Management of First-Time Patellar Dislocation

Lars Blønd, orthopaedic surgeon, Copenhagen, Denmark. Past. Past president of the Danish Society of Sports Medicine and ESSKA Patellofemoral Instability Group member. Expert in Patellofemoral surgery. Developed the surgical technique Arthroscopic Deepening trochleoplasty to treat Trochlear Dysplasia. Published 48 peer-reviewed papers, surgical videos and six book chapters and authored the book ‘Aspects of Femoral Trochlear Dysplasia.

Through this article, Blønd highlights the shift toward early, individualised and evidence-based management of first-time patellar dislocation (FTPD).

How we understand and treat first-time patellar dislocation (FTPD) is evolving. Recent scientific advancements challenge old assumptions and provide new guidelines for managing this surprisingly common injury. In 2022, the European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) launched an ambitious effort to establish consensus guidelines on FTPD. Three years later, those guidelines are now shaping clinical practice across Europe. The entire project can also be read more detail on the ESSKA website and the scientific articles can be downloaded from www.larsblond.com.

A Rigorous Consensus Process

Creating these guidelines wasn’t simple. It involved a structured, evidence-based process designed to reach the highest level of scientific consensus. Fifty-five European orthopaedic surgeons and researchers participated, representing a broad geographic and clinical spectrum. They formulated 32 critical questions about FTPD and used scientific literature and clinical expertise to answer them.

The consensus aimed to bridge the gap between scientific evidence and everyday clinical practice. Orthopaedic surgeons and physiotherapists now have clear guidelines, making diagnosing and treating FTPD easier.

FTPD: More Common and Complex Than Many Think

One of the key findings from the consensus process is that FTPD is more common than previously believed, especially among individuals under 16 years old. It occurs more frequently in this age group than the well-known anterior cruciate ligament (ACL) injury.

The consensus also highlights that many patients struggle long after their first dislocation. About half of them experience ongoing symptoms, including pain, swelling, instability and psychological limitations. This can severely impact their quality of life, curbing their ability to play sports or even participate in routine social activities.

Moving Beyond Traditional Approaches

For decades, standard practice dictated that surgery was only considered after a second dislocation. This approach is now being reconsidered. The consensus highlights the importance of early intervention, especially for children and adolescents with underlying anatomical issues that increase the risk of recurrent dislocation.

New research shows that persistent instability—where the patella feels like it could dislocate again even if it doesn’t— can be just as debilitating as repeated dislocations. This realisation changes how orthopaedic surgeons approach FTPD, particularly for young patients previously advised to “wait and see.”

Understanding the Causes of Instability

The consensus report emphasises that FTPD is rarely a one-off event without underlying causes. Several anatomical factors can predispose individuals to instability, such as trochlear dysplasia (an abnormal knee groove), patella alta (a high-riding kneecap) and malalignment issues. Torsional abnormalities, where the kneecap points inward, also play a role.

Understanding these risk factors is essential because they don’t just cause instability—they can also lead to chronic knee pain. The guidelines now recommend that all patients undergo thorough clinical examination and imaging, typically MRI scans, to identify these issues early on.

Individualised Treatment Plans

The new guidelines’ cornerstone is a patient-centered approach. Patients’ anatomy, symptoms, lifestyle and personal goals must be considered when planning treatment. Clinicians now have a range of tests to help identify the underlying causes of instability, including a relatively new assessment called the “reversed dynamic patella apprehension test.”

By gradually extending the knee from a bent position while testing for instability, clinicians can better pinpoint the severity of the problem without causing unnecessary discomfort. This patient-friendly test has proven particularly useful. Another cardinal clinical assessment is the eventual presence or absence of a J-sign since this is also related to more severe bony abnormalities. Finally, should the patient be examined for an eventual torsional abnormality since it is linked to an inferior outcome of surgery if this is not handled surgically?

Surgery: A Changing Paradigm

Surgery is no longer reserved exclusively for repeat dislocations. The consensus recommends surgical intervention for patients with high-risk anatomical features or persistent instability, even after a single dislocation. Early intervention can prevent cartilage damage, improve quality of life and allow patients to maintain higher physical activity levels.

MPFL reconstruction as first-line surgical treatment.

treatment. The most common surgical procedure, medial patellofemoral ligament (MPFL) reconstruction, is now preferred over outdated repair techniques. The report also advises against routinely immobilising braces after FTPD, as evidence suggests they may do more harm than good.

The Importance of Correcting Bony Abnormalities

One of the consensus’s most critical insights is that successful medial patellofemoral ligament (MPFL) reconstruction often depends on addressing underlying bony abnormalities. If structural issues like trochlear dysplasia, patella alta or torsional abnormalities are not corrected during surgery, there is a significant risk of failure, particularly the development of patellofemoral pain. This complication has often been overlooked, but these abnormalities, when necessary, are essential for achieving durable, pain-free stability.

The Role of Rehabilitation

Despite limited evidence that physiotherapy alone prevents further instability, the consensus group still recommends guided rehabilitation since the absence of evidence is not evidence of absence. Improving muscle control and joint stability could help reduce symptoms and potentially prevent future dislocations.

The ESSKA consensus report provides a groundbreaking framework for managing FTPD in 2025. Not only is FTPD more common than many previously believed, but its impact on quality of life is more significant than once thought. Individualised treatment, early MRI imaging and a willingness to intervene surgically when needed are now central to best practices.

These guidelines aim to provide clinicians with the tools to offer better, more consistent care to patients struggling with FTPD, particularly those who are young and at higher risk. It’s a new era for patellar dislocation management that prioritises evidence-based, individual, patient-centered care.