Care for Pediatric Patellofemoral Instability Prior to Orthopaedic Referral.

Abstract

Background: Patellofemoral instability is a common condition in the pediatric population with increasing incidence. Recent guidelines recommend radiographs and nonoperative treatment for simple first-time dislocations and surgical consideration after a repeated event. However, it is not known whether non-orthopaedic clinicians are initiating these treatments. We sought to characterize injury history, diagnostic evaluations and treatments pursued by referring clinicians prior to orthopaedic evaluation of patellofemoral instability events.

Methods: We performed a retrospective review of pediatric patient records with a patellofemoral instability event referred for orthopaedic evaluation. Data collected include demographics, referral clinician specialty, previous injury, mechanism of injury, imaging performed and findings, treatments pursued, surgical timeline, and outcomes. Cases were grouped by their referring clinician specialty into emergency settings, primary care, and other settings.

Results: Of the 100 cases, 44 were referred from emergency settings, 41 from primary care, and 15 from other settings. Thirty-one cases ultimately underwent surgical intervention. The primary care group was the least likely to have performed radiographs prior to referral (n = 21, 51.2%) compared with the emergency group (n = 43, 97.7%). The primary care group was also found to be more likely to have already had recurrent dislocations (n = 18, 43.9%). Lastly, of the 32 recurrent cases, only 12 cases had been recommended physical therapy.

Conclusions: We found that radiographs and nonoperative treatments are inconsistently used prior to orthopaedic referral. This impacts the timeline of management, which can lead to further injury. Our study identified that there are upstream referral factors influencing patellofemoral instability outcomes. Future research may include methods to improve concordance with treatment guidelines.

Key concepts: (1)Identifying clinician groups referring to orthopaedic practices for pediatric patellofemoral instability (PFI) events.(2)Describing evaluations and treatments pursued by clinicians for pediatric PFI events prior to orthopaedic referral.(3)Algorithm-based approaches are more adherent to current proposed pediatric PFI management guidelines.(4)Education of referring clinicians may help to improve surgical outcomes.

Level of evidence: III, Retrospective Cohort Study.