Operative Treatment has Greater Expected Value than Nonoperative Treatment for First-Time Patellar Dislocations: A Meta-Analysis and Expected Value Decision Analysis.

Abstract

Purpose: The purpose of this study is to use expected value decision analysis to determine the optimal treatment for first time patellar dislocations.

Methods: A meta-analysis according to PRISMA guidelines and expected-value decision analysis were performed. A decision tree addressing the clinical question (operative vs. non-operative) was created, and a meta-analysis was performed to assess the probability of outcomes after operative versus non operative treatment. 70 patients were assessed regarding potential outcome preferences to a hypothetical injury. An expected-value decision analysis was performed to systematically quantify the clinical decision. Statistical fold back analysis calculated optimal treatment, and a sensitivity analysis was performed to determine the effect of changing redislocation rates on the expected value.

Results: Forty-five participants (mean age 20 years [range 12-33], 58% male, 71% athletes) met inclusion criteria. Meta-analysis of 10 randomized controlled trials with 624 patients revealed the probability of a "well" outcome was significantly greater for operative treatment (59.3%, 95% CI 53.7% - 64.7%) than nonoperative treatment (44.7%, 95% CI 39.0% - 50.5%). Subsequent redislocation rates with operative treatment were significantly lower (29.8%, 95% CI 24.5% - 35.17%) compared to nonoperative treatment (44.7%, 95% CI 39.0% - 50.5%). MPFL reconstruction showed an 88% probability of a "well" outcome, and a 3% redislocation rate. Operative management had a higher chance of a well outcome (RR: 1.43 (95% CI: 1.12, 1.83), p = 0.005). The overall expected value for operative treatment was 6.09 versus 4.96 for nonoperative treatment. Secondary analysis of 27 articles for solely MPFL reconstruction demonstrated an expected value of 7.80 for operative treatment.

Conclusions: Meta-analysis demonstrated more frequent favorable outcomes and lower subsequent dislocation rates with operative treatment. Decision analysis based on healthy patient responses to hypothetical scenarios demonstrates that operative treatment has a higher expected value for first time patellar dislocations than non-operative treatment.

Level of evidence: Level IV, economic study.