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Aspirate the hemarthrosis and place in a patellar stabilizing brace
13%
104/786
Begin physical therapy for range of motion and subsequent strengthening
10%
82/786
Schedule for arthroscopic loose body removal versus osteochondral fragment fixation
67%
530/786
Schedule for isolated medial patellofemoral ligament (MPFL) reconsturction
4%
33/786
Schedule for tibial tubercle osteotomy (TTO) with MPFL reconstruction with possible trochleoplasty
3%
26/786
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The patient had a first-time patellar dislocation with a large retained osteochondral fragment that should be appropriately treated with an arthroscopic surgery to either remove the fragment or fix it if it is large enough (Answer 3).Patellar dislocations typically occur via a non-contact twisting injury with the knee extended and the foot externally rotated. Most self-reduce with a reflexive contraction of the quadriceps, during which time osteochondral fractures may occur as the patella relocates. Though not a true "knee dislocation," many patients will present with this as the chief complaint. A primary patellar dislocation in a skeletally immature patient without loose osteochondral or pure chondral fragments is typically allowed to recover in physical therapy without surgical intervention. In up to 40% of cases, however, there may be large fragments floating in the joint that radiographs taken in the ED alone may not be sufficient to capture. MRI in this scenario can drastically improve detection of these fragments, allowing for appropriate surgical decision-making. Re-dislocation rates with non-operative treatment may be high (15-50%) at 2-5 years, at which time procedures such as an MPFL reconstruction with or without a TTO may be indicated if the tibial tubercle-trochlear groove (TT-TG) distance exceeds 20 mm on CT. Qiu et al. reviewed MRI as the optimal imaging modality for assessment and management of osteochondral fractures (OCF) and loose bodies following traumatic patellar dislocation. The authors included forty studies totaling 3074 patients, 2446 of which were first-time dislocators, and found that 43.3% of patients with a first-time dislocation and 34.7% of patients with previous dislocations had at least one OCF. They concluded that the highest rate of OCF detection was with MRI, and thus, surgeons should consider routinely ordering an MRI in patients with first-time patellar dislocation.Redler et al. reviewed the surgical management of patellofemoral instability in the skeletally immature patient. The authors note that surgical treatment is the standard of care for patients with recurrent instability and requires important and technically challenging physeal considerations. They conclude that patient-specific surgical techniques and proper surgical indications are crucial for successful outcomes.Figure A is an axial STIR MRI sequence of a knee status post a lateral patellar dislocation with bone marrow edema seen at the medial patellar articular facet and focal osteochondral injury showing a large displaced fragment within the lateral synovial recess. The medial patellar retinaculum shows relative thinning with partial fiber disruption and peri-ligamentous edema denoting partial-thickness tear of the MPFL without complete disruption.Incorrect Answers: Answers 1 and 2: Non-operative management is not indicated for a patient with a large retained osteochondral fragment. Answers 4 and 5: The literature for first-time dislocators does not sufficiently support immediate isolated MPFL reconstruction or TTO.
3.7
(6)
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