A Modified 4-in-1 Stanisavljevic Procedure for Treating Obligatory or Congenital Patellar Dislocations in Children: A Surgical Technique

Introduction Patellar instability and dislocation pose complex clinical and surgical challenges, especially in children. Congenital (fixed) and obligatory (habitual) dislocations present significant anatomical and etiological complexity, frequently leading to deformities and functional impairments, which can range from walking difficulties to sports limitations. Conservative treatment is often inadequate.Technique: We describe a surgical technique for treating congenital or obligatory patellar dislocations in patients with various underlying diagnoses-including Down syndrome, nail-patella syndrome, and skeletal dysplasia-that involves extensive subperiosteal quadriceps realignment, distal realignment (Roux-Goldthwait or tibial tuberosity transfer), and optional medial plication. This modified 4-in-1 technique follows the principles described in 1976 by Stanisavljevic, which involves subperiosteal quadriceps mobilization, thus minimizing muscle damage, bleeding, and postoperative muscular adherences.Results: In 24 patients treated at our institution between 2002 and 2021 (35 knees; age range = 5.5-16.8 years; 13 girls, 11 boys), with a mean follow-up of 8.2 years (2.4-20 years), we achieved satisfactory improvements in patellar stability, range of motion, and quality of life with a modified 4-in-1 Stanisavljevic technique. A total of 9 patients (7 with obligatory dislocations and 2 with congenital dislocations) could engage in recreational or competitive sports. The average postoperative pediatric International Knee Documentation Committee (pedi-IKDC) score was 78.45 +/- 22.3 (range = 0-100); a patient with DiGeorge syndrome and 1 with multiple epiphyseal dysplasia had scores of 35 and 48, respectively.Discussion: We found at our institution that a modified 4-in-1 Stanisavljevic technique produced favorable outcomes in patellar stability, range of motion, and quality of life in pediatric patients with congenital or obligatory patellar dislocation. More study is warranted to determine the procedure's overall benefits for children with obligatory or congenital dislocations of complex etiology.