Unique Activity Characteristics of Adolescents With Patellar Dislocations: A Retrospective Review at a Single Institution

Abstract

Background:

While much evidence exists on the epidemiology of and prevention strategies for anterior cruciate ligament (ACL) injuries, there is less information on patellar dislocations.

Purpose:

We sought to compare the activities of adolescents who underwent a medial patellofemoral ligament reconstruction (MPFLR) to those who underwent an ACL reconstruction (ACLR).

Methods:

We conducted a retrospective review of routinely collected preoperative data of adolescent patients who underwent either an MPFLR or ACLR by 1 of 2 fellowship-trained pediatric sports medicine orthopedic surgeons at a single institution between February 1, 2016, and April 15, 2023. A total of 912 patients were identified, and 540 of these met the final inclusion and exclusion criteria. A total of 228 MPFLR participants were successfully matched to 228 ACLR participants based on sex and age within 1 year at the time of surgery. The mean age was 14.8 ± 2.1 years and 53% were female. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), Pediatric International Knee Documentation Committee, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference, and PROMIS Mobility were collected.

Results:

We found that 61% of the MPFLR cohort and 94% of the ACLR cohort sustained their injuries while playing an organized sport. The MPFLR group had significantly lower HSS Pedi-FABS scores than the ACLR group, suggesting that the MPFLR group had lower preoperative athletic activity levels compared to the ACLR group.

Conclusions:

In this retrospective study, participation in organized sports was associated with 61% of patellar dislocations. Among girls, dance was the second most common sport participated in at the time of patellar dislocation. This suggests that further investigation into injury prevention strategies for adolescent female dancers is warranted.

Level of Evidence:

Level III: Retrospective therapeutic study.

Keywords

patellar dislocation pediatrics sports injury prevention activity

Introduction

The importance of studying knee injury rates in youth sports is underscored by the rising number of patellar dislocations reported in adolescents.^1,2 This trend is frequently attributed to increased participation in youth sports; in fact, peak incidence for patellar dislocation is reported to be during adolescence.^3–5 While there are several pathoanatomical risk factors for patellar instability⁶ in growing athletes, factors such as growth spurts, changes in body composition, and decreased complex motor skills are thought to contribute to increased risk.^7,8 The advancement of surgical techniques has led to increased rates of patellar stabilization surgery, specifically medial patellofemoral ligament reconstruction (MPFLR), in adolescents, resulting in improved knee stability and outcomes.^1,9

The mechanism of injury, the loss of knee stability, and the resultant decrease in function after patellar dislocation are similar to those seen in adolescents after anterior cruciate ligament (ACL) tears.¹⁰ Both injuries require prolonged time off from sports, extensive rehabilitation, and increased risk of future arthritis.^11,12 However, while there is a growing body of evidence on the epidemiology of and injury prevention methods for athletes with ACL injuries, there are fewer studies on patellar dislocations. Investigating the preoperative activity and sports participation of patients who undergo an MPFLR may allow for the identification of tailored prevention programs for particularly high-risk activities.

This study aimed to explore the characteristics of adolescent patients who underwent an MPFLR and compare this group to age- and sex-matched patients who underwent an ACL reconstruction (ACLR).

Methods

After Institutional Review Board approval, we retrospectively reviewed routinely collected preoperative medical records of patients who underwent either an MPFLR (defined as undergoing CPT code 27427 with a linked diagnosis of patellar instability) or an ACLR (defined as undergoing CPT code 29888) by 1 of 2 fellowship-trained pediatric sports medicine orthopedic surgeons at a single institution between February 1, 2016, and April 15, 2023. Patients were excluded if they were syndromic patellofemoral dislocators or if they did not complete a baseline preoperative Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) questionnaire within 3 months before surgery.

A total of 912 patients were identified (471 MPFLR patients and 441 ACLR patients), and 540 patients met the final inclusion and exclusion criteria (Figure 1). A total of 228 MPFLR participants were successfully matched to 228 ACLR participants. MPFLR participants were matched to the ACLR participants based on sex and age within 1 year at the time of surgery. The mean age of the study cohort was 14.8 ± 2.1 years (MPFLR: 14.8 ± 2.1 years, ACLR: 14.8 ± 2.0 years), and 53% were female (Table 1).

Figure 1.

Diagram demonstrating inclusion and exclusion criteria for final MPFLR and ACLR cohorts.

Table 1.

Data for the matched MPFLR and ACLR Patients (n = 456).

Characteristic	MPFLR (n = 228)	ACLR (n = 228)	All Patients (n = 456)
Mean ± SD
Age at Surgery	14.8 ± 2.1	14.8 ± 2.0	14.8 ± 2.1
N (%)
Sex
Female	121 (53)	121 (53)	242 (53)
Male	107 (47)	107 (47)	214 (47)
Injury During Sport	139 (61)	215 (94)	354 (78)
Median (IQR)
HSS Pedi-FABS	16.0 (22.0)	23.0 (23.0)	18.00 (24.0)
PROMIS Pain Interference	53.6 (13.6)	52.1 (10.5)	52.7 (12.1)
PROMIS Mobility	35.3 (12.1)	35.1 (7.3)	35.3 (9.1)
Pedi-IDKC	45.7 (28.3)	46.4 (19.5)	46.0 (22.4)

Abbreviations: ACLR, anterior cruciate ligament reconstruction; HSS Pedi-FABS, Hospital for Special Surgery Pediatric Functional Activity Brief Scale; IQR, interquartile range; MPFLR, medial patellofemoral ligament reconstruction; PROMIS, Patient-Reported Outcomes Measurement Information System.

For patients who had multiple surgeries, the baseline HSS Pedi-FABS for their first surgery was used. Pediatric International Knee Documentation Committee (Pedi-IKDC), Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Pain Interference, and pediatric mobility were also collected. Demographics and activity during the time of injury for all matched participants were gathered.

A Shapiro-Wilk Test for normality was performed for all variables. Normally distributed continuous variables are represented as means and standard deviations, and non-normally distributed continuous variables are represented as medians and interquartile ranges. An independent sample Mann-Whitney U test was performed to compare baseline HSS Pedi-FABS, PROMIS Pain Interference, PROMIS Mobility, and Pedi-IKDC scores between MPFLR and ACLR participants. Two-tailed statistical significance was set to P ≤ .05. The data are reported according to the reporting of studies conducted using observational routinely collected health data (RECORD) checklist.

Results

We found that 61% of patients in the MPFLR cohort and 94% in the ACLR cohort sustained their injury during organized sports. The MPFLR group had significantly lower HSS Pedi-FABS scores than the ACLR group (MPFLR: median = 16.0, ACLR: median = 23.0, P < .001; Figure 2), suggesting that the MPFLR group had lower preoperative athletic activity levels compared to the ACLR group. The most common sports participation at the time of injury was soccer. The variety of sports participants engaged in is documented in Table 2. Injury mechanisms for patellar dislocation sustained outside of sports included activities of daily living (standing, walking, and descending stairs), non-sport-related physical activities (gym class, running and jumping, and horseplaying), and falls. There were no significant differences in PROMIS Pain Interference (P = .054), PROMIS Mobility (P = .730), and Pedi-IKDC (P = .247) between the MPFLR group and the ACLR group (Table 3).

Figure 2.

Distribution of baseline HSS Pedi-FABS scores between MPFLR and ACLR patients. Adolescents who underwent MPFLR had significantly lower baseline HSS Pedi-FABS scores compared to the ACLR cohort (median score 16 vs. 23, p < .001).

Table 2.

The Most Common Types of Sports Participation at the Time of Injury.

MPFL Injury		ACL Injury
Males	Females	Males	Females
Basketball (n = 19)	Soccer (n = 14)	Soccer (n = 23)	Soccer (n = 44)
Football (n = 14)	Dance (n = 11)	Football (n = 20)	Basketball (n = 17)
Soccer (n = 9)	Basketball (n = 8)	Basketball (n = 18)	Lacrosse (n = 14)
Wrestling (n = 4)	Volleyball (n = 6)	Lacrosse (n = 15)	Skiing (n = 13)
Baseball (n = 4)	Cheerleading (n = 3) Gymnastics (n = 3)	Skiing (n = 6)	Gymnastics (n = 4)

Abbreviations: ACL, anterior cruciate ligament; MPFL, medial patellofemoral ligament.

Table 3.

Comparison of Baseline PROMs Between Matched MPFLR and ACLR Patients (n = 456).

Patient-reported outcome measure	MPFLR (n = 228)	ACLR (n = 228)	P-Value
HSS Pedi-FABS	16.0 (22.0)	23.0 (23.0)	<.001^*
PROMIS Pain Interference	53.6 (13.6)	52.1 (10.5)	.054
PROMIS Mobility	35.3 (12.1)	35.1 (7.3)	.730
Pedi-IDKC	45.7 (28.3)	46.4 (19.5)	.247

Abbreviations: ACLR, anterior cruciate ligament reconstruction; HSS Pedi-FABS, Hospital for Special Surgery Pediatric Functional Activity Brief Scale; MPFLR, medial patellofemoral ligament reconstruction; PROMIS, Patient-Reported Outcomes Measurement Information System ; Pedi-IKDC, The Pediatric International Knee Documentation Committee.

All values are reported as Median (Interquartile Range).

P ≤ .05

Discussion

Among adolescent patients undergoing MPFL or ACLR, organized sports accounted for 61% of patellar dislocations and 94% of ACL tears. This is consistent with previous studies reporting that 51% to 61% of patellar dislocations occur during sports participation.^5,13 In females who sustained injuries during sports, soccer was the most common sport at the time of either patellar dislocation or ACL tear. In males, soccer, basketball, and football were the three most common sports played at the time of either patellar dislocation or ACL tear. The results are consistent with prior studies reporting level 1 (jumping, hard cutting, and pivoting) sports to have high rates of patellar dislocations^2,5,14 and ACL injuries.^15,16 In this study population, dance was the second most common sport in which females sustained a patellar dislocation. This finding is similar to a prior study that also reported dance to be one of the common sports participated in by patients who underwent patellar stabilization surgery.¹⁴

While the current study had a large sample, there are several limitations to this study. First, due to the retrospective nature of the study, we were limited to the existing data. Because this data did not track first vs recurrent dislocation, we were unable to consider this issue. Second, this study included patients who underwent surgery. While MPFL reconstruction and ACLR may be used as a surrogate for patellar dislocations and ACL tears, our study did not include patients who sustained less severe injuries and did not require surgical intervention. Moreover, since patients with recurrent patellar instability frequently wait longer for surgery than those with ACL tears, there may be patients who were not captured in this study simply because they had not yet undergone surgery. Finally, all patients in this study originated from a single, urban, academic medical center whose population may not be widely representative. A larger cohort including diverse geographic and socioeconomic groups would permit further generalizability.

While much attention has focused on ACL prevention programs, very little effort has been directed to prevent patellar dislocations—despite the increased incidence in the adolescent population. Nonetheless, the effectiveness of ACL injury prevention programs in cutting and pivoting sports is well documented.^17,18 Specifically, in adolescent girls, neuromuscular training has been reported to reduce noncontact ACL injury rates by 53% to 88% in soccer and basketball.^18–21 Patellar dislocations often occur as a noncontact injury while pivoting with the knee in slight flexion and a valgus force, similar to ACL injuries.^2,22–24 While not classically considered a cutting and pivoting sport, dance requires pivoting on one leg and landing jumps and leaps. Moreover, the presence of joint hypermobility has been identified in many young dancers;^25,26 this is a risk factor for patellar dislocation.⁶ Injury prevention for adult professional ballet dancers focused on proximal stabilization, leg strengthening, and neuromuscular control has been shown to be effective in reducing lower extremity injury rates,²⁷ but there is little evidence on the risk of patellar dislocation or effective prevention strategies in adolescent dancers. The identification of dance as a high-risk sport for patellar dislocation may inspire the investigation of injury prevention strategies for adolescent dancers.

While there were no differences between the groups in the knee or overall physical function as quantified by the Pedi-IKDC and PROMIS mobility or pain-interference scores, the MPFLR group reported significantly lower preoperative athletic activity levels as suggested by the HSS Pedi-FABS. One possible explanation for this is the time from injury to surgery. Previous reports have found that patients with patellar dislocation wait five times longer for surgery despite similar limitations of knee function.²⁸ In contrast, most patients with an ACL tear undergo reconstruction within weeks after their injury to restore knee stability and function and reduce the risk of further injury.²⁹ Since the HSS Pedi-FABS gauges activity during the previous month, it is possible that the MPFLR cohort in our study reported a lower activity score because they had a longer time of activity avoidance after injury. Another explanation for lower activity scores may be attributed to 30% of the MPFLR cohort not being involved in any sport. Patients with patellar dislocation often present with hypermobility, which may deter them from pursuing athletic activity due to generalized instability and pain.³⁰ Although sports participation is a choice, this group of patients may benefit from education on joint protection strategies and exposure to a variety of safe physical activity options for the promotion of health and lifelong physical fitness. While the current study highlights characteristics of adolescents who underwent MPFL reconstruction, future studies may compare this population to those with a patellar dislocation who did not undergo surgery. Understanding the activity and sports participation characteristics of patients with patella dislocation who underwent surgery and those who did not may help inform the surgical decision-making process.

In conclusion, this retrospective study found that among adolescents who underwent MPFLR or ACLR, participation in organized sports was associated with 61% of patellar dislocations and 94% of ACL tears. The MPFLR group reported significantly lower preoperative athletic activity levels than the ACLR group. Dance was identified as the second most common sport at the time of patellar dislocation injury in girls, unique to the MPFLR cohort. This finding warrants further investigation into injury prevention strategies for girls participating in dance.

Supplemental Material

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Supplemental material, sj-docx-1-hss-10.1177_15563316251372594 for Unique Activity Characteristics of Adolescents With Patellar Dislocations: A Retrospective Review at a Single Institution by Danielle E. Chipman, Yukiko Matsuzaki, Gabrielle Dykhouse, Preston W. Gross, Peter M. Cirrincione, Ruth H. Jones, Peter D. Fabricant and Daniel W. Green in HSS Journal®

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Supplemental material, sj-docx-5-hss-10.1177_15563316251372594 for Unique Activity Characteristics of Adolescents With Patellar Dislocations: A Retrospective Review at a Single Institution by Danielle E. Chipman, Yukiko Matsuzaki, Gabrielle Dykhouse, Preston W. Gross, Peter M. Cirrincione, Ruth H. Jones, Peter D. Fabricant and Daniel W. Green in HSS Journal®

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Supplemental material, sj-docx-7-hss-10.1177_15563316251372594 for Unique Activity Characteristics of Adolescents With Patellar Dislocations: A Retrospective Review at a Single Institution by Danielle E. Chipman, Yukiko Matsuzaki, Gabrielle Dykhouse, Preston W. Gross, Peter M. Cirrincione, Ruth H. Jones, Peter D. Fabricant and Daniel W. Green in HSS Journal®

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Supplemental material, sj-docx-8-hss-10.1177_15563316251372594 for Unique Activity Characteristics of Adolescents With Patellar Dislocations: A Retrospective Review at a Single Institution by Danielle E. Chipman, Yukiko Matsuzaki, Gabrielle Dykhouse, Preston W. Gross, Peter M. Cirrincione, Ruth H. Jones, Peter D. Fabricant and Daniel W. Green in HSS Journal®

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Supplemental material, sj-docx-9-hss-10.1177_15563316251372594 for Unique Activity Characteristics of Adolescents With Patellar Dislocations: A Retrospective Review at a Single Institution by Danielle E. Chipman, Yukiko Matsuzaki, Gabrielle Dykhouse, Preston W. Gross, Peter M. Cirrincione, Ruth H. Jones, Peter D. Fabricant and Daniel W. Green in HSS Journal®

Footnotes

ORCID iDs

Yukiko Matsuzaki, PT, DPT, SCS

Gabrielle Dykhouse

Peter D. Fabricant

Consent to Participate

Informed consent was waived from all participants included in this study by the IRB at the Hospital for Special Surgery (IRB Approval: 2023-0650).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Peter D. Fabricant, MD, MPH, declares relationships with BICMD, Clinical Orthopaedics and Related Research, Osso VR, and Springer. Daniel W. Green, MD, MS, FACS, FAAP, declares relationships with Arthrex, Pega Medical, and Synthes. The other authors declare no potential conflicts of interest.

Supplemental Material

Supplemental material for this article is available online.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration.

Required Author Forms

Disclosure forms provided by the author are available with the online version of this article as supplemental material.

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