Current Practice Trends in the Surgical Management of Patellofemoral Instability: A Survey of the Paediatric Research in Sports Medicine (PRiSM) Society

Abstract

Purpose Patellofemoral instability (PFI) in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. The purpose of this study was to identify trends in management of PFI in children and adolescents in the United States and nationwide. Methods A 27-question multiple choice survey was distributed in 2018 to the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding treatment of PFI in paediatric and adolescent patients. Results In all, 56 of the respondents who were orthopaedic surgeons that manage patellar instability in children and adolescents and had performed PFI surgery more than five times in the past year completed the entire survey. A total of 41% of respondents reported that surgery for fragment refixation or loose body removal was indicated when a loose body or osteochondral fragment was evident, regardless of fragment size. Overall, 74% reported that if surgery was performed for an osteochondral loose body, primary repair (36%) or reconstruction (38%) of medial patellofemoral ligament (MPFL) was also completed. A total of 89% of members reported MPFL reconstruction in the absence of alignment or rotational abnormalities, tibial tubercle lateralization or trochlear dysplasia in skeletally immature patients; 59% reported performing the MPFL reconstruction with hamstring allograft, while 30% prefer autograft (hamstring, quadriceps). For patients with significant trochlear dysplasia, 87% reported no surgical management of trochlea in first-time or in revision surgery. Conclusion There is a lack of consensus regarding optimal diagnostic and treatment algorithms in the management of PFI, however, consistent trends have emerged among paediatric sports medicine surgeons. Level of Evidence Level V – survey of expert opinion and experience

The Joystick Method: A Mini Open Technique for Repairing Patellar Osteochondral Fractures With Concomitant Medial Patellofemoral Ligament Reconstruction

“… 1 Of the survey respondents who proceeded with acute OCF fixation, 36% performed MPFL repair, 38% performed MPFL reconstruction, and 27% of respondents performed no concomitant procedure for the MPFL. 9 This is an interesting finding, as there has been shown a 59% to 61% redislocation rate among individuals who underwent MPFL repair or no MPFL procedure at the time of OCF fixation. 3 , 4 Although other factors for recurrent patellar dislocations also must be considered, such as increased tibial tuberosity-trochlear groove distance, a trend is becoming more apparent in the literature that MPFL reconstruction is superior to repair.…”

“…In a recent survey among Paediatric Research in Sports Medicine (PRiSM) members, 89% of respondents proceeded with OCF fixation if identified on imaging acutely on first-time patellofemoral dislocations. 9 Acute OCF is typically defined as within 2 weeks of injury, as the fragment can start to undergo chondral degeneration beyond that point. 1 Of the survey respondents who proceeded with acute OCF fixation, 36% performed MPFL repair, 38% performed MPFL reconstruction, and 27% of respondents performed no concomitant procedure for the MPFL.…”

Conservative management following patellar dislocation: a level I systematic review

“…Exercises to strengthen the quadriceps (including vastus medialis) and hip muscles; gain/maintenance of knee flexibility (hamstring stretching); use of braces with controlled free motion seem to be equivalent [38]. Surgical intervention is an appropriate option if patients continue to experience recurrent patellar dislocations and remain symptomatic, and conservative treatment options have been exhausted [51].…”

Surgical techniques for medial Patellofemoral ligament reconstruction: a systematic review and meta‐analysis of level I and II studies

“…There is notable variability in surgical techniques utilized for MPFL fixation [34]. Differences in graft types, such as autografts, allografts and synthetic grafts, have been studied over the years, each offering unique benefits and drawbacks [26].…”