar dislocation treated non-surgically were retrospectively reviewed. They were assigned into two groups according to the newly introduced classification scheme, which classified MPFL injury into three types: injury in overlap region, injury in non-overlap region and combined injury of both regions. For study purpose, patients with combined injury were not included. Of 85 patients, 33 were in the overlap-region group (Group 1) and 52 in the non-overlap-region group (Group 2). Clinical patellar instability rate and patellofemoral score were measured and recorded at 2-year follow-up.

RESULTS

The patellar instability rate was 15.2 % in Group 1 and 38.5 % in Group 2, with statistically significant difference between the two groups (P = 0.022). The mean visual analogue scale for Group 1 and Group 2 was 15.6 points and 28.3 points, respectively (P = 0.026). The mean Kujala score was 91.1 points and 82.6 points (P = 0.009), with a good or excellent subjective result recorded for 27 of 33 patients (81.8 %) in Group 1 compared with 30 of 52 patients (57.7 %) in Group 2 (P = 0.021).

CONCLUSIONS

Non-surgical treatment achieves better clinical outcomes with respect to a lower patellar instability rate and better subjective function for the overlap-region injury of MPFL than for the non-overlap-region injury, and can be considered as treatment of choice for overlap-region injury of MPFL. The optimal choice for the non-overlap-region injury still requires further researches.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

First-time traumatic patellar dislocation: a systematic review

Acute patellar dislocations can result in patellar instability, pain, recurrent dislocations, decreased level of sporting activity, and patellofemoral arthritis. The initial management of a first-time traumatic patellar dislocation is controversial with no evidence-based consensus to guide decision making. Most first-time traumatic patellar dislocations have been traditionally treated nonoperatively; however, there has been a recent trend in initial surgical management. We performed a systematic review of Level I-IV studies to make evidence-based medicine recommendations on how a clinician should approach the diagnosis and treatment of a first-time traumatic dislocation. More specifically we answer the primary question of when initial treatment should consist of operative versus closed management. Based on the review of 70 articles looking at study design, mean followup, subjective and validated outcome measures, redislocation rates, and long-term symptoms, we recommend initial nonoperative management of a first-time traumatic dislocation except in several specific circumstances. These include the presence of an osteochondral fracture, substantial disruption of the medial patellar stabilizers, a laterally subluxated patella with normal alignment of the contralateral knee, or a second dislocation, or in patients not improving with appropriate rehabilitation.

Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment

OBJECTIVE

This report evaluates the subjective, clinical, and functional long-term results comparing surgical and conservative treatment in patients with a primary traumatic patellar dislocation.

DESIGN AND SETTING

This retrospective clinical study focuses on patients with primary acute traumatic patellar dislocation. Patients with radiologic signs indicative of a predisposition for recurrent patellar instability were excluded from this study.

PATIENTS

A total of 126 patients were examined a mean of 8.1 years after initial treatment of their primary patellar dislocation.

INTERVENTIONS AND MAIN OUTCOME MEASUREMENTS

Patients were retrospectively divided into groups with conservative therapy (n = 63), diagnostic arthroscopy only (n = 20), immediate surgical reconstruction of the parapatellar ligament complex (n = 37), and refixation of osteochondral fragments (n = 6). Redislocation and resurgery rate, activity level, and subjective, clinical, and functional results were evaluated in these patients, and the outcomes in these groups were compared.

RESULTS

In the long term, functional results (as expressed in the Lysholm score) were excellent or good in 85% of the patients, and good subjective results were reported by 71%, but follow-up revealed a recurrence rate of 26% in the total study population. The high activity level before the initial trauma could not be completely regained after treatment. There was no significant difference between the surgically and conservatively treated groups in the redislocation and reoperation rates, level of activity, or functional and subjective outcomes.

CONCLUSIONS

Even with a focus on acute traumatic etiology and when factors predisposing to recurrent instability are largely excluded, the redislocation rate after treatment of acute patellar dislocation is still high, despite good clinical and subjective results. Conservative management seems to be the treatment of choice in patients with acute patellar dislocation, provided that the generally accepted indications for surgery, such as evidence of osteochondral fragments and major defects of the parapatellar ligament complex, are given due consideration.

Patellar tendonitis and patellar dislocations

Common sports injuries, such as patellar tendonitis and patellar dislocation, can be treated either surgically or with rehabilitation and physical therapy. Most patients with patellar tendonitis will respond well to conservative measures; however, some recalcitrant cases will require surgical intervention. To date, the literature is not able objectively to identify the patients best suited to surgery. Likewise, in the case of patellar dislocations, it is still unclear which patients respond best to conservative therapy and which respond best to surgical treatment, although evidence continues to accumulate. A practical approach to this problem can be deduced from the available evidence, but more well-designed clinical trials are needed for the establishment of definitive treatment protocols.