Treating Patella Instability in

Skeletally Immature Patients

Patrick Vavken, MD., M.Sc., et al

INTRODUCTION
Conservative vs Surgical Treatment
Damage to physes and subsequent growth
disturbance.
Acute dislocations are typically treated with
conservative treatment, unless there is evidence
of osteochondral damage.
Acute dislocation + anatomic deficiencies
considered equivalent to osteochondral
damagesurgical treatment.

 Objectives
Review current orthopaedic treatments of
skeletally immature patient with patellar
instability (acute and recurrent).
Asses current evidence for different types of
surgical treatments that are clinically available.
Provide summation and evidence needed in the
management of pediatric patellar instability

METHODS
After statement of PRISMA (Preferred Reporting
Items for Systemic reviews and Meta-Analyses)
and QUOROM (Quality of Reporting of Metaanalyses) in previous article in Arthroscopy.
Studies were included report on surgical or
conservative treatment (or both) of patellar
instability in skeletally immature individuals or
adolescents, with at least 6 months of follow-up.

METHODS
Inclusion Criteria :
Immature : Radiologic proof of open physes or
Tanner stage (stage 4 or lower).
If neither physeal status nor tanner stage was
reported, age 19 was considered the cut-off
threshold between adolescent and adulthood.
*this age refers to the age at surgery, not at
dislocation

Exclusion Criteria
Patellar instability in association with syndrome
(e.g., Turner syndrome)
Turner syndrome is one of the most common
chromosomal abnormalities. That caused by the
absence of the one set of genes from short arm of
one X chromosome. (45X)

 Search from online database PubMed, CINAHL,

EMBASE, Cochrane Central Register of
Controlled Trials, and Cochrane Database of
Systemic Reviews.
All searches were unlimited, i.e., publication in
all language and at all dates were considered.
The last search was performed on October 1,
2012.

RESULT
Twenty articles
reporting on a total
of 456 knees in 425
patients (131 male,
295 females)
followed-up for 56.7
42.2 months on
average.
The average age
across all studies
was 12.9 3.1 years

Acute Patellar Dislocation

Three studies focused on acute dislocations. Two studies presented data on a

direct comparison of conservative and surgical treatments of patellar instability
after acute patellar dislocation in pediatric and adolescent patients.
Apostolovic et al found no difference in outcome between surgical and
conservative treatment. they did not report on a formal power analysis in
the face of P = .091 for functional outcome. Assessment of patellofemoral
anatomy was not reported.
Palmu et al published a study of 71 patients with patellar dislocation treated
with medial restraint repair or conservatively and followed for 14
years. All patients had slight trochlear dysplasia (>150 average sulcus angle)
and some level of patella alta (average Insall-Salvati ratio of 1.3), but no data
were reported on Q angles or the tibial tuberosity-trochlear groove distance.
However, at 7 and 14 years of follow-up, there was no difference in outcome.

 Recurrence rates for dislocations were fairly

high, ranging from 4% to 20% (Table 3). The
highest rates were seen in the oldest patients and
with the oldest arthroscopic techniques.

Recurrent Patellar Instability

Three studies presented data on 4 groups of patients with

recurrent instability treated with proximal realignment,
such as a medial retinacular or VMO plasty.
Ji et al. found high clinical scores after medial
retinacular plication, but there was no control
group.
Zhao et al. compared medial retinacular plication with
VMO plasty and found better stability and clinical
scores in the stronger repair with the VMO plasty.
Ma et al. compared medial capsular reefing with
MPFL repair and found better results with the latter.

 Camp et al. and Kwon et al. presented data on open and

arthroscopic MPFL repair (to the patella) and found them to
be feasible and effective techniques to treat recurrent instability
despite recurrence rates as high as 28%.
Five studies reported on classic MPFL reconstruction with a
hamstring graft. Drez et al. and Deie et al. sutured
autologous semitendinosus to the patella.
Kumahashi et al., Yercan et al., and Nelitz et al. used
intraosseous fixation of semitendinosis or gracilis grafts
with good clinical results and no reported growth disturbances or
fractures.

DISCUSSION
MPFL provides more than 50% of medial restrain;
in most of dislocations, MPFL undergoes some
level of injuries.
Current best evidence suggest conservative
treatment in first acute patellar
dislocation.
Two studies included showed no significant
difference in clinical score and recurrence
between conservative and surgical treatment.
(Apostolovic et al. and Palmu et al.)

 Bracers have shown to stabilize the patella

successfully but lead to stiffness in the long
term. (Larsen et al.)*
VMO strengthening and proprioeptive training;
close chain more effective than open chain but
do more stress to cartilage. (Irish et al.)*
Abnormal extensor alignment cause abnormal
patellar tracking thus interfere with
healingconsider surgical approach

Surgical Approach
Proximal Realignment
Release of lateral retinaculum
Medial procedures
Plication/imbrication of capsule or retinaculum
VMO plasty
Reconstruction of MFPL

Distal Realignment
Tenodesis based on semitendinous
Transfering patellar tendon medially

Proximal Realignment
Ma et al. found better subjective score and
postoperative stability on medial MPFL repair
compared to reefing of the medial capsule
Zhao et al. found that simple medial capsule
plication affords less improvement than VMO
plasty
50-80% of medial restrain injuries occur at
MPFL attachment.

Potensial Problems
Allograft or autograft from hamstring is much
more stiffer than natural MPFL (Colvin, 2008)
minimal malposition induce stress
patellofemoral degeneration (Elias, 2006 and
Beck et al., 2007).
Strategies:
MPFL anchored to adductor magnus (Yercan et
al.,2011)/use MCL as pulley (Deie et al.,2011)
Tensioning in 60 to 90 degrees of flexion rather
than conventional 30 degrees(Colvin, 2008)

 Risk of MPFL reconstruction on skeletal growth:

Keppler et al. showed in an MRI studies: MPFL
insertion is on average 5 mm distal to the physis.
Neliz et al. and Schottle et al. put MPFL insertion
6.4 and 6.5 mm distal to physes .
provide secure and safe placement of anchor
suture or tunnel without jeopardizing growth.

LIMITATIONS
Depended on quality of included primary
studies.
Level of evidence of the included studies were
limited.
Unclear terminology
A number of studies mixed adolescent and adult
patiens.

CONCLUSIONS
Current best evidence does not support the
superiority of surgical intervention over
conservative treatment in acute patellar
dislocation.
Anatomic variations and their effect on healing
should be considered in decision making.
In recurrent patellar instability in pediatric and
adolescent patients, reconstruction of MPFL is the
most effective options together with extensor
realignment as needed.

Thank You