Patellar dislocation: cylinder cast, splint or brace? An evidence-based review of the literature

Abstract

Patellar dislocations are a common injury in the emergency department. The conservative management consists of immobilisation with a cylinder cast, posterior splint or removable knee brace. No consensus seems to exist on the most appropriate means of conservative treatment or the duration of immobilisation. Therefore the aims of this review were first to examine whether immobilisation with a cylinder cast causes less redislocation and joint movement restriction than a knee brace or posterior splint and second to compare the redislocation rates after conservative treatment with surgical treatment. A systematic search of Pubmed, Embase and the Cochrane Library was performed. We identified 470 articles. After applying the exclusion and inclusion criteria, only one relevant study comparing conservative treatment with a cylinder cast, brace and posterior splint remained (Mäenpää et al.). In this study, the redislocation frequency per follow-up year was significant higher in the brace group (0.29; p < 0.05) than in the cylinder cast group (0.12) and the posterior splint group (0.08). The proportion of loss of flexion and extension was the highest in the cylinder cast group and the lowest in the posterior splint group (not significant). The evidence level remained low because of the small study population, difference in duration of immobilisation between groups and use of old braces. Also, 12 studies comparing surgical with conservative treatment were assessed. Only one study reported significantly different redislocation rates after surgical treatment. In conclusion, a posterior splint might be the best therapeutic option because of the low redislocation rates and knee joint restrictions. However, this recommendation is based on only one study with significant limitations. Further investigation with modern braces and standardisation of immobilisation time is needed to find the most appropriate conservative treatment for patellar luxation. Furthermore, there is insufficient evidence to confirm the added value of surgical management.

Management of Acute Patellar Dislocation: A Case Report

“…[3][4][5][6]11,12 Multiple randomized control studies and one systematic review have addressed operative vs nonoperative treatment in first-time traumatic patellar dislocations. 1,10,12,16 The area and degree of injury to the MPFL, ligament hyperlaxity, medial retinacular injury, sub-patellar effusion and fractures to bone or cartilage are factors in deciding on surgical management of the dislocated patella. 3,11,13 Some defects may be obvious on examination, however evaluation of the supporting structures of the knee by MRI or computed tomography is important to verify the patency of supporting ligaments and presence of osteochondral fractures.…”

“…There is no substantial difference in long-term outcomes between the surgically and conservatively treated patients in regard to redislocation rates, level of activity, or functional and subjective outcomes. 2,3,8,11,16 A randomized study by Nikku et al compared operative vs closed treatment in 125 patients with patellar dislocations without tibiofemoral ligament or osteochondral fractures that necessitated surgical stabilization, with a 2-year follow-up. 2 The results concluded that both treatments gave almost identical outcomes after 2 years in terms of a subjective score, recurrent instability, and function.…”

Paediatric First-Time Patella Dislocators: An Approach to Conservative Management

“…Two recent meta-analyses in 2010 8 and 2012 9 could not give us conclusive answers due to a paucity of literature. After thorough literature searches, Smith identified only two studies that met their inclusion criteria, 6,12 and van Gemert et al 9 found an article by Maenpaa and Lehto 6 (1997) to be the only study that met theirs.…”

I.S.Mu.L.T. first-time patellar dislocation guidelines

“…Early immobilization of the knee and the use of crutches is always to be provided immediately after the reduction. It may be useful to administer dietary supplements of chondroitin sulfate and glucosamine, natural elements necessary for the biosynthesis of proteoglycans essential for the health of joint cartilage [63][64][65][66] .…”

“…Casting has been advocated to allow healing of the medial retinaculum and of the MPFL, but prolonged immobilization results in adverse effects on ligament, bone, cartilage and muscles. The use of braces or tapes could offer faster functional recovery, but with a longer time for MPFL healing [91][92][93] .…”