Abstract
Background:
Patellofemoral instability (PFI) is a significant cause of knee dysfunction in children and adolescents, often requiring surgery when conservative treatment fails. Literature suggests that surgical approaches for PFI in this population have evolved in recent decades. This study aimed to 1) evaluate nationwide trends in the timing and type of surgical interventions to treat PFI and 2) compare complication rates between interventions.
Hypothesis:
Utilization of medial patellofemoral ligament reconstruction (MPFLR)-based procedures has increased over time and is associated with lower complication rates compared to other surgical treatments for pediatric PFI.
Methods:
A retrospective analysis of a large national administrative claims database (PearlDiver) identified pediatric patients (≤18 years old) who underwent surgery for PFI between 2010 and 2022. Procedures were cohorted as MPFLR with and without tibial tubercle osteotomy (TTO) or other primary stabilization techniques (including MPFLR and repair of dislocating patellar procedures with proximal or distal realignment). Trends in the incidence (procedures/million patients) and distribution of these procedures were assessed. Patients with ≥1 year follow-up were analyzed for complications requiring surgical treatment, including infection, arthrofibrosis, patellar fracture, and growth arrest. Statistical analyses included Student t-tests, chi-square tests, and linear regression, with significance set at p<0.05.
Results:
Among 365,031 pediatric patients with PFI, 5,204 underwent surgical intervention, and 4,635 had ≥1 year follow-up. Patients aged 15-18 comprised the majority of surgical patients (72.5%), followed by those aged 10-14 (26.4%). Mean age at surgery remained stable overall, but trended downward for MPFL (p=0.007) and other stabilization procedures (p=0.003). From 2010 to 2022, the population-normalized incidence of MPFLR (p<0.001) and MPFLR+TTO (p<0.001) increased, while other stabilization procedures declined (p<0.001). Patellar fractures occurred more frequently in other stabilization procedures (9.0%) compared to MPFLR (5.2%) and MPFLR+TTO (1.6%) (p<0.001). Infection rates were higher in other procedures at both 30 days (p=0.013) and 90 days (p=0.049) but not at 1 year (p=0.235). There were no differences in arthrofibrosis (p=0.553) or growth arrest (p=0.520). Overall, MPFLR (8.3%) and MPFLR+TTO (3.1%) had lower complication rates compared to other procedures (11.6%) (p<0.001).
Conclusion:
MPFLR, with or without TTO, has become the leading surgical approach for treating PFI in pediatric patients. Its increasing utilization over the past decade reflects growing acceptance as a safe and effective option, with low rates of serious complications requiring return to the operating room observed across all procedures. These findings offer valuable insight for risk-related counseling and surgical decision-making in this population.
