Physeal-Sparing Soft Tissue Realignment in Pediatric Patellofemoral Instability Patients: A Review of Treatment Options and Outcomes

Overview

Journal J Clin Med

Specialty General Medicine

Date 2025 Feb 26

PMID 40004647

Authors

Christian F Zirbes

Alyssa Henriquez

Alaowei Amanah

Aaron D Therien

Sebastian Perez-Espina

Emilie Dorrestein

Diana Zheng

Jason Lilly

Emily J Luo

Michael A Fox

Brian C Lau

Affiliations

Soon will be listed here.

Abstract

Patellofemoral instability is a common condition in children, with an annual incidence of approximately 50 cases per 100,000 children. Instability of the patella involves a number of structures, such as the medial patellofemoral ligament and the vastus medialis obliquus, which can be used for patellar realignment in soft tissue, physeal-sparing procedures. In this rapid review, we aim to review the surgical interventions, post-operative outcomes, and associated surgical complications of global soft tissue procedures in the management of patellofemoral instability. A search of the Medline database was conducted to identify studies evaluating the treatment and outcomes of global treatment of pediatric patellofemoral instability. The included studies analyzed the surgical management of patellofemoral instability in pediatric patients, utilizing soft tissue global procedures and reported functional outcomes, return to sport or play, and post-operative complications. A total of eight studies were included, comprising a cohort of 270 pediatric and adolescent patients and 334 knees. The average patient age was 10.6 years, with 60.4% (163/270) patients being female, and the mean follow-up duration was 58.4 months. Of the eight studies, two examined the three-in-one procedure, three examined the four-in-one procedure, one examined a combination of medial and lateral release, and two examined the Galeazzi procedure. This review underscores the variety of global physeal-sparing surgical procedures available for treating patellofemoral instability. While outcomes are generally favorable, with high rates of return to sport, recurrent residual instability and recurrent dislocation remain significant challenges, with residual instability affecting nearly half of patients. Future research should focus on exploring long-term outcomes, optimizing patient selection, and identifying the causes of recurrent instability to further enhance patient outcomes and reduce complication rates.

References

Rueth M, Koehl P, Schuh A, Goyal T, Wagner D . Return to sports and short-term follow-up of 101 cases of medial patellofemoral ligament reconstruction using gracilis tendon autograft in children and adolescents. Arch Orthop Trauma Surg. 2022; 143(1):447-452. DOI: 10.1007/s00402-022-04365-w. View

Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J . Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003; 73(9):712-6. DOI: 10.1046/j.1445-2197.2003.02748.x. View

Mao Y, Li J, Li Y, Zhu J, Xiong Y, Li J . A Combined Surgical Approach for Recurrent Patellar Dislocation in Adolescents With Patella Alta and Increased Tibial Tuberosity-Trochlear Groove Distance: Improved Clinical Outcomes but Decreased Posterior Tibial Slopes in Skeletally Immature.... Arthroscopy. 2023; 40(5):1529-1540. DOI: 10.1016/j.arthro.2023.09.001. View

Trisolino G, Depaoli A, Gallone G, Ramella M, Olivotto E, Zarantonello P . A 20-Year Retrospective Study of Children and Adolescents Treated by the Three-in-One Procedure for Patellar Realignment. J Clin Med. 2023; 12(2). PMC: 9861102. DOI: 10.3390/jcm12020702. View

Beasley L, Vidal A . Traumatic patellar dislocation in children and adolescents: treatment update and literature review. Curr Opin Pediatr. 2004; 16(1):29-36. DOI: 10.1097/00008480-200402000-00007. View

Li M, Wang F, Ji G, Liu F, Fan C, Yang G . Combined medial and lateral patellar retinaculum plasty for skeletally immature patients with patellar dislocation and low-grade trochlear dysplasia. Knee. 2019; 27(1):9-17. DOI: 10.1016/j.knee.2019.11.019. View

Parikh S, Lopreiato N, Veerkamp M . 4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children. J Pediatr Orthop. 2023; 43(4):237-245. DOI: 10.1097/BPO.0000000000002351. View

Leite C, Hinckel B, Ribeiro G, Giglio P, Santos T, Bonadio M . Medial patellofemoral ligament reconstruction in skeletally immature patients without correction of bony risk factors leads to acceptable outcomes but higher failure rates. J ISAKOS. 2023; 8(3):189-196. DOI: 10.1016/j.jisako.2023.02.003. View

Monaco E, Criseo N, Annibaldi A, Carrozzo A, Pagnotta S, Cantagalli M . Medial Patellofemoral Ligament Reconstruction Using Gracilis Tendon Graft and "All Suture" Knotless Anchors for Patellar Fixation. Arthrosc Tech. 2024; 12(12):e2329-e2334. PMC: 10773230. DOI: 10.1016/j.eats.2023.08.002. View

10.

Alm L, Krause M, Mull C, Frosch K, Akoto R . Modified adductor sling technique: A surgical therapy for patellar instability in skeletally immature patients. Knee. 2017; 24(6):1282-1288. DOI: 10.1016/j.knee.2017.08.051. View

11.

Shea K, Styhl A, Jacobs Jr J, Ganley T, Milewski M, Cannamela P . The Relationship of the Femoral Physis and the Medial Patellofemoral Ligament in Children: A Cadaveric Study. Am J Sports Med. 2016; 44(11):2833-2837. DOI: 10.1177/0363546516656366. View

12.

Kumar N, Bastrom T, Dennis M, Pennock A, Edmonds E . Adolescent Medial Patellofemoral Ligament Reconstruction: A Comparison of the Use of Autograft Versus Allograft Hamstring. Orthop J Sports Med. 2018; 6(5):2325967118774272. PMC: 5971386. DOI: 10.1177/2325967118774272. View

13.

Lind M, Enderlein D, Nielsen T, Christiansen S, Fauno P . Clinical outcome after reconstruction of the medial patellofemoral ligament in paediatric patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc. 2014; 24(3):666-71. DOI: 10.1007/s00167-014-3439-x. View

14.

Schlichte L, Sidharthan S, Green D, Parikh S . Pediatric Management of Recurrent Patellar Instability. Sports Med Arthrosc Rev. 2019; 27(4):171-180. DOI: 10.1097/JSA.0000000000000256. View

15.

Husen M, Milbrandt T, Shah V, Krych A, Stuart M, Saris D . Medial Patellofemoral Ligament Reconstruction Using Allografts in Skeletally Immature Patients. Am J Sports Med. 2023; 51(6):1513-1524. DOI: 10.1177/03635465231164400. View

16.

Nelitz M, Dreyhaupt J, Reichel H, Woelfle J, Lippacher S . Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents with open growth plates: surgical technique and clinical outcome. Am J Sports Med. 2012; 41(1):58-63. DOI: 10.1177/0363546512463683. View

17.

Kalinterakis G, Vlastos I, Gianzina E, Dimitriadis S, Mastrantonakis K, Chronopoulos E . MPFL Reconstruction in Skeletally Immature Patients: Comparison Between Anatomic and Non-Anatomic Femoral Fixation-Systematic Review. Children (Basel). 2024; 11(11). PMC: 11592832. DOI: 10.3390/children11111275. View

18.

Abouelsoud M, Abdelhady A, Elshazly O . Anatomic physeal-sparing technique for medial patellofemoral ligament reconstruction in skeletally immature patients with ligamentous laxity. Eur J Orthop Surg Traumatol. 2015; 25(5):921-6. DOI: 10.1007/s00590-015-1618-1. View

19.

Quinlan N, Tomasevich K, Mortensen A, Hobson T, Adeyemi T, Metz A . Medial Patellofemoral Ligament Reconstruction in the Pediatric Population: Skeletal Immaturity Does Not Affect Functional Outcomes but Demonstrates Increased Rate of Subsequent Knee Injury. Arthrosc Sports Med Rehabil. 2022; 4(5):e1589-e1599. PMC: 9596869. DOI: 10.1016/j.asmr.2022.05.007. View

20.

Nelitz M, Dornacher D, Dreyhaupt J, Reichel H, Lippacher S . The relation of the distal femoral physis and the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc. 2011; 19(12):2067-71. DOI: 10.1007/s00167-011-1548-3. View