Interdisciplinary Orthopedic Management of Pediatric Patella Dislocation and Instability: An Educational Case Series

Abstract

Pediatric patellar instability and/or dislocation is a challenging diagnosis category that requires an interdisciplinary team consisting of orthopedic surgeons and physical therapists for optimized patient outcomes. This educational case series outlines core concepts for three patients with unique patellar dislocation presentations. Case 1 is a 16-year-old male who presented with a history of five knee traumatic patellar dislocations with self-reduction and underwent knee arthroscopic surgery with debridement and microfracture of the patella chondral defect, arthroscopic lateral release to improve the patellar tilt, and medial patellofemoral ligament (MPFL) reconstruction. Case 2 is a 15-year-old female who presented with chronic knee pain and patella instability who underwent knee arthroscopic surgery with abrasion arthroplasty, microfracture of the patella, lateral release, tibial tubercle osteotomy medializing osteotomy, and MPFL reconstruction. Case 3 is a 14-year-old male who presented after a single episode of lateral patella dislocation and underwent open reduction and fixation of the lateral femoral condyle osteochondral fracture, a Grammont patellar medialization procedure, and MPFL reconstruction. All three patients received postoperative physical therapy (PT) to improve function and outcomes. These cases represent important concepts of patellar containment, risk factors for recurrent instability, associated pathology, and appropriate surgical care and postoperative rehabilitation. Furthermore, this case series highlights management decisions and pathways for three patients with different symptoms related to patellar instability, subsequent surgical correction, and postoperative physical therapy. Overall, interdisciplinary care of common pediatric orthopedic conditions can help improve patient outcomes and satisfaction. By understanding the biomechanics and decision-making surgical parameters regarding patellofemoral instability, clinicians can provide patients with better care.

Keywords: interdisciplinary; medial patellofemoral ligament; orthopedic surgery; patellar instability; physical therapy.

Figure 1. MRI for the first patient, revealing a bony contusion of the lateral femoral condyle

The arrow indicates the bony contusion of the lateral femoral condyle.

Figure 2. (A) A deep sulcus results in improved containment of the patella within the trochlea to decrease risk of patella dislocation; (B) a shallow sulcus provides an insufficient barrier to patella translation and increases the risk of patella dislocation.

Image Credits: Morgan B. Weber

Figure 3. MRI of the knee for the second patient, which demonstrates trochlear dysplasia with a shallow groove, patellar tilt, and lack of patellar containment with the patella overhanging the lateral facet of the trochlea.

The arrow indicates the region of trochlear dysplasia with a shallow groove, patellar tilt, and lack of patellar containment.

Figure 4. Tibial tubercle osteotomy and medialization of the tibial tubercle allows the patella to sit more centrally within the trochlea and provides tension to lateral translation.

Image Credits: Morgan B. Weber

Figure 5. (A) An attenuated native MPFL results in lack of adequate resistance to lateral patella translation, which places patients at risk of lateral patella dislocation; (B) MPFL reconstruction results in improved containment of the patella within the trochlear groove and resistance to lateral patella translation.

Image Credits: Morgan B. Weber MPFL: Medial patellofemoral ligament

Figure 6. MRI of the knee of the third patient, demonstrating severe effusion, trochlear dysplasia, and severe lack of patellar containment.

The arrow indicates the region of severe effusion, trochlear dysplasia, and the severe lack of patellar containment.