O3264: Trends in the Surgical Management of Pediatric Patellofemoral Instability in the United States: A Retrospective Analysis from 2010 to 2022

Background: Patellofemoral instability (PFI) is a significant cause of knee dysfunction in children and adolescents, often requiring surgery when conservative treatment fails. Literature suggests that surgical approaches for PFI in this population have evolved in recent decades. This study aimed to 1) evaluate nationwide trends in the timing and type of surgical interventions to treat PFI over time and 2) compare complication rates between interventions in this population.

Methods: A retrospective analysis of a large national administrative claims database (PearlDiver) identified pediatric patients (≤18 years old) who underwent surgery for PFI between 2010 and 2022. Surgical procedures were cohorted as medial patellofemoral ligament reconstruction (MPFLR) with and without tibial tubercle osteotomy (TTO) or other primary stabilization techniques (including MPFLR and repair of dislocating patellar procedures with proximal or distal realignment). Trends in the incidence (procedures/million patients) and distribution of these procedures were assessed. Patients with at least one year of follow-up were analyzed for postoperative complications requiring surgical treatment, including infection, arthrofibrosis, patellar fracture, and growth arrest. Statistical analyses included Student t-tests, chi-square tests, and linear regression, with significance set at p< 0.05.

Results: Among 365,031 pediatric patients diagnosed with PFI, 5,204 underwent surgical intervention, and 4,635 had ≥1 year follow-up. Patients aged 15-18 comprised the majority of surgical patients (72.5%), followed by those aged 10-14 (26.4%). While the overall mean age at surgery remained stable over the study period, a downward trend in age was observed for patients undergoing MPFL (p=0.007) and other primary stabilization procedures (p=0.003). From 2010 to 2022, the population-normalized incidence of MPFLR (p < 0.001) and MPFLR+TTO (p < 0.001) increased, while other stabilization procedures declined (p < 0.001). Patellar fractures occurred more frequently in other stabilization procedures (9.0%) compared to MPFLR (5.2%) and MPFLR+TTO (1.6%) (p < 0.001). Short-term infection rates were higher in other procedures at both 30 days (p=0.013) and 90 days (p=0.049), though 1-year infection rates were not significantly different (p=0.235). There were no differences in arthrofibrosis (p=0.553) or growth arrest (p=0.520). Overall, MPFLR (8.3%) and MPFLR+TTO (3.1%) had lower complication rates compared to other procedures (11.6%) (p < 0.001).

Conclusion: MPFLR, with or without TTO, has become the leading surgical approach for treating PFI in pediatric patients. Its increasing utilization over the past decade reflects growing acceptance as a safe and effective option, with low rates of serious complications requiring return to the operating room observed across all procedures. These findings offer valuable insight for risk-related counseling and surgical decision-making in this population.