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

Patellofemoral instability (PFI) is a significant cause of knee dysfunction in children and adolescents, sometimes 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 recent nationwide temporal trends in the timing and type of surgical interventions to treat PFI and 2) compare complication rates between interventions in this population. 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 categorized 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, and growth arrest. Statistical analyses included Student t-tests, chi-square tests, and the Mann-Kendall trend test. 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 years 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 MPFLR (p=0.020). From 2010 to 2022, the population-normalized incidence of MPFLR (p<0.001) and MPFLR+TTO (p<0.001) significantly increased, while other stabilization procedures declined (p<0.001). At one year postoperatively, there were no differences in rates of infection (p=0.235), arthrofibrosis (p=0.553), or growth arrest (p=0.520) between different procedures. 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. • Utilization Trends: MPFLR has increasingly replaced non-anatomic stabilization procedures and is now the predominant operative technique for pediatric patellofemoral instability. • Patient Demographics: Most patients undergoing surgery were adolescents, with a modest shift toward younger age in MPFLR cases reflecting wider adoption of physeal-sparing techniques. • Safety Profile: One-year rates of infection, arthrofibrosis, and growth disturbance were low across all procedures, with no significant differences between MPFLR, MPFLR+TTO, and other stabilization approaches. • Clinical Implications: MPFLR, with selective use of TTO in appropriately indicated patients, remains a reliable and safe option for pediatric patellofemoral instability and supports individualized, anatomy-guided care.