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Patellofemoral joint alignment is a major risk factor for recurrent patellar dislocation in children and adolescents: a systematic review
  1. Martina Barzan1,
  2. Sheanna Maine2,
  3. Luca Modenese1,3,
  4. David G Lloyd1,
  5. Christopher P Carty1,4
  1. 1 School of Allied Health Sciences and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
  2. 2 Department of Orthopaedics, Children’s Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
  3. 3 Department of Civil and Environmental Engineering, Imperial College London, London, UK
  4. 4 Queensland Children’s Motion Analysis Service, Queensland Paediatric Rehabilitation Service, Children’s Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
  1. Correspondence to Miss Martina Barzan, School of Allied Health Sciences and Menzies Health Institute Queensland, Griffith University, Southport, QLD 4222, Australia; martina.barzan{at}


Importance The complex interplay of risk factors that predispose individuals to recurrent patellar dislocation is poorly understood, especially in paediatric patients who exhibit the most severe forms.

Objective The primary aim of this study was to systematically review the current literature to characterise the lower limb alignment, patellofemoral morphology and soft tissue restraints of the patellofemoral joint (PFJ) through medical imaging measurements in paediatric recurrent patellar dislocators and age-matched control participants. The secondary aims were to synthesise the data to stratify the factors that influence PFJ stability and provide recommendations on the assessment and reporting of PFJ parameters in this patient population.

Evidence review A systematic search was performed using CINAHL, the Cochrane Library, EMBASE, PubMed and Web of Science databases until June 2017. Two authors independently searched for studies that included typical children and adolescents who experienced patellar dislocation and also had direct measures of structural and dynamic risk factors. The methodological quality of the included studies was assessed through a customised version of the Downs and Black checklist. Weighted averages and SDs of measures that have been reported in more than one study were computed. A fixed-effects model was used to estimate the mean differences with 95% CIs regarding the association of recurrent patellar dislocation with patella alta, tibial tuberosity to trochlear groove (TT-TG) distance and bony sulcus angle.

Findings 20 of 718 articles met the inclusion criteria. Thirty-one risk factors were found; however, only 10 of these measurements had been assessed in multiple articles and only four had both dislocator and control population results. With respect to controls, patients with recurrent patellar dislocations had higher TT-TG distance (p<0.01) and higher bony sulcus angle (p<0.01).

Conclusions and relevance Based on the current scientific literature, increased TT-TG distances and bony sulcus angles predispose children and adolescents to recurrent patellar dislocation. Besides these measurements, studies reporting on recurrent patellar dislocation in children and adolescents should also include characterisation of lower limb alignment in coronal and axial planes and assessment of generalised ligamentous laxity.

Level of evidence Systematic review of prognostic studies, Levels II–IV.

  • mri
  • knee
  • instability
  • Ct-scan
  • X-ray
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  • Contributors All authors have made substantial contribution to the work reported in the manuscript. Specific contributions of each author are: Conception and design of study: MB, CPC, SM; Literature search: MB; Paper selection and scoring: MB, CPC, SM; Analysis and interpretation of data: MB, CPC, SM, LM, DGL; Drafting the manuscript: MB; Revising the manuscript critically for important intellectual content: CPC, SM, LM, DGL.

  • Funding LM and CPC were supported by an Imperial College Research Fellowship and an Advance Queensland Research Fellowship, respectively.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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