MPFL reconstruction is best used to treat episodic lateral patellar instability owing to excessive laxity of medial retinacular patellar stabilizers.

The ideal candidate has minimal pain between episodes of patellar instability and seeks medical care primarily to address the occasional dislocation or subluxation.

It is imperative that the surgeon documents MPFL laxity by physical examination¹ before committing to an MPFL reconstruction. An examination under anesthesia is necessary to confirm laxity of the medial retinacular structures owing to patient apprehension and discomfort in the clinic. Examination under anesthesia is typically done just prior to surgical reconstruction, but can be done in isolation in rare cases where the diagnosis is uncertain.

MPFL reconstruction is not recommended to address patellofemoral pain. Stabilization of the patella will not reliably treat pain that is not directly caused by their instability episodes.

First-time dislocators are better served with a nonoperative approach. In a natural history study performed at author’s institution, only 17% of first-time dislocators suffered a second dislocation within the subsequent 2 to 5 years.² Others have reported recurrence of up to 71%; in these reports, MPFL repair or “reefing” did not reliably reduce the recurrence rate.³,⁴,⁵,⁶ Several levels 1 and 2 prospective studies have shown no benefit of MPFL repair compared to nonoperative treatment after initial patellar dislocation.³,⁵,⁷,⁸,⁹ There is at least one prospective randomized trial that reported improved clinical scores, lower redislocation rates, and better outcomes after MPFL reconstruction compared to nonoperative treatment for acute patellar dislocation.¹⁰

Controversy persists regarding operative treatment of the first-time patellar dislocator vis-à-vis the MPFL. The standard of care at this time remains a trial of nonoperative treatment. Subsequent dislocation or subjective instability despite an adequate course of physical therapy would be an indication for MPFL reconstruction.