What is the best course of treatment for a young, active individual with patellar instability, possibly due to trauma or repetitive knee injuries?

Treatment of Patellar Instability in Young, Active Individuals

For young, active patients with patellar instability, initial conservative management with aggressive rehabilitation is appropriate for first-time dislocations without osteochondral fractures, but surgical intervention—specifically medial patellofemoral ligament (MPFL) reconstruction—should be strongly considered for recurrent instability or when anatomic risk factors are present, as this approach achieves 94-100% stability rates and prevents progression to arthritis. 1, 2, 3

Initial Diagnostic Workup

The diagnostic evaluation must identify both the acute injury pattern and underlying anatomic predispositions:

• Obtain weight-bearing axial radiographs to assess patellar tilt, subluxation degree, trochlear dysplasia, and patellar height (Insall-Salvati ratio). 1
• MRI is mandatory to evaluate for osteochondral fractures (present in 9% of cases), medial patellofemoral ligament (MPFL) tears (injured in 96% of dislocations, typically at femoral attachment), and cartilage lesions. 4, 5
• CT imaging should be obtained when detailed assessment of tibial tubercle-trochlear groove (TT-TG) distance is needed, particularly if surgical planning is anticipated. 1, 4
• Key anatomic risk factors to identify include trochlear dysplasia (present in 81% of cases), increased TT-TG distance (>15mm abnormal, mean 14.66mm in affected patients), patella alta, and abnormal sulcus angle. 5, 2

Treatment Algorithm Based on Clinical Scenario

First-Time Dislocation Without Osteochondral Fracture

Conservative management is recommended when anatomically normal knee structure exists and MRI rules out osteochondral fracture. 4

• Immobilization protocol: Partial immobilization for 6 weeks with progressive weight-bearing. 5
• Aggressive, multidimensional rehabilitation focusing on quadriceps strengthening (particularly vastus medialis obliquus), hip abductor strengthening, and proprioceptive training. 6
• Eccentric exercise programs are specifically recommended to reduce symptoms and increase strength. 7

Critical caveat: Conservative treatment carries a 41.7% recurrence rate, and two-thirds of dislocations occur in patients under 20 years old during sports activities. 5 Close monitoring for recurrence is essential.

First-Time Dislocation With Osteochondral Fracture

Immediate surgical intervention is indicated when osteochondral fractures or free bodies are identified on MRI. 4, 3

• Surgical options include débridement, structural grafting, or cell-based treatment depending on lesion size and symptoms. 3
• MPFL repair or reconstruction should be performed concurrently. 6

Recurrent Patellar Instability

Surgical stabilization is strongly indicated even in young patients with recurrent dislocations, as this prevents further osteochondral injury and progression to arthritis. 5, 3

Surgical Decision-Making Based on Anatomic Factors:

MPFL reconstruction is the foundation of surgical treatment and is effective in many cases, achieving stability in 94.4-100% of patients. 2, 3

• Reconstruction with tendon graft (rather than simple tightening) eliminates recurrence risk entirely compared to 29.6% recurrence with traditional tightening procedures. 5
• The MPFL is the primary stabilizer and is injured as an essential lesion in virtually all patellar dislocations. 6

Add tibial tubercle osteotomy when:

• TT-TG distance is at borderline/abnormal levels (>15mm, present in 55.6% of cases). 5, 2
• Patella alta is present (requires distalization). 3
• This procedure was performed in 61.76% of surgical cases in recent series. 2

Consider trochleoplasty when:

• Severe trochlear dysplasia is present (found in 81% of affected patients). 5, 3
• Both tibial tubercle osteotomy and trochleoplasty are options for this anatomic variant. 3

Lateral release is rarely indicated (only 5.88% of cases) and should not be performed in isolation. 2

Expected Outcomes and Patient Counseling

• Surgical stabilization achieves 94.4% stability with mean IKDC scores of 66.7 and Lysholm scores of 74.9 at 3-year follow-up. 2
• Patient satisfaction rates are variable (77% satisfied), as patients may remain symptomatic despite achieving stability. 2
• Long-term concerns include retropatellar pain and sport-limiting extensor mechanism impairment even after treatment. 6
• Risk of contralateral ACL tear exists in this patient population. 7

Common Pitfalls to Avoid

• Do not rely on conservative management alone when anatomic risk factors are present—this leads to 41.7% recurrence rates. 5
• Avoid simple MPFL tightening procedures in favor of formal reconstruction with tendon graft, as tightening carries high recurrence rates. 5
• Do not perform isolated lateral release—this addresses only one component of a multifactorial problem. 2
• Do not miss osteochondral fractures—these mandate surgical intervention and are present in 9% of cases. 4, 5