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Acute patellar dislocations can result in patellar instability, pain, recurrent dislocations, decreased level of sporting activity, and patellofemoral arthritis. The initial management of a first-time traumatic patellar dislocation is controversial with no evidence-based consensus to guide decision making. Most first-time traumatic patellar dislocations have been traditionally treated nonoperatively; however, there has been a recent trend in initial surgical management. We performed a systematic review of Level I-IV studies to make evidence-based medicine recommendations on how a clinician should approach the diagnosis and treatment of a first-time traumatic dislocation. More specifically we answer the primary question of when initial treatment should consist of operative versus closed management. Based on the review of 70 articles looking at study design, mean followup, subjective and validated outcome measures, redislocation rates, and long-term symptoms, we recommend initial nonoperative management of a first-time traumatic dislocation except in several specific circumstances. These include the presence of an osteochondral fracture, substantial disruption of the medial patellar stabilizers, a laterally subluxated patella with normal alignment of the contralateral knee, or a second dislocation, or in patients not improving with appropriate rehabilitation.Level of Evidence: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.