Is surgery more effective than bracing in children with acute first-time lateral patella dislocation?

Children with a first-time acute lateral patella dislocation who are treated surgically have fewer dislocations in the subsequent 2 years than those who are treated with knee braces. (LOE = 2b)

Askenberger M, Bengtsson Mostrom E, Ekstrom W, et al. Operative repair of medial patellofemoral ligament injury versus knee brace in children with an acute first-time traumatic patellar dislocation: a randomized controlled trial. Am J Sports Med 2018;46(10):2328-2340.  [PMID:29847145]

Randomized controlled trial (nonblinded)

Foundation

Concealed

Outpatient (specialty)

These surgeons conducted a randomized controlled trial of knee bracing (n = 37) or surgical intervention (n = 37) in skeletally immature children (aged 9 to 14 years) with a first-time lateral patella dislocation less than 2 weeks before enrollment. To confirm the diagnosis, the children needed to have 3 of the following 4 MRI findings: hemarthrosis, edema at the medial patellofemoral ligament, bone bruise of the medial patella, and bone bruise of the lateral femoral condyle. All children underwent a diagnostic arthroscopy. The randomization occurred during this diagnostic procedure. Based on this initial assessment, it is unclear why the study was unmasked. The researchers could have easily copied other studies that used sham interventions in a masked fashion. The children randomized to receive knee bracing wore the brace day and night for 4 weeks, were allowed full weight bearing, and underwent physical therapy. The surgically treated children wore a soft cast for 4 weeks, were allowed full weight bearing, and also underwent physical therapy. After 2 years, using intention-to-treat analysis, the authors report that 16 (43%) of the brace-treated children had another dislocation compared with 8 (22%) of the surgically treated patients (number needed to treat = 5; 95% CI 3 - 340). However, there was no meaningful difference in quality of life or function, and satisfaction was high in each group. The authors do not report on any negative consequences of each treatment.