First-Time Patellar Dislocation in the High-Risk Athlete: The Case for Early Surgical Stabilization

Introduction
First-time patellar dislocation has typically been treated nonoperatively with closed reduction, possible brief immobilization, and physical therapy, while surgery typically has been reserved for recurrent dislocations, irreducible dislocation, if a loose body, or failed nonoperative treatment. However, outcome data suggests this default may undertreat a population with a high risk of failure and negative long-term sequalae.

Soft tissue trauma occurs with each dislocation and likely is not reversible. Magnetic resonance imaging (MRI) and arthroscopic correlation show medial patellofemoral ligament (MPFL) injury occurs in 99% of skeletally immature patients after a first dislocation.¹ The ligament which provides patellar stability is therefore usually torn after one event leading to high risk of recurrent instability.¹ In a matched population-based cohort, patients who had a lateral patellar dislocation developed patellofemoral osteoarthritis at substantially higher rates than matched controls, with recurrence and osteochondral injury as the strongest predictors.²

Long-term series report persistent symptoms in roughly half of patients and redislocation rates as high as 42%.^3,4 Failure to return to sport (RTS) has been reported in up to 55% of patients, with only about two-thirds returning to their prior level.^3,4 Further, high rates of chronic instability after a first dislocation have been reported.⁵ In pediatric and adolescent patients, nonoperative treatment fails in up to 69% of cases, with open physes and trochlear dysplasia being the strongest predictors of a second dislocation.⁶ Clinical prediction models exist which incorporate age, skeletal maturity, trochlear dysplasia, patella alta, and TT-TG distance to determine which patients face a high long-term recurrence risk.^7,8

More recent studies with modern surgical techniques have shown better subjective outcomes and lower recurrence than nonoperative treatment.⁹ Recurrent instability has been shown to be lower after surgery. Some early studies reporting no benefit utilized surgeries that are now widely considered outdated. For example, one commonly cited 2015 systematic review used pooled data with outdated techniques such as lateral release, medial imbrication, and Roux-Goldthwait procedures together with MPFL reconstruction.¹⁰

Why Consider Surgery?
Multiple meta-analyses with modern techniques show surgical treatment reduces redislocation rates compared with nonoperative management, though the magnitude varies by study and technique. A 2023 Cochrane review included 10 studies (eight randomized controlled trials [RCTs]) with 519 patients and found fewer subluxations and 157 fewer redislocations per 1000 patients with surgery at two to nine years.¹¹ They noted uncertainty, however, in determining if there was a difference in patient-reported outcomes between operative and nonoperative treatments. They noted patient-specific decision-making was required as well as appropriately powered RCTs. A 2026 meta-analysis of RCTs found operative treatment had a significantly lower recurrent instability rate (10.7% vs 30.0%; RR 2.49, P = .004) and recommended consideration for operative treatments of first-time patellar dislocations, though they noted the current data was insufficient for definitive conclusions.¹² Improved functional outcomes of surgical intervention for first-time patellar dislocation is unclear. As mentioned, a 2023 Cochrane review found no clear difference in Kujala scores between groups,¹¹ while a 2019 study by Yang et al of pooled RCTs and cohort studies found higher Kujala scores with surgery, but no difference in patient satisfaction or pain VAS.¹³ Pagliazzi et al reported a 10.2 point higher Kujala score at short and mid-term follow-up, but after six years, there was no difference.¹⁴ They also noted the need for higher-level studies.

In skeletally immature patients, lower redislocation rates have been reported with surgery, with one retrospective study of 142 patients treated with MPFL reconstruction having failure rates of 15.4% vs. 58.5%, as well as better functional outcomes and higher return to sports.¹⁵ Another meta-analysis of pediatric patients found lower redislocation rates (25.1% vs. 46.4%), but no difference in Kujala scores.¹⁶ 

Despite these studies, in 2018, The International Patellofemoral Study Group reached 100% consensus that nonoperative management is the standard of care for first-time dislocation in circumstances without an osteochondral fragment.¹⁷ However, when a loose body requires excision, these experts agreed that patellar instability should be addressed concurrently (89% agreement).¹⁷ They noted that the evidence utilized to make these decisions are poor. A survey of 438 surgeons in 2023 found that surgeons favor MPFL reconstruction for younger patients (<35 years), those in contact sports, and those with significant anatomic risk factors (trochlear dysplasia types C/D, TT-TG ≥15–20 mm, patella alta).¹⁸ The ESSKA formal consensus, involving 54 orthopaedic surgeons and one physiotherapist across 20 European countries, concluded that treatment should be individualized based on recognized risk factors rather than defaulting to nonoperative care for every first-time dislocator, explicitly stating that surgical options are increasingly appropriate for skeletally immature patients and those at elevated recurrence risk.^19,20 These consensus statements and others note treatment of first-time patellar dislocation remains controversial, with more certain operative indications including loose body and recurrent instability.

The type of surgical intervention also plays an important role in determining treatment of first-time patellar dislocations. A 2025 systematic review and meta-analysis of pediatric first-time patella dislocations found a weighted redislocation rate of 3.1% after MPFL reconstruction, versus 39.4% with older surgical techniques, but no difference in patient-reported functional scores.¹⁶ Based on patient-specific factors, MPFL reconstruction with sometimes additional procedures currently has the best evidence for the lowest risk of redislocation. Independent network meta-analyses from 2021 and 2023 ranked MPFL reconstruction above repair, proximal realignment, and conservative management with the lowest redislocation rates with MPFL reconstruction.^21,22

Early studies typically did not perform individualized surgery, a design flaw that may understate the benefit. A recent multicenter randomized-controlled trial specifically evaluated individualized, pathology-matched surgery including MPFL reconstruction, tibial tubercle transfer, or trochleoplasty compared with conservative treatment.²³ An anatomically tailored approach results in considerably lower redislocation rates. As mentioned, individualized treatment is essential for first time dislocators based on their anatomic factors. Zheng et al demonstrated that MPFL reconstruction in skeletally mature patients with at least one predisposing anatomic factor of patella alta, lateral tilt, trochlear dysplasia, increased TT-TG distance, resulted in zero redislocations and significantly better Kujala scores compared with 20.5% failure with nonoperative treatment.²⁴

A 2025 comparison in adolescent athletes found that those stabilized after their first dislocation returned to sport faster and achieved superior outcome scores compared to those who underwent surgery only after recurrent instability.²⁵ One 2025 clinical commentary noted the psychological impact of patellar instability, mentioning that even if it is not recurrent, successful return to sport depends on psychological readiness and confidence, not just strength and range of motion, and both are harder to rebuild the longer an athlete lives with a knee that keeps giving way.²⁶ 

As the literature now includes studies matching surgery to individual anatomy, tailored stabilization in patients with recognized risk factors appears to be the best approach, such as age 25 or younger, open growth plates, trochlear dysplasia, patella alta, elevated TT-TG distance, and athletes. The quality of evidence is modest; however, as most include expert opinion rather than high level data, reflecting a continued shortage of large, randomized studies.^19,20 While low, surgical complications are not zero, and some adolescents reduce their activity level regardless of how successful the stabilization is.²⁷ Finally, not every first-time dislocator is high risk. A skeletally mature patient with normal trochlear anatomy, normal TT-TG distance, and no patella alta carries meaningfully lower recurrence risk, which highlights the importance of risk-stratification based on the individual.^7,8 

Early, anatomically tailored MPFL stabilization reduces recurrent instability, shortens and improves return to sport compared with surgery after multiple dislocations, and likely protects against the long-term arthritis driven by recurrence and osteochondral injury.^2,16,25 Risk factor stratification and individualized treatments with shared decision making with the patient and family are the best way to decrease recurrence patellar instability and lead to the most ideal long-term patient outcomes.

The debate continues! Read the counterpart article, “Why Nonoperative Management Remains the Preferred Initial Treatment,” for the case for starting with nonoperative care.

References

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