Search for


search for




 

Current understanding of the first-time patellar dislocation
Arthrosc Orthop Sports Med 2023;10:10-18
Published online May 1, 2023;  https://doi.org/10.14517/aosm23004
© 2023 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine.

Byung Hoon Lee

Department of Orthopaedics Surgery, Gachon University College of Medicine, Incheon, Korea
Correspondence to: Byung Hoon Lee, https://orcid.org/0000-0002-1548-5691
Department of Orthopaedics Surgery, Gachon University Gil Medical Center, Gachon University College of Medicine, 21 Namdongdaero 774beon-gil, Namdong-gu, Incheon 21565, Korea. Tel: +82-32-460-3384, Fax: +82-32-423-3384, E-mail: oselite@naver.com
Received March 10, 2023; Revised March 17, 2023; Accepted March 22, 2023.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Most first-time patellar dislocation patients can be managed conservatively. Surgical treatment is suggested primarily in cases of relevant concomitant injuries, like osteochondral fractures, and predisposing factors for recurrence. Simple radiographs and CT are crucial to diagnosing bony risk factors for patellar dislocation, such as trochlear dysplasia, enhanced tibial tubercle-trochlear groove (TT-TG) distance, and patellar alta. MRI offers information on cartilage status and the medial patellofemoral ligament (MPFL) injury type for treatment planning. MPFL reconstruction can be an effective treatment option for patients with a specific situation (ex. osteochondral fracture, anatomical predisposing factors).
Keywords : Knee; Patella; Dislocation; Medial patellofemoral ligament
References
  1. Stefancin JJ, Parker RD. First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat Res 2007;455:93-101.
    Pubmed CrossRef
  2. Arendt EA, Fithian DC, Cohen E. Current concepts of lateral patella dislocation. Clin Sports Med 2002;21:499-519.
    Pubmed CrossRef
  3. Sillanpää P, Mattila VM, Iivonen T, Visuri T, Pihlajamäki H. Incidence and risk factors of acute traumatic primary patellar dislocation. Med Sci Sports Exerc 2008;40:606-11.
    Pubmed CrossRef
  4. Fithian DC, Paxton EW, Stone ML, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med 2004;32:1114-21.
    Pubmed CrossRef
  5. Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med 2000;28:472-9.
    Pubmed CrossRef
  6. Hsiao M, Owens BD, Burks R, Sturdivant RX, Cameron KL. Incidence of acute traumatic patellar dislocation among activeduty United States military service members. Am J Sports Med 2010;38:1997-2004.
    Pubmed CrossRef
  7. Mäenpää H, Huhtala H, Lehto MU. Recurrence after patellar dislocation. Redislocation in 37/75 patients followed for 6-24 years. Acta Orthop Scand 1997;68:424-6.
    Pubmed CrossRef
  8. Bicos J, Carofino B, Andersen M, Schepsis AA, Fulkerson JP, Mazzocca A. Patellofemoral forces after medial patellofemoral ligament reconstruction: a biomechanical analysis. J Knee Surg 2006;19:317-26.
    Pubmed CrossRef
  9. Puzzitiello RN, Waterman B, Agarwalla A, et al. Primary medial patellofemoral ligament repair versus reconstruction: rates and risk factors for instability recurrence in a young, active patient population. Arthroscopy 2019;35:2909-15.
    Pubmed CrossRef
  10. Loeb AE, Tanaka MJ. The medial patellofemoral complex. Curr Rev Musculoskelet Med 2018;11:201-8.
    Pubmed KoreaMed CrossRef
  11. Nikku R, Nietosvaara Y, Aalto K, Kallio PE. The mechanism of primary patellar dislocation: trauma history of 126 patients. Acta Orthop 2009;80:432-4.
    Pubmed KoreaMed CrossRef
  12. Mizuno Y, Kumagai M, Mattessich SM, et al. Q-angle influences tibiofemoral and patellofemoral kinematics. J Orthop Res 2001;19:834-40.
    Pubmed CrossRef
  13. Philippot R, Boyer B, Testa R, Farizon F, Moyen B. The role of the medial ligamentous structures on patellar tracking during knee flexion. Knee Surg Sports Traumatol Arthrosc 2012;20:331-6.
    Pubmed CrossRef
  14. Fox AJ, Wanivenhaus F, Rodeo SA. The basic science of the patella: structure, composition, and function. J Knee Surg 2012;25:127-41.
    Pubmed CrossRef
  15. Zhang LK, Wang XM, Niu YZ, Liu HX, Wang F. Relationship between patellar tracking and the “screw-home” mechanism of tibiofemoral joint. Orthop Surg 2016;8:490-5.
    Pubmed KoreaMed CrossRef
  16. Elias JJ, Bratton DR, Weinstein DM, Cosgarea AJ. Comparing two estimations of the quadriceps force distribution for use during patellofemoral simulation. J Biomech 2006;39:865-72.
    Pubmed CrossRef
  17. Hinton RY, Sharma KM. Acute and recurrent patellar instability in the young athlete. Orthop Clin North Am 2003;34:385-96.
    Pubmed CrossRef
  18. Burks RT, Desio SM, Bachus KN, Tyson L, Springer K. Biomechanical evaluation of lateral patellar dislocations. Am J Knee Surg 199811:24-31.
  19. Hing CB, Shepstone L, Marshall T, Donell ST. A laterally positioned concave trochlear groove prevents patellar dislocation. Clin Orthop Relat Res 2006;447:187-94.
    Pubmed CrossRef
  20. Goutallier D, Bernageau J, Lecudonnec B. [The measurement of the tibial tuberosity. Patella groove distanced technique and results (author’s transl)]. Rev Chir Orthop Reparatrice Appar Mot 1978;64:423-8. French.
  21. Camp CL, Stuart MJ, Krych AJ, et al. CT and MRI measurements of tibial tubercle-trochlear groove distances are not equivalent in patients with patellar instability. Am J Sports Med 2013;41:1835-40.
    Pubmed CrossRef
  22. Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J. The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee 2006;13:26-31.
    Pubmed CrossRef
  23. Arima J, Whiteside LA, McCarthy DS, White SE. Femoral rotational alignment, based on the anteroposterior axis, in total knee arthroplasty in a valgus knee. A technical note. J Bone Joint Surg Am 1995;77:1331-4.
    Pubmed CrossRef
  24. Whiteside LA, Arima J. The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Relat Res 1995;(321):168-72.
    CrossRef
  25. Saudan M, Fritschy D. [AT-TG (anterior tuberosity-trochlear groove): interobserver variability in CT measurements in subjects with patellar instability]. Rev Chir Orthop Reparatrice Appar Mot 2000;86:250-5. French.
  26. Koëter S, Horstmann WG, Wagenaar FC, Huysse W, Wymenga AB, Anderson PG. A new CT scan method for measuring the tibial tubercle trochlear groove distance in patellar instability. Knee 2007;14:128-32.
    Pubmed CrossRef
  27. Julliard R, Ligeon R. [Major dysplasia of the trochlea. Contribution to the measurement of A.T. T.G. Proposal of a x-ray computed tomographic protocol]. J Radiol 1992;73:403-7. French.
  28. Nha K, Nam YJ, Shin MJ, et al. Referencing the trochlear groove based on three-dimensional computed tomography imaging improves the reliability of the measurement of the tibial tuberositytrochlear groove distance in patients with higher grades of trochlea dysplasia. Knee 2019;26:1429-36.
    Pubmed CrossRef
  29. Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 1994;2:19-26.
    Pubmed CrossRef
  30. Dejour D, Saggin P. The sulcus deepening trochleoplasty-the Lyon’s procedure. Int Orthop 2010;34:311-6.
    Pubmed KoreaMed CrossRef
  31. Colvin AC, West RV. Patellar instability. J Bone Joint Surg Am 2008;90:2751-62.
    Pubmed CrossRef
  32. Weber-Spickschen TS, Spang J, Kohn L, Imhoff AB, Schottle PB. The relationship between trochlear dysplasia and medial patellofemoral ligament rupture location after patellar dislocation: an MRI evaluation. Knee 2011;18:185-8.
    Pubmed CrossRef
  33. Virolainen H, Visuri T, Kuusela T. Acute dislocation of the patella: MR findings. Radiology 1993;189:243-6.
    Pubmed CrossRef
  34. Elias DA, White LM, Fithian DC. Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-43.
    Pubmed CrossRef
  35. Petri M, Liodakis E, Hofmeister M, et al. Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial. Arch Orthop Trauma Surg 2013;133:209-13.
    Pubmed CrossRef
  36. Balcarek P, Ammon J, Frosch S, et al. Magnetic resonance imaging characteristics of the medial patellofemoral ligament lesion in acute lateral patellar dislocations considering trochlear dysplasia, patella alta, and tibial tuberosity-trochlear groove distance. Arthroscopy 2010;26:926-35.
    Pubmed CrossRef
  37. Balcarek P, Walde TA, Frosch S, et al. Patellar dislocations in children, adolescents and adults: a comparative MRI study of medial patellofemoral ligament injury patterns and trochlear groove anatomy. Eur J Radiol 2011;79:415-20.
    Pubmed CrossRef
  38. Nomura E. Classification of lesions of the medial patello-femoral ligament in patellar dislocation. Int Orthop 1999;23:260-3.
    Pubmed KoreaMed CrossRef
  39. Sillanpää PJ, Peltola E, Mattila VM, Kiuru M, Visuri T, Pihlajamäki H. Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow-up study. Am J Sports Med 2009;37:1513-21.
    Pubmed CrossRef
  40. Askenberger M, Bengtsson Moström E, Ekström W, et al. Operative repair of medial patellofemoral ligament injury versus knee brace in children with an acute first-time traumatic patellar dislocation: a randomized controlled trial. Am J Sports Med 2018;46:2328-40.
    Pubmed CrossRef
  41. Sillanpää PJ, Mäenpää HM. First-time patellar dislocation: surgery or conservative treatment? Sports Med Arthrosc Rev 2012; 20:128-35.
    Pubmed CrossRef
  42. Mäenpää H, Lehto MU. Patellar dislocation has predisposing factors. A roentgenographic study on lateral and tangential views in patients and healthy controls. Knee Surg Sports Traumatol Arthrosc 1996;4:212-6.
    Pubmed CrossRef
  43. Elgafy H, El-Kawy S, Elsafy M, Ebraheim NA. Internal torsion of the distal femur as a cause of habitual dislocation of the patella: a case report and a review of causes of patellar dislocation. Am J Orthop (Belle Mead NJ) 2005;34:246-8.
  44. Insall J, Goldberg V, Salvati E. Recurrent dislocation and the highriding patella. Clin Orthop Relat Res 1972;88:67-9.
    Pubmed CrossRef
  45. Hawkins RJ, Bell RH, Anisette G. Acute patellar dislocations. The natural history. Am J Sports Med 1986;14:117-20.
    Pubmed CrossRef
  46. Steensen RN, Bentley JC, Trinh TQ, Backes JR, Wiltfong RE. The prevalence and combined prevalences of anatomic factors associated with recurrent patellar dislocation: a magnetic resonance imaging study. Am J Sports Med 2015;43:921-7.
    Pubmed CrossRef
  47. Carson WG Jr, James SL, Larson RL, Singer KM, Winternitz WW. Patellofemoral disorders: physical and radiographic evaluation. Part II: radiographic examination. Clin Orthop Relat Res 1984;(185):178-86.
    CrossRef
  48. Neyret P, Robinson AH, Le Coultre B, Lapra C, Chambat P. Patellar tendon length--the factor in patellar instability? Knee 2002;9:3-6.
    Pubmed CrossRef
  49. Grawe B, Stein BE. Tibial tubercle osteotomy: indication and techniques. J Knee Surg 2015;28:279-84.
    Pubmed CrossRef
  50. Tjoumakaris FP, Forsythe B, Bradley JP. Patellofemoral instability in athletes: treatment via modified Fulkerson osteotomy and lateral release. Am J Sports Med 2010;38:992-9.
    Pubmed CrossRef
  51. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med 2014;42:2006-17.
    Pubmed CrossRef
  52. Stephen JM, Lumpaopong P, Dodds AL, Williams A, Amis AA. The effect of tibial tuberosity medialization and lateralization on patellofemoral joint kinematics, contact mechanics, and stability. Am J Sports Med 2015;43:186-94.
    Pubmed CrossRef
  53. Kuroda R, Kambic H, Valdevit A, Andrish JT. Articular cartilage contact pressure after tibial tuberosity transfer. A cadaveric study. Am J Sports Med 2001;29:403-9.
    Pubmed CrossRef
  54. Saranathan A, Kirkpatrick MS, Mani S, et al. The effect of tibial tuberosity realignment procedures on the patellofemoral pressure distribution. Knee Surg Sports Traumatol Arthrosc 2012; 20:2054-61.
    Pubmed KoreaMed CrossRef
  55. Balcarek P, Jung K, Ammon J, et al. Anatomy of lateral patellar instability: trochlear dysplasia and tibial tubercle-trochlear groove distance is more pronounced in women who dislocate the patella. Am J Sports Med 2010;38:2320-7.
    Pubmed CrossRef
  56. Nietosvaara Y, Aalto K. The cartilaginous femoral sulcus in children with patellar dislocation: an ultrasonographic study. J Pediatr Orthop 1997;17:50-3.
    Pubmed CrossRef
  57. Merchant AC, Mercer RL, Jacobsen RH, Cool CR. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am 1974;56:1391-6.
    Pubmed CrossRef
  58. Boutefnouchet T, Downham C, Bassett J, Thompson P, Sprowson A. The efficacy of medial patellofemoral ligament reconstruction combined with tibial tuberosity transfer in the treatment of patellofemoral instability. Knee Surg Relat Res 2016;28:99-109.
    Pubmed KoreaMed CrossRef
  59. Moiz M, Smith N, Smith TO, Chawla A, Thompson P, Metcalfe A. Clinical outcomes after the nonoperative management of lateral patellar dislocations: a systematic review. Orthop J Sports Med 2018;6:2325967118766275.
    Pubmed KoreaMed CrossRef
  60. Kaewkongnok B, Bøvling A, Milandt N, Møllenborg C, Viberg B, Blønd L. Does different duration of non-operative immobilization have an effect on the redislocation rate of primary patellar dislocation? A retrospective multicenter cohort study. Knee 2018;25:51-8.
    Pubmed CrossRef
  61. Scali K, Roberts J, McFarland M, Marino K, Murray L. Is multijoint or single joint strengthening more effective in reducing pain and improving function in women with patellofemoral pain syndrome? A systematic review and meta-analysis. Int J Sports Phys Ther 2018;13:321-34.
    Pubmed KoreaMed CrossRef
  62. Crossley KM, van Middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med 2016;50:844-52.
    Pubmed KoreaMed CrossRef
  63. van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SM, van Middelkoop M. Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev 2015;1:CD010387.
    KoreaMed CrossRef
  64. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59-65.
    Pubmed CrossRef
  65. Willis RB, Firth G. Traumatic patellar dislocation: loose bodies and the MPFL. J Pediatr Orthop 2012;32 Suppl 1:S47-51.
    Pubmed CrossRef
  66. Nikku R, Nietosvaara Y, Aalto K, Kallio PE. Operative treatment of primary patellar dislocation does not improve medium-term outcome: a 7-year follow-up report and risk analysis of 127 randomized patients. Acta Orthop 2005;76:699-704.
    Pubmed CrossRef
  67. Longo UG, Ciuffreda M, Locher J, Berton A, Salvatore G, Denaro V. Treatment of primary acute patellar dislocation: systematic review and quantitative synthesis of the literature. Clin J Sport Med 2017;27:511-23.
    Pubmed CrossRef
  68. Xing X, Shi H, Feng S. Does surgical treatment produce better outcomes than conservative treatment for acute primary patellar dislocations? A meta-analysis of 10 randomized controlled trials. J Orthop Surg Res 2020;15:118.
    Pubmed KoreaMed CrossRef
  69. Saccomanno MF, Sircana G, Fodale M, Donati F, Milano G. Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis. Int Orthop 2016;40: 2277-87.
    Pubmed CrossRef
  70. Lee DY, Park YJ, Song SY, Hwang SC, Park JS, Kang DG. Which technique is better for treating patellar dislocation? A systematic review and meta-analysis. Arthroscopy 2018;34:3082-93.e1.
    Pubmed CrossRef
  71. Erickson BJ, Mascarenhas R, Sayegh ET, et al Does operative treatment of first-time patellar dislocations lead to increased patellofemoral stability? A systematic review of overlapping metaanalyses. Arthroscopy 2015;31:1207-15.
    Pubmed CrossRef
  72. Hing CB, Smith TO, Donell S, Song F. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 2011;(11):CD008106.
    CrossRef
  73. Previtali D, Milev SR, Pagliazzi G, Filardo G, Zaffagnini S, Candrian C. Recurrent patellar dislocations without untreated predisposing factors: medial patellofemoral ligament reconstruction versus other medial soft-tissue surgical techniques-a metaanalysis. Arthroscopy 2020;36:1725-34.
    Pubmed CrossRef
  74. Zaffagnini S, Colle F, Lopomo N, et al. The influence of medial patellofemoral ligament on patellofemoral joint kinematics and patellar stability. Knee Surg Sports Traumatol Arthrosc 2013;21:2164-71.
    Pubmed CrossRef
  75. Petri M, von Falck C, Broese M, et al. Influence of rupture patterns of the medial patellofemoral ligament (MPFL) on the outcome after operative treatment of traumatic patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2013;21:683-9.
    Pubmed CrossRef
  76. Arendt EA, Moeller A, Agel J. Clinical outcomes of medial patellofemoral ligament repair in recurrent (chronic) lateral patella dislocations. Knee Surg Sports Traumatol Arthrosc 2011;19:1909-14.
    Pubmed CrossRef
  77. Camp CL, Krych AJ, Dahm DL, Levy BA, Stuart MJ. Medial patellofemoral ligament repair for recurrent patellar dislocation. Am J Sports Med 2010;38:2248-54.
    Pubmed CrossRef
  78. Tian G, Yang G, Zuo L, Li F, Wang F. Conservative versus repair of medial patellofemoral ligament for the treatment of patients with acute primary patellar dislocations: a systematic review and meta-analysis. J Orthop Surg (Hong Kong) 2020;28: 2309499020932375.
    Pubmed CrossRef
  79. Liu Z, Yi Q, He L, et al. Comparing nonoperative treatment, MPFL repair, and MPFL reconstruction for patients with patellar dislocation: a systematic review and network meta-analysis. Orthop J Sports Med 2021;9:23259671211026624.
    Pubmed KoreaMed CrossRef
  80. Kizher Shajahan MB, Choh CTA, Yew KSA, et al. Strain behavior of native and reconstructed medial patellofemoral ligaments during dynamic knee flexion - a cadaveric study. J Exp Orthop 2019;6:31.
    Pubmed KoreaMed CrossRef
  81. Sim JA, Lim JK, Lee BH. Anatomic double-bundle medial patellofemoral ligament reconstruction with aperture fixation using an adjustable-length loop device: a 2-year follow-up study. BMC Musculoskelet Disord 2018;19:346.
    Pubmed KoreaMed CrossRef
  82. Thompson P, Metcalfe AJ. Current concepts in the surgical management of patellar instability. Knee 2019;26:1171-81.
    Pubmed CrossRef
  83. Gruskay JA, Gomoll AH, Arendt EA, Dejour DH, Strickland SM. Patellar instability and dislocation: optimizing surgical treatment and how to avoid complications. Instr Course Lect 2020;69:671-92.
  84. Shih SSW, Kuo CL, Lee DYH. MPFL reconstruction corrects patella alta: a cohort study. Eur J Orthop Surg Traumatol 2022;32: 883-9.
    Pubmed CrossRef

May 2023, 10 (1)
Full Text(PDF) Free

Social Network Service
Services