Operative Versus Nonoperative Treatment of Medial Patellofemoral Ligament Injuries: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis

Abstract

Background: The medial patellofemoral ligament (MPFL) serves as a major stabilizer in the knee, providing restraint against lateral patellar translation. The optimal approach for treating patients with first-time MPFL injuries remains uncertain, as the choice between operative and nonoperative treatment depends on the risks and variability associated with individual patient anatomy, activity, and presentation. Purpose: To evaluate high-level literature on outcomes after operative and nonoperative treatment of MPFL injuries to guide decision-making. Study Design: Meta-analysis; Level of evidence, 1. Methods: This systematic review and meta-analysis utilized PubMed, CINAHL, MEDLINE, Web of Science, and SPORTDiscus through November 25, 2024, to find randomized controlled trials that assess the outcomes associated with operative versus nonoperative treatment for MPFL tears. The primary outcomes were rates of recurrent dislocation and patient-reported outcomes. Statistical analysis included relative risk (RR) with 95% confidence intervals (95% CIs) along with trial sequential analysis (TSA) and assessment of fragility index. Results: A total of 306 patients (55.9% female) had a frequency-weighted mean ± SD age of 19.68 ± 4.24 years (range, 9-40) and follow-up time of 21.61 ± 5.34 months and underwent nonoperative (n = 147) or operative (n = 159) treatment. When compared with nonoperative treatment, operative treatment had a significantly lower rate of recurrent instability (10.69% vs 29.93%; RR, 2.49; 95% CI, 1.34-4.61; P = .004) with robust evidence (fragility index, 7 patients) but no difference in Kujala scores (79.02 ± 10.71 vs 88.78 ± 2.91; overall mean difference, –9.32; 95% CI, –19.45 to 0.81; P = .071). Subgroup analysis showed that repair had a significantly lower rate of recurrent instability as compared with nonoperative treatment (15.74% vs 35.42%; RR, 1.87; 95% CI, 1.11-3.17; P = .019). Similarly, reconstruction showed a significantly lower rate of recurrent instability as compared with nonoperative treatment (3.92% vs 33.33%; RR, 6.80; 95% CI, 1.93-23.95; P = .003). TSA for all primary outcomes demonstrated that the Z curve did not cross the required information size, suggesting that the current volume of data is not sufficient to draw definitive conclusions for each comparison. Conclusion: Operative treatment of MPFL injuries resulted in a robust and significantly lower rate of recurrent instability when compared with nonoperative treatment, although there was no difference in Kujala scores. Given the current evidence, operative treatment appears to be the more ideal approach to treating first-time patellar dislocations. However, the key to these findings is the need for further studies, as TSA showed that the current level of evidence is insufficient to draw definitive conclusions.