CURRENT PRACTICE TRENDS IN THE SURGICAL MANAGEMENT OF PATELLOFEMORAL INSTABILITY; A SURVEY OF THE PEDIATRIC RESEARCH IN SPORTS MEDICINE (PRiSM) SOCIETY

Abstract

Background: Patellofemoral instability in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. Surgical options and treatments are heterogeneous among orthopaedic surgeons. The purpose of this study is to survey members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding their practice and treatment for patellofemoral instability and to identify trends in management of patellofemoral instability in children and adolescents nationwide. Methods: A 27-question multiple choice online survey was distributed to the members of the PRiSM Society. The survey was sent via email 3 times over a six week time span after which time the survey was closed. Members were asked about clinical and imaging evaluation, methods of conservative treatment, surgical indications, and surgical techniques when treating patellofemoral instability. Results: 65/70 (93%) of respondents reported performing surgery for patella instability more than 5 times in the past year. Of these 65, 56 respondents completed the questionnaire in its entirety. While some trends regarding treatment emerged, the respondent data demonstrated the large discrepancies in practice patterns that exist nationwide. 48% (27/56) of respondents obtained an MRI for patients with a 1+ knee effusion or greater on exam within one week after a first-time traumatic patellar dislocation while 20% (11/56) obtain an MRI in all patients presenting with a patella dislocation. To assess skeletal maturity, 75% (42/56) of respondents obtained knee x-rays to evaluate the physes around the knee, whereas 53% (30/56) obtained a hand x-ray to assess bone age. 41% (23/56) of respondents reported that surgical intervention for fragment refixation or loose body removal is indicated anytime there is evidence of a loose body or osteochondral fragment regardless of fragment size. 11% (6/56) reported only performing osteochondral fracture repair when the fragment was large enough to repair. If surgery is performed for an osteochondral loose body, 38% (21/56) of respondents performed an MPFL reconstruction. 59% (33/56) reported performing the MPFL reconstruction in children and adolescent athletes with hamstring allograft, while 30% (17/56) prefer autograft (hamstring, quadriceps). MRI was strongly preferred over CT when considering a tibial tubercle anteromedialization. TT-TG distance is the diagnostic measurement of choice with no respondents selecting TT-PCL as their preferred diagnostic measurement. The indication for surgical correction of angular deformity in the setting of patellar instability had mixed responses. 18% (10/56) would indicate surgery when the mechanical axis is lateral to the center of the lateral femoral condyle, while others considered this angular correction only when the patient is skeletally immature or when the mechanical axis is lateral to the lateral tibial spine. For surgical recommendations in a patient with significant trochlear dysplasia, 46% (26/56) reported no surgical management of trochlear dysplasia in first-time surgery while 41% (23/56) reported no surgical management of trochlear dysplasia in first-time or revision surgery. Conclusion: There was significant heterogeneity among respondents that highlights a lack of consensus regarding optimal diagnostic and treatment algorithms. Understanding management trends nationwide may help practicing surgeons gain insights and develop evidence based treatment algorithms to best serve patients with this condition.