Summary

Even though conservative management demonstrates good outcome in first time patella dislocations in pediatric patients, surgical management can be an effective treatment when risk factors for instability are present.

Abstract

Purpose

To compare outcomes of non-operative versus operative management in pediatric patients after first-time patellofemoral dislocation.

Methods

All consecutive skeletally immature patients that sustained a first-time patellofemoral dislocation were included in this prospective study. Patients were divided in two cohorts depending on management. Non-operative management consisted of bracing and physical therapy. Operative management consisted of double bundle medial patellofemoral ligament / medial quadriceps tendon femoral ligament (MPFL/MQTFL) reconstruction using the pediatric Schottle point at the femoral side, and one bony and one soft tissue attachment at the patella side. The primary outcome measured was failure (defined as any subsequent dislocation or subluxation event). Minimun follow up time was 2 years. Other outcomes recorded were demographic data, risk factors for patellofemoral instability, functional outcomes (Kujala and pedi-IKDC scores), pain, activity level, return to sports and complications. A correlation analysis attempted to identify potential association of failure with risk factors. SPSS was used for statistical analysis with statistical significance set at p<0.05.

Results

Eighty-two consecutive patients were included in the analysis with 53 patients in the non- operative management cohort and 29 patients in the operative management cohort that met the inclusion/exclusion criteria. Mean age was 12.1±2.3 and female to male ratio was 55/27. Failure rate was 55% in the conservative group and 24% in the surgical group (p=0.01). Kujala and IKDC scores were significantly higher at the operative group versus the non-operative group (91.0±9.1 vs 83.5±10.6, p=0.001 and 88.0±10.9 vs 78.4±12.1, p=0.0007, respectively). Activity level was also higher at the operative group (6.0±1.8 vs 4.2±1.6, p=0.0001). There were 7 complications recorded in the operative group (24%). From the different risk factors analyzed, trochlear dysplasia, patella alta, pre-injury activity level, and flexibility were associated with higher risk of recurrence.

Conclusions

Non-operative management in skeletally immature patients with first-time patellofemoral dislocation remains a reasonable and safe option but appears to be associated with high failure rate. Operative management is an effective alternative, especially when risk factors are present, that demonstrates lower failure rate, higher functional outcome and higher activity level, but with an increased risk of complications in this cohort.