REVIEW ARTICLE
First-Time Patellar Dislocation: Surgery
or Conservative Treatment?
Petri J. Sillanpaa, MD, PhD and Heikki M. Maenpaa, MD, PhD
Abstract: Primary patellar dislocation injures the medial patellofe-
moral ligament (MPFL), the major soft-tissue stabilizer of the pa-
tella, which may lead to recurrent patellar instability. Recurrent
patellar dislocation are common and may require surgical inter-
vention. The variation in location of injury of the MPFL and the
presence of an osteochondral fracture produces challenges in clinical
decision making between nonoperative and operative treatment, in-
cluding the surgical modality, to repair or reconstruct the MPFL.
Current evidence suggests that not all primary dislocations should
undergo the same treatment. MPFL reconstruction may theoretically
be more reliable than repair, but the optimal time to perform addi-
tional bony corrections is not known. A normal or minor dysplastic
patellofemoral joint may be suitable for nonoperative treatment,
whereas a higher grade of trochlear dysplasia or other signicant
abnormalities may benet from surgical treatment. In this paper, we
present a treatment algorithm for primary patellar dislocation.
Key Words: patella, medial patellofemoral ligament, dislocation,
injury, knee, magnetic resonance imaging
(Sports Med Arthrosc Rev 2012;20:128135)
F irst-time (primary) patellar dislocation commonly occurs
in the young physically active population1 and is asso-
ciated with a high rate of recurrent patellar instability. De-
pending on the patient cohort, 44% to 70% patients sustain
recurrent dislocations.24 With a complete dislocation of the
patella, the primary stabilizer, the medial patellofemoral
ligament (MPFL), is frequently torn. A total or partial
MPFL disruption can be observed by magnetic resonance
imaging (MRI).5,6 Biomechanical studies79 reveal that the
MPFL is the major ligamentous restraint against lateral
patellar dislocation. The MPFL extends from the medial
margin of the patella and attaches rmly to the femur be-
tween the adductor tubercle and the medial epicondyle.10,11
The MPFL is estimated to contribute 50% to 60% of the
restraining force against lateral patellar displacement.79
Patellar dislocation and MPFL injury can be diagnosed
using MRI.5,6,12 A variable amount of anatomic abnor-
malities may be involved in patients with primary patellar
dislocation.13 Primary dislocation might thus be related to
trochlear dysplasia, patella alta, or malalignment, whereas
primary dislocation can occur in a normal patellofemoral
joint if extensive external forces twist or rotate the knee in
certain way.1 Primary patellar dislocations quite often in-
volve an osteochondral fracture that may require surgical
xation.2,14 Therefore the signicant variation in the injury
From the Department of Orthopaedic Surgery, Tampere University
Hospital, Tampere, Finland.
Disclosure: The authors declare no conict of interest.
Reprints: Petri J. Sillanpaa, MD, PhD, Department of Orthopaedic
Surgery, Tampere University Hospital, Teiskontie 35, Tampere
33521, Finland.
Copyright r 2012 by Lippincott Williams & Wilkins
128 | www.sportsmedarthro.com Sports Med Arthrosc Rev
pattern and other associated factors such as alignment, dys-
plasia, and osteochondral injury can make treatment chal-
lenging. The majority of primary dislocations can be managed
nonsurgically, although occasionally surgery is warranted and
a thorough evaluation of each case is required.15 The optimal
strategy is not yet established.
The aim of this paper is to review the evidence in the
treatment of primary patellar dislocation. Surgical techni-
ques for acute MPFL injuries and additional injuries are
also discussed. A treatment algorithm for primary patellar
dislocation, based on the evidence from current literature, is
presented.
ETIOLOGY AND RISK FACTORS FOR PRIMARY
DISLOCATION
When the patella dislocates laterally, the medial pa-
tellar restraints are injured, particularly the MPFL.1,9,16
The patella may spontaneously relocate back to the femoral
trochlear groove. The force required to dislocate the patella
most likely depends on the individual patellofemoral mor-
phology. When the femur rotates internally and the tibia
externally, with the foot xed on the ground, the patella
may dislocate without any pathologic structures in the pa-
tellofemoral joint.1,17 Quite often, however, patellar dis-
location occurs in a knee that has predisposing anatomic
features for patellar instability. These include trochlear
dysplasia, patella alta, increased femoral antetorsion, in-
creased external tibial torsion, and valgus alignment of the
lower limb.13 Rarely, ligamentous laxity can be present.
The incidence of primary patellar dislocation is re-
ported to range from 6 to 112 per 100,000 persons de-
pending on the age of the population.1,16,1820 In a study of
military conscripts, the calculated incidence of acute trau-
matic primary patellar dislocation was 77.4 per 100,000
persons per year; in females 104.6 per 100,000 persons per
year.1 In that study, 63% of the injuries occurred during
sports activities and 37% occurred during military training,
indicating that injury was related to physical activity. The
mechanism of injury is reported to be knee valgus stress and
internal rotation of the femur with the foot xed on the
ground.1,16,17,21 The risk factors for primary patellar
dislocation are tall height and excess weight (Table 1).1
The risk factors for recurrent patellar instability are well
described and include anatomic predisposing factors;
trochlear dysplasia, patella alta, variations of limb
alignment, connective tissue laxity, and insuciency of
previously injured medial restraints.3,13,22
DIAGNOSIS OF PRIMARY PATELLAR
DISLOCATION
Patellar dislocation is usually diagnosed on the basis of
the clinical ndings and the patient may describe kneecap
was out of place. Clinical ndings include tenderness of the
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Sports Med Arthrosc Rev  Volume 20, Number 3, September 2012 First-Time Patellar Dislocation

plain radiographs are always needed to evaluate patellar

TABLE 1. Risk Factors for Acute Traumatic Primary Patellar position and assess osteochondral fractures. Sagittal and
Dislocations Among Military Conscripts (Median and SD)
anteroposterior views with axial Merchant view are essen-
Acute Traumatic Healthy tial.24 Axial views are particularly important, and both
Primary Patellar Controls patellae should be included in this view. The patella may be
Risk Factors Dislocation (n = 75) (n = 130,421) P lateralized if compared with the contralateral side (Fig. 1),
Sex and fragmentation of the medial patella, a defect of the
Male 73 128,642 0.283 patellar articular surface, or a loose osteochondral frag-
Female 2 1992 ment may be observed (Fig. 2). MRI is recommended to
Age (y) 19.8 (0.8) 20.0 (1.3) 0.287 assess the cartilage more precisely.25 MPFL injury location
Height (cm) 180.3 (7.2) 178.5 (6.7) 0.031* can be assessed reliably by MRI.6 MPFL injuries are clas-
Weight (kg) 77.2 (4.3) 73.2 (12.7) 0.014* sied in 3 categories based on location: at the level of the
Muscle 16.4 (3.5) 16.4 (3.6) 0.960 MPFL patellar insertion, at the midsubstance of the MPFL
strength
Run test (m) 2500 (371) 2520 (355) 0.703
and medial retinaculum, and at the femoral origin of the
Body mass 23.7 (3.8) 22.9 (3.5) 0.105 MPFL (Table 2).6,12 Therefore, MRI is recommended in
index cases of primary dislocation to verify the diagnosis, evaluate
additional injuries, and, importantly, describe the anatomic
*Considered signicant with P-value <0.05. factors of the patellofemoral joint.6,2630 Because of the
Reprinted with permission of Wolters Kluwer Health Sillanpaa et al.1
high prevalence of osteochondral fractures, MRI should be
performed quite soon after the injury.
medial restraints. A medial hematoma may be observed.
The patella may be lateralized, and an apprehension test
positive. The knee is acutely swollen and hemarthrosis can
REVIEW OF THE CURRENT CLINICAL EVIDENCE
be aspirated for pain relief. The patella is usually sponta- A recent Cochrane Review concluded that there was
neously reduced, and is quite rarely still dislocated when the insucient evidence to conrm a signicant dierence in the
patient arrives at the hospital. Children and adults may have outcome between surgical or nonsurgical initial manage-
quite dierent symptoms. Children can have a relatively ment in those who have sustained a primary patellar dislo-
atraumatic dislocation with slight or no eusion, indicating cation.4 A meta-analysis regarding nonsurgical and surgical
dysplasia in the patellofemoral joint, which allows the pa- care of acute primary patellar dislocation concluded that
tella to dislocate without extensive soft-tissue damage. The surgery was not better than nonsurgical treatment.3 Below,
primary dislocation can then be an atraumatic primary dis- we discuss prospective studies that include primary patellar
location, because of patellofemoral joint laxity. This sit- dislocation and factors aecting clinical decision making
uation is nearly impossible in mature skeletons. In adults between surgical and nonsurgical treatment.5,21,23,31
who sustain a primary dislocation without prior knee com- Generally, prospective studies report variable results
plaints, soft-tissue damage and medial restraint injury with after surgical treatment for patellar dislocation.3 Studies
acute hemarthrosis occur.1,2,23 Additional injuries such as initiated >10 years ago mainly utilized surgical techniques
osteochondral fractures are more frequent in traumatic pri- that were nonanatomic and are no longer used.5,21,23 There-
mary dislocations.2,14 Traumatic dislocation means a twist- fore, those results are considered less reliable than modern
ing, bending, rotating, or valgusing movement of the lower surgical techniques. MPFL repair by sutures is not better
limb, and that tissue damage has occurred. Both conditions, than nonsurgical treatment, and does not decrease recurrent
atraumatic dislocation in young children and traumatic dis- instability rate in skeletally immature children and do not
location in young adults, can sometimes be dicult to di- improve subjective results in adults.5,21,23 Acute arthro-
agnose, because of the lack of clinical ndings or painfully scopic MPFL repair is also not superior to nonsurgical
swollen knee. Radiographs are therefore always needed to management.12 Arthroscopic repair is likely an insucient
conrm the diagnosis. method to approach the MPFL injury locations. Delayed
repair is usually not targeted to the previous injury location
and is therefore not useful.3234
IMAGING Two prospective randomized studies described better
Imaging of the patellofemoral joint is described more patellar stability after MPFL repair compared with conser-
thoroughly in another chapter in this issue. Primary patellar vative treatment.5,31 However, only 1 study described clin-
dislocation has certain important signs that aect decision ically signicant improvement in subjective outcome.31 An
making between surgical and nonsurgical methods. First, older study included a suture repair technique5 and a recent

FIGURE 1. Axial Merchant radiographic view after primary patellar dislocation. Right side (R) has been dislocated and the patella is
abnormally lateralized. Left side (L) is normal.

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Sillanpaa and Maenpaa Sports Med Arthrosc Rev
FIGURE 2. Medial osteochondral avulsion fracture with articular
surface involvement (at the patellar insertion of the medial pa-
tellofemoral ligament). Axial proton-density magnetic resonance
image.
study included MPFL reinsertion with anchors,31 showing
more favorable results with surgical treatment. The more
recent the prospective randomized study, the more favor-
able the result toward operative treatment. All of the pro-
spective randomized studies utilized dierent kinds of
MPFL repair.5,21,23,31,33 To date, no study has compared
MPFL reconstruction to nonoperative treatment in a pro-
spective and randomized study setting.
The clinical importance of an MPFL injury location
was evaluated in 1 study.28 In that study, MPFL disruption
at the femoral attachment was related to more frequent
subsequent instability than patellar or midsubstance MPFL
injuries.28 The study is limited by its retrospective nature
and the use of only male subjects. MPFL patellar attach-
ment injury was recently reported to be at least as common
as femoral attachment injury.6,27,29,30 Midsubstance MPFL
disruption as an independent injury location is less com-
mon.6,28 Partial tears or wavy features of the midsubstance
MPFL structure are commonly seen in cases of patellar or
femoral attachment MPFL disruption.6,30 Patellar MPFL
injury may include an osteochondral avulsion fracture, in
which the MPFL structure is relatively intact and attached
to the avulsed bone from the medial margin of the patella.30
In some cases, articular cartilage involvement is seen14
TABLE 2. Classification on MPFL Injuries Based on Injury Location and Reported Incidence in the Literature6,2630
MPFL Injury Anatomic
Classication Description
Patellar MPFL patellar attachment
Midsubstance MPFL midsubstance (region between patellar
and femoral attachments)
Femoral MPFL femoral attachment
MPFL indicates medial patellofemoral ligament.
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 Volume 20, Number 3, September 2012
(Fig. 2). On the basis of these previous ndings, MPFL
repair may be considered more unreliable than MPFL re-
construction, in terms of providing sucient medial soft-
tissue stability.
Studies of the long-term clinical outcome of primary
patellar dislocation regarding the injury location are limited
to retrospective studies28 and are insucient to prove any
clear benets of certain treatment modalities.
PRINCIPLES OF NONSURGICAL MANAGEMENT
FOR PRIMARY DISLOCATION
Conservative treatment has been historically suggested
for patients with primary patellar dislocation. A short im-
mobilization period is used for patient comfort and is fol-
lowed by formal physiotherapy. A recent systematic review
regarding the clinical outcomes of rehabilitation for patients
after lateral patellar dislocation concluded that no random-
ized controlled clinical trials had been published that as-
sessed dierent physiotherapy interventions.35 Therefore, the
optimal conservative management has yet to be established.
Acute primary patellar dislocation is painful. He-
marthrosis can be aspirated for pain relief, after which
clinical examination is controlled and the patient undergoes
diagnostic imaging studies. There is no clear evidence that
the knee should be immobilized after primary dislocation.
Studies have poorly described the primary and recurrent
nature of the patellar dislocation and the immobilization
period has varied widely between 0 to 6 weeks.5,31,35,36 A
recent report of preliminary results of a prospective ran-
domized study in which immediate mobilization was com-
pared with exion restriction with a patellar brace found no
dierence at 2 years.37 The study is ongoing and will pro-
vide additional information in a few years. A feasibility
study for a pragmatic randomized controlled trial com-
paring cast immobilization versus no immobilization for
patients after rst-time patellar dislocation suggested better
short-term functional result for those not immobilized, but
the reported preliminary sample was too small to make any
conclusions.38
The aims of physiotherapy are to restore knee range of
motion, and to strengthen the quadriceps muscles to restore
the dynamic part of the patellar soft-tissue stabilizers.39
Patients should be encouraged to activate the quadriceps as
tolerated by pain and after a few weeks, strenuous exercises
should be started aimed at normalizing quadriceps strength
and control. At 4 to 6 weeks, by which point walking and
knee range of motion have been normalized, exercises con-
tinue with more extensive extension raises, proprioceptive
activities, and core stability training. Return to full activity
can be suggested at 3 months. Avoiding chronic muscle
weakness and imbalance is the main rehabilitation goal.
Proportion in Primary Mean Reported
Dislocations Incidence (%)
13%-76% 54
0%-30% 12
12%-66% 34
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A variety of dierent clinical outcomes have been re-

ported in patients after physiotherapy management after a
lateral patellar dislocation.35 The results are discussed more
thoroughly in another chapter in this issue.
In conclusion, because of the lack of clinical evidence,
it is not possible to determine the optimal nonsurgical sche-
ma after primary patellar dislocation. Most likely physi-
otherapy treatments are recommended for patients after
primary patellar dislocation, because quadriceps control and
strength can be compromised, thereby aecting long-term
clinical outcome. No evidence is available as to whether
quadriceps weakness and especially vastus medialis oblique
(VMO) muscle inactivity are an acquired clinical situation
after primary patellar dislocation or present before the in-
jury.40 Because of the nature of the primary dislocation,
which is usually a sport-related injury or related to other
physical activities,1,16 muscle weaknesses or imbalances are
perhaps subsequent side eects of the injury resulting from
medial capsular disruption, potential neural injuries, and loss
of proprioceptive control.

SURGICAL OPTIONS FOR PRIMARY

DISLOCATION
As described earlier, in primary patellar dislocation,
MPFL injury location can be diagnosed by MRI.6 Secon-
dary dislocation may not have a clear MPFL disruption
due to prior MPFL laxity, and MRI is less useful in sec-
ondary dislocations if surgery is not planned. MPFL injury
location should not be assessed surgically because it re-
quires a large incision and involves dissecting the medial
capsular structures including VMO fascia, which can
potentially produce comorbidity to muscle function and
saphenous nerve branches.10,7,9
In primary patellar dislocation, the MPFL is the in-
jured part of the patellar stability complex, whereas limb
alignment and patellofemoral joint morphology are in-
dividual persistent factors. Theoretically, repair of the in-
jured part of this complex structure should be the primary
surgical option. Surgical stabilization of the patella can be
performed with MPFL repair or reconstruction. Surgical
repair can be performed if the injury location is known.28
Some patients, however, may have remarkable underlying
pathology that critically aects patellar stability, although
there is no evidence available when osseous abnormalities
should be addressed in addition to restoring the MPFL.
Additional procedures involving osseous anatomy should
be selected on an individual basis and are generally not
considered necessary as a rst-line treatment after primary
patellar dislocation.
MPFL patellar or femoral attachment injury can be
surgically reinserted with satisfying results and may lead to a
better outcome than nonsurgical treatment,31 although
some controversy exists in the results of prospective stud-
ies.5,21,23,33 MPFL midsubstance injuries seem to not benet
from acute repairs.28 MPFL injury at the femoral or patellar
attachment can be repaired with sutures or suture anchors
(Fig. 3).31 Midsubstance MPFL injury is dicult to repair
adequately and is not recommended.5,21 Midsubstance
MPFL injury should be repaired only in rare cases with
extensive VMO fascial disruption in a high-energy dis-
location (Fig. 4). In such cases, the VMO detaches from the
medial patellar capsule (Fig. 4), and the quadriceps pull
vector may be signicantly lateralized, therefore the patella
dislocates in extension when the quadriceps is activated.
FIGURE 3. Medial patellofemoral ligament injury at the femoral
or patellar attachment is repaired with suture anchors.
Patellar attachment MPFL injury can be classied as a
ligamentous or bony avulsion from the medial margin of the
patella.28 A third type includes an osteochondral fragment
with articular cartilage involvement from the medial patella
(Fig. 2). According to a retrospective study, ligamentous
patellar MPFL avulsion is not associated with an increased
rate of recurrent instability compared with femoral MPFL
avulsion injury with similar nonsurgical management.28
Articular cartilage involvement can be considered an in-
dication for surgery, and cartilage defects should be repaired
by reduction and xation of the fragment (Fig. 5).14,15 In
particular, fractures located in a high-pressure area, central
or lateral patellar cartilage, or lateral trochlear wall, should
be repaired if possible. A fragment size >510 mm can be
xated, and based on the experience of the authors, large
fragments heal well if xation is performed within 1 week of
the injury. Fixation is performed with bioabsorbable nails,
pins, small screws, or sutures. Small osteochondral fractures
can be managed nonsurgically, especially in cases when the
fracture is located in a low-pressure area, the distal lateral
margin in the lateral condyle of the femur, which normally
does not carry weight or articulate with the patella. In such
cases, a small fracture may be arthroscopically removed if it
acts as a loose body and produces symptoms.28 Symptoms
usually persist >4 weeks in cases of loose body formation

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Sillanpaa and Maenpaa
FIGURE 4. Extensive, combined medial patellofemoral ligament
patellar attachment (small arrow) and midsubstance injury with
vastus medial oblique muscular detachment (large arrow) from
the medial patellar capsule. Only skin and subcutaneous have
been incised before photography. All parts of the medial stabi-
lizing structures of the patella (P) have been injured and the
patella does not stay its place when medial and lateral part of the
quadriceps muscle pulls patella cranially.
and disappear in cases of fracture incorporation with the
synovial tissue, indicating no need for fragment removal.
In some cases, the MPFL may be injured in 2 loca-
tions.6 Most likely, MPFL patellar or femoral attachment
disruption can be accompanied by a midsubstance total or
partial tear. Therefore, MPFL reconstruction may be more
reliable surgical method than MPFL repair. MPFL re-
construction cannot be safely performed at the time of in-
jury if there is a medial patellar margin MPFL avulsion
fracture (Fig. 2).28 MPFL reconstruction requires experi-
ence in patellofemoral surgery and is considered technically
more demanding than repair. MPFL reconstruction pro-
duces good stability in the majority of cases with few
complications, as described in many studies.41 MPFL re-
construction techniques are described in another chapter of
this issue. Current evidence for MPFL repair is, however,
very limited compared with that for MPFL reconstruction.
MPFL repair cannot be performed without MRI ver-
ication of the injury location and repair is inappropriate if
performed later in cases of chronic patellar instability.32
Repair is perhaps best indicated in acute cases with MRI-
veried patellar or femoral attachment MPFL disruption
within a few weeks of the injury. An additional indication
FIGURE 5. Acute osteochondral fracture (size, 10 18 mm) involving the medial facet and central articular surface of the patella (A). The
defect should be repaired by reduction and fixation of the fragment (B).
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Sports Med Arthrosc Rev  Volume 20, Number 3, September 2012
could be an osteochondral fragment from the medial patella
with simultaneous patellar attachment MPFL avulsion
(Fig. 2).
To summarize, if surgical treatment has been chosen,
primary dislocation in adults without any prior knee com-
plaints requires only MPFL reconstruction in most cases.
MPFL repair can be performed at the patellar or femoral
attachment, but may be more unreliable than reconstruction.
Skeletally immature patients and adolescents with primary
dislocation quite often have severe trochlear dysplasia or
alignment abnormalities that may need to be addressed if
surgery is performed after primary dislocation. The vast
majority of the primary dislocations belong to this group. It
might be that repair alone is especially insucient in ana-
tomically abnormal population, based on the high proba-
bility of recurrent patellar instability, which is reported to be
as high as 70%, especially in a very young population.23
A treatment algorithm, based on current evidence in
the literature and the experience of the authors, is shown
in Figure 6.
AFTER MANAGEMENT OF PRIMARY PATELLAR
DISLOCATION
After initial surgical or nonsurgical treatment for pri-
mary patellar dislocation, the knee is usually immobilized for
a short period to relief pain. If MPFL reconstruction is
performed, immobilization is usually not needed. Additional
surgical procedures may require their own specic aftercare,
which are discussed in other chapters of this issue. During
the rst few weeks to 3 months, patients undergo physi-
otherapy to recover any muscle atrophy or joint range of
motion restrictions related to the injury. Patients are then
encouraged to return to physical activity after 3 months and
to sports when quadriceps strength and proprioceptive con-
trol are regained. The return to preinjury levels of physical
activity vary between 44% to 60% after primary patellar
dislocation, regardless of treatment modality.5,12,28,35
RECURRENT DISLOCATIONS
After primary dislocation, patients tend to have a
2-year period before the risk of recurrence increases.23 This
may be partly because of the inability to participate in
physical activities for a long time after injury. Many studies
have assessed the frequency of recurrent patellar dislocation
after primary dislocation. The ndings indicate that 33%
(range, 6% to 100%) of patients experience patellar in-
stability after primary dislocation.4,22 Reoperation rate
after primary dislocation varies between 10% and 55%.4
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Sports Med Arthrosc Rev  Volume 20, Number 3, September 2012 First-Time Patellar Dislocation

Primary (First-time)
Patellar Dislocation

Clinical examination
and radiographs,
including axial view

No fractures, patella No fractures, patella

highly unstable, pops is stable enabling Osteochondral
out of it place in active knee extension fracture
extension or flexion and flexion

Immobilization, MRI
Short immobilization
and operative MRI, operative
for patient comfort,
treatment (MPFL treatment, fixation of
MRI within 2 weeks,
reconstruction and the fragment and
assessment of MPFL
individual additional MPFL reinsertion or
injury and additional
procedures, if severe reconstruction
injuries
abnormalities)

MPFL
MPFL
MPFL disruption at midsubstance
disruption at femoral
patellar attachment disruption or partial
attachment
MPFL injury

MPFL patellar
MPFL patellar Nonoperative
insertion disruption Nonoperative
insertion bony treatment if no severe
without articular treatment with
avulsion with dysplasia
cartilage physiotherapy
articular cartilage Operative treatment
involvement, initiated as tolerated
involvement, (individual) if severe
nonoperative by pain
operative treatment abnormalities
treatment

FIGURE 6. A treatment algorithm for primary patellar dislocation. MPFL indicates medial patellofemoral ligament; MRI, magnetic
resonance imaging.

Recurrent dislocations are exceptionally common in skel- DISCUSSION

etally immature patients, as reported by Palmu et al23 and Primary patellar dislocation leads to MPFL injury.
Nikku et al21 (study included, but was not restricted to, Some studies advocate surgical management for primary
children), that 70% of their cohort presented with recurrent patellar dislocation whereas others recommend nonsurgical
patellar instability after rehabilitation. treatment.21,23,31 Because of the insucient amount of

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Sillanpaa and Maenpaa Sports Med Arthrosc Rev
evidence in the literature, there is currently no universally
accepted, optimal strategy for primary patellar dislocation
available.4 The complexity of patellar instability leads to
challenges in decision making between dierent treatment
modalities. Most cases are suitable for initial nonsurgical
management with physiotherapy, although recurrent insta-
bility is very common.4 Osteochondral fragments amenable
for surgical xation are an indication for surgery, and
MPFL reconstruction may be a more reliable method of
stabilizing the patella than MPFL repair, which has limi-
tations related to the MPFL injury location. Osseous sur-
gery is usually not needed if surgery is planned after primary
dislocation, but corrections are needed in cases with severe
bony abnormalities.
The MPFL injury location can be reliably assessed by
MRI.6 Several recent studies advocate MRI after acute
patellar dislocation,2,5,28 as the acutely injured knee usually
shows hemarthrosis as a sign of tissue damage and clinical
diagnosis can sometimes be dicult. MRI can be used to
diagnose the signs of acute patellar dislocation and asso-
ciated injuries, such as osteochondral fractures and me-
niscal or ligament injuries.6 Previous randomized studies of
primary patellar dislocations concluded that surgery is not
superior to nonsurgical treatment if all the patients with
dierent types of MPFL injuries are treated similarly.5,21,23
In contrast, a recent prospective randomized study in which
nonsurgical treatment was compared with surgical re-
insertion in either femoral or patellar attachment, surgery
resulted in better stability than nonoperative treatment.31
Because of the high, 44% to 70%, redislocation rate after
primary dislocation4 some cases might benet from initial
surgery, and surgery should denitely be considered for
cases with a high risk of failure after nonsurgical treatment.
Patients with patellar MPFL avulsion fracture and femoral
attachment MPFL disruption may be at greater risk of
subsequent dislocation.28 In these patients, restoring the
integrity of the MPFL might be necessary to ensure better
stability. Ruptures at the MPFL midsubstance or patellar
insertion regions are generally not related to signicant
subsequent patellar instability.28 We therefore suggest that
rupture of the MPFL at its midsubstance or near the pa-
tellar attachment should be treated nonsurgically.
The clinical outcome of various MPFL injuries, however,
remains highly uncertain with regard to the well-known
factors that predispose a patient to patellar instability, such
as trochlear dysplasia, axial and torsional lower-limb
alignment abnormalities, and MPFL injuries.13,22,42 Most
likely, the more dysplastic the trochlear shape, the more
devastating the injury to the MPFL is to patellar stability.
Surgical treatment needs to be tailored individually, based
on the MRI ndings of the MPFL injury and osseous
anatomy, although nonoperative treatment is still preferred
in most cases.
In conclusion, primary patellar dislocation leads to
MPFL injury. MPFL injuries can occur in dierent loca-
tions and may be combined with an osteochondral avulsion
fracture of the medial patellar margin or an impact fracture,
which should be treated with initial xation of the fragment.
MRI is recommended for assessment of the MPFL injury
and the exclusion of additional injuries. Current evidence
supports nonoperative management for primary patellar
dislocation in majority of the cases. Surgery should prob-
ably be considered for MPFL patellar or femoral attach-
ment disruptions in cases with 1 or more dysplastic features,
especially if patella is highly unstable after dislocation. In
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 Volume 20, Number 3, September 2012
some cases, osseous corrections may be needed, but the
majority will stabilize with MPFL reconstruction alone.
Because of the complex nature of patellar instability, treat-
ment of primary patellar dislocation is challenging. The
optimal treatment has not yet been established and further
prospective randomized studies are required.
REFERENCES
1. Sillanpaa P, Mattila VM, Iivonen T, et al. Incidence and risk
factors of acute traumatic primary patellar dislocation. Med
Sci Sports Exerc. 2008;40:606611.
2. Stefancin JJ, Parker RD. First-time traumatic patellar
dislocation: a systematic review. Clin Orthop Relat Res. 2007;
455:93101.
3. Smith TO, Song F, Donell ST, et al. Operative versus non-
operative management of patellar dislocation. A meta-analysis.
Knee Surg Sports Traumatol Arthrosc. 2011;19:988998.
4. Hing CB, Smith TO, Donell S, et al. Surgical versus non-
surgical interventions for treating patellar dislocation. Cochrane
Database Syst Rev. 2011;11CD008106.
5. Sillanpaa PJ, Mattila VM, Maenpaa H, et al. Treatment with
and without initial stabilizing surgery for primary traumatic
patellar dislocation. A prospective randomized study. J Bone
Joint Surg Am. 2009;91:263273.
6. Elias DA, White LM, Fithian DC. Acute lateral patellar
dislocation at MR imaging: injury patterns of medial patellar
soft-tissue restraints and osteochondral injuries of the infer-
omedial patella. Radiology. 2002;225:736743.
7. Conlan T, Garth WP Jr, Lemons JE. Evaluation of the medial
soft-tissue restraints of the extensor mechanism of the knee.
J Bone Joint Surg Am. 1993;75:682693.
8. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to
lateral patellar translation in the human knee. Am J Sports
Med. 1998;26:5965.
9. Hautamaa PV, Fithian DC, Kaufman KR, et al. Medial soft
tissue restraints in lateral patellar instability and repair. Clin
Orthop. 1998;174182.
10. LaPrade RF, Engebretsen AH, Ly TV, et al. The anatomy of
the medial part of the knee. J Bone Joint Surg Am. 2007;
89:20002010.
11. Warren LF, Marshall JL. The supporting structures and layers
on the medial side of the knee: an anatomical analysis. J Bone
Joint Surg Am. 1979;61:5662.
12. Sillanpaa PJ, Maenpaa HM, Mattila VM, et al. Arthroscopic
surgery for primary traumatic patellar dislocation: a prospec-
tive, nonrandomized study comparing patients treated with
and without acute arthroscopic stabilization with a median
7-year follow-up. Am J Sports Med. 2008;36:23012309.
13. Dejour H, Walch G, Nove-Josserand L, et al. Factors of
patellar instability: an anatomic radiographic study. Knee Surg
Sports Traumatol Arthrosc. 1994;2:1926.
14. Slabaugh MA, Hess DJ, Bajaj S, et al. Management of
chondral injuries associated with patellar instability. Oper Tech
Sports Med. 2010;18:115122.
15. Mehta VM, Inoue M, Nomura E, et al. An algorithm guiding
the evaluation and treatment of acute primary patellar
dislocations. Sports Med Arthrosc. 2007;15:7881.
16. Colvin AC, West RV. Patellar instability. J Bone Joint Surg
Am. 2008;90:27512762.
17. Nikku R, Nietosvaara Y, Aalto K, et al. The mechanism of
primary patellar dislocation: trauma history of 126 patients.
Acta Orthop. 2009;80:432434.
18. Hsiao M, Owens BD, Burks R, et al. Incidence of acute
traumatic patellar dislocation among active-duty United States
military service members. Am J Sports Med. 2010;38:
19972004.
19. Fithian DC, Paxton EW, Stone ML, et al. Epidemiology and
natural history of acute patellar dislocation. Am J Sports Med.
2004;32:11141121.
r 2012 Lippincott Williams & Wilkins
Sports Med Arthrosc Rev  Volume 20, Number 3, September 2012
20. Nietosvaara Y, Aalto K, Kallio PE. Acute patellar dislocation
in children: incidence and associated osteochondral fractures.
J Pediatr Orthop. 1994;14:513515.
21. Nikku R, Nietosvaara Y, Aalto K, et al. Operative treatment
of primary patellar dislocation does not improve medium-term
outcome: a 7-year follow-up report and risk analysis of 127
randomized patients. Acta Orthop. 2005;76:699704.
22. Maenpaa H, Lehto MU. Patellar dislocation has predisposing
factors. A roentgenographic study on lateral and tangential
views in patients and healthy controls. Knee Surg Sports
Traumatol Arthrosc. 1996;4:212216.
23. Palmu S, Kallio PE, Donell ST, et al. Acute patellar dislocation
in children and adolescents: a randomized clinical trial. J Bone
Joint Surg Am. 2008;90:463470.
24. Merchant AC, Mercer RL, Jacobsen RH, et al. Roentgeno-
graphic analysis of patellofemoral congruence. J Bone Joint
Surg Am. 1974;56:13911396.
25. Smith TO, Drew BT, Toms AP, et al. Accuracy of magnetic
resonance imaging, magnetic resonance arthrography and
computed tomography for the detection of chondral lesions of
the knee. Knee Surg Sports Traumatol Arthrosc. 2012. [Epub
ahead of print]. doi: 10.1007/s00167-012-1905-x.
26. Zaidi A, Babyn P, Astori I, et al. MRI of traumatic patellar
dislocation in children. Pediatr Radiol. 2006;36:11631170.
27. Weber-Spickschen TS, Spang J, Kohn L, et al. The relationship
between trochlear dysplasia and medial patellofemoral liga-
ment rupture location after patellar dislocation: an MRI
evaluation. Knee. 2011;18:185188.
28. Sillanpaa PJ, Peltola E, Mattila VM, et al. Femoral avulsion of
the medial patellofemoral ligament after primary traumatic
patellar dislocation predicts subsequent instability in men:
a mean 7-year nonoperative follow-up study. Am J Sports
Med. 2009;37:15131521.
29. Kepler CK, Bogner EA, Hammoud S, et al. Zone of injury
of the medial patellofemoral ligament after acute patellar
dislocation in children and adolescents. Am J Sports Med.
2011;39:14441449.
30. Guerrero P, Li X, Patel K, et al. Medial patellofemoral
ligament injury patterns and associated pathology in lateral
patella dislocation: an MRI study. Sports Med Arthrosc
Rehabil Ther Technol. 2009;1:17.
31. Camanho GL, Viegas Ade C, Bitar AC, et al. Conservative
versus surgical treatment for repair of the medial patellofemoral
r 2012 Lippincott Williams & Wilkins
First-Time Patellar Dislocation
ligament in acute dislocations of the patella. Arthroscopy.
2009;25:620625.
32. Arendt EA, Moeller A, Agel J. Clinical outcomes of medial
patellofemoral ligament repair in recurrent (chronic) lateral
patella dislocations. Knee Surg Sports Traumatol Arthrosc.
2011;19:19091914.
33. Christiansen SE, Jakobsen BW, Lund B, et al. Isolated repair
of the medial patellofemoral ligament in primary dislocation of
the patella: a prospective randomized study. Arthroscopy.
2008;24:881887.
34. Camp CL, Krych AJ, Dahm DL, et al. Medial patellofemoral
ligament repair for recurrent patellar dislocation. Am J Sports
Med. 2010;38:22482254.
35. Smith TO, Davies L, Chester R, et al. Clinical outcomes of
rehabilitation for patients following lateral patellar dislocation:
a systematic review. Physiotherapy. 2010;96:269281.
36. Maenpaa H, Lehto MU. Patellar dislocation. The long-term
results of nonoperative management in 100 patients. Am J
Sports Med. 1997;25:213217.
37. Maenpaa H, Sillanpaa PJ, Paakkala A. A prospective,
randomized trial following conservative treatment in acute
primary patellar dislocation with special reference to patellar
braces. Knee Surg Sports Traumatol Arthrosc. 2010;18(suppl
1):119.
38. Armstrong BM, Hall M, Crawfurd E, et al. A feasibility study
for a pragmatic randomised controlled trial comparing cast
immobilisation versus no immobilisation for patients following
first-time patellar dislocation. Knee. 2011. [Epub ahead of
print]. doi:10.1016/j.knee.2011.08.004.
39. Greiwe RM, Saifi C, Ahmad CS, et al. Anatomy and
biomechanics of patellar instability. Oper Tech Sports Med.
2010;18:6267.
40. Smith TO, Bowyer D, Dixon J, et al. Can vastus medialis
oblique be preferentially activated? A systematic review of
electromyographic studies. Physiother Theory Pract. 2009;
25:6998.
41. Smith TO, Walker J, Russell N. Outcomes of medial
patellofemoral ligament reconstruction for patellar instability:
a systematic review. Knee Surg Sports Traumatol Arthrosc.
2007;15:13011314.
42. Teitge RA. Patellofemoral syndrome a paradigm for current
surgical strategies. Orthop Clin North Am. 2008;39:287311.
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