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22-year-old female with multiple previous dislocations, the MRI findings in Figure A, and a tibial tubercle-trochlear groove (TT-TG) distance of 26 mm
1%
38/2681
22-year-old female with the MRI findings in Figure B and a TT-TG distance of 18 mm
4%
120/2681
13-year-old female with no prior history of knee injury and the MRI findings in Figure A
85%
2280/2681
13-year-old female with no prior history of knee injury and the MRI findings in Figure B
7%
198/2681
13-year-old female with multiple previous dislocations despite PT and the MRI findings in Figure A
17/2681
Select Answer to see Preferred Response
Bracing and physical therapy is indicated for patients with first time patellar dislocations without fracture or osteochondral loose bodies. Patellar instability and dislocation may be seen in young, active individuals following a traumatic event or chronically from generalized ligament laxity. Patellar instability may occur from coronal, rotational misalignment, patella alta, trochlea dysplasia, tight lateral structures, or damage to the medial patellofemoral ligament (MPFL), the primary restraint to patella lateral dislocation. In the absence of knee intraarticular fractures or loose bodies, the mainstay treatment for first time patellar dislocation consists of bracing and physical therapy. Debridement and/or MPFL repair or reconstruction is indicated in the presence of displaced osteochondral fractures and loose bodies. Anterior and medial tibial tubercle transfer (Fulkerson-type osteotomy) is indicated for skeletally-mature patients with significant malalignment. Clark et al. reviewed patellar instability in adolescent patients. They reported that nonoperative management should be undertaken for first-time dislocators, often permitting delay of operative treatment until skeletal growth is complete in patients who sustain recurrent dislocations. They conclude that restoration of normal anatomy via MPFL repair, MPFL reconstruction, trochleoplasty, or tibial tubercle transfer may ultimately be needed to prevent further instability when nonoperative management fails. Palmu et al. conducted a randomized controlled trial comparing long-term subjective and functional results after nonoperative and operative management of primary acute patellar dislocations in children under 16 years of age. They found equivalent subjective scores as well as recurrent dislocation rates in the two cohorts. They recommended nonoperative management for acute patellar dislocations in children and adolescents. Weber et al. reviewed the management of recurrent lateral patellar dislocations. They reported that recurrent instability is often multifactorial, consisting of coronal malalignment, patella alta, tibial malrotation, dyplastic trochlea, or weakened/disrupted MPFL. They recommended nonoperative management for first-time lateral patellar dislocations, and reserve MPFL repair, reconstruction, or distal realignment procedures in cases of recurrent instability. Figure A is an axial MRI image depicting an MPFL rupture with no evidence of fractures or loose bodies. Figure B is an axial MRI image depicting a lateral patellar dislocation with associated MPFL rupture, medial patella facet fracture, and osteochondral loose bodies. Incorrect Answers: Answer 1: A skeletally mature patient with recurrent patellar instability and limb malalignment should undergo a distal realignment procedure. Answer 2 and 4: Debridement (removal of loose body) with or without repair is indicated for patients with lateral patellar instability with osteochondral fragments and loose bodies. Answer 5: Continued nonoperative management is inappropriate for an adolescent with recurrent instability from chronic MPFL disruption, and will likely require MPFL reconstruction.
1.8
(4)
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