invitation for this symposium. In this presentation I will focus on the current evidence regarding first-time patellar dislocation. So first-time patellar dislocation is a common injury during adolescent years, particularly among females with a recurrence rate ranging from 10 to 50%. Several factors increase the risk of recurrence, including age under 18, female patients, a history of contralateral dislocation, family history, and developmental abnormalities. Developmental abnormalities contributing to patellar dislocation can be classified as bony or soft tissue-related. These abnormalities can vary in severity and may differ between needs in the same patient. The most frequent anatomical abnormalities are listed. Patients with any anatomical abnormality are more likely to experience early dislocation. However, those without abnormalities have a lower risk of recurrence but a higher risk of associated injuries due to the greater force required for dislocation. Accurate assessment at the time of first dislocation is important to confirm the diagnosis, rule out alternative injuries, and evaluate associated injuries. A detailed history, physical examination, and appropriate imaging study should be performed to assess the risk of redislocation and evaluate other knee injuries. After a suspected patellar dislocation, X-rays should always be taken. And indications for MRI include hematosis, suspected osteochondral injury, locked knee, uncertain diagnosis, and a difficult patient assessment. The management of first-time dislocation is primarily based on limited evidence. Most evidence shows that initial treatment should be conservative except in specific cases with other associated injuries which require surgery like repairable osteochondral fractures. During the last 8 years, we've had 6 relevant systematic reviews related with this topic. They've showed that surgical treatment has a lower redislocation rate but higher complications. In the long-term, over 5 years follow-up, there was little difference between the groups. Most studies describe the reconstruction of MPFL as a surgical procedure. This is a summary of the best evidence of the last 3 years which show 4 systematic reviews. In most of the outcomes evaluated, no differences were observed in conservative versus surgical treatment. And when differences are observed, these were of low clinical significance. For example, 6 points on a pain scale of 0 to 100. Despite the above, surgery decreases the recurrence rate of dislocation with a relative risk close to 0.6. In other words, patients with surgical treatment would have a 40% decrease of risk of having another dislocation episode. It is interesting to see the results of the systematic review of Zhang because that review only includes patients less than 18 years old. In that review, Kujala and Kuh's score was better with conservative treatment and long-term follow-up studies of this review showed that after a 5-year follow-up, redislocation rate between groups was similar. So conservative treatment should be the initial approach focusing on rest, immobilization, anti-inflammatories, and controlled weight-bearing as tolerated with the assistance of crutches. Early physical therapy is essential to restore range of motion, quadricep function, core hip stability, and gait re-location. This international survey evaluated the opinion of more than 400 surgeons regarding the management of a first episode of patellofemoral dislocation. Most of them recommended the use of the brace for no more than two to three weeks. Likewise, they recommended weight-bearing as tolerated and partial restriction of the range of motion for the first four weeks with a progressive increase in range of motion. Surgery should be considered for individuals with symptomatic recurrent dislocation despite conservative treatment addressing underlying anatomic abnormalities and reconstruction of MPFL. Acute surgery may be necessary for associated injuries during dislocation or re-location of the patella as repairable osseocontrol fractures. So we know that for the treatment of recurrent patellar dislocation, a Menuhin-Lacarte or individualized treatment is recommended according to the different risk factors of the patient. We currently do not have an algorithm of this type for first dislocation, but it could be considered in the future for which more studies are required to evaluate every patient risk factors and outcomes in the medium and long-term follow-up. In this study, Dr. Arendt with Karolinska Institute studied more than 100 patients with first dislocation, and it was observed that they had a higher frequency and higher degree of anatomical risk factors for patellofemoral instability than control subjects. Chocolate dysplasia was a main risk factor, and together with lateral patellar tilt, they had the strongest association with dislocation. And Dr. Arendt also defined a clinical prediction model based on MRI variables showing that the three most important predictors were open growth plate, Sulcus angle over 154, and Insalzabati over 1.3. AOSSM and the Patellofemoral Foundation published a consensus about patellofemoral instability which showed that for the first time dislocation, X-rays and MRI should be used, that there is no evidence that favors the use of immobilization, so we should indicate it according to patient pain. We should start with conservative treatment and leave surgical indications for repairable osteochondral injuries, and there is some controversy in the treatment of cases with high risk of recurrence. As conclusions, the management of first-time patellar dislocation should be individualized according to the patellofemoral instability risk factors and also considering each patient's concerns and expectations. Conservative treatment is generally recommended with surgery reserved for cases of symptomatic recurrent dislocation or repairable associated injuries. Further research is needed to determine optical treatment approaches and long-term outcomes, including patients with higher risk factors. Thank you. »» Thank you.

patellar dislocation

adolescents

recurrence rate

risk factors

treatment approaches