Treatment choices for recurrent patellar instability in children and adolescents

Chronic patellofemoral instability is common in children and adolescents. While it may follow a single traumatic injury to an otherwise healthy and anatomically normal knee, several predisposing anatomical risk factors are often present. This review assesses the treatment of recurrent patellar dislocation in children and adolescents. A literature review was performed, accompanied by the authors' current suggested practice. Surgical interventions are often required, and the available procedures depend on the stage of skeletal maturity. Soft-tissue procedures aim to restore medial patellar constraints, with medial patellofemoral ligament reconstruction being the most important treatment across all age groups. Reconstruction of the medial patellotibial ligament and medial quadriceps tendon femoral ligament is a developing technique to enhance medial stability. In skeletally immature children, patella alta may be addressed with tendon shortening, and an increased tibial tuberosity versus trochlear groove distance may warrant medialization procedures such as the Grammont technique. Valgus knee is managed with growth modulation. After physeal closure, treatment options include tibial tuberosity osteotomy with distalization and medialization, as well as femoral varus or rotational osteotomy in severe cases. Trochleoplasty is also an option for adolescents after growth plate fusion. Thorough clinical and imaging evaluation is essential in cases of recurrent lateral patellar dislocation. Treatment is selected based on the likelihood of success with isolated medial patellofemoral ligament reconstruction, success underpinned by the presence of underlying anatomical risk factors and the stage of skeletal maturity for each patient. Level of evidence: Level III.