What is the recommended management for a first-time patellar dislocation, according to the Journal of Shoulder and Elbow Surgery (JSES)?

Management of First-Time Patellar Dislocation

Conservative management is recommended for most first-time patellar dislocations, except in specific circumstances that require surgical intervention.

Initial Evaluation

• Imaging:
  • Anteroposterior and lateral knee radiographs as initial imaging
  • Consider adding patellofemoral view to better evaluate patellar position and potential fractures 1
  • MRI indicated when suspecting:
    • Osteochondral fracture
    • Substantial disruption of medial patellar stabilizers
    • Associated internal derangement 1

Treatment Algorithm

Conservative Management (First-Line)

Conservative treatment is the standard approach for most first-time dislocations 2, consisting of:

1. Acute Phase (0-2 weeks):

   • Pain control with NSAIDs (naproxen 500mg twice daily or ibuprofen 1.2-2.4g daily) 1
   • Protected range of motion
   • Immobilization with brace or splint (avoid >4 weeks to prevent quadriceps atrophy) 1
   • Cryotherapy for acute pain relief

2. Early Rehabilitation (2-4 weeks):

   • Early strengthening exercises
   • Progressive range of motion
   • Avoid activities that cause pain

3. Intermediate Rehabilitation (4-8 weeks):

   • Progressive strengthening exercises
   • Eccentric training
   • Focus on quadriceps strengthening

4. Advanced Rehabilitation (8-12 weeks):

   • Occupation-specific training
   • Functional exercises
   • Gradual return to activities 1

Indications for Primary Surgical Intervention

Surgery is indicated in the following scenarios 2:

• Presence of osteochondral fracture
• Substantial disruption of the medial patellar stabilizers
• Laterally subluxated patella with normal alignment of the contralateral knee
• Large loose bodies requiring removal

Surgical Options

When surgery is indicated, options include:

• Medial patellofemoral ligament (MPFL) repair or reconstruction
• Removal of loose bodies
• Fixation of osteochondral fragments
• Tibial tubercle osteotomy (for lateralized tibial tubercle or patella alta) 3

Risk Factors for Recurrence

Factors associated with higher risk of recurrent dislocation include:

• Age under 25 years
• Female gender
• Trochlear dysplasia
• Patella alta
• Increased tibial tuberosity-trochlear groove (TT-TG) distance
• Generalized ligamentous laxity 1, 4

Follow-up Protocol

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

  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 1

• Return to full activity permitted when:

  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side
  • Successful completion of occupation-specific functional tests 1

Common Pitfalls to Avoid

1. Prolonged immobilization: Avoid immobilization beyond 4 weeks as it leads to quadriceps atrophy and worse outcomes 1

2. Delayed referral: Consider specialist referral if no improvement after 6-8 weeks of conservative treatment 1

3. Missed associated injuries: Thoroughly evaluate for osteochondral fractures and MPFL tears that may require surgical intervention 4

4. Inadequate rehabilitation: Insufficient strengthening increases risk of recurrence 1

5. Overlooking anatomic risk factors: In patients with significant anatomic risk factors, recurrence is more likely even with appropriate conservative management 5