First-time Dislocation Research Articles

Is an individually tailored programme of intense leg resistance and dynamic exercise acceptable to adults with an acute lateral patellar dislocation? A feasibility study

BackgroundLateral patellar dislocations mainly affect active teenagers and young adults. To help people recover, non-surgical exercise-based treatment is often recommended but the optimal exercise-based treatment is unknown. Currently, treatment outcomes after this injury are variable. Common problems include recurrent dislocation, reduced activity levels, and later surgery. A programme of intense leg resistance exercises, and dynamic exercises related to participants’ activity-related goals, has rationale, but has not been previously reported. In line with the Medical Research Council guidance, this study aimed to assess the acceptability of a novel evidence-based exercise programme for adults after acute lateral patellar dislocation and the feasibility of future research evaluating this treatment.MethodsA single-group prospective study was conducted at the John Radcliffe Hospital, Oxford, UK. Participants were 16 years or older with an acute first-time or recurrent lateral patellar dislocation. Participants received up to six face-to-face, one-to-one, physiotherapy sessions, over a maximum of 3 months, and performed intensive home exercises independently at least three times per week. Strategies to increase exercise adherence were used. Primary objectives were to determine the number of eligible patients, the recruitment rate (proportion of eligible patients that provided written informed consent), participant adherence to scheduled physiotherapy sessions and self-reported adherence to prescribed exercise, and intervention acceptability to participants measured by attrition and a study-specific questionnaire. Data were analysed using descriptive statistics.ResultsFifteen of 22 (68%) patients with a lateral patellar dislocation were eligible. All eligible (100%) were recruited. Two of 15 (13%) participants provided no outcome data, 2/15 (13%) provided partial outcome data, and 11/15 (73%) provided all outcome data. Questionnaire responses demonstrated high intervention acceptability to participants. Participants attended 56/66 (85%) physiotherapy sessions and 10/11 (91%) participants reported they ‘always’ or ‘often’ completed the prescribed exercise. One participant redislocated their patella; another experienced knee pain or swelling lasting more than one week after home exercise on three occasions.ConclusionThe intervention appeared acceptable to adults after acute lateral patellar dislocation, and a future randomised pilot trial is feasible. This future pilot trial should estimate attrition with increased precision over a longer duration and assess participants’ willingness to be randomised to different treatments across multiple centres.Trial registrationClinicalTrials.govNCT03798483, registered on January 10, 2019

Risk assessment and management of primary patellar dislocation is complex and multifactorial: a survey of Australian knee surgeons

ObjectivesRecurrent patellar instability following first-time lateral patellar dislocation is associated with a variety of bony, soft tissue and patient-related risk factors. The specific management of recurrent dislocation may vary depending on the presence and combination of these factors as well as the treating physician’s interpretation of these. Therefore, this study aimed to determine which factors Australian knee surgeons regard as increasing the risk of recurrence following first-time patellar dislocation and to characterise the surgical decision-making process of these surgeons in the management of lateral patellar instability.MethodsAn online survey was sent to all active members of the Australian Knee Society (AKS). The survey addressed (i) risk factors for recurrence following first-time patellar dislocation and (ii) the surgical decision-making process in treating patellar instability.ResultsSeventy-seven per cent (53 of 69) Australian Knee Society members responded. Factors identified by respondents as significantly increasing the risk of recurrence were a history of contralateral recurrent patellar dislocation (74% respondents), an atraumatic injury mechanism (57%), trochlear dysplasia (49%) younger age (45%), patella alta (43%) and generalised ligamentous laxity (42%). Forty-four per cent replied that there may be an indication for surgical intervention following first-time patellar dislocation with no apparent loose body present. All respondents would recommend operative management of recurrent patellar dislocation after a third episode, with 45% of surgeons recommending surgery after a second episode. The most common surgical procedures performed by respondents were medial patellofemoral ligament (MPFL) reconstruction (94%), tibial tuberosity medialisation (91%) and tibial tuberosity distalisation (85%). Only 23% of respondents consider trochleoplasty for primary surgical intervention.ConclusionSurgeons identified a large number of factors that they use to assess risk of recurrence following first-time patellar dislocation, many of which are not supported by the literature. The two highest ranked factors (history of contralateral recurrent patellar dislocation and an atraumatic injury mechanism) are without a significant evidence base. There was considerable variation in the criteria used to make the decision to perform a patellar stabilisation procedure. MPFL reconstruction was the most commonly used procedure, either in isolation or combined with another procedure.Level of evidenceCross-sectional study; expert opinion (Level V).

Team Approach: Treatment of Shoulder Instability in Athletes.

Shoulder instability is a complex problem with a high rate of recurrence in athletes. Treatment of a first-time subluxation or dislocation event is controversial and depends on patient-specific factors as well as the identified pathology. Athletic trainers and physical therapists are an integral part of the treatment team of an in-season athlete who has experienced a shoulder instability event. Through comprehensive physiological assessments, these providers can effectively suggest modifications to the patient's training regimen as well as an appropriate rehabilitation program. Surgical intervention for shoulder stabilization should use an individualized approach for technique and timing. A team-based approach is necessary to optimize the care of this high-demand, high-risk population.

Patellar instability: will my patella dislocate again?

The incidence of patellar instability in pediatric patients ranges is 50-100 in 100,000 patients per year. Risk of recurrent dislocations however has been cited from 8.6% to 88% depending on individual patient factors. This manuscript highlights the demographical, historical, and anatomic factors associated with recurrent patellar instability following a first-time patella dislocation in the pediatric population. In recent years, various studies have focused on identifying risk factors for recurrent patellar instability following a primary patellar dislocation. A mix of patient factors, including age of first dislocation, patella alta, elevated tibial tubercle to trochlear groove and trochlear dysplasia have all been noted in the literature, which have helped to develop various scoring tools to predict recurrent dislocation following nonoperative treatment. Risk of recurrent patellar instability in patients who have previously suffered a patellar dislocation can be due to many factors. These risk factors should be used and applied to a variety of risk scores in order to provide physicians and healthcare providers with a tool to counsel patients and families on their patellar redislocation risk and help guide further management.

Patellar Instability in Pediatric Patients: Review of the Literature

Patellar instability is a common pathology of the knee in pediatric patients. The management of this condition can be a challenge for the orthopedic surgeon, and a comprehensive understanding of the anatomy and biomechanics of the structures around the knee is of utmost importance in formulating a treatment plan. Predisposing factors can be related to: trochlear and patellar morphological abnormalities, ligamentous stabilizers, limb geometries in the axial plane, and patellar height abnormalities. Traditionally, first-time dislocators have been treated non-operatively; however, recent evidence suggests that certain factors are related to recurrent instability, and surgical treatment may be considered even after the first dislocation. It is important to keep in mind that younger children with open physes are not suitable candidates for certain surgical techniques. In this comprehensive review, we aimed to focus on the most up-to-date information on this topic and emphasize the importance of individualizing the treatment of pediatric patients.

Does the immediate repair of Bankart lesion following first dislocation reduce the chances of recurrence after arthroscopic repair in soldiers?

The study attempted to compare the effects of immediate and delayed arthroscopic Bankart repair on the shoulder dislocation recurrence. In total, 465 soldiers with first-time anterior shoulder dislocation were included in the study. Of the total, 285 soldiers underwent a quick arthroscopic Bankart repair procedure, whether 180 soldiers underwent a delayed repair procedure. The initial dislocation was traumatic in both groups and operated using the standard arthroscopic suture anchor repair technique. Patient's age, repair time since the first dislocation, number of dislocations before surgery, number of suture anchors used during the repair, duration of surgical procedure, duration from surgery to return to work, and recurrence of dislocation after surgery were recorded. Rowe score, Constant score, and American Shoulder and Elbow Surgeons score were used for clinical assessment. The operating time and recurrence rate were higher in the group subjected to delayed repair procedure than in the group subjected to immediate repair procedure. Repair timing was found to be crucial for a successful outcome. The findings suggest that Bankart repair must be performed immediately to minimize recurrence and other degenerative changes, which may require an additional surgical procedure for satisfactory repair. More studies are required to reach a definitive conclusion. Level III.

MANAGEMENT OF FIRST-TIME PATELLAR DISLOCATION: A SURVEY OF PRISM MEMBERS (201)

Objectives:There are no current guidelines for optimal management of first-time patellar dislocation in children and adolescents. The objective of this study was to develop consensus-based guidelines for management of first-time dislocation in adolescents.Methods:A 29-question, case-based, multiple-choice survey was developed after 2-rounds of iterations by 20 members of the Patellofemoral RIG. The survey contained two case scenarios of first-time patellar dislocation in adolescents - one with and one without an osteochondral fracture. The survey was administered to primary sports medicine and orthopedic surgeons of the PRISM Society in April 2020 and the responses were analyzed. Consensus-based guidelines were generated when at least 66% of the respondents agreed.Results:81/276 (29%) members responded to the survey and 6 consensus-based guidelines were generated from those responses (Table 1).There was no consensus between conservative (60%) and operative (40%) treatment of contralateral patellar dislocation. Free-text analysis revealed several variables that influence the decision-making process.Conclusions:There are changes in trends related to management of first-time dislocation in adolescents. MRI, though not recommended for all patients with first-time dislocation, was obtained by 51% of respondents. The survey provides details of conservative treatment, including the role and duration of bracing and physical therapy. For first-time dislocation with an osteochondral fracture, concomitant patellar stabilization is preferred over isolated fixation. Simultaneous guided-growth for genu valgum correction is recommended. There were several variables that influenced the decision-making process and there were several areas of discordance. Further research studies on these parameters could potentially improve outcomes. *PF RIG members: Matthew Ellington, MD, Craig J Finlayson, MD, Joseph Molony, Jr., PT, MS, SCS, CSCS, Nicole Friel, MD MS, Daniel W Green, MD, Jeffery L Mikutis, DO, Todd A Milbrandt, MD, James L Pace, MD, Albert M Pendleton, MD, Lauren H Redler, MD, Jason Rhodes, MD, Shannon D Safier, MD, John A Schlechter, MD, Beth E Shubin Stein, MD, Curtis Vandenberg, MD, Jeffrey M Vaughn, DO, Eric J Wall, MD, Drew E Warnick, MD, Moshe Yaniv, MD, Shital N Parikh, MD.

Treatment Decisions in Pediatric Sports Medicine: Do Personal and Professional Bias Affect Decision-Making?

Background:Personal and professional biases can affect decision-making regarding important issues in pediatric sports medicine. Gaining insight into the opinions of health care professionals who specialize in pediatric sports medicine will provide information that may be useful for directing ongoing research in this field.Hypothesis:It was hypothesized that surgeons would demonstrate bias toward early surgical intervention versus nonsurgeons. In addition, it was hypothesized that youth sports medicine professionals who were parents of a child with a previous major sports injury or concussion would be less likely to allow their child to play American tackle football or return to football after a concussion.Study Design:Cross-sectional study.Methods:An online survey was provided to the active members of the Pediatric Research in Sports Medicine Society. We used both professional background information and responses to questions related to personal experiences with youth sports injuries to determine potential factors associated with underlying biases. Survey responses among subgroups were compared using the Fisher exact test. The Pearson correlation coefficient was used to evaluate years in practice versus opioid use.Results:Of the survey participants, 62.5% were pediatric surgeons, and 37.5% represented different nonsurgical youth sports medicine professions. Surgeons were less likely than nonsurgeons to agree to allow their child to return to football after sustaining a concussion and completing a concussion protocol (48% vs 76%, P = .013). Surgeons were more likely than nonsurgeons to agree to both elective shoulder stabilization after a first-time dislocation and elective drilling of a stable knee osteochondritis dissecans (OCD) before nonoperative treatment (41% vs 10%, P = .003 and 52% vs 23%, P = .013, respectively). Those who reported having a child with a concussion history were more likely to support him or her returning to football after a concussion (65% vs 33%, P = .026).Conclusion:Surgeons were more likely to favor elective shoulder-stabilization surgery after a first-time dislocation and drilling of a stable knee OCD instead of nonoperative management. Personal experience of having a child who sustained a major sports injury or concussion did not demonstrate a bias against participation in football or return to football after a concussion.

Arthroscopic Labral Repair Using Knotless Suture Anchors in the Setting of a 270° Labral Tear of the Shoulder

Extensive glenoid labral tears, whether the result of repetitive instability or first-time dislocation, compromise the mechanical stability of the glenohumeral joint due to disruption of the anterior, inferior, posterior, and/or superior portions of the labrum. These lesions often result in recurrent multiplanar instability and pain that is nonresponsive to conservative management and difficult to diagnose due to variability in clinical presentation and advanced imaging findings. Arthroscopic repair techniques to address symptomatic shoulder instability have showed positive patient-reported outcomes, low failure rates, and high return-to-sport rates. The evolution of knotless suture anchors offers a fixation method that has proven to be functionally equivalent to knotted suture anchors while avoiding the risks of knotted anchors (knot loosening, knot migration, articular abrasion) and allowing easier placement and decreased operative time. The purpose of this technique is to describe our preferred method to treat a 270° labral tear through arthroscopic knotless anchor repair and demonstrate the expanded application of this technique for extensive glenoid labral pathology.

Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-Analysis.

There is an ongoing debate about whether to perform operative or nonoperative treatment following a first-time anterior dislocation or wait for recurrence before operating. The aim of this systematic review is to compare recurrence rates following operative treatment following first-time anterior dislocation (OTFD) with recurrence rates following (1) nonoperative treatment (NTFD) or (2) operative treatment after recurrent anterior dislocation (OTRD). A literature search was conducted by searching PubMed (Legacy), Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics from 1990 to April 15, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane was used to determine bias in randomized controlled trials, and the methodological index for non-randomized studies (MINORS) was used to determine the methodological quality of non-randomized studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using GRADEpro software. Of the 4,096 studies for which the titles were screened, 9 comparing OTFD and NTFD in a total of 533 patients and 6 comparing OTFD and OTRD in a total of 961 patients were included. There is high-quality evidence that OTFD is associated with a lower rate of recurrence (10%) at >10 years of follow-up compared with NTFD (55%) (p < 0.0001). There is very low-quality evidence that patients receiving OTFD had a lower recurrence rate (11%) compared with those receiving OTRD (17%) (p < 0.0001). There is high-quality evidence showing a lower recurrence rate at >10 years following OTFD compared with NTFD (or sham surgery) in young patients. There is evidence that OTFD is more effective than OTRD, but that evidence is of very low quality. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Athletes With Anterior Shoulder Instability: A Prospective Study on Player Perceptions of Injury and Treatment.

Background:Many in-season athletes choose to delay or avoid surgery in order to continue playing and avoid downtime such as missed games or seasons.Purpose:To learn about the attitudes toward the injury and treatment of in-season shoulder instability in competitive athletes who have suffered a shoulder dislocation.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A study-specific questionnaire about athletes’ perceptions of injury and treatment was administered to injured players. Secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI). Mean scores and standard deviations were calculated, and between-group analyses with t tests were performed to compare the ASES and WOSI scores. The Mann-Whitney U test was used for analyses performed on the following groups: early operative versus nonoperative management; age <18 versus ≥18 years; first-time dislocators versus recurrent dislocators; self-reducing subluxations versus dislocations requiring assistance; and dominant arm affected versus nondominant arm.Results:There were 45 patients included in this study (33 male, 12 female) with a mean age of 18 ± 2.8 years. Several sports were represented, with the most common being football, baseball, soccer, and rugby. In this study of in-season athletes with shoulder instability, 13 (28.9%) chose early surgery, 4 (8.9%) chose surgery at season’s end, while 28 (62.2%) chose physical therapy followed by a wait-and-see approach, with 13 (46.4%) of these patients ultimately requiring surgery. Athletes who chose nonoperative treatment were statistically more likely to believe that their shoulder would heal on its own (P < .001) or with physical therapy (P < .025); they were also more likely to agree that they would rather stop sports than undergo surgery (P < .04). Athletes with worse ASES and WOSI scores at injury were more likely to choose surgery (P < .03 and P < .05, respectively). Athletes with >1 dislocation were less likely to believe that the shoulder would heal without surgery (P < .025). Most athletes agreed that seasonal timing and recruitment prospects were an important factor in their decision in favor of surgery (P < .038), and most agreed that their doctor influenced their ultimate treatment decision (P < .006). Most athletes also agreed that a repeat dislocation would cause further injury to the shoulder.Conclusion:Treatment decisions were most strongly related to the athletes’ perceptions of injury severity and the influence of the treating surgeon.

Assessment of knee flexor muscles strength in patients with patellar instability and its clinical implications for the non-surgical treatment of patients after first patellar dislocation - pilot study

BackgroundBiomechanical studies indicate that during outward rotation of the tibia and the valgus knee joint position, the patella is shifted in the lateral direction. After first-time patellar dislocation, the dynamic position of the femur in relation to the tibia plays an important role in joint stability, because the medial stabilizer of the patella (mostly the MPFL) is damaged or inefficient. The most important factor in controlling the rotational movement of the tibia in relation to the thigh are the hamstring muscles. The aim of the study therefore is to determine whether patients with patellar instability have a significant weakness in the knee flexor muscles, which can predispose to recurrent dislocations. This is an important consideration when planning the rehabilitation of patients with first-time patellar dislocation.MethodsThe study enrolled 33 patients with confirmed recurrent patellar dislocation, including six patients with bilateral involvement. In the study group, the hamstring muscles (both sides) were evaluated at velocities of 60 and 180 deg/s for the following parameters: peak torque, torque at 30 degrees of knee flexion, angle of peak torque and peak torque hamstring to quadriceps ratio (H/Q ratio).ResultsIn the recurrent patellar dislocation group, a statistically significant weakness in knee flexors was observed for both angular velocities compared to age and gender normative data. No such relationship was observed in the control group of heathy subjects. In patients with one-sided dislocation, no differences were found in knee flexors peak torque, torque at 30 degrees of knee flexion, angle of peak torque or H/Q ratio between the healthy and affected limbs for either angular velocity.ConclusionsIn patients with recurrent patellar dislocation, knee flexors strength is decreased significantly in both the unaffected and affected limbs. This may indicate a constitutional weakening of these muscles which can predispose to recurrent dislocations.Trial registrationThe study was retrospectively registered on ClinicalTrials.gov (NCT04838158), date of registration; 22/03/2021.

Management of Patellar Instability: A Network Meta-analysis of Randomized Control Trials

Background: Multiple surgical options exist for the treatment of patellar instability; however, the most common procedures involve either a reconstruction of the medial patellofemoral ligament (MPFL) or a repair/plication of the MPFL and medial soft tissues. Purpose: To perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature to compare MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability. Study Design: Systematic review and network meta-analysis; Level of evidence, 1. Methods: The literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability were included. Clinical outcomes included recurrent instability (including both dislocations and subluxations), redislocation, and Kujala score. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using the statistical software R. The treatment options were ranked using P scores. Results: There were 13 RCTs with a total of 789 patients, all with a minimum follow-up of 24 months. There were 150 patients treated using MPFL reconstruction, 353 treated using MPFL repair, and 286 treated nonoperatively. Overall, MPFL reconstruction had the highest P score (0.9967) and resulted in a significantly lower recurrence rate than did MPFL repair (odds ratio [OR], 0.42; 95% CI, 0.07-0.72) and nonoperative management (OR, 0.09; 95% CI, 0.03-0.32). In addition, MPFL repair resulted in a significantly lower recurrence rate than did nonoperative management (OR, 0.42; 95% CI, 0.25-0.70). MPFL reconstruction had the highest P score (0.9651) and resulted in a significantly higher Kujala score than did nonoperative management (mean difference, 10.45; 95% CI, 0.41-20.49) but not MPFL repair (mean difference, 0.15; 95% CI, 0.03-0.68). Subgroup analysis revealed that MPFL reconstruction had the highest P score for all outcomes in those with first-time dislocation. Conclusion: The current study demonstrated that MPFL reconstruction results in the lowest rate of recurrent patellar instability and best functional outcomes as measured using the Kujala score.

Arthroscopic Bankart Repair Versus Open Latarjet for First-Time Dislocators in Athletes.

Background:In athletes with a first-time shoulder dislocation, arthroscopic Bankart repair (ABR) and the open Latarjet procedure (OL) are the most commonly utilized surgical procedures to restore stability and allow them to return to play (RTP).Purpose:To compare the outcomes of ABR and OL in athletes with a first-time shoulder dislocation.Study Design:Cohort study; Level of evidence, 3.Methods:We performed a retrospective review of patients with first-time shoulder dislocation who underwent primary ABR and OL and had a minimum 24-month follow-up. Indications for OL over ABR in this population were those considered at high risk for recurrence, including patients with glenohumeral bone loss. Patients who underwent ABR were pair-matched in a 2:1 ratio with patients who underwent OL by age, sex, sport, and level of preoperative play. The rate, level, and timing of RTP, as well as the Shoulder Instability–Return to Sport after Injury (SIRSI) score were evaluated. Additionally, we compared recurrence, visual analog scale pain score, Subjective Shoulder Value, Rowe score, satisfaction, and whether patients would undergo the surgery again.Results:Overall, 80 athletes who underwent ABR and 40 who underwent OL were included, with a mean follow-up of 50.3 months. There was no significant difference between ABR and OL in rate of RTP, return to preinjury level, time to return, or recurrent dislocation rate. There were also no differences between ABR and OL in patient-reported outcome scores or patient satisfaction. When collision athletes were compared between ABR and OL, there were no differences in RTP, SIRSI score, or redislocation rate.Conclusion:ABR and OL resulted in excellent clinical outcomes, with high rates of RTP and low recurrence rates. Additionally, there were no differences between the procedures in athletes participating in collision sports.

Iatrogenic fracture during shoulder dislocation reduction: characteristics, management and outcomes

BackgroundShoulder dislocation and the cases of iatrogenic fractures during manual reduction are becoming increasingly common. The aim of this study was to investigate the characteristics, management, and patient outcomes of iatrogenic proximal humeral fracture during the manual reduction of shoulder dislocation.MethodsA retrospective and multi-center study was performed to identify all patients presenting with shoulder dislocation from January 2010 to January 2020. The sex and age of patients, associated injuries, first-time or habitual shoulder dislocation, type of anesthesia, time from injury to revision surgery, and functional outcomes were analyzed.ResultsA total of 359 patients with a mean age of 62.1 ± 7.3 years (range 29–86 years) were included. Twenty-one patients (female/male ratio 17:4) with an average age of 66.3 ± 9.7 years (range 48–86 years) were identified with a post-reduction iatrogenic fracture. Female cases with greater tuberosity fractures (GTF) were more likely than male cases to have iatrogenic fractures during reduction (P = 0.035). Women aged 60 years or older experienced more iatrogenic fractures during manual reduction (P = 0.026). Closed reduction under conscious sedation was more likely than that under general anesthesia to have iatrogenic fractures (P = 0.000). A total of 21 patients underwent open reduction and internal fixation (ORIF) when iatrogenic fractures occurred. The mean follow-up period was 19.7 ± 6.7 months (range 12–36 months). The mean Neer scores were 80.5 ± 7.6 (range 62–93), and the mean visual analog score (VAS) was 3.3 ± 1.5 (range 1–6). Significant differences were observed in the Neer score and VAS with the time (more or less 8 h) from injury to revision surgery (P < 0.05).ConclusionA high risk of iatrogenic proximal humeral fracture is present in shoulder dislocation with GTF in senile females without general anesthesia. ORIF performed in a timely manner may help improve functional outcomes in the case of iatrogenic injury.

Factor Structure of the Shoulder Instability Return to Sport After Injury Scale: Performance Confidence, Reinjury Fear and Risk, Emotions, Rehabilitation and Surgery

Background: Rates of return to play after shoulder dislocation vary between 48% and 96%, and there has been scant attention given to the psychosocial factors that influence return to play after a shoulder injury. Purpose: To establish the factor structure of the Shoulder Return to Sport after Injury (SI-RSI) scale and examine how the SI-RSI is associated with the Western Ontario Shoulder Instability Index (WOSI). Study Design: Cross-sectional study; Level of evidence, 3. Methods: The SI-RSI is designed to measure psychological readiness to return to play after shoulder dislocation and was administered to participants who had at least 1 episode of shoulder dislocation and were planning or had returned to sports. The WOSI was also completed by the participants, and descriptive data were gathered. Reliability (Cronbach α) and factor analysis of the SI-RSI were undertaken. Correlations between the SI-RSI and WOSI were made, and differences between various patient subgroups (first-time dislocations vs multiple episodes of instability, surgery vs no surgery, return to sports vs no return) were analyzed. Results: The SI-RSI had high internal consistency (Cronbach α = 0.84) and was shown to have 4 distinct factors that represented the following constructs: performance confidence, reinjury fear and risk, emotions, and rehabilitation and surgery. Moderate correlations were seen between SI-RSI and WOSI scores. Participants who had undergone surgery scored significantly lower on the reinjury fear and risk subscale of the SI-RSI (P = .04). Those who had sustained multiple dislocations were significantly more concerned about having to undergo rehabilitation and surgery again (P = .007). Participants who had returned to sports had significantly greater fear and thought they were more at risk of reinjury (P = .02). Conclusion: Athletes return to sports after a shoulder dislocation despite reporting high levels of fear and concern for their shoulder. High levels of fear and concern may underpin why rates of recurrent shoulder instability are so high. Four distinct elements of psychological readiness appeared to be present in this patient group.

MANAGEMENT OF FIRST-TIME PATELLAR DISLOCATION: A SURVEY OF PRISM MEMBERS

Background:There are no current guidelines for optimal management of first-time patellar dislocation in children and adolescents.Purpose:To develop consensus-based guidelines for management of first-time dislocation in adolescents.Methods:A 29-question, case-based, multiple-choice survey was developed after 2-rounds of iterations by 20 members of the Patellofemoral RIG. The survey contained two case scenarios of first-time patellar dislocation in adolescents - one with and one without an osteochondral fracture. The survey was administered to primary sports medicine and orthopedic surgeons of the PRISM Society in April 2020 and the responses were analyzed. Consensus-based guidelines were generated when at least 66% of the respondents agreedResults:81/276 (29%) members responded to the survey and 6 consensus-based guidelines were generated from those responses.There was no consensus between conservative (60%) and operative (40%) treatment of contralateral patellar dislocation. Free-text analysis revealed several variables that influence the decision-making process.Conclusion:There are changes in trends related to management of first-time dislocation in adolescents. MRI, though not recommended for all patients with first-time dislocation, was obtained by 51% of respondents. The survey provides details of conservative treatment, including the role and duration of bracing and physical therapy. For first-time dislocation with an osteochondral fracture, concomitant patellar stabilization is preferred over isolated fixation. Simultaneous guided-growth for genu valgum correction is recommended. There were several variables that influenced the decision-making process and there were several areas of discordance. Further research studies on these parameters could potentially improve outcomes.

DESCRIPTIVE EPIDEMIOLOGY STUDY OF THE JUSTIFYING PATELLAR INSTABILITY TREATMENT BY EARLY RESULTS (JUPITER) COHORT

Background:Patellar instability is a common injury in young patients and can lead to significant morbidity and arthritis. Its management is controversial. JUPITER (Justifying Patellar Instability Treatment by Early Results) is a hypothesis-driven, multi-center, multi-armed, prospective cohort study developed to describe clinical characteristics and predictors of clinical outcomes in the young patellar instability population.Purpose:To describe the formation of JUPITER and provide a descriptive, epidemiologic analysis of patient demographics and clinical features of the patients in this prospective cohort.Methods:After training and institutional review board approval, surgeons began enrolling patients between 10-30 years of age who sustained a patellar dislocation. Patient demographics, dislocation history, physical exam characteristics, and PROMs were collected.Results:By January 1, 2019, 28 surgeons from 12 sites had prospectively enrolled 661 patients (677 knees) with patellar instability. 62% were female and mean age was 15.8 years. 447 knees (66%) were in the operative group and 230 (34%) in the non-operative group. 55% of knees reported that they had more than 1 dislocation (operative group 73%; non-operative group 27%, p<0.001). Operative treatment was indicated in 39% of first-time dislocators and 85% of recurrent dislocators (p<0.001).Recurrent and operative group patients had more positive physical exam findings than first-time and non-operative group patients on the affected knee (p<0.05 for J-sign, apprehension, crepitus) and the contralateral knee (p<0.05 J-sign, apprehension). The recurrent group was nearly twice as likely to be ligamentously lax (Beighton score 5 or greater) compared to first-time patients (p<0.001).Baseline PROMs varied with the recurrent group having lower Pedi-FABS (p=0.001) and KOOS-QoL (0.008) scores and higher Kujala (0.009), KOOS ADL (0.008), KOOS Sports (<0.001), and Pedi-IKDC (0.014) scores than the first-time dislocator group.Conclusions:The JUPITER Group has been able to accumulate the largest prospectively collected patellar instability database to date. Over half of patients in this group reported they sustained more than one dislocation. Operative management was indicated in 39% of first-time dislocators, 50% of which had sustained an osteochondral fracture, and 85% of recurrent dislocators. Recurrent dislocators were more likely to have positive physical exam findings on both the affected and contralateral knee.

Conservative versus tailored surgical treatment in patients with first time lateral patella dislocation: a randomized-controlled trial

BackgroundPatellar instability has a high incidence and occurs particularly in young and female patients. If the patella dislocates for the first time, treatment is usually conservative. However, this cautious approach carries the risk of recurrence and of secondary pathologies such as osteochondral fractures. Moreover, there is also risk of continuous symptoms apparent, as recurrent patella dislocation is related to patellofemoral osteoarthritis as well. An initial surgical treatment could possibly avoid these consequences of recurrent patella dislocation.MethodsA prospective, randomized-controlled trial design is applied. Patients with unilateral first-time patella dislocation will be considered for participation. Study participants will be randomized to either conservative treatment or to a tailored patella stabilizing treatment. In the conservative group, patients will use a knee brace and will be prescribed outpatient physical therapy. The surgical treatment will be performed in a tailored manner, addressing the pathologic anatomy that predisposes to patella dislocation.The Banff Patellofemoral Instability-Instrument 2.0, recurrence rate, apprehension test, joint degeneration, and the Patella Instability Severity Score will serve as outcome parameters. The main analysis will focus on the difference in change of the scores between the two groups within a 2-year follow-up.Statistical analysis will use linear mixed models. Power analysis was done for the comparison of the two study arms at 2-year follow-up with regard to the BPII Score. A sample size of N = 64 per study arm (128 overall) provides 80% power (alpha = 0.05, two-tailed) to detect a difference of 0.5 standard deviations in a t-test for independent samples.DiscussionAlthough several studies have already dealt with this issue, there is still no consensus on the ideal treatment concept for primary patellar dislocation. Moreover, most of these studies show a unified surgical group, which means that all patients were treated with the same surgical procedure. This is regarded as a major limitation as surgical treatment of patella dislocation should depend on the patient’s anatomic pathologies leading to patellar instability. To our knowledge, this is the first study investigating whether patients with primary patella dislocation are better treated conservatively or operatively with tailored surgery to stabilize the patella.Trial registrationThe study will be prospectively registered in the publicly accessible database www.ClinicalTrials.gov.

Medial Patellofemoral Ligament Reconstruction for Adolescents With Acute First-Time Patellar Dislocation With an Associated Loose Body

Background: The management of adolescents with acute first-time patellar dislocation with an associated loose body remains a debated topic. The rate of recurrent dislocation in these patients may be up to 61% if the medial patellofemoral ligament (MPFL) is repaired or not addressed surgically. To our knowledge, a prospective evaluation of MPFL reconstruction for adolescents with acute first-time patellar dislocation with an associated chondral or osteochondral loose body has not been previously performed. Purpose/Hypothesis: The purpose of this study was to analyze patients with a first-time patellar dislocation who required surgery for a loose body, comparing those who underwent MPFL repair or no treatment with those who underwent MPFL reconstruction during the index procedure. The hypothesis was that performing MPFL reconstruction would reduce the rate of recurrent instability and improve patient-reported outcomes compared with MPFL repair or no treatment. A secondary objective was to report outcomes of those patients who underwent reconstruction versus those who did not. Study Design: Case series; Level of evidence, 4. Methods: This was a prospective analysis of adolescents treated with MPFL reconstruction for acute first-time patellar dislocation with associated loose bodies between 2015 and 2017 at a single pediatric level 1 trauma center with minimum 2-year follow-up. Retrospective analysis was previously performed for a similar cohort of adolescents treated with MPFL repair or no treatment. Patient characteristic data, radiographic measurements, and surgical variables were compared. Primary outcome measures included recurrent subluxation or dislocation and the need for further stabilization procedures. Secondary outcomes included Kujala score, Single Assessment Numeric Evaluation score, patient satisfaction, and ability to return to sport. Results: A total of 76 patients were included, 30 in the MPFL reconstruction cohort and 46 in the MPFL repair or no-treatment cohort. The only difference noted in patient characteristic, radiographic, or surgical variables was a smaller Insall-Salvati ratio in the reconstruction group (1.29 vs 1.42; P = .011). Compared with MPFL repair or no treatment, MPFL reconstruction was associated with less recurrent instability (10.0% vs 58.7%; P < .001), fewer secondary procedures (6.7% vs 47.8%; P < .001), and more frequent return to sports (66.7% vs 39.1%; P = .003). No differences in patient-reported outcomes were noted. Conclusion: Performing concomitant MPFL reconstruction in adolescents with first-time patellar dislocation and an intra-articular loose body results in a 5-fold reduction in recurrent instability, reduces the need for subsequent surgery, and improves patients’ ability to return to sports compared with repairing or not treating the MPFL.