What is the treatment for patellar dislocation?

Treatment for Patellar Dislocation

The treatment for patellar dislocation should initially be non-operative management for first-time dislocations, with surgery reserved for specific circumstances such as osteochondral fractures, substantial disruption of medial patellar stabilizers, or recurrent dislocations. 1, 2

Initial Assessment and Imaging

• Radiographs: Should be the first imaging study for acute knee trauma with suspected patellar dislocation

  • Minimum of anteroposterior and lateral views
  • Additional patellofemoral view to evaluate for patellar fractures and/or subluxation 3

• MRI: Recommended for comprehensive evaluation after radiographs when patellar dislocation is suspected

  • Identifies typical injury patterns: MPFL tears, bone bruises on patella and lateral femoral condyle
  • Evaluates for osteochondral fractures and additional soft tissue injuries
  • Assesses risk factors for recurrent dislocations (trochlear dysplasia, patella alta) 3, 4

Non-operative Management (First-line Treatment)

Acute Phase (0-4 weeks)

1. Immobilization:

   • Neoprene nonhinged knee brace is preferred over motion-restricting braces
   • Motion-restricting braces lead to more quadriceps atrophy and worse early functional outcomes 5
   • Brace should be worn continuously for approximately 4 weeks

2. Pain Management:

   • NSAIDs for short-term pain relief
   • Ice application to reduce swelling and pain 6

3. Protected Range of Motion:

   • Gentle range-of-motion exercises to prevent stiffness
   • Avoid activities that risk redislocation 6

Intermediate Phase (4-8 weeks)

1. Progressive Strengthening:

   • Focus on quadriceps strengthening exercises
   • Emphasis on vastus medialis oblique (VMO) strengthening 3, 6

2. Patellar Taping:

   • Medial taping can provide short-term pain relief and functional improvement
   • Most effective when compared to no taping rather than sham taping 3

Advanced Phase (8-12 weeks)

1. Functional Exercises:

   • Sport-specific or occupation-specific training
   • Gradual return to activities 6

2. Return to Activity Criteria:

   • Complete resolution of pain
   • Full range of motion
   • Strength symmetry >90% compared to uninjured side
   • Successful completion of functional tests 6

Surgical Management

Indications for Surgery

Surgery should be considered in the following circumstances:

1. Presence of osteochondral fracture
2. Substantial disruption of the medial patellar stabilizers
3. Laterally subluxated patella with normal alignment of contralateral knee
4. Second or recurrent dislocation
5. Failure to improve with appropriate rehabilitation 1, 2

Surgical Options

1. MPFL Reconstruction: Primary procedure for restoring medial patellar stability
2. Trochleoplasty: For significant trochlear dysplasia
3. Tibial Tuberosity Medialization: For lateralized tibial tuberosity
4. Medial Capsular Plication: To tighten the medial restraints 4

Outcomes and Prognosis

• Recurrence Rate: Up to 40% of patients with first-time dislocations may experience recurrent dislocations 1
• Surgical vs. Non-surgical: Evidence comparing surgical vs. non-surgical management shows uncertain benefits due to very low certainty of evidence 1
• Long-term Concerns: Recurrent dislocations can lead to patellofemoral arthritis, chronic pain, and decreased activity levels 7

Follow-up Recommendations

• Regular assessment at 2,6, and 12 weeks to evaluate:

  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 6

• Consider MRI or additional imaging for persistent symptoms or suspected complications 3

Common Pitfalls to Avoid

1. Prolonged Immobilization: Leads to quadriceps atrophy and worse functional outcomes
2. Neglecting Risk Factor Assessment: Failure to identify anatomic risk factors for recurrence
3. Delayed Treatment of Osteochondral Injuries: Can lead to long-term joint damage
4. Inadequate Rehabilitation: Insufficient strengthening of quadriceps and hip muscles
5. Missing Associated Injuries: Meniscal tears or other ligament injuries may accompany patellar dislocations

By following this structured approach to treatment, patients with patellar dislocation can achieve optimal outcomes with minimized risk of recurrence and long-term complications.