Update on Patellar Instability

Severino, Nilson Roberto; Severino, Fabrício Roberto; de Camargo, Osmar Pedro Arbix; Guglielmetti, Luiz Gabriel Betoni; de Oliveira, Victor Marques; Cury, Ricardo de Paula Leite

doi:10.1055/s-0040-1713389

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Revista Brasileira de Ortopedia

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Update Article • Rev. bras. ortop. 56 (2) • Mar-Apr 2021 • https://doi.org/10.1055/s-0040-1713389 copy

Update on Patellar Instability

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Patellar instability is a multifactorial clinical condition that affects a significant number of patients and occurs due to morphological variations of the joint and patellofemoral alignment. The present literature review study aimed to identify and summarize current concepts on patellar instability, in relation to associated risk factors, diagnostic criteria, and the benefits and risks of conservative and surgical treatments. For this purpose, a search was conducted in the following electronic databases: MEDLINE (via Pubmed), LILACS and Cochrane Library. It is concluded that the accurate diagnosis depends on the detailed clinical evaluation, including the history and possible individual risk factors, as well as imaging exams. The initial treatment of patellar instability is still controversial, and requires the combination of conservative and surgical interventions, taking into consideration both soft tissues and bone structures, the latter being the most common reason for choosing surgical treatment, especially lateral patellar instability.

Keywords
patella; patellofemoral joint; joint instability; patellar dislocation

Study/Year	Included and participating studies	Quality of studies included (GRADE)	Results
Yang et al.,³⁵35 Yang F, Guo W, Wang Q, et al. Surgical versus nonsurgical treatment of primary acute patellar dislocation: A systematic review and meta-analysis. Medicine (Baltimore) 2019;98(29): e16338 2019	16 ECRs/observational studies N = 918 participants 23 to 36 years old Follow up: 1 to 5 years	Low	Significant difference in favor of surgery: - Kujala: DMP 0.79 [0.30 to 1.28] - Relapse: OR 0.44 [0.30 to 0.63]
		Low	There was no significant difference between the groups: - Pain (EAV): DMP 0.84 [0.36 to 9.03]
Lee et al.,²⁶26 Lee DY, Park YJ, Song SY, Hwang SC, Park JS, Kang DG. Which Technique Is Better for Treating Patellar Dislocation? A Systematic Review and Meta-analysis. Arthroscopy 2018;34(11):3082–3093. e1 2018	4 ECRs N = 275 participants 23 to 36 years old Follow up: 1 to 5 years	Moderate to low	There was no significant difference between the groups: - Recidivism: RR 1.33 [0.89 to 2.00] - Alley: DM 1.76 [- 2.02 a 5.54] - Instability: RR 1.11 [0.89 to 1.40] - Pain: DM - 0.39 [- 6.97 to 6.20] - Tegner: DM 0.63 [- 0.32 to 1.58]
Longo et al.,³⁶36 Longo UG, Ciuffreda M, Locher J, Berton A, Salvatore G, Denaro V. Treatment of Primary Acute Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature. Clin J Sport Med 2017;27(06):511–523 2017	17 ECRs/observational studies N = 2,086 (2,134 knees) Average 20.3 years old Follow up: average 5 years	NA	Significant difference in favor of surgery: - Relapse: OR 0.54 [0.40 to 0.70] (36.4% conservative x 25% surgical)
Saccomano et al.,⁸8 Saccomanno MF, Sircana G, Fodale M, Donati F,Milano G. Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis. Int Orthop 2016;40(11): 2277–2287 2016	9 ECRs N = 430 knees 13 to 36 years old Follow up: 2 to 14 years	Moderate to low	Significant difference in favor of surgery: - Recurrence: RR 0.62 [0.39 to 0.98] - Pain: DMP - 0.32 [- 0.61 to - 0.03]
		Moderate to low	There was no significant difference between the groups: - Kujala: DMP 0.74 [0.08 to 1.40] - Lysholm: DMP - 0.10 [- 0.45 to 0.26] - Tegner: DMP - 0.61 [- 1.25 to 0.02]
Smith et al.,⁴4 Smith TO, Donell S, Song F, Hing CB. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 2015;(02):CD008106 2015	6 ECRs N = 344 participants 19 to 27 years old Follow up: up to 2 years	Too low	Significant difference in favor of surgery (after 2 to 5 years) : - Recurrence: RR 0.53 [0.33 to 0.87] - Alley: DM 13.93 [5.33 a 22.53] - Instability: RR 0.44 [0.27 to 0.72]
		Too low	There was no significant difference between the groups: Recidivism: after 6 to 9 years: RR 0.67 [-0.42 to 1.08] after 14 years RR 0.93 [-0.67 to 1.30] - Kujala: after 6 to 9 years: RR -0.35 [-10.61 to 4.11] after 14 years RR -1.00 [-8.60 to 6.60]

Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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[1] Address for correspondence Nilson Roberto Severino, Rua Dr. Cesário Motta Júnior, 112, Vila Buarque, SãoPaulo, SP, 01221-020, Brazil (e-mail: nrseverino@uol.com.br).