Conservative treatment is better than surgical management for first patellar dislocation
Date First Published:
March 1, 2000
Last Updated:
February 19, 2003
Report by:
Martin Thomas, Research Fellow (Manchester Royal Infirmary)
Search checked by:
Paul Wallman, Manchester Royal Infirmary
Three-Part Question:
In [patients with primary patellar dislocation] is [surgery better than conservative treatment] in [reducing symptoms and preventing redislocation]?
Clinical Scenario:
A 20 year old woman presents to the emergency department having suffered her first lateral patellar dislocation 1 hour before. She has managed to reduce it herself. You wonder whether surgery is superior to conservative management.
Search Strategy:
Medline 1966-06/99 using the OVID interface.
Search Details:
[({exp patella OR patella$.mp} AND {exp dislocations OR dislocate$.mp OR dislocation$.mp}) AND {exp emergency treatment OR exp treatment failure OR exp treatment outcome OR treatment$.mp}] AND maximally sensitive RCT filter) LIMIT to human and english.
Outcome:
79 papers found of which 74 irrelevant and 3 of insufficient quality for inclusion. The remaining papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Treatment of acute patellar dislocation. Cash JD and Hughston JC. USA 1988 | 103 primary patellar dislocations over 30 years. Conservative treatment (74) vs athroscopy (13) alone vs arthrotomy (16) Subanalysis predisposed to dislocate (69) vs no predisposition (34) |
Retrospective cohort | Recurrence rate (more than 1 redislocation) | 36.5% vs 23% vs 0 | Retrospective non- randomised series over 30 years. Very small numbers in some groups. |
| Recurrence rate (more than 1 redislocation) congenital predisposition vs none | Conservative 43% vs 20%<br>Arthroscopy 0 vs 11%<br>Arthrotomy 0 vs 0 | ||||
| Operative versus closed treatment of primary dislocation of the patella. Nikku R, Nietosvaara Y, Kallio PE et al. Finland 1997 | 125 patients with acute primary patellar dislocation. Conservative (55) vs operative (70) |
PRCT | Instability (redislocation or subluxation) | No significant difference | Randomised by year of birth. Operations not standardised. All patients had EUA and arthroscopy prior to randomisation. |
| Patient opinion | No significant difference | ||||
| Lysholm II score | No significant difference | ||||
| Hughston VAS | No significant difference | ||||
| Number of major complications | 4 in operative group |
Author Commentary:
There are a great number of single treatment case series in this area. Only one comparative series is randomised, and the surgical treatment is not standardised in either series. There is a suggestion that outcome may be different if there is a predisposition to dislocate but the evidence for this is very weak. Further work is required.
Bottom Line:
Conservative management of primary patellar dislocation is as effective as surgery and has a lower complication rate. It is the treatment of choice.
References:
- Cash JD and Hughston JC.. Treatment of acute patellar dislocation.
- Nikku R, Nietosvaara Y, Kallio PE et al.. Operative versus closed treatment of primary dislocation of the patella.