James Bicos, MD

In the study by Gurusamy and colleagues, they looked at rate of recurrent patellar instability, the need for further stabilization procedures and the ability to return to sport in young patients with a first-time patellar dislocation who required surgery for a loose body. They compared those who underwent MPFL repair or no treatment with those who underwent an MPFL reconstruction during the index procedure. Their idea for the research study stemmed from a previous article by the similar authors in 2019 showing that in children or adolescents who undergo loose body removal or fixation without MPFL reconstruction, the rate of recurrent patellar instability was 61%.

The results of this study showed that patients who were stabilized acutely with MPFL reconstruction had a significantly lower risk of recurrent instability and required fewer subsequent surgeries. Those patients were also more likely to return to sports at a minimum of 2-year follow-up. The focus of the study and the difference between other published studies is on the intra-articulate loose body after the dislocation. In this study, regardless of how the MPFL was managed, most patients had their loose body removed, but 24% underwent fixation. The rates of fixation of the loose bodies were not different between the MPFL repair/no-treatment group and the MPFL reconstruction group.

It is well known that young patients with first-time patellar dislocations do well with conservative management, as long as there is no associated chondral or loose body injury. Especially in children, loose bodies after patellar dislocations can encompass a large portion of the patellar chondral surface and have a good chance of healing with an acute repair of the cartilage fragment. 

I believe this is a good study showing that if you are considering operating on a young patient with a first-time patellar dislocation and a loose body, that performing an MPFL reconstruction is better than just a loose body removal, an MPFL repair or doing nothing. Although some of the risks of doing an MPFL reconstruction include stiffness with poor graft positioning and/or growth plate injury in children with open physes, the overall risks of doing an MPFL reconstruction surgery do not outweigh the benefits of a patellar stabilization surgery with a properly placed MPFL reconstruction.

John P. Fulkerson, MD

I want to further emphasize what Dr. Bicos is saying. MPFL surgery must be anatomic to be better than nonoperative. Some of the worst problems I see are poorly done MPFL reconstructions. Anatomic graft placement is imperative. If there is any doubt about knowing the anatomy, just remove the loose body.