Management of the first episode of traumatic patellar dislocation: an international survey

Abstract

Purpose: This international survey aimed to evaluate the potential controversies regarding the management of first patellar dislocation amongst experienced knee surgeries in the treatment of the first episode of patellar dislocation without osteochondral fragments.

Methods: An online survey was conducted from February 2021 to December 2021 to assess the global trend in the diagnosis and management of first-time patellar dislocation without osteochondral fragments. The online survey was accessible on the homepage of the website of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The questionnaire consisted of multiple-choice questions and was divided into three sections. The first section consisted of eight questions regarding demographic information, professional activity, and responder experience. The second section consisted of 13 questions regarding the approach to a first patellar dislocation (clinical examination, imaging, and rehabilitation). The third section contained 2 questions concerning the relevance of patient characteristics to the therapeutic algorithm (age, sports, and pathoanatomical predisposing risk factors).

Results: A total of 438 orthopaedic surgeons worldwide completed the questionnaire. At the first approach to diagnose a first-time patellar dislocation, 251 (57%) of the surgeons requested plain radiographs, and 158 (36%) requested magnetic resonance imaging (MRI). In conservatively treated patients, 368 (84%) of the respondents recommended the use of a knee brace. Amongst them, 14 (3%) advocated its use for one week, 75 (17%) for two weeks, 123 (28%) for three weeks, 105 (24%) for four weeks, and 97 (22%) for six weeks. In conservatively treated patients, 215 (49%) of the surgeons recommended load to tolerance, 148 (34%) recommended 30% to 60% of the bodyweight, and 75 (17%) advised against weight-bearing. More than half of the surgeons considered a patient aged less than 35 years practising contact sports to be a candidate for the medial patello-femoral ligament (MPFL) procedure. In addition, a tibial tuberosity to trochlear groove distance (TT-TG) distance of 15 to > 20 mm (for > 75% of the surgeons) and a trochlea types C and D (for > 70% of the surgeons) were considered possible indications for direct surgical management.

Conclusion: At the first approach to diagnose a first-time patellar dislocation, plain radiographs and MRI should be performed. In conservatively treated patients, most of the surgeons recommend weight-bearing to tolerance and a knee brace during the first four weeks, with range of motion of full extension to 30° during the first 15 days and up to 60° for an additional 15 days. Surgical management should be performed in patients in the second and third decades of life practising contact sports and in those patients who present types C and D trochlea dysplasia and patella alta.

Level of evidence: IV.

Keywords: Patellar dislocation; Patellofemoral instability; Survey.