Acute Patellar Dislocation in Children and Adolescent: A Randomised Clinical Trial

J Bone Joint Surg Am. 2008;90:463-470. doi:10.2106/JBJS.G.00072 Sauli Palmu, Pentti E. Kallio, Simon T. Donell, Ilkka Helenius and Yrjn Nietosvaara

Introduction
Acute patellar dislocation is the most common acute knee disorder in paeds and adolescent May lead to functional disability Peak incidence 15y.o 43/100000 for pts below 16y.o

 Predisposing factor:
Patellofemoral dysplasia Female Positive family history Young age of on set ( risk of recurrent)

 Traditionally, treated non-operatively unless susbstantial joint surface damage Primary operative repair of the medial patellastabilizing soft tissues became popular during the 1980s Not many study on pediatric population and no reports comparing the results of operative and nonoperative treatment

Hypothesis
Primary operative repair of the injured medial retinacular structures would reduce the redislocation rate and improve the results of treatment in pediatric patients with an acute patellar dislocation

Aim
To compare the long term result in both treatment group, non-operative and operative To identify possible risk factor for late poor subjective and functional outcomes

Material and Method

Patient selection and demographic data

All children younger than 16 with evident of acute patella dislocation(APD) admited to A&E in 1991 and 1992 P/E, xray, EUA, and diagnostic arthroscopy done in all Diagnostic criteria for APD
Lat dislocation patella needing reduction Typical finding on arthroscopy Dislocatable under EUA

74 knees in 71 pts meet at least 1 of 3 criteria

 Inclusion criteria
1) the occurrence of an acute lateral patellar dislocation within two weeks before treatment 2) no history of previous knee surgery or substantial knee injury 3) no major coexistent tibiofemoral ligamentous injury requiring repair 4) no large osteochondral fracture fragments (diameter >15 mm) requiring fixation 5) a willingness of the patient and parents to participate.

10 knees were excluded

Randomization and Treatment

64 Knees in 61 pt included in the study Randomised according year of birth
Odd non-operative (28 knees) Even- operative( 36 knees)

+ve Fhx in 15 pts in both groups Mean pre-injury Tegner activity scores = 5 in both groups

 29 knees from operative group , disloctable during EUA

Operative repair was performed by means of direct absorbable suture placement at the site of injury without aponeurotic or tendinous augmentations. Lateral release was also performed in all except four knees

7 Knees not dislocatable

Only lateral release done

 After care was same in non-operative and operative grp

Those dislocatable under EUA, managed with removable knee extension orthosis x 3/52 then patella-stabilizing orthosis for 3/52 Those not dislocatable, patella-stabilizing orthosis for 6/52

Thigh muscle exercise and FWB started as tolerated All pts encourage to use orthosis during rehab session and athletic act for 1st 6/12

Follow-up
All pts were
examined after 2 years Interviewed by telephone at 6 years Final phone interview after 14 years

Each follow up, assessed on

Subjective result(excellent,good,fair,poor) Hx of sublux Time of recurrence Hx of reoperation Change in activity level Repeat patella dislocation

Outcomes were evaluated with the Hughston visual analog scale knee score , the Kujala score, and a subjective grade The activity level was analyzed with use of the Tegner activity scale

Results

Subjective result
After fourteen years, a good or excellent subjective result was recorded
for 21 (75%) of twenty-eight knees that had been randomized to the nonoperative treatment group twenty-one (66%) of thirty-two knees that had been randomized to the operative treatment group

Positive correlation between the final subjective result and the Hughston visual analog scale (p < 0.001) and Kujala scores ( p < 0.001).