Primary Dislocation of the Patella : A Clinical Study

A total of 177 patients with primary dislocation of the patella (PDP) were admitted to two trauma centers in Helsinki, Finland during 1991 to 1992. The inclusion criteria were: 1. Acute (≤14 days old) first-time lateral dislocation of the patella. 2. No previous knee operations or major knee injuries. 3. No ligament injuries to be repaired. 4. No osteochondral fractures requiring fixation. 50 patients were excluded. 30 of these excluded patients would have met the inclusion criteria, 19 patients received treatment by consultants not involved in the study, 7 refused to participate and 4 had an erroneous randomization. 127 patients including, 82 females, were then randomized to have either tailor-made operative procedure (group O) or conservative treatment (group C). The aftercare was similar for both groups. The mean age of the patients was 20 (9-47) years. All patients were subjected to analysis of trauma history (starting position and knee movement during the dislocation), examination under anesthesia (EUA) and arthroscopy. 70 patients (52 females) were randomized by their odd year of birth to operative group O and 57 patients (30 females) by their even year of birth to conservative group C. The diagnosis of PDP was based on locked dislocation in 68 patients, on dislocatability in EUA in 47 patients, and on subluxation in EUA combined with typical intra-articular lesions in 12 patients. In group O, 63 patients had exploration of the injuries on the medial side of the knee and tailor made reconstruction added with lateral release in 54 cases. The medial injury was operated by suturing in 39 patients, by duplication in 18 patients and by additional augmentation of the medial patellofemoral ligament (MPFL) with adductor magnus tenodesis in 6 patients. 7 patients, without locking in trauma history and only subluxation in EUA had only lateral release for realignment. In adductor magnus tenodesis the proximal end of the distal tendinous part was rerouted to the upper medial border of the patella. In the conservative group C, the treatment was adjusted to the extent of patellar displacement in EUA. Patients with dislocation in EUA had 3 weeks’ immobilization with the knee in slight flexion. Mobilization was started with a soft patellar stabilizing orthosis (PSO) used for additional three weeks. The patients with subluxation in EUA wore an orthosis for six weeks. The aftercare was similar in group O. The outcome was similar in both groups. After an average of 25 (20-45) months´ follow-up, the subjective result was better in group C in respect of the mean Hughston VAS knee score (87 for group O and 90 for group C, p=0.04, visual analog scale), but similar in terms of the patient’s own overall opinion and the mean Lysholm II knee score. Recurrent instability episodes occurred in 18 patients in group O and in 20 patients in group C. After an average of 7 (6-9) years´ follow-up, the groups did not show statistical difference either in respect of the patient’s own overall opinion, or the mean Hughston VAS and Kujala knee scores. The proportions of stable patellae was 25/70 (36%) in group O and 17/57 (30%) in group O (p=0.5). In a multivariate risk analysis, there was a correlation between low Kujala score (<90) as dependent parameter and female gender (OR: 3.5; 95% CI: 1.4-9.0), and loose body on primary radiographs (OR: 4.1; 95% CI: 1.2-15). Recurrent instability correlated with young age at the time of PDP (OR: 0.9; 95% CI: 0.8-1.0/year). Girls with open tibial apophysis had the worst prognosis for instability (88%; 95% CI: 77-98). The most common mechanisms in trauma history of the patients were movement to flexion from a straight start (78%) and movement to extension from a well-bent start (8%). Spontaneous relocation of the patella had taken place in 13/39 of girls, in 11/21 of boys, in 26/42 of women and in 17/24 of men with skeletal maturity of the tibia. The dislocation in EUA was non-rotating in 96/126 patients followed by outward rotating dislocation in 14/126 patients. Operative treatment policy in PDP is not recommended. Locking tendency of the patella in PDP depended on the skeletal maturation. Recurrence rate after PDP was higher than expected.127 potilasta (82 naista) hoidettiin polvilumpion ensimmäisen sijoiltaanmenon jälkeen välittömästi joko leikkauksella (70 potilasta) tai leikkaamatta (57 potilasta). Liitännäismurtumat, jotka vaativat kiinnittämistä tai vakavammat nivelsidevammat estivät osallistumisen satunnaistettuun tutkimukseen. Potilaiden ikäjakauma oli 9-47 vuotta ja keskiarvo 20 vuotta. Kaikille potilaille suoritettiin lumpion liikkuvuuden anestesiatutkimus ja polven tähystys. Leikkauksena käytettiin havaitun pidätinsäievamman suoraa ompelua (39 potilasta), kaksinkertaista päällekkäin asettavaa ompelua (18 potilasta) tai jännevahviketta (6 potilasta, adductor magnus jänne). Ulomman pidätinsäikeen vapautus (lateral release) tehtiin seitsemälle potilaalle ainoana toimenpiteenä ja 54 potilaalle liitännäistoimenpiteenä. Jatkohoito oli molemmissa ryhmissä yhteneväinen: Polven liike sallittiin 3 viikon kuluttua osittain ja 6 viikon kuluttua täysin. Ensimmäinen sijoiltaanmeno tapahtui yleisimmin lähellä pystyasentoa kyykkyyn menessä (78 %) tai kyykystä ylös noustessa (8 %). Lumpion kiilautuminen tapaturmatilanteessa oli yleisintä kasvunsa päättäneillä miehillä ja harvinaisinta kasvuaan jatkavilla tytöillä. Anestesiatutkimuksessa lumpio meni yleisimmin helposti sijoiltaan, muttei kiertynyt (76 %) tai kiertyi ulospäin (11 %). Jälkitutkimuksissa kahden ja seitsemän vuoden kuluttua ei pystytty havaitsemaan tilastollista eroa leikkaushoidon eduksi sijoiltaanmenon uusimisessa eikä potilaiden tyytyväisyydessä (Lysholm II-, Hughston VAS-ja Kujala-pisteytykset). Polvilumpio oli pysynyt vakaana leikkaushoidon jälkeen 25/70 (36 %) potilaalla ja 17/57 (30 %) leikkaamattomista. Riskianalyysissä sukukupuoli (nainen) ja pienikin irtopala ennakoivat huonoa polvipisteytystä (Kujala