Cochrane Database of Systematic Reviews (Reviews) || -- Hing, Caroline B -- 2011

Surgical versus non-surgical interventions for treating patellar
dislocation (Review)
Hing CB, Smith TO, Donell S, Song F
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2011, Issue 11
http://www.thecochranelibrary.com
Surgical versus non-surgical interventions for treating patellar dislocation (Review)

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Analysis 1.1. Comparison 1 Surgical versus non-surgical management. Recurrent instability episodes, Outcome 1 Number
of participants sustaining recurrent patellar dislocation. . . . . . . . . . . . . . . . . . . . 28
of participants sustaining recurrent patellar subluxation. . . . . . . . . . . . . . . . . . . . 29
of participants sustaining any episode of instability. . . . . . . . . . . . . . . . . . . . . . 30
of participants who underwent subsequent surgery (five to seven year follow-up). . . . . . . . . . . 31
Analysis 2.1. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes, Outcome 1 Kujala
patellofemoral disorder score (0: worst outcome to 100: best outcome). . . . . . . . . . . . . . . 32
Analysis 2.2. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes, Outcome 2 Hughston
VAS patellofemoral score (28 to 100: best outcome). . . . . . . . . . . . . . . . . . . . . 33
Analysis 2.3. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes, Outcome 3 Tegner
activity score (over 2 year follow-up). . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analysis 2.4. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes, Outcome 4 KOOS at
two year follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Analysis 2.5. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes, Outcome 5 Lysholm
score (0 to 100: best score) at two year follow-up. . . . . . . . . . . . . . . . . . . . . . 35
Analysis 2.6. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes, Outcome 6 Knee
pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Analysis 2.7. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes, Outcome 7 Patient
satisfaction (reported good or excellent). . . . . . . . . . . . . . . . . . . . . . . . . . 37
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 43
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Surgical versus non-surgical interventions for treating patellar dislocation (Review) i

[Intervention Review]
Surgical versus non-surgical interventions for treating patellar

dislocation
Caroline B Hing1 , Toby O Smith2 , Simon Donell3 , Fujian Song3
1 Department of Trauma & Orthopaedic Surgery, Watford General Hospital, Watford, UK. 2 School of Allied Health Professions,
University of East Anglia, Norwich, UK. 3 School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
Contact address: Caroline B Hing, Department of Trauma & Orthopaedic Surgery, Watford General Hospital, Vicarage Road, Watford,
WD18 0HB, UK. CaroH2712@aol.com.
Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.

Publication status and date: Edited (no change to conclusions), comment added to review, published in Issue 1, 2012.
Review content assessed as up-to-date: 16 August 2010.
Citation: Hing CB, Smith TO, Donell S, Song F. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane
Database of Systematic Reviews 2011, Issue 11. Art. No.: CD008106. DOI: 10.1002/14651858.CD008106.pub2.
ABSTRACT
Background
Patellar dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. Following reduction of the
dislocation, conservative rehabilitation with physiotherapy may be used. Since recurrence of dislocation is common, some surgeons
have advocated surgical intervention in addition to rehabilitation.
Objectives
The purpose of this review was to assess the clinical and radiological outcomes of surgical, compared with non-surgical, interventions
for treating people with primary or recurrent patellar dislocation.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group’s Specialised Register, the Cochrane Central Register of Controlled
Trials (The Cochrane Library), MEDLINE, EMBASE, AMED, CINAHL, ZETOC, Physiotherapy Evidence Database (PEDro), and
a variety of other literature databases and trial registries. Corresponding authors were contacted to identify additional studies. Date
searched: August 2010.
Selection criteria
Eligible for inclusion were randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interven-
tions for treating lateral patellar dislocation.
Data collection and analysis
Two reviewers independently examined titles and abstracts of each identified study to assess study eligibility, extract data and assess risk
of bias. Primary outcomes assessed were the frequency of recurrent dislocation, and validated patient-rated knee or physical function
scores. When appropriate, data were pooled. Risk ratios were calculated for dichotomous outcomes, and mean differences for continuous
outcomes.
Surgical versus non-surgical interventions for treating patellar dislocation (Review) 1
Main results
Five studies (339 participants) were included. All studies had methodological shortcomings, especially the two quasi-randomised trials
that presented a high risk for selection bias. Follow-up was a minimum of two years in two studies and between five and seven years
in three studies. There was no significant difference between surgical and non-surgical management of primary (first-time) patellar
dislocation in the risk of recurrent dislocation (47/182 versus 53/157; risk ratio 0.81, 95% confidence interval 0.56 to 1.17; 5 trials),
Kujala patellofemoral disorder scores (mean difference 3.13, 95% confidence interval -7.34 to 13.59; 5 trials) nor the requirement
for subsequent surgery (risk ratio 1.09, 95% CI 0.72 to 1.65; 3 trials). Adverse events were reported by one trial, citing four major
complications that occurred in the surgical group. No randomised controlled trials have assessed populations with recurrent patellar
dislocation.
Authors’ conclusions
There is insufficient high quality evidence to confirm any significant difference in outcome between surgical or non-surgical initial
management of people following primary patellar dislocation, and none examining this comparison in people with recurrent patellar
dislocation. Adequately powered randomised, multi-centre controlled trials, conducted and reported to contemporary standards are
recommended.
PLAIN LANGUAGE SUMMARY
Operation versus physiotherapy alone following patellar dislocation
The patella or knee cap is a lens shaped bone situated at the front of the knee. It is incorporated into the tendon of the quadriceps
muscles of the thigh and moves within a groove at the lower end of the thigh bone (femur). Patellar dislocation occurs when the patella
completely moves out of this groove. It commonly occurs in young and physically active people, often during sporting activities.
When the patella dislocates, injury to the soft tissues of the knee joint occurs, which requires a period of rehabilitation. This may
include treatments such as immobilisation and bracing to limit knee movement, exercises, manual therapy, taping and electrotherapeutic
modalities. Some surgeons have suggested that people may have a better outcome if surgical procedures repairing or reconstructing the
injured soft tissues, or carrying out other procedures to restrain the knee cap from dislocating again.
This Cochrane review included five studies (339 participants) which have looked at the results of surgery compared with non-surgical
treatment alone for people who have sustained a knee cap dislocation. All the trial participants were being treated for a primary (first-
time) dislocation. These studies were small and had some weaknesses in their design and conduct.
Based on pooled data from all five studies, the review found no significant differences between surgical and non-surgical management
for risk of recurrent dislocation or in the scores of a condition-related knee outcome measure. The pooled data from three studies
indicated no difference between the treatment groups for the need for subsequent operations. The only study reporting complications
reported that all four treatment complications occurred in the surgical management group.
The review concluded that there was insufficient evidence to confirm a significant difference in outcome between surgical or non-
surgical initial management of people who have sustained a patellar dislocation. Further research is recommended.
Patellar dislocation occurs when the patella disengages completely,

BACKGROUND
from the trochlear (femoral) groove, typically to the lateral side
when the femur rotates internally on the tibia with the foot fixed
on the ground. The patella may spontaneously slip back into its
Description of the condition original position, or require manual reduction to push it back

into place. The term “patellar instability” is used to include both These interventions may be performed separately or in combina-
patellar dislocation and subluxation. tion: the choice of surgical intervention may be determined by the
When the patella dislocates laterally, injury occurs to the soft tis- specific anatomical abnormalities predisposing the individual to
sues of the medial aspect of the knee joint, particularly to the their recurrent instability problem.
medial patello-femoral ligament (Colvin 2008). This predisposes
to subsequent episodes of patellar dislocation or subluxation, and
eventually to degenerative change in the knee joint. As well as in-
jury of the medial capsular structures, a range of anatomical fac- How the intervention might work
tors may predispose to patellar instability; these include variations Conservative treatments including physiotherapy aim to restore
of limb alignment or of architecture/geometry of the patella and knee range of motion, and improve patellar stability with quadri-
lower femur, particularly of the trochlear groove (Hing 2006), or ceps strengthening exercises (Beasley 2004; Cosgarea 2002; Woo
connective tissue laxity. 1998). It has been suggested that one principal cause of recurrent
The term ’primary patellar dislocation’ refers to the first time a patellar dislocation is that of weakness of one of the four mus-
person experiences a patellar dislocation. Its incidence is highest in cles forming the quadriceps, the vastus medialis (Dath 2006). By
young and physically active people in the second and third decades strengthening this muscle, it has been hypothesised that the patella
of life (Buchner 2005; Kiviluoto 1986; Merchant 2007). The an- will track more centrally in the trochlear groove, avoiding a more
nual incidence of primary patellar dislocation has been estimated lateral position that may increase the likelihood of recurrent dis-
at 43 per 100,000 in children under 15 years (Nietosvaara 1994), location and instability symptoms (Donell 2006a).
but the incidence across all age groups is much lower (estimated Range of motion and strengthening exercises are also an integral
at 7 per 100,000 by Atkin 2000). Females are more likely to be part of surgical treatments of patellar dislocation. In addition,
affected than males (Fithian 2004). Recurrent patellar dislocation they offer repair or reconstruction of soft tissues, or procedures to
can occur in 15% to 45% of primary dislocation cases (Cash 1988; deepen the trochlear groove or to realign the patellar tendon, as
Hawkins 1986; Woo 1998). described above, in order to stabilise the patella in a more medial
position. The hypothesis is that adding an appropriate surgical
procedure will be more effective in reducing the recurrent instabil-
ity which may substantially limit functional capabilities and qual-
Description of the intervention ity of life.
Following reduction of the patellar dislocation, people frequently
undergo conservative treatment consisting of physiotherapy and
rehabilitation (Beasley 2004; Boden 1997; Woo 1998). This may Why it is important to do this review
include treatments such as immobilisation and bracing to limit
knee movement, exercises, manual therapy, taping and electrother- Some authors have suggested that surgical intervention should be
apeutic modalities. considered rather than physiotherapy (Boden 1997; Guhan 2009).
Some surgeons also advocate surgical intervention for primary, or Others have recommended that surgical intervention may be no
more frequently, recurrent dislocation (Donell 2006a; Fukushoma better in preventing recurrent dislocation and functional restora-
2004). Such orthopaedic surgical interventions may be loosely tion, when compared with a conservative approach (Mears 2001;
grouped into three types: Nikku 1997a; Palmu 2008a). The purpose of this systematic re-
1. Proximal patellar realignment soft tissue procedures, view is to inform practice through the examination of the evidence
designed to repair or reconstruct the capsular, ligamentous and from randomised trials comparing surgical to non-surgical treat-
tendinous soft tissues on the medial side of the knee which resist ment approaches following patellar dislocation.
lateral dislocation, particularly the medial patellofemoral
ligament (MPFL) (Conlan 1993;Hautamaa 1998). If the lateral
capsular soft tissues appear too tight, they may be incised (lateral
release).
2. Osseous (bony) procedures specifically for trochlear OBJECTIVES
dysplasia (abnormal anatomy): This includes a trochleoplasty
To assess the effects (benefits and harms) of surgical versus non-
where the surgeon constructs a groove in the femur for the
surgical interventions for treating people with primary or recurrent
patella to move within (Dejour 1994; Donell 2006b).
patellar dislocation.
3. Distal patellar realignment procedures. This can include: a
tibial tubercle transfer or Roux-Goldthwaite procedure where the
surgeon alters where the patella attaches onto the tibia (Donell
2006a). METHODS

Criteria for considering studies for this review Secondary outcomes
• Other knee function and activity scores
• Return to former activities: work and sports
• Knee pain
Types of studies
• Complications, e.g. infection
Randomised and quasi-randomised (method of allocating partic- • Range of motion
ipants to a treatment which is not strictly random: e.g. by date • Patient-reported instability symptoms
of birth, hospital record number, alternation) controlled clinical • Patient reported satisfaction
trials (RCTs) evaluating surgical versus non-surgical interventions • Subsequent requirement for surgery
for treating patellar dislocation.
Search methods for identification of studies

Types of participants
People of any age with a reported history of patellar dislocation,
either primary or recurrent, recorded either as a historical account Electronic searches
from the participants, or observed by a health care professional.
Excluded were trials specifically focused on the treatment of ante- We searched the Cochrane Bone, Joint and Muscle Trauma
rior knee pain or patellar subluxation where the patients had not Group’s Specialised Register (October 2010), the Cochrane Cen-
experienced a frank patellar dislocation. tral Register of Controlled Trials (in The Cochrane Library 2010,
Issue 3), MEDLINE (1950 to August Week 5 2010), EMBASE
(1980 to August Week 5 2010), Allied and Complementary
Medicine (AMED) (1985 to August Week 5 2010), Cumulative
Types of interventions Index to Nursing and Allied Health Literature (CINAHL) (1981
Non-surgical intervention, or conservative management, is the to August Week 5 2010), Health Management Information Con-
control intervention in this review. Non-surgical treatment strate- sortium (to August Week 5 2010) and Zetoc (to August Week
gies following patellar dislocation include: a period of immobili- 5 2010). These were accessed through the UK National Health
sation, bracing or splinting, manual therapy, exercise-based treat- Service Health Information Resources website, with the excep-
ments, education and advice, electrotherapeutic modalities and tion of The Cochrane Library which was searched using the Wi-
taping techniques. ley Interscience interface, and MEDLINE and EMBASE which
Surgical treatment strategies include: medial reefing, quadricep- were searched using the Ovid interface. Finally, the Physiotherapy
splasty, lateral release, tibial tubercle transfer, Roux-Goldthwaite Evidence Database (PEDro) was also searched to August Week
procedures, trochleoplasty, medial patellofemoral ligament repair 5 2010. Unpublished or grey literature was reviewed using the
or reconstruction. database OpenSIGLE (System for Information on Grey Litera-
ture in Europe). We searched the WHO International Clinical
Trials Registry Platform, Current Controlled Trials, UKCRN
Types of outcome measures Portfolio Database, National Technical Information Service and
the UK National Research Register Archive for ongoing and re-
The following clinical and radiological outcome measures were cently completed trials up to August Week 5 2010. There were no
assessed: constraints based on language or publication status.
In MEDLINE we combined a subject-specific search with the
Cochrane Highly Sensitive Search Strategy for identifying ran-
Primary outcomes domised trials in MEDLINE (sensitivity-maximizing version)
• Recurrent dislocation (Lefebvre 2008) (see Appendix 1). Details of search strategies for
• Validated patient-rated knee and physical function scores all databases are shown in Appendix 1, and are based on the Scot-
for patellar dislocation outcomes (Paxton 2003): e.g. the tish Intercollegiate Guidelines Network (SIGN) search filters.
Lysholm score (Lysholm 1982), the Tegner activity score (Tegner
1985), the Hughston visual analogue score (VAS) (Flandry
1991), and the Short Form-12 (Ware 1996). Searching other resources
• Specific tool for appraising patella disorders: the Kujala Conference proceedings from the British Orthopaedic Association
score (Kujala 1993) Annual Congress, the British Trauma Society meetings, European
Federation of National Associations of Orthopaedics and Trauma-
Ideally, these would be assessed at least one year after treatment. tology (EFORT) and British Association for Surgery of the Knee

were also searched via the supplements of the Journal of Bone and Unit of analysis issues
Joint Surgery - British Volume. The unit of randomisation in the majority of trials included in this
We searched bibliographies of relevant articles and contacted trial review was the individual participant. Exceptionally, as in the case
investigators in this area. of trials including people with bilateral patellar dislocations, data
for trials may be presented for dislocations or knees rather than
an individual person. Where such unit of analysis issues arose and
appropriate corrections were not made, we presented the data for
Data collection and analysis such trials only when the disparity between the units of analysis
and randomisation was small.
Selection of studies Dealing with missing data

For masking purposes, one author (TS) deleted source and author Corresponding authors were contacted in respect to any missing
information from citations identified by the search strategy before key information from their respective publications. Where appro-
providing the edited download to another author (CH). These priate, we performed intention-to-treat analyses to include all peo-
two authors (TS and CH) then independently selected the poten- ple randomised to the intervention groups. We investigated the
tially eligible articles from citation titles and, if available, abstracts. effect of drop-outs and exclusions by conducting worst and best
Upon obtaining full articles, the same two authors independently scenario analyses. We were alert to the potential mislabelling or
performed the study selection. In cases of disagreement of paper non identification of standard errors and standard deviations. Un-
inclusion/exclusion, a consensus was reached through discussion. less missing standard deviations could be derived from confidence
It was planned that if still not possible, arbitration would be gained interval data, we did not assume values in order to present these
from a third author (SD). in the analyses.
Assessment of heterogeneity
Data extraction and management
We appraised the clinical diversity in terms of participants, inter-
Two authors (TS and CH) independently extracted data from trial
ventions and outcomes for the included studies. Statistical hetero-
reports. We contacted corresponding authors when key informa-
geneity was assessed by visual inspection of the forest plot and by
tion was missing. In cases of disagreement, a consensus was sought
using the I² and Chi² statistical tests.
through discussion or adjudication by a third author (SD). Once
completed, these data were synthesised to form a comprehensive
and agreed data extraction table. This presented all key trial data Assessment of reporting biases
and participant information from the included articles.
Outcome reporting bias was assessed by considering the effects
of missing data on measured outcomes. Had sufficient data been
available (from at least 10 trials), we planned to assess publication
Assessment of risk of bias in included studies bias using funnel plots.
Two authors (TS and CH) independently assessed the risk of bias
of the included studies using The Cochrane Collaboration’s ’Risk
Data synthesis
of bias’ tool (Higgins 2011). Risk of bias was categorised as low,
uncertain or high for each of the included studies. If differences The main characteristics and results of included studies were de-
between the ratings of the two assessors could not be resolved scriptively summarised. When judged appropriate, results from
through discussion, a third author (SD) was asked to adjudicate. individual studies was quantitatively pooled in meta-analyses us-
ing fixed- or random-effects models (depending on the results of
heterogeneity tests) and 95% confidence intervals (CI).
Measures of treatment effect

Treatment effects were measured using risk ratios (RR) for binary Subgroup analysis and investigation of heterogeneity
data and mean differences (MD) for continuous data. Should dif- Where appropriate, short term data and medium term follow-up
ferent scales or tools have been used to measure the same outcome, data were presented under each comparison and pooled as separate
we would have calculated standardised mean differences (SMDs) subgroups allowing tests for subgroup differences.
for continuous data. Ninety-five per cent confidence intervals were Should data become available in a future update, we plan to carry
used throughout. out subgroup analyses to assess the difference in outcome between

participants over the age of 16 years (adults) and those younger age ranged from 13 years (Palmu 2008) to 24.6 years with a total
than 16 years (children); males versus females; those who are hy- mean of 19.5 years (standard deviation (SD) 4.2 years), and in-
permobile versus non-hypermobile, in order to investigate whether cluded 74 males and 109 females. In the non-surgical groups, the
these are important prognostic variables in this patient group. We mean age ranged from 13 years (Palmu 2008) to 24.6 years with
will also assess the outcomes of patients who received treatment a total mean of 19.9 years (SD 4.9 years), and included 81 males
following primary dislocation compared with patients who were and 77 females. Palmu 2008 reported the outcomes of 74 knees
managed after recurrent patellar dislocation. We do not intend to in 71 patients. Given this, the unit of analysis for this study was
analyse the effect of timing of surgery or conservative intervention the knee, and therefore presenting trial data by patellar dislocation
in relation to the time since the patient’s primary patellar disloca- was unavoidable in this instance.
tion. All five studies recruited participants who had sustained a pri-
mary patellar dislocation; none recruited people who had expe-
rienced recurrent or previous patellar dislocations. The diagno-
Sensitivity analysis sis of patellar dislocation was made on the basis of a variety of
Where appropriate, we planned sensitivity analyses to examine different combinations of signs and symptoms made on the ini-
various aspects of trial and review methodology, including inclu- tial clinical examination. These included: patellar dislocation re-
sion of trials at high risk of bias (primarily, lack of allocation con- quiring reduction in three trials (Christiansen 2008; Camanho
cealment) and trials where the population was poorly defined. 2009; Palmu 2008), a history of acute knee trauma in two stud-
ies (Camanho 2009; Nikku 1997; Sillanpaa 2009), intra-articular
haematoma in one study (Christiansen 2008), tenderness on the
medial epicondyle in one study (Christiansen 2008) and a positive
RESULTS lateral patellar apprehension test results in one study (Christiansen
2008). Exclusion criteria included the presence of a large osteo-
chondral fracture, used in three trials (Camanho 2009; Nikku
Description of studies 1997; Sillanpaa 2009), an inability to follow-up the planned treat-
ment regimens (Christiansen 2008), a previously reported patel-
See: Characteristics of included studies; Characteristics of excluded lar dislocation or instability (Camanho 2009; Christiansen 2008;
studies. Nikku 1997; Palmu 2008; Sillanpaa 2009) and prior knee surgery
(Christiansen 2008; Nikku 1997).
Non-surgical management in all studies consisted of initial mobil-
Results of the search
isation in a cast, splint or locked orthosis, followed by active mo-
A total of 1328 references were produced by the search strategy bilisation with physiotherapy. There was variation in the detail of
(see Appendix 1). Two review authors assessed them against the duration of immobilisation and in components of the physiother-
eligibility criteria, identifying a total of 12 studies which appeared apy programmes (see Characteristics of included studies). Whilst
pertinent to the research question. Full texts of these studies were all participants of Christiansen 2008 underwent arthroscopy prior
ordered and five trials were confirmed as satisfying the inclusion to randomisation, this was a diagnostic arthroscopic procedure
criteria and were subsequently included in the review. The remain- and not a therapeutic arthroscopy. Of note in Sillanpaa 2009, all
ing seven studies were not eligible and were excluded from the re- participants in the non-operative group received knee aspiration
view. For further details, please see the Characteristics of included to relieve pain and four underwent arthroscopic removal of an
studies and Characteristics of excluded studies. osteochrondral fragment. Both these studies were included given
the non-corrective nature of these procedures.
Included studies The predominant operative intervention adopted was repair or
reconstruction of the soft tissues of the medial aspect of the knee
Five trials published between 1997 and 2009, all of which were
joint. Both Camanho 2009 and Christiansen 2008 reported that
written in English, were included in the review. Three studies were
all participants solely received a MPFL suture repair. Nikku 1997
conducted in Finland (Nikku 1997; Palmu 2008; Sillanpaa 2009);
reported that all surgically-allocated participants in their trial re-
one study was performed in Brazil (Camanho 2009) and one in
ceived a medial reefing with an MPFL augmentation using ad-
Denmark (Christiansen 2008).
ductor magnus in six participants, or medial reefing with a lateral
Three studies reported randomisation (Camanho 2009;
release in 54 participants. Palmu 2008 reported allocating their
Christiansen 2008; Sillanpaa 2009), and two (Nikku 1997; Palmu
surgical cohort to a suture repair of the MPFL with a combined
2008) were quasi-randomised by odd or even birth year. In total,
lateral release for 32 participants, and a MPFL repair alone for
339 participants were included; 183 people were allocated to the
four participants. Sillanpaa 2009 allocated 14 participants in the
surgical treatment in comparison with 156 randomised to receive
surgical group to receive a combined medial reefing procedure and
the non-surgical interventions. In the surgical groups, the mean

MPFL suture repair; a Roux-Goldthwaite procedure for four par- pain score (Nikku 1997; Sillanpaa 2009).
ticipants, and an arthroscopic repair was also required for an osteo- Participant satisfaction was reported by Nikku 1997 and Palmu
chondral fracture in six people. The post-operative rehabilitation 2008. Nikku 1997 reported a number of functional performance
programmes used in each study was identical to that used in the tests (timed ’figure-of-eight’ running, one leg hop distance, max-
non-operative group, with the exception of Camanho 2009 who, imum number of squat downs in one minute).
rather than immobilising the participants in an inguinal-malleolar Specific reported physical signs with diagnostic relevance to
splint for three weeks, permitted their surgical patients to wear a patellar instability or adverse effects of injury or surgery in-
removable immobiliser for three weeks and to commence passive cluded positive patellar apprehension test (Camanho 2009; Nikku
knee range of motion exercises during this early post-operative 1997), Smillie test results (Camanho 2009), thigh circumference
period. (Nikku 1997; Sillanpaa 2009), knee range of motion (Sillanpaa
Two studies reported only two year minimum follow-up data ( 2009), patellofemoral crepitus (Nikku 1997), prepatellar sensibil-
Camanho 2009; Christiansen 2008), three studies reported data ity (Nikku 1997), and scar sensibility (Nikku 1997).
from follow-up between five to seven years (Nikku 1997; Palmu Sillanpaa 2009 reported MRI presence of patellar and femoral
2008; Sillanpaa 2009). All included studies provided data for the chondral lesions, participant reported outcomes of activity level,
primary outcomes (recurrent dislocation), and a validated health severity of patellofemoral joint osteoarthritis, subjective assess-
related quality of life measure, the Kujala patellofemoral disorders ment of pain and functional knee limitations for stairs, running,
score. Three studies reported the Tegner activity score (Nikku squatting, and pain, and the radiological assessment of sulcus an-
1997; Palmu 2008; Sillanpaa 2009), whilst two studies provided gle, lateral patellofemoral angle, lateral patellar displacement and
data on the Hughston VAS patellofemoral score (Nikku 1997; patellar height (as assessed using the Blackburne-Peel ratio).
Palmu 2008).
There was variation in the definition used for ’instability’. Nikku
1997 included both dislocation and subluxation but as data on Excluded studies
dislocations were also provided, it was possible to calculate the Seven studies were excluded from the review as they were not ran-
number of subluxations. Christiansen 2008 did not report data domised or quasi-randomised trials (see Characteristics of excluded
on subluxation. Palmu 2008 reported no difference between the studies).
groups but did not provide data.
Three studies (Nikku 1997; Palmu 2008; Sillanpaa 2009) reported
the number of participants in each group undergoing reoperation. Risk of bias in included studies
Validated patient-completed scores reported comprised the Knee
Our judgements of the risk of bias in the five included trials are
Injury and Osteoarthritis Outcome Score (KOOS) (Christiansen
summarised in the ’Risk of bias’ graph (Figure 1) and the ’Risk of
2008), Lysholm knee score (Nikku 1997), Hughston VAS knee
bias’ summary (Figure 2). Overall, we assessed the body of evidence
score (Nikku 1997; Palmu 2008), and visual analogue scale (VAS)
as ’unclear’ to ’high risk of bias’.
Figure 1. Risk of bias graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies.

Figure 2. Risk of bias summary: Review authors’ judgements about each risk of bias item for each included
study.

Allocation assessed as at ’high risk of bias’.
Of the five included trials, three (Camanho 2009; Christiansen
2008; Sillanpaa 2009) were assessed as carrying ’unclear’ risk of
Selective reporting
bias for both sequence generation and allocation concealment.
The two quasi-randomised studies (Nikku 1997; Palmu 2008) Nikku 1997, the only study to report adverse events of surgery,
were assessed as carrying ’high risk of bias’ for both sequence gen- was assessed as ’low risk of bias’ in this domain. All other studies
eration and allocation concealment. were assessed as at ’unclear’ risk.
Effects of interventions
Blinding
None of the studies reviewed blinded their assessors to treatment
Primary outcomes
allocation. Due to the design of these studies, and the topic under
investigation, it would have been very difficult, if not impossible, to
Recurrent dislocation
blind treating clinicians to treatment allocation, or participants to
their allocation intervention. All were assessed as carrying ’unclear’ All five studies reported the findings of the frequency of recur-
risk of bias, with the exception of Christiansen 2008 which was rent dislocation after surgery compared with non-surgical inter-
assessed at high risk of bias, as the study report clearly states that ventions.
the control group ’received no further treatment or brace usage’. Pooling of data from all five trials showed no significant difference
between surgical and non surgical management (47/182 versus
53/157; RR 0.81, 95% CI 0.56 to 1.17; Analysis 1.1; Figure 3).
Incomplete outcome data There was no significant difference in the risk ratio between the
Small losses to follow-up, assessed as carrying ’unclear risk of bias’ minimum two year and five to seven year follow-up periods (test
were reported in all but one study (Camanho 2009) which was for subgroup differences: Chi² = 0.32, df = 1 (P = 0.57), I² = 0%).
Figure 3. Forest plot of comparison 1. Surgical versus non-surgical management. Outcome: 1.1 Number of
participants sustaining recurrent patellar dislocation.
Figure 4) showed no difference between treatment groups (MD

Kujala patello-femoral disorder score
3.13, 95% CI -7.34 to 13.59). However, this pooled analysis and
The Kujala patellofemoral disorder score (100 point scale) was its subgroups exhibit substantial heterogeneity. There was a sig-
evaluated in all five studies. Overall, pooled data (Analysis 2.1,
nificant difference between the effect size between minimum two
year results and five to seven year results (test for subgroup differ-
ences: Chi² = 5.29, df = 1 (P = 0.02), I² = 81.1%).
Figure 4. Forest plot of comparison 2. Surgical versus non-surgical management. Patient reported
outcomes. Outcome: 2.1 Kujala patellofemoral disorder score (2 years or more follow-up).
Secondary outcomes
Hughston VAS patellofemoral score
The Hughston VAS patellofemoral score was evaluated in two
studies (Nikku 1997; Palmu 2008). The pooled data (Analysis 2.2) Other knee function and activity scores
demonstrated a difference between the treatment groups (MD - Nikku 1997 conducted performance tests consisting of timed ’fig-
4.07, 95% CI -7.85 to -0.29). ure-of-eight’ running, one leg hop distance, maximum number of
squat downs in one minute, reporting a significantly better squat
result (P = 0.03) and superior timed ’figure-of-eight’ run perfor-
Other validated patient-rated knee and physical function
mance (P = 0.004) in the adults in the non-surgical group com-
scores
pared with the surgery group. There was, however, no statistically
Three trials reported the Tegner activity score. Pooled data from significant difference in one-leg hop quotient between the inter-
Nikku 1997, Palmu 2008 and Sillanpaa 2009 showed no statisti- ventions (P = 0.8). Patient reported outcomes of activity level were
cally significant difference between groups (MD = -0.46, 95% CI evaluated in Sillanpaa 2009. They reported that there was no sta-
-0.96 to 0.05; P = 0.08; Analysis 2.3). tistically significant difference in the subjective assessment of pain
The Knee Injury and Osteoarthritis Outcome Score (KOOS) was and functional knee limitations for stairs, running and squatting
assessed by Christiansen 2008, who found small non-significant (P > 0.05).
differences between surgical and non-surgical intervention groups
at two years in respect to the KOOS symptoms, pain, ADL, sports
and recreation or quality of life subsections (P > 0.05). The results Return to pre-injury activities
from this analysis are presented in Analysis 2.4. Sillanpaa 2009 reported no statistically significant difference be-
Finally, the Lysholm knee score was reported by Nikku 1997, who tween their surgical and non-surgical groups in respect to the fre-
found no statistically significant difference between the two groups quency of participants who regained the same activity level as be-
(MD 1.00, 95% CI -4.63 to 2.63; P = 0.6) at two year follow-up fore their dislocation (13/17 versus 15/21; RR 1.07 95% CI 0.73
(see Analysis 2.5). to 1.56; P = 0.73; analysis not shown).
Knee pain The proportion of participants in each group reporting an episode
Two studies assessed knee pain using a visual analogue scale (VAS), or episodes of patellar subluxation during follow up was reported
one at two year follow-up (Nikku 1997) and the other at medium in three studies (Camanho 2009; Nikku 1997; Sillanpaa 2009).
of seven years (Sillanpaa 2009). Overall, pooled data (Analysis There was no significant difference between groups (RR 0.67, 95%
2.6) showed a statistically difference between treatment groups CI 0.23 to 1.94; Analysis 1.2).
with significantly lower pain scores for the non-surgical group The number of participants in each group suffering episodes of
(MD 0.51, 95% CI 0.10 to 0.93). However, this pooled analysis instability (dislocation, subluxation, or both) was reported in three
exhibited substantial heterogeneity (Chi² = 5.50, df = 1 (P = 0.02), studies (Camanho 2009; Nikku 1997; Sillanpaa 2009). Pooled
I² = 82%). data showed that surgical treatment was associated with a statis-
tically significant reduction in episodes of instability during par-
ticipant follow-up (RR 0.70, 95% CI 0.54 to 0.90; Analysis 1.3).
However, this significant difference was lost (RR 0.80, 95% CI
Complications / adverse events of interventions
0.62 to 1.03) on removal of Camanho 2009, a study judged at
Only one study (Nikku 1997) reported on adverse effects. All four high risk of bias on account of incomplete outcome data.
’major’ complications occurred in the surgical group. Paresis of the
sciatic nerve, possibly due to tourniquet compression and resulting
in severe permanent disability, was reported in one participant in Patient satisfaction
the surgical group. A deep wound infection and bacterial arthritis, Patient satisfaction was assessed in two studies (Nikku 1997;
which resolved with revision surgery and antibiotic therapy, oc- Palmu 2008). Overall, pooled data (Analysis 2.7) showed a sta-
curred in one operated participant. A superficial wound infection tistically difference between treatment groups with a significantly
and a burn injury on the insensible anterior aspect of the knee greater frequency of good to excellent patient satisfaction out-
occurred in one participant. comes in the non-surgical treatment group (RR 0.61, 95% CI
0.44 to 0.84). However, this pooled analysis exhibited substantial
heterogeneity (Chi² = 2.39, df = 1 (P = 0.12), I² = 58%).
Range of knee motion
Range of knee motion was assessed in one study (Sillanpaa 2009).
Subsequent requirement for surgery
There was no statistically significant difference in total knee range
of motion of the affected knee between surgical (median 138 de- Three studies (Nikku 1997; Palmu 2008; Sillanpaa 2009) reported
grees) and non-surgical (median 140 degrees) interventions at the the number of participants in each group who had undergone
seven year follow-up (P > 0.05). subsequent surgical intervention by five to seven year follow-up.
There was no statistically significant difference between groups
(36/123 versus 27/106; RR 1.09, 95% CI 0.72 to 1.65; Analysis
1.4; Figure 5). Several participants in both Nikku 1997 and Palmu
Patient-reported instability symptoms
2008 had more than one operation.
Figure 5. Forest plot of comparison: 1 Surgical versus non-surgical management. Recurrent instability
episodes, outcome: 1.4 Number of participants who underwent subsequent surgery (five to seven year follow-
up).

fore be interpreted with some caution with patients less than 16
years of age, and should not be used to justify the treatments of
Subgroup analysis those people who are managed following recurrent lateral patellar
We initially planned to undertake a subgroup analysis to compare dislocation.
the findings of males versus females, and those who are hypermo- Palmu 2008 noted that both management groups reported high
bile versus non-hypermobile, to investigate whether these are im- recurrent dislocation rates but that functionally, children had good
portant prognostic variables in this population. However, it was outcomes, and were able to perform all their activities of daily
not possible to obtain the original study data to allow such an living, irrespective or recurrent patellar instability and dislocation
analysis. We intended also to assess the outcomes of people who events.
received treatment following primary dislocation compared with A number of different surgical and rehabilitative interventions
patients who were managed after recurrent patellar dislocation. were used in the included studies. It was not possible to determine
However, since all the participants recruited in the studies reviewed the comparative efficacy of these surgical interventions, In addi-
had experienced a primary patellar dislocation, with those experi- tion, there is some heterogeneity amongst the participants. Some
encing recurrent patellar dislocation excluded from these trials, it individuals suffering patellar dislocation may have had predispos-
was again not possible to undertake this secondary analysis. ing factors (e.g. family history, particular anatomical morphology
of the patello-femoral joint, soft tissue integrity or hypermobility).
Some suffered complications of the dislocation such as separation
of osteochondral fragments into the knee joint. Although more
recent studies have reported these factors (Palmu 2008; Sillanpaa
2009), the included studies were uneven in the description of
DISCUSSION
anatomical pathology present in their participants, the diagnostic
Summary of main results procedures used to investigate them, or the rationale for choice of
surgical technique.
The findings of this review based on five studies involving 339 par-
The non-operative management strategies used to treat people fol-
ticipants found no robust evidence of improved clinical or func-
lowing a patellar dislocation were variably described. Whilst most
tional outcomes in people who, following primary patellar dislo-
studies appropriately reported immobilisation methods and their
cation, were managed with surgical repair, compared with those
duration, details which might have been important were limited.
who underwent rehabilitation without surgical repair. However,
This is a recurrent limitation in the patellar instability evidence
our results do raise hypotheses which should inform future re-
base (Smith 2010). Consequently, it was not possible to effectively
search.
assess methodological heterogeneity in the non-operative manage-
ment of participants. It should be noted that all ’non-operative’
Overall completeness and applicability of group participants had had diagnostic arthroscopy prior to ran-
evidence domisation in Christiansen 2008 and all received knee aspiration
to relieve pain in Sillanpaa 2009.
The objective of the review, to assess the benefits and harms of sur-
We suggest that before further trials are conducted, expert con-
gical compared with non-surgical interventions for treating peo-
sensus be achieved on a data set adequately defining both surgical
ple with primary or recurrent patellar dislocation, has been met
and non-surgical interventions, and the anatomical or pathologi-
in part. Our findings are relevant to the management of people
cal variations which may be relevant to both choice of these inter-
who seek treatment following a first time or primary lateral patel-
ventions and the natural history of patellar instability. Such a con-
lar dislocation. No randomised controlled trials have assessed the
sensus would inform the design and conduct of future randomised
outcomes of surgical or non-surgical interventions following re-
trials of management of primary or recurrent patellar instability
current or secondary patellar dislocation.
Although pooled data for the primary outcomes measure, recur-
rent dislocation of the patella, and validated knee function scores
were not statistically significant overall, the secondary outcome
Quality of the evidence
’episodes of patellar instability’ favoured surgical management, al- The current evidence base presented with a number of substan-
though this finding was lost on sensitivity analysis. We also found tial methodological weaknesses. Only Nikku 1997 included more
that a tendency to early benefit from surgery on the Kujala func- than 100 participants; the other studies were small and underpow-
tional score at two year minimum follow-up was no longer appar- ered to confirm any difference between the experimental and con-
ent at five to seven year follow-up. trol groups. Selection bias and performance bias were at high or
Only one study included in this review (Palmu 2008) addressed unclear risk in all included studies. Although it would have been
exclusively the management of children and adolescents with pri- possible, no study reported blinding of outcome assessors to the
mary patellar dislocation. The findings of this review should there- treatment allocation. Risk of detection bias was unclear in all, as

was attrition bias from losses to follow-up in all but one. Nikku 1997. Despite the very different criteria for study inclusion,
There was some heterogeneity amongst the individual included its findings and those of our review are consistent.
studies. For the primary outcome of recurrent episodes of disloca- Stefancin 2007 recommended that initial management of primary
tion, the included studies fall into two categories. Although there patellar dislocation should be non-surgical, except in cases where
were differences in operative details between them, Nikku 1997, there was an osteochondral fragment evident, a chondral injury, or
Palmu 2008 and Christiansen 2008 found no evidence of differ- a large medial patellar stabilizer defect as detected by CT and/or
ence between groups, and there was no statistical heterogeneity. MRI findings. This recommendation was based on the conclusion
Sillanpaa 2009 and Camanho 2009 both, although small studies, that the outcomes of surgical and non-surgical interventions were
reported a statistically significant reduction in the number of par- not dissimilar, but that all major complications, when occurred,
ticipants experiencing a recurrent dislocation during follow-up; presented in the surgically managed groups.
we found no inter-study heterogeneity between them. Neither re-
ported any recurrent dislocation amongst participants undergoing
surgery. There is no obvious clinical reason for the heterogeneity
between the two categories.
AUTHORS’ CONCLUSIONS
Potential biases in the review process
Implications for practice
We believe that our search strategy was comprehensive and iden-
There is insufficient evidence from randomised or quasi-ran-
tified all relevant published trials which met the inclusion criteria.
domised studies to identify a significant difference in outcomes be-
In our analyses, we presented the data in two subgroups based on
tween surgical and non-surgical interventions for the initial man-
length of follow-up (two years minimum, and five to seven years)
agement of primary patellar dislocation in children, adolescents,
and have given overall pooled estimates and tests for subgroup
or adults. No randomised controlled trials have assessed the out-
difference. This carries a potential risk of attrition bias from dif-
comes of surgical compared with non-surgical treatments in peo-
ferential losses over time. However, we think that this is unlikely,
ple who seek treatment following a recurrent or secondary patellar
as the three studies in the five to seven year subgroup all reported
dislocation.
small losses, and the only study assessed at high risk of attrition
bias was in the two year follow-up group. For now, given that adverse events may be associated with surgery,
it makes sense for practitioners to adopt non-surgical management
Agreements and disagreements with other of primary patellar dislocation until a stronger evidence base is
studies or reviews established. This should be the case unless there are specific in-
dications for a surgical intervention; such indications include an
Systematic reviews of the outcomes of MPFL repair (Smith 2007), osteochondral fracture or other intra-articular disorder within the
trochleoplasty (Smith 2008), and non-operative rehabilitation in- knee joint, or demonstrated evidence of a major tear of the medial
terventions (Smith 2010) have been reported. No relevant ran- soft tissues stabilizing the patella.
domised trials were identified by these reviews; their results are
consistent with this review. A meta-analysis including five ran-
Implications for research
domised and six non-randomised controlled trials assessing sur-
gical to non-surgical interventions for patients following patellar It is plausible that surgical management of primary patellar dislo-
dislocation reported similar concerns regarding the methodologi- cation may offer improved function and a reduction in recurrent
cal quality of the current evidence-base (Smith 2011). The authors episodes of instability, but the evidence from published trials is
also reported a statistically significant difference between interven- insufficient to confirm or refute this hypothesis.
tions for outcomes including: frequency of recurrent dislocation,
The shortcomings of the present evidence base include small study
development of osteoarthritis and Hughston VAS patellofemoral
bias, selection bias, performance bias, detection bias, and attrition
score. The difference in findings with respect to recurrent dislo-
bias. Reporting of the methods and results of included studies
cation may be attributed to the inclusion of non-randomised tri-
did not meet best contemporary standards. Further research seems
als which were excluded in this Cochrane review, in addition to
justified.
difference in statistical and methodological analysis methods and
overall eligibility criteria. Based on the incidence of primary outcomes in the studies in-
We found one previous systematic review comparing surgical and cluded in this review, a case could be made for a multi-centre
non-surgical management of primary traumatic patellar disloca- study managed from a clinical research centre, enrolling in excess
tion (Stefancin 2007). This included 70 studies, all but one of of 600 participants, conducted and reported to the standards of
which were non-randomised, published up to the end of 2006; the CONSORT statement (CONSORT 2010). We suggest that
therefore of the studies included in our review, this included only before such a trial is conducted, expert consensus be achieved on

the standards for future research. This might include clearer defi- ACKNOWLEDGEMENTS
nition of both surgical and non-surgical interventions, and a suite
We thank Helen Handoll, Paul Jenkins and Jane Mackintosh for
of “standard” outcomes which should be reported. These might
their constructive comments at the protocol stage; and Lindsey
include recurrent dislocation, recurrent subluxation, recurrent in-
Elstub for editorial support. We also acknowledge Joanne Elliott
stability episodes, validated functional and quality of life scores,
for her help in the development of the search strategies. We would
at two year and five year follow-up. As individuals with patellar
particularly like to thank Professor William Gillespie, Emeritus
instability may have multiple episodes, recording both the num-
Professor of Orthopaedics at the Hull York Medical School, for his
ber of participants sustaining an event and the number of events
guidance, assistance and directions as first assessor to the review.
in each group to allow calculation of both risk rate and rate ratio
would be desirable. Key anatomical or pathological factors par- We would like to thank Alexandre Bitar, University of São Paulo,
ticularly relevant to the natural history of patellar instability, and Risto Nikku, Helsinki University Central Hospital, Martin Lind,
thus to the choice of intervention should also be recorded. Such a Aarhus University Hospital, Denmark, and Petri Sillanpaa, Cen-
consensus would inform the design and conduct of a large study of tral Military Hospital, Helsinki, Finland, for providing additional
management of primary patellar instability, and would be useful data used as part of the meta-analysis.
also in research evaluating the place of surgery in the management
We would also like to thank the library staff at the Norfolk and
of recurrent dislocation.
Norwich University Hospital’s Sir Thomas Browne Library who
assisted in the gathering of papers required for this review.
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dislocation. Physiotherapy 2010; Vol. 96:269–281.
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Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Camanho 2009
Methods Single centre RCT.

Allocation by blind drawing slips of paper allocating group.
Follow-up period in surgical group mean 40.4 months, and 36.3 months in non-surgery
group
Location and person who randomised or assessed not stated.
Participants Trial performed in Brazil. The period in which the study was undertaken was not stated
N = 33; Primary patellar dislocation with a convincing history of traumatic dislocation,
requirement for reduction and absence of osteochondral fracture and no previous knee
surgery
Interventions Surgery (n = 17; mean age 24.6; 11 females/6 males) - arthroscopic MPFL repair followed
by three weeks in a removable immobiliser and physiotherapy
Non-surgery (n = 16; mean age 26.8; 9 females/7 males) - immobilised in a cylinder
cast for three weeks, followed by a physiotherapy programme consisting of strengthening
exercises particularly VMO. Hamstring and retinacular stretching begun after one month
post-dislocation
Outcomes Participants reviewed at least once every six months during a maximum of 60 months
(mean 40.4 months). Outcome measurements collected included: recurrent patellar dis-
location, positive apprehension test, recurrent instability symptoms, Smillie test results,
and the Kujala patellofemoral disorders score
Notes Not concealed allocation; location and person who randomised not stated. No details
provided on rehabilitation programme used. Sample size was not based on a power
calculation. Number of surgeons not stated
Additional standard deviation values were obtained from the authors. The authors kindly
reviewed the search strategy results
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection Unclear risk Quote “Patients were randomly divided
bias) into 2 groups by means of a drawing, by
blindly selecting a slip of paper that as-
signed them to either the surgical treatment
group or the conservative treatment group”
No report of how sequence was generated.
Allocation concealment (selection bias) Unclear risk Quote “Patients were randomly divided
into 2 groups by means of a drawing, by
blindly selecting a slip of paper that as-
signed them to either the surgical treatment

Camanho 2009 (Continued)
group or the conservative treatment group”
Blinding of participants and personnel Unclear risk Blinding of participants and personnel not
(performance bias) reported, but extremely unlikely
All outcomes
Blinding of outcome assessment (detection Unclear risk Blinding of outcome assessors not reported,
bias) and unlikely. Participants completing ques-
All outcomes tionnaires for the Kujala and Tegner scores
were clearly unblinded
Incomplete outcome data (attrition bias) High risk The title indicates that it is a study on the
management of acute patellar dislocation,
and the text (page 621 right hand col-
umn) states “All were operated on less than
1 month after the trauma causing the lesion
had occurred.”
However, in the inclusion criteria we find
“a minimum follow-up time of 25 months
after the dislocation episode”, and in the ex-
clusion criteria we find “follow-up after the
first dislocation shorter than 24 months.”
This appears to mean that randomised par-
ticipants from both groups were excluded
from the analysis, but there is no report of
losses
Selective reporting (reporting bias) Unclear risk Planned outcomes defined in the methods
section were reported, but did not include
adverse effects of surgery
Christiansen 2008
Methods Single centre RCT.

Follow-up two year following randomisation.
Randomised by concealed envelopes.
Participants Trial performed in Denmark from April 1998 to September 2002

N = 80 (77 reported as 3 excluded as did not complete final follow-up). Criteria: in-
dividuals following primary patellar dislocation aged 13 to 30 years. All participants
underwent an arthroscopy
Interventions Surgery (n = 42; 18 females/24 males; mean age 20.0; mean BMI 22.6) repair of the
MPFL performed on average 50 days post-dislocation
Non-surgical (n = 35; 17 females/18 males; mean age 19.9; mean BMI 22.2) brace from
zero to two weeks immobilised 0 to 20 knee range of motion degrees

Christiansen 2008 (Continued)
Outcomes Outcomes recorded at two weeks, six weeks, one year and two years post-injury. Out-
comes measured included the incidence of re-dislocation at 2 years, Kujala patellofemoral
disorders score, and the Knee Injury and Osteoarthritis Outcome Score (KOOS)
Notes Power calculation used. Requiring 39 in each group. Intention-to-treat analysis principles
were not adopted
The authors kindly reviewed the search strategy results.
Risk of bias
Random sequence generation (selection Unclear risk Quote:“Randomization between surgery

bias) and conservative treatment was performed
by random drawing of 100 envelopes”. No
report of how sequence was generated
Allocation concealment (selection bias) Unclear risk Sealed envelope system. Quote: “Random-
ization between surgery and conservative
treatment was performed by random draw-
ing of 100 envelopes” but no report of
whether these were securely sealed and al-
located sequentially
Blinding of participants and personnel High risk Blinding is not mentioned in the study re-
(performance bias) port. Treatment staff and participants un-
All outcomes likely to be blinded, as randomisation was
conducted at arthroscopy. After care clearly
not identical in both groups (Quote: “Pa-
tients randomised to conservative treat-
ment received no further treatment or brace
usage.”)
All outcomes tionnaires for the Kujala and KOOS scores
were clearly unblinded
Incomplete outcome data (attrition bias) Unclear risk Three lost to follow-up post-randomisation
and data not included
section were reported, but did not include
adverse effects of surgery.

Nikku 1997
Methods Multi-centre RCT

Quasi-randomisation through year of birth.
Follow-up at 25 months (20 - 45).
Participants Trial performed in Finland with participants recruited from January 1991 to December
1992
N = 125. Primary lateral patellar dislocation where injury was less than 14 days; no
previous knee injury or surgery, no fractures or tibiofemoral injury
Interventions Surgery (n = 70; 52 females; 18 males; mean age 19.5 SD 9; mean BMI 21.8 SD 4)
medial reefing (18), repair or medial retinaculum (39) or augmentation of MPFL (6) or
lateral release (54). Post-op: Thigh muscle exercises and FWB. If patellar dislocatable on
EUA, immobilised on splint/cast for three weeks. Mobilisation started with orthosis for
three weeks and used during sporting activities for the first six months post-dislocation
Non-surgery (n = 55; 30 females/25 males; mean age 19.1 SD 7.5; mean BMI 22.2 SD
3.9) identical rehabilitation programme to surgical group
Outcomes Outcomes were collected at the final evaluation, a mean of 25 months (range 20 to 45
months) post-randomisation. Outcomes collected included: patient satisfaction to out-
come, Lysholm knee score, Hughston VAS knee score, Tegner activity score, recurrent
dislocation rates, recurrent subluxation rates; subsequent surgical intervention, perfor-
mance tests consisting of timed figure of eight running, one leg hop distance, maximum
number of squat downs in one minute, and subsequent pain on VAS, thigh circumference
knee range of motion, patellofemoral crepitus, apprehension test, prepatellar sensibility,
and scar sensibility
Notes Two orthopaedic consultants and two registrars did 88% of operations. Assessment
clinically performed by two surgeons. Intention-to-treat analysis principles were not
adopted. Sample size was not based on a power calculation
The authors kindly reviewed the search strategy results.
Risk of bias
Random sequence generation (selection High risk Quote: “randomization was based on the
bias) year of birth (even/odd)
Allocation concealment (selection bias) High risk Quote: ”randomization was based on the
year of birth (even/odd)
Blinding of participants and personnel Unclear risk Quote: “After-care was identical in both
(performance bias) groups”.
All outcomes
Blinding of outcome assessment (detection Unclear risk Quote: “Recurrences were asked about
bias) twice: by a mailed questionnaire and by the
All outcomes examiner at the final evaluation”. Quote:
“The clinical examination was performed

Nikku 1997 (Continued)
by two of the authors (YN, RN).”

Participants completing questionnaires for
the Lysholm, Hughston VAS, Kujala and
Tegner scores were clearly unblinded
Incomplete outcome data (attrition bias) Low risk Quote: “123/125 patients attended the
performance test and clinical examination.
2 patients returned only the questionnaires.
”
Selective reporting (reporting bias) Low risk Planned outcomes defined in the methods
section were reported. Adverse effects of
surgery were reported
Palmu 2008
Methods Single centre RCT

Quasi-randomisation through year of birth.
Randomisation performed by one author at the time of admission
Follow-up period two years for clinical examination and 14 years (range 11-15 years) via
telephone assessment
Participants Trial performed in Finland with participants recruited from 1991 to 1992
Children under 16 years of age
N = 74 knees (71 patients) satisfied at least one of three diagnostic criteria of acute patellar
dislocation: lateral dislocation necessitating reduction (30 knees), ability to dislocate the
patella on EUA (55 knees), presence of findings typical of acute patellar dislocation in-
cluding synovial tear medial to patella on diagnostic arthroscopy (74 knees). Dislocation
had occurred within two weeks of randomisation, no previous knee surgery or substan-
tial knee injury, no concomitant tibiofemoral ligament injury, no large osteochondral
fracture
Interventions Surgery (n = 36; 27 females; 9 males; mean age 13 SD 2) repair of the MPFL (36) in
addition to lateral release (32). Post-operatively, those with patella dislocatable under
anaesthesia immobilised in removable knee brace for three weeks followed by orthosis,
those who were not dislocatable immediately managed in an orthosis and used during
rehabilitation and sporting activities during the first six months. Thigh muscle exercises
and FWB started as tolerated
Non-surgery (n = 28; 19 females/9 males; mean age 13 SD 2) rehabilitation programme
as operative group
Outcomes Outcome measures were collected clinically at two years, and then by telephone interview
at an mean of six years (range five to eight years) and 14 years (range 11 to 15 years)
. Outcomes recorded included: participant reported satisfaction, frequency of recurrent
patellar dislocation, frequency of recurrent patellar subluxation, frequency of subsequent
surgical interventions, Tegner activity score, Hughston VAS knee score, and the Kujala
patellofemoral disorders score

Palmu 2008 (Continued)
Notes Independent observer but not clear if this person was blinded. Intention-to-treat analysis
principles were not adopted
Risk of bias
Random sequence generation (selection High risk Quote: “randomization was performed ac-
bias) cording to the year of birth, with pa-
tients who had been born in odd years
being randomised to non-operative treat-
ment (twenty eight knees) and those who
had been born in even years being ran-
domized to operative treatment (thirty-six
knees). Randomization was performed by
the treating surgeon (Y.N.) at the time of
admission.”
Allocation concealment (selection bias) High risk Quote: “randomization was performed ac-
cording to the year of birth, with pa-
tients who had been born in odd years
being randomised to non-operative treat-
ment (twenty eight knees) and those who
had been born in even years being ran-
domised to operative treatment (thirty-six
knees). Randomization was performed by
the treating surgeon (Y.N.) at the time of
admission.”
Blinding of participants and personnel Unclear risk Blinding is not mentioned in the study re-
(performance bias) port. Treatment staff and participants un-
All outcomes likely to be blinded
All outcomes tionnaires for Kujala, Tegner and Hughston
visual analogue scale scores were clearly un-
blinded
Incomplete outcome data (attrition bias) Unclear risk Four participants lost to follow-up in the
surgical group; none in the control group
Selective reporting (reporting bias) Unclear risk Data for a planned outcome defined in
the methods section.were incompletely re-
ported for the two treatment groups. All
episodes of instability was reported only
as “Patellofemoral instability, including re-
current patellar dislocation and subjective
sensations of subluxation occurred in 91%

Palmu 2008 (Continued)
(fifty-eight) of the sixty-four randomized

knees, with no significant differences be-
tween the two treatment groups.” Adverse
effects of surgery were not reported
Sillanpaa 2009
Methods Single centre RCT

Randomised by sealed enveloped. Unclear who randomised.
Follow-up period = 7 years (6 to 9).
Operations performed by two orthopaedic surgeons
Participants Trial performed in Finland with participants recruited from 1998 to 2000
N = 40. Primary acute traumatic patellar dislocation individuals with no previous sub-
luxation or pre-existing ipsilateral or contralateral knee pathology or previous ligament
or fracture injury to the involved knee, or large osteochondral fracture
Interventions Surgery (n = 18; females 1/males 17; mean age 20.0) medial reefing and repair of MPFL
(14); Roux-Goldthwaite procedure (4) arthroscopic repair of osteochondral fracture (6)
Non-surgical intervention (n = 22; females 2/males 21; mean age 20.0) knee orthosis,
guided isometric quadriceps exercises. First three weeks immobilised 0 to 30 degrees knee
flexion, three to six weeks immobilised form 0 to 90 degrees and free range of motion
from six weeks onwards. (All participants of this group received knee aspiration to relieve
pain and four underwent arthroscopic removal of an osteochrondral fragment.)
Outcomes Outcome measures were collected at a mean of seven years (range 6 to 9 years). Outcomes
recorded included: recurrent dislocation rates, frequency of subluxation rates, Kujala
patellofemoral disorder score, VAS pain, knee range of motion, Tegner score, Quadri-
ceps girth, MRI presence of patellar and femoral chondral lesions, participant reported
outcomes of activity level, frequency of reoperation rate, severity of patellofemoral joint
osteoarthritis, subjective assessment of pain and functional knee limitations for stairs,
running, squatting, and pain, radiological findings for sulcus angle, lateral patellofemoral
angle, lateral patellar displacement, Blackburne-Peel ratio
Notes Not clear whether the assessors were blinded. Sample size was based on power calculation
Additional standard deviation values were obtained from the authors. The authors kindly
reviewed the search strategy results
Risk of bias
Random sequence generation (selection Unclear risk No report of how sequence was generated.
bias)
Allocation concealment (selection bias) Unclear risk Quote: “Written informed consent was
obtained from each patient. With use of
a sealed-envelope method, forty patients

Sillanpaa 2009 (Continued)
were randomly allocated to two treat-

ment groups: (1) initial patellar stabiliza-
tion surgery and (2) non-operative treat-
ment with a knee orthosis (as well as arthro-
scopic removal of an osteochondral frag-
ment if necessary).”
Blinding of participants and personnel Unclear risk Quote: “The post-injury or postoperative
(performance bias) rehabilitation protocols were identical for
All outcomes the two groups”. However, quote: “Four
patients in the nonoperatively treated
group underwent arthroscopic removal of
an osteochondral fragment, but no addi-
tional procedures were performed. Since
primary traumatic patellar dislocations
are frequently associated with osteochon-
dral fractures, we believe that perform-
ing arthroscopy initially in some patients
may be unavoidable, even in a randomized
study. Ten patients (four treated nonoper-
atively and six treated with surgical stabi-
lization) had removable fragments, and the
osteochondral fractures were treated iden-
tically (i.e. with arthroscopic removal of the
fragments) in the two treatment groups.”
Blinding of outcome assessment (detection Unclear risk Blinding of outcomes assessment not de-
bias) scribed. Participants completing question-
All outcomes naires for the Kujala and Tegner scores were
clearly unblinded
Incomplete outcome data (attrition bias) Unclear risk One participant lost from each group (flow
chart)
section were reported, but adverse events
were not reported
MPFL = medial patellofemoral ligament

Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Arnbjornsson 1992 Not a randomised controlled trial.
Buchner 2005 Not a randomised controlled trial.
Cash 1988 Not a randomised controlled trial.
Marcacci 1995 Not a randomised controlled trial.
Savarese 1990 Not a randomised controlled trial.
Sillanpaa 2008a Not a randomised controlled trial. All received some operative procedure
Sillanpaa 2008b Not a randomised controlled trial.

DATA AND ANALYSES
Comparison 1. Surgical versus non-surgical management. Recurrent instability episodes
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Number of participants 5 339 Risk Ratio (M-H, Random, 95% CI) 0.81 [0.56, 1.17]
sustaining recurrent patellar
dislocation
1.1 Two years minimum 2 110 Risk Ratio (M-H, Random, 95% CI) 0.55 [0.12, 2.57]
follow-up
1.2 Five to seven years 3 229 Risk Ratio (M-H, Random, 95% CI) 0.82 [0.53, 1.29]
follow-up
2 Number of participants 3 198 Risk Ratio (M-H, Random, 95% CI) 0.67 [0.23, 1.94]
sustaining recurrent patellar
subluxation
2.1 Two years minimum 1 33 Risk Ratio (M-H, Random, 95% CI) 0.09 [0.01, 1.44]
follow-up
2.2 Five to seven years 2 165 Risk Ratio (M-H, Random, 95% CI) 0.99 [0.61, 1.61]
follow-up
3 Number of participants 3 198 Risk Ratio (M-H, Fixed, 95% CI) 0.70 [0.54, 0.90]
sustaining any episode of
instability
3.1 Two years minimum 1 33 Risk Ratio (M-H, Fixed, 95% CI) 0.06 [0.00, 0.89]
follow-up
3.2 Five to seven years 2 165 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.62, 1.03]
follow-up
4 Number of participants who 3 229 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.72, 1.65]
underwent subsequent surgery
(five to seven year follow-up)
Comparison 2. Surgical versus non-surgical management. Patient-reported outcomes
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Kujala patellofemoral disorder 5 341 Mean Difference (IV, Random, 95% CI) 3.13 [-7.34, 13.59]
score (0: worst outcome to 100:
best outcome)
1.1 Two years minimum 2 110 Mean Difference (IV, Random, 95% CI) 14.36 [1.00, 29.72]
follow-up
1.2 Five to seven years 3 231 Mean Difference (IV, Random, 95% CI) -4.51 [-9.29, 0.26]
follow-up
2 Hughston VAS patellofemoral 2 189 Mean Difference (IV, Random, 95% CI) -4.07 [-7.85, -0.29]
score (28 to 100: best outcome)
2.1 Two years follow-up 1 125 Mean Difference (IV, Random, 95% CI) -2.80 [-6.70, 1.10]
2.2 Six years follow-up 1 64 Mean Difference (IV, Random, 95% CI) -5.00 [-13.48, -0.52]
3 Tegner activity score (over 2 year 3 229 Mean Difference (IV, Random, 95% CI) -0.46 [-0.96, 0.05]
follow-up)
3.1 Two year minimum 1 125 Mean Difference (IV, Random, 95% CI) -0.60 [-1.28, 0.08]
follow-up
3.2 Six to nine years follow-up 2 104 Mean Difference (IV, Random, 95% CI) -0.28 [-1.04, 0.48]
4 KOOS at two year follow-up 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
4.1 Symptoms 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.2 Pain 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.3 Activities of Daily Living 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.4 Sports and recreation 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.5 Quality of life 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
5 Lysholm score (0 to 100: best 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
score) at two year follow-up
6 Knee pain 2 163 Mean Difference (IV, Fixed, 95% CI) 0.51 [0.10, 0.93]
6.1 Two year follow-up 1 125 Mean Difference (IV, Fixed, 95% CI) 0.20 [-0.29, 0.69]
6.2 Six to nine year follow-up 1 38 Mean Difference (IV, Fixed, 95% CI) 1.30 [0.52, 2.08]
7 Patient satisfaction (reported 2 133 Risk Ratio (M-H, Fixed, 95% CI) 0.61 [0.44, 0.84]
good or excellent)
7.1 Two year follow-up 1 69 Risk Ratio (M-H, Fixed, 95% CI) 0.38 [0.17, 0.83]
7.2 Six year follow-up 1 64 Risk Ratio (M-H, Fixed, 95% CI) 0.74 [0.53, 1.04]

Analysis 1.1. Comparison 1 Surgical versus non-surgical management. Recurrent instability episodes,
Outcome 1 Number of participants sustaining recurrent patellar dislocation.
Review: Surgical versus non-surgical interventions for treating patellar dislocation
Comparison: 1 Surgical versus non-surgical management. Recurrent instability episodes
Outcome: 1 Number of participants sustaining recurrent patellar dislocation
Non-surgical
Study or subgroup Surgical intervention intervention Risk Ratio Weight Risk Ratio
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
1 Two years minimum follow-up
Camanho 2009 0/17 3/16 1.6 % 0.13 [ 0.01, 2.42 ]
Christiansen 2008 7/42 7/35 13.4 % 0.83 [ 0.32, 2.15 ]
Subtotal (95% CI) 59 51 15.0 % 0.55 [ 0.12, 2.57 ]

Total events: 7 (Surgical intervention), 10 (Non-surgical intervention)
Heterogeneity: Tau2 = 0.56; Chi2 = 1.47, df = 1 (P = 0.23); I2 =32%
Test for overall effect: Z = 0.76 (P = 0.45)
2 Five to seven years follow-up
Nikku 1997 22/70 22/57 41.6 % 0.81 [ 0.51, 1.31 ]
Palmu 2008 18/36 15/28 41.8 % 0.93 [ 0.58, 1.50 ]
Sillanpaa 2009 0/17 6/21 1.7 % 0.09 [ 0.01, 1.56 ]
Subtotal (95% CI) 123 106 85.0 % 0.82 [ 0.53, 1.29 ]

Total (95% CI) 182 157 100.0 % 0.81 [ 0.56, 1.17 ]
Test for subgroup differences: Chi2 = 0.24, df = 1 (P = 0.62), I2 =0.0%
0.002 0.1 1 10 500

Favours surgical Favours non-surgical

Outcome 2 Number of participants sustaining recurrent patellar subluxation.
Outcome: 2 Number of participants sustaining recurrent patellar subluxation
Non-surgical
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI

Camanho 2009 0/17 5/16 11.8 % 0.09 [ 0.01, 1.44 ]
Subtotal (95% CI) 17 16 11.8 % 0.09 [ 0.01, 1.44 ]

Heterogeneity: not applicable
Nikku 1997 (1) 23/70 18/57 60.6 % 1.04 [ 0.63, 1.73 ]
Sillanpaa 2009 2/17 4/21 27.6 % 0.62 [ 0.13, 2.98 ]
Subtotal (95% CI) 87 78 88.2 % 0.99 [ 0.61, 1.61 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.39, df = 1 (P = 0.53); I2 =0.0%
Total (95% CI) 104 94 100.0 % 0.67 [ 0.23, 1.94 ]
Test for subgroup differences: Chi2 = 2.81, df = 1 (P = 0.09), I2 =64%
0.005 0.1 1 10 200

(1) Reported data were for dislocations, and all episodes of instability. Event data entered are all episodes minus dislocations

Outcome 3 Number of participants sustaining any episode of instability.
Outcome: 3 Number of participants sustaining any episode of instability
Non-surgical
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Camanho 2009 (1) 0/17 8/16 14.2 % 0.06 [ 0.00, 0.89 ]
Subtotal (95% CI) 17 16 14.2 % 0.06 [ 0.00, 0.89 ]

Nikku 1997 (2) 45/70 40/57 71.4 % 0.92 [ 0.72, 1.17 ]
Sillanpaa 2009 (3) 2/17 10/21 14.5 % 0.25 [ 0.06, 0.98 ]
Subtotal (95% CI) 87 78 85.8 % 0.80 [ 0.62, 1.03 ]

Heterogeneity: Chi2 = 3.94, df = 1 (P = 0.05); I2 =75%
Total (95% CI) 104 94 100.0 % 0.70 [ 0.54, 0.90 ]
0.002 0.1 1 10 500

sulucations.
(1) Data are one episode of dislocation in the surgery group, and all reported episodes of recurrence in the control group, of which 3 apppear to have been dislocations
and 5
(2) . All episodes of instability reported
(3) The reported data are the sum of redislocations and painful subluxations.

Outcome 4 Number of participants who underwent subsequent surgery (five to seven year follow-up).
Outcome: 4 Number of participants who underwent subsequent surgery (five to seven year follow-up)
Non-surgical
Nikku 1997 20/70 13/57 48.0 % 1.25 [ 0.68, 2.29 ]
Palmu 2008 16/36 11/28 41.4 % 1.13 [ 0.63, 2.04 ]
Sillanpaa 2009 0/17 3/21 10.6 % 0.17 [ 0.01, 3.16 ]
Total (95% CI) 123 106 100.0 % 1.09 [ 0.72, 1.65 ]

Heterogeneity: Chi2 = 1.76, df = 2 (P = 0.42); I2 =0.0%
Test for subgroup differences: Not applicable
0.005 0.1 1 10 200


Analysis 2.1. Comparison 2 Surgical versus non-surgical management. Patient-reported outcomes,
Outcome 1 Kujala patellofemoral disorder score (0: worst outcome to 100: best outcome).
Comparison: 2 Surgical versus non-surgical management. Patient-reported outcomes
Outcome: 1 Kujala patellofemoral disorder score (0: worst outcome to 100: best outcome)
Non-surgical Mean Mean

Study or subgroup Surgical intervention intervention Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

Camanho 2009 (1) 17 91.23 (5.01) 16 69.06 (14.02) 19.8 % 22.17 [ 14.90, 29.44 ]
Christiansen 2008 42 84.6 (17.5) 35 78.1 (15.9) 19.7 % 6.50 [ -0.97, 13.97 ]
Subtotal (95% CI) 59 51 39.6 % 14.36 [ -1.00, 29.72 ]

Nikku 1997 70 81.54 (18.09) 57 88.11 (10.76) 20.9 % -6.57 [ -11.65, -1.49 ]
Palmu 2008 36 81 (21) 28 88 (8) 19.7 % -7.00 [ -14.47, 0.47 ]
Sillanpaa 2009 (2) 18 91 (13) 22 90 (9.8) 19.8 % 1.00 [ -6.27, 8.27 ]
Subtotal (95% CI) 124 107 60.4 % -4.51 [ -9.29, 0.26 ]

Total (95% CI) 183 158 100.0 % 3.13 [ -7.34, 13.59 ]
Heterogeneity: Tau2 = 130.01; Chi2 = 47.47, df = 4 (P<0.00001); I2 =92%
-20 -10 0 10 20
Favours non-surgical Favours surgical
(1) Standard deviation values obtained directly from authors (Bitar A, Personal communication, 2010)
(2) Standard deviation values obtained directly from authors (Sillanpaa P, personal communication, 2010).

Outcome 2 Hughston VAS patellofemoral score (28 to 100: best outcome).
Outcome: 2 Hughston VAS patellofemoral score (28 to 100: best outcome)

1 Two years follow-up

Nikku 1997 70 87.3 (11.2) 55 90.1 (10.9) 69.8 % -2.80 [ -6.70, 1.10 ]
Subtotal (95% CI) 70 55 69.8 % -2.80 [ -6.70, 1.10 ]

2 Six years follow-up
Palmu 2008 36 83 (17) 28 90 (9) 30.2 % -7.00 [ -13.48, -0.52 ]
Subtotal (95% CI) 36 28 30.2 % -7.00 [ -13.48, -0.52 ]

Total (95% CI) 106 83 100.0 % -4.07 [ -7.85, -0.29 ]
-20 -10 0 10 20

Outcome 3 Tegner activity score (over 2 year follow-up).
Outcome: 3 Tegner activity score (over 2 year follow-up)

1 Two year minimum follow-up

Nikku 1997 70 4.7 (1.8) 55 5.3 (2) 55.9 % -0.60 [ -1.28, 0.08 ]
Subtotal (95% CI) 70 55 55.9 % -0.60 [ -1.28, 0.08 ]

2 Six to nine years follow-up
Palmu 2008 36 4.7 (2) 28 5.2 (2.1) 24.8 % -0.50 [ -1.52, 0.52 ]
Sillanpaa 2009 (1) 18 5 (1.8) 22 5 (1.9) 19.3 % 0.0 [ -1.15, 1.15 ]
Subtotal (95% CI) 54 50 44.1 % -0.28 [ -1.04, 0.48 ]

Total (95% CI) 124 105 100.0 % -0.46 [ -0.96, 0.05 ]
Test for subgroup differences: Chi2 = 0.38, df = 1 (P = 0.54), I2 =0.0%
-2 -1 0 1 2
(1) Standard deviation values obtained directly from authors (Sillanpaa P, personal communication, 2010).

Outcome 4 KOOS at two year follow-up.
Outcome: 4 KOOS at two year follow-up

Study or subgroup Surgical intervention intervention Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Symptoms
Christiansen 2008 42 80.9 (17.4) 35 80.2 (15.9) 0.70 [ -6.75, 8.15 ]
2 Pain
Christiansen 2008 42 95.5 (6.9) 35 92.3 (7.9) 3.20 [ -0.15, 6.55 ]
3 Activities of Daily Living

Christiansen 2008 42 94.7 (10.3) 35 91.1 (9.8) 3.60 [ -0.90, 8.10 ]
4 Sports and recreation

Christiansen 2008 42 87.2 (11.1) 35 83.6 (11.4) 3.60 [ -1.45, 8.65 ]
5 Quality of life
Christiansen 2008 42 90.4 (8.9) 35 87.7 (9.7) 2.70 [ -1.49, 6.89 ]
-10 -5 0 5 10

Outcome 5 Lysholm score (0 to 100: best score) at two year follow-up.
Outcome: 5 Lysholm score (0 to 100: best score) at two year follow-up

Study or subgroup Surgical intervention intervention Difference Difference
Nikku 1997 70 88.2 (9.7) 55 89.2 (10.7) -1.00 [ -4.63, 2.63 ]
-4 -2 0 2 4

Outcome 6 Knee pain.
Outcome: 6 Knee pain

1 Two year follow-up

Nikku 1997 70 1.8 (1.5) 55 1.6 (1.3) 71.4 % 0.20 [ -0.29, 0.69 ]
Subtotal (95% CI) 70 55 71.4 % 0.20 [ -0.29, 0.69 ]

2 Six to nine year follow-up
Sillanpaa 2009 17 2.8 (1.3) 21 1.5 (1.1) 28.6 % 1.30 [ 0.52, 2.08 ]
Subtotal (95% CI) 17 21 28.6 % 1.30 [ 0.52, 2.08 ]

Total (95% CI) 87 76 100.0 % 0.51 [ 0.10, 0.93 ]
-2 -1 0 1 2

Outcome 7 Patient satisfaction (reported good or excellent).
Outcome: 7 Patient satisfaction (reported good or excellent)
Non-surgical
1 Two year follow-up

Nikku 1997 7/42 12/27 37.1 % 0.38 [ 0.17, 0.83 ]
Subtotal (95% CI) 42 27 37.1 % 0.38 [ 0.17, 0.83 ]

2 Six year follow-up
Palmu 2008 21/36 22/28 62.9 % 0.74 [ 0.53, 1.04 ]
Subtotal (95% CI) 36 28 62.9 % 0.74 [ 0.53, 1.04 ]

Total (95% CI) 78 55 100.0 % 0.61 [ 0.44, 0.84 ]
0.2 0.5 1 2 5

APPENDICES
Appendix 1. Search strategies
The Cochrane Library (Wiley InterScience)

#1 MeSH descriptor Patellar Dislocation, this term only (10)
#2 MeSH descriptor Patella, this term only (192)
#3 MeSH descriptor Dislocations, this term only (170)
#4 (#2 AND #3) 4
#5 (patell* NEAR/3 (dislocat* or sublux* or instability) ):ti,ab,kw (41)
#6 (#1 OR #4 OR #5) (36 Clinical Trials)
MEDLINE (Ovid interface)

1. Patellar Dislocation/ (323)
2. Patella/ and Dislocations/ (987)
3. (patell$ adj3 (dislocat$ or sublux$ or instability)).tw. (1482)
4. or/1-3 (1930)
5. trochleoplasty.tw. (21)
6. Roux-Goldthwaite.tw. (1)
7. (tibial tubercle adj3 transfer).tw. (47)
8. quadricepsplasty.tw. (72)
9. (medial patellofemoral ligament adj3 (reconstruction or repair)).tw.(87)
10. medial reefing.tw.(7)
11. medial augmentation.tw.(3)
12. lateral release.tw.(354)
13. Orthopedics/ (14061)
14. exp Surgical Procedures, Operative/ (1979096)
15. su.fs. (1351414)
16. surg$.tw. (1035962)
17. operat$.tw. (570147)
18. realign$.tw. (2270)
19. exp Rehabilitation/ (122609)
20. exp Physical Therapy Modalities/ (100640)
21. “Physical Therapy (Specialty)”/ (1632)
22. Braces/ (3954)
23. Immobilization/ (10684)
24. rh.fs. (138285)
25. rehabilitat$.tw. (80647)
26. physiotherapy.tw. (7960)
27. physical therapy.tw. (7523)
28. (non-surg$ or nonsurg$ or non-operat$ or nonoperat$ or conserv$).tw. (261096)
29. (immobilis$ or immobiliz$ or therap$ or exercis$ or taping or tape$ or brace or bracing or manual therapy or electrotherap$).tw.
(1586921)
30. or/5-29 (4601386)
31. and/4,30 (1461)
32. Randomized Controlled Trial.pt. (303247)
33. Controlled Clinical Trial.pt. (82970)
34. randomized.ab. (208863)
35. placebo.ab. (123669)
36. Drug Therapy.fs. (1426072)
37. randomly.ab. (152210)
38. trial.ab. (216266)
39. groups.ab. (1012255)
40. or/32-39 (2637973)
41. and/31,40 (138)
EMBASE (Ovid interface)

1 Patellar Dislocation/ (1200)
2 Patella/ and Dislocation/ (480)
3 (patell$ adj3 (dislocat$ or sublux$ or instability)).tw. (1707)
4 or/1-3 (2367)
5 Clinical Trial/ (812921)
6 Randomized Controlled Trial/ (283119)
7 Randomization/ (52705)
8 Single Blind Procedure/ (13445)
9 Double Blind Procedure/ (99650)
10 Crossover Procedure/ (29454)
11 Placebo/ (169403)
12 randomi?ed controlled trial$.tw. (57001)
13 RCT.tw. (6038)
14 random allocation.tw. (994)
15 randomly allocated.tw. (14756)
16 allocated randomly.tw. (1675)
17 (allocated adj2 random).tw. (678)
18 single blind$.tw. (10456)
19 double blind$.tw. (113788)
20 ((treble or triple) adj blind$).tw. (226)
21 placebo$.tw. (151527)
22 Prospective Study/ (157312)
23 or/5-22 (1093128)
24 Case Study/ (10449)
25 case report.tw. (192430)
26 Abstract Report/ or Letter/ (757574)
27 or/24-26 (956891)
28 23 not 27 (1061348)
29 limit 28 to human (979304)
30 and/4,29 (115)
CINAHL (NHS Health Information Resources)

1 PATELLA DISLOCATION/ (86)
2 PATELLA/ AND DISLOCATIONS/ (37)
3 ((patell* ADJ3 dislocat*) OR (patell* ADJ3 sublux*) OR (patell* ADJ3 instability)).ti,ab (247)
4 1 OR 2 OR 3 (280)
5 exp CLINICAL TRIALS/ (87278)
6 exp EVALUATION RESEARCH/ (14690)
7 COMPARATIVE STUDIES/ (55231)
8 CROSSOVER DESIGN/ (5958)
9 5 OR 6 OR 7 OR 8 (151632)
10 (((clinical OR controlled OR comparative OR placebo OR prospective OR randomised OR randomized) AND (trial OR
study))).ti,ab (135531)
11 (random* AND (allocat* OR allot* OR assign* OR basis* OR divid* OR order*)).ti,ab (22603)
12 ((singl* OR doubl* OR trebl* OR tripl*) AND (blind* OR mask*)).ti,ab (12803)
13 (“cross over” OR cross-over OR crossover).ti,ab (4872)
14 ((allocat* OR allot* OR assign* OR divid*) AND (condition* OR experiment* OR intervention* OR treatment* OR therap* OR
control* OR group*)).ti,ab (31577)
15 10 OR 11 OR 12 OR 13 OR 14 (159039)
16 9 OR 15 (252094)
17 4 AND 16 (48)
AMED (NHS Health Information Resources)

1 Patella/ (284)
2 Dislocations/ (366)
3 and/1-2 (13)
4 (patell$ adj3 (dislocat$ or sublux$ or instability)).tw. (52)
5 or/3-4 (54)
Health Management Information Consortium (NHS Health Information Resources)

1 Patella/ (112)
3 and/1-2 (13)
Physiotherapy Evidence Database (PEDro)

1 Patella/ (119)
3 and/1-2 (1)
Zetoc (NHS Health Information Resources)

1 Patella/ (2414)
3 and/1-2 (217)
OpenSIGLE
1 Patellar dislocation/ (415)
WHO International Clinical Trials Registry Platform

1 Patella/ (1332)
3 and/1-2 (2)
Current Controlled Trials

1 Patella/ (51)
3 and/1-2 (5)
UKCRN Portfolio Database

1 Patella/ (0)
2 Dislocations/ (0)
3 and/1-2 (0)

National Technical Information Service
1 Patella/ (48)
3 and/1-2 (1)
National Research Register Archive

1 Patellar dislocation/ (195)
FEEDBACK
Presentational errors, 17 November 2011
Summary
We have used this new review for teaching purposes in our post-graduate programme and realized that Figure 3 is wrong and does not
match with Analysis 1.1:
1. It does not contain all the graphical elements for sections 1.1.1 and 1.1.2.
2. The point estimates and diamonds shown are on the wrong side (i.e. favouring non-surgical interventions).
3. In Analysis 1.3, the label of the x-axis (exp/control) differs from the other forest plots.
We hope these errors can be corrected.
Reply
We thank Dr von Elm for contacting us and are glad with his use of our review. His observations are all correct. Regarding the mismatch
between Analysis 1.1 and Figure 1, errors of reproduction appear to have occurred at some point in the processing of the review,
including in the generation of the pdf files for publication. We have revised the scale of Analysis 1.1 and checked that Figure 1 accurately
reflects this in RevMan before resubmission for publication. The Managing Editor of the Bone, Joint and Muscle Trauma Group has
notified the RevMan support team and Wiley of this problem.
The inconsistent labelling of Analysis 1.3 has now been changed to read “surgical” : “non-surgical” for consistency.
Contributors
Comment from: Dr Erik von Elm
Reply from: Professor William Gillespie and Dr Helen Handoll (Cochrane, Bone, Joint and Muscle Trauma Group), 22 November
2011
WHAT’S NEW
Last assessed as up-to-date: 16 August 2010.

Date Event Description
22 November 2011 Feedback has been incorporated Feedback incorporated and minor changes made.
HISTORY
Protocol first published: Issue 4, 2009
Review first published: Issue 11, 2011
CONTRIBUTIONS OF AUTHORS
Caroline Hing and Toby Smith co-ordinated and conceived the protocol, and with assistance of Lesley Gillespie from the Cochrane
Bone, Joint and Muscle Trauma Group, designed the search strategy. Fujian Song provided a methodological and statistical analysis
perspective during the development of the protocol. Caroline Hing, Toby Smith and Simon Donell provided a clinical perspective
during the protocol development and review preparation. Caroline Hing, Toby Smith, Fujian Song and Simon Donell designed and
wrote the protocol.
Caroline Hing and Toby Smith performed the search strategy, identified the studies, extracted the data and prepared the data extraction
table for analysis. Toby Smith and Fujian Song analysed the data. Caroline Hing, Toby Smith and Simon Donell provided a clinical
perspective during the full review development and preparation. Caroline Hing, Toby Smith, Fujian Song and Simon Donell all revised
and agreed the full review.
Caroline Hing is the guarantor of the protocol and full review.
DECLARATIONS OF INTEREST
Simon Donell was an investigator of a trial on this topic. This trial was assessed independently by other review authors.
SOURCES OF SUPPORT
Internal sources
• West Hertfordshire Hospitals NHS Trust, Watford, UK.
• Norfolk and Norwich University Foundation Hospital NHS Trust, Norwich, UK.
• University of East Anglia, Norwich, UK.

External sources
• No sources of support supplied
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

1. In the review, two additional outcome measures were reported as secondary outcome measures. They were patient-reported satisfaction
and the subsequent requirement for surgery. Both outcomes were reported by a number of original research studies, and therefore
considered important to include in the final review.
2. We revised our risk of bias assessment to comply with the new guidance in Higgins 2011.
3. We presented the data for primary outcomes in two subgroups characterized by length of follow-up.
INDEX TERMS
Medical Subject Headings (MeSH)

Patellar Dislocation [surgery; ∗ therapy]; Randomized Controlled Trials as Topic
MeSH check words

Humans


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Surgical versus non-surgical interventions for treating patellar

Hing CB, Smith TO, Donell S, Song F

Surgical versus non-surgical interventions for treating patellar dislocation (Review)

Surgical versus non-surgical interventions for treating patellar dislocation (Review) i

Surgical versus non-surgical interventions for treating patellar

Caroline B Hing1 , Toby O Smith2 , Simon Donell3 , Fujian Song3

Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.

Data collection and analysis

PLAIN LANGUAGE SUMMARY

Operation versus physiotherapy alone following patellar dislocation

Patellar dislocation occurs when the patella disengages completely,

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 2

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 3

Search methods for identification of studies

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 4

Selection of studies Dealing with missing data

Measures of treatment effect

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 5

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 6

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 7

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 8

Figure 4) showed no difference between treatment groups (MD

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 11

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 12

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 13

References to studies included in this review - American Volume 2008;90(3):463–70. [MEDLINE:

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 16

Characteristics of included studies [ordered by study ID]

Methods Single centre RCT.

Bias Authors’ judgement Support for judgement

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 17

group or the conservative treatment group”

Methods Single centre RCT.

Participants Trial performed in Denmark from April 1998 to September 2002

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 18

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Quote:“Randomization between surgery

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 19

Methods Multi-centre RCT

Bias Authors’ judgement Support for judgement

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 20

by two of the authors (YN, RN).”

Methods Single centre RCT

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 21

Bias Authors’ judgement Support for judgement

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 22

(fifty-eight) of the sixty-four randomized

Methods Single centre RCT

Bias Authors’ judgement Support for judgement

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 23

were randomly allocated to two treat-

MPFL = medial patellofemoral ligament

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 24

Study Reason for exclusion

Arnbjornsson 1992 Not a randomised controlled trial.

Buchner 2005 Not a randomised controlled trial.

Cash 1988 Not a randomised controlled trial.

Marcacci 1995 Not a randomised controlled trial.

Savarese 1990 Not a randomised controlled trial.

Sillanpaa 2008b Not a randomised controlled trial.

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 25

Comparison 1. Surgical versus non-surgical management. Recurrent instability episodes

Comparison 2. Surgical versus non-surgical management. Patient-reported outcomes

Surgical versus non-surgical interventions for treating patellar dislocation (Review) 27