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Inter-rater Reliability of the Classification of the J-Sign Is Inadequate Among Experts. Clin J Sport Med 2022; 32:480-485. [PMID: 36083327 DOI: 10.1097/jsm.0000000000000997] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 11/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the inter-rater and intra-rater reliability of the symmetry, classification, and underlying pathoanatomy associated with the J-sign in patients with recurrent lateral patellofemoral instability. STUDY DESIGN Blinded, inter-rater reliability study. SETTING N/A. PARTICIPANTS Thirty patellofemoral joint experts. INTERVENTIONS Thirty clinicians independently assessed 30 video recordings of patients with recurrent lateral patellofemoral instability performing the J-sign test. MAIN OUTCOME MEASURES Raters documented J-sign symmetry and graded it according to the quadrant and Donell classifications. Raters indicated the most significant underlying pathoanatomy and presence of sagittal plane maltracking. Intra-rater reliability was assessed by 4 raters repeating the assessments. Mean pairwise simple and/or weighted Cohen's kappa were performed to measure inter-rater and intra-rater reliability, as well as calculation of percent agreement. RESULTS J-sign symmetry demonstrated fair inter-rater reliability (k = 0.26), whereas intra-rater reliability was moderate (k = 0.48). Inter-rater reliability for the quadrant and Donell classifications indicated moderate agreement, k = 0.51 and k = 0.49, respectively, whereas intra-rater reliability was k = 0.79 and k = 0.72, indicating substantial agreement. Inter-rater reliability of the foremost underlying pathoanatomy produced only slight agreement (k = 0.20); however, intra-rater reliability was substantial (k = 0.68). Sagittal plane maltracking demonstrated slight inter-rater agreement (k = 0.23) but substantial intra-rater agreement (k = 0.64). CONCLUSIONS The symmetry, classification, and underlying pathoanatomy of the J-sign demonstrated fair to moderate inter-rater reliability and moderate to substantial intra-rater reliability among expert reviewers using video recordings of patients with recurrent lateral patellofemoral instability. These findings suggest individual raters have a consistent standard for assessing the J-sign, but that these standards are not reliable between assessors. LEVEL OF EVIDENCE III.
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Kim HK, Parikh S. Patellofemoral Instability in Children: Imaging Findings and Therapeutic Approaches. Korean J Radiol 2022; 23:674-687. [PMID: 35555883 PMCID: PMC9174504 DOI: 10.3348/kjr.2021.0577] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 02/08/2022] [Accepted: 02/19/2022] [Indexed: 11/15/2022] Open
Abstract
Patellofemoral instability (PFI) is common in pediatric knee injuries. PFI results from loss of balance in the dynamic relationship of the patella in the femoral trochlear groove. Patellar lateral dislocation, which is at the extreme of the PFI, results from medial stabilizer injury and leads to the patella hitting the lateral femoral condyle. Multiple contributing factors to PFI have been described, including anatomical variants and altered biomechanics. Femoral condyle dysplasia is a major risk factor for PFI. Medial stabilizer injury contributes to PFI by creating an imbalance in dynamic vectors of the patella. Increased Q angle, femoral anteversion, and lateral insertion of the patellar tendon are additional contributing factors that affect dynamic vectors on the patella. An imbalance in the dynamics results in patellofemoral malalignment, which can be recognized by the presence of patella alta, patellar lateral tilt, and lateral subluxation. Dynamic cross-sectional images are useful for in vivo tracking of the patella in patients with PFI. Therapeutic approaches aim to restore normal patellofemoral dynamics and prevent persistent PFI. In this article, the imaging findings of PFI, including risk factors and characteristic findings of acute lateral patellar dislocation, are reviewed. Non-surgical and surgical approaches to PFI in pediatric patients are discussed.
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Affiliation(s)
- Hee Kyung Kim
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati, College of Medicine, Cincinnati, OH, USA.
| | - Shital Parikh
- Devision of Pediatric Orthopedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Shen A, Boden BP, Grant C, Carlson VR, Alter KE, Sheehan FT. Adolescents and adults with patellofemoral pain exhibit distinct patellar maltracking patterns. Clin Biomech (Bristol, Avon) 2021; 90:105481. [PMID: 34562716 DOI: 10.1016/j.clinbiomech.2021.105481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 08/27/2021] [Accepted: 09/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic idiopathic patellofemoral pain is associated with patellar maltracking in both adolescents and adults. To accurately target the underlying, patient-specific etiology, it is crucial we understand if age-of-pain-onset influences maltracking. METHODS Twenty adolescents (13.9 ± 1.4 years) and 20 adults (28.1 ± 4.9 years) female patients with idiopathic patellofemoral pain (age-of-pain-onset: < 14 and > 18 years of age, respectively) formed the patient cohort. Twenty adolescents and 20 adults (matched for gender, age, and body mass index) formed the control cohort. We captured three-dimensional patellofemoral kinematics during knee flexion-extension using dynamic MRI. Patellar maltracking (deviation in patient-specific patellofemoral kinematics, relative to their respective age-controlled mean values) was the primary outcome measure, which was compared between individuals with adolescent-onset and adult-onset patellofemoral pain using ANOVA and discriminant analysis. FINDINGS The female adolescent-onset patellofemoral pain cohort demonstrated increased lateral (P = 0.032), superior (P = 0.007), and posterior (P < 0.001) maltracking, with increased patellar flexion (P < 0.001) and medial spin (P = 0.002), relative to the adult-onset patellofemoral pain cohort. Post-hoc analyses revealed increased lateral shift [mean difference ± 95% confidence interval = -2.9 ± 2.1 mm at 10° knee angle], posterior shift [-2.8 ± 2.1 mm, -3.3 ± 2.3 mm & -3.1 ± 2.4 mm at 10°, 20°& 30°], with greater patellar flexion [3.8 ± 2.6 mm & 5.0 ± 2.8 mm, at 20°& 30°] and medial spin [-2.2 ± 1.7 mm & -3.4 ± 2.3 mm at 20°& 30°]. Axial-plane maltracking accurately differentiated the patient age-of-pain-onset (60-75%, P < 0.001). INTERPRETATION Age-of-pain-onset influences the maltracking patterns seen in patients with patellofemoral pain; with all, but 1, degree of freedom being unique in the adolescent-onset-patellofemoral pain cohort. Clinical awareness of this distinction is crucial for correctly diagnosing a patient's pain etiology and optimizing interventional strategies.
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Affiliation(s)
- Aricia Shen
- Department of Rehabilitation Medicine, NIH, Bethesda, MD, USA
| | | | - Camila Grant
- Department of Rehabilitation Medicine, NIH, Bethesda, MD, USA.
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Maine S, Ngo-Nguyen C, Barzan M, Stockton C, Modenese L, Lloyd D, Carty C. Bisect offset ratio and cartilaginous sulcus angle are good combined predictors of recurrent patellar dislocation in children and adolescents. J ISAKOS 2021; 6:265-270. [PMID: 33893181 DOI: 10.1136/jisakos-2020-000461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Recurrent patellar dislocation (RPD) is found most commonly in the juvenile population. While risk factors have been well-established in adults, there remains a paucity in radiographical data to define normal and pathoanatomical juvenile cohorts. The objectives of this paper were to elucidate the differences in the patellofemoral joint between RPD and typically developed (TD) juvenile populations, using MRI measurements, and determine the best independent and combined predictors of RPD. METHODS A prospective, cross-sectional study was conducted with 25 RPD and 24 TD participants aged between 8 and 19 years. MR images were obtained to assess common measures of lower limb alignment, patellofemoral alignment, and trochlear dysplasia. RESULTS Significant differences were evident for acetabular inclination, tibial-femoral torsion, tibial tubercle-to-trochlear groove (TT-TG) distance, lateral patellar tilt (LPT), cartilaginous sulcus angle (CSA) and bisect offset ratio (BOR). CSA and BOR were included in the final predictive model, which correctly classified 89.4% of RPD cases. CONCLUSION Radiographical parameters that stratify risk of RPD in adults are also able to predict RPD in the pediatric population (TT-TG, LPT, CSA and BOR). Together, CSA and BOR accurately identified 89.4% of RPD. These measures should be included in the evaluation of pediatric patients who present with patellar dislocation. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sheanna Maine
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Griffith Centre of Biomedical and Rehabilitation Engineering, Griffith University, Gold Coast, Queensland, Australia
| | - Christina Ngo-Nguyen
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Martina Barzan
- Griffith Centre of Biomedical and Rehabilitation Engineering, Griffith University, Gold Coast, Queensland, Australia
| | - Chris Stockton
- Medical Imaging and Nuclear Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Luca Modenese
- Griffith Centre of Biomedical and Rehabilitation Engineering, Griffith University, Gold Coast, Queensland, Australia.,Department of Civil and Environmental Engineering, Imperial College London, London, UK
| | - David Lloyd
- Griffith Centre of Biomedical and Rehabilitation Engineering, Griffith University, Gold Coast, Queensland, Australia
| | - Christopher Carty
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Griffith Centre of Biomedical and Rehabilitation Engineering, Griffith University, Gold Coast, Queensland, Australia
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Grant C, Fick CN, Welsh J, McConnell J, Sheehan FT. A Word of Caution for Future Studies in Patellofemoral Pain: A Systematic Review With Meta-analysis. Am J Sports Med 2021; 49:538-551. [PMID: 32816535 PMCID: PMC9906796 DOI: 10.1177/0363546520926448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patellar maltracking is widely accepted as an underlying mechanism of patellofemoral pain. However, methodological differences in the literature hinder our ability to generate a universal quantitative definition of pathological patellofemoral kinematics (patellar maltracking) in patellofemoral pain, leaving us unable to determine the cause of patellofemoral pain. PURPOSE To systematically review the literature to provide evidence regarding the influence of confounding variables on patellofemoral kinematics. STUDY DESIGN Systematic review and random effects meta-analysis of control-case studies. METHODS A literature search of case-control studies that evaluated patellofemoral kinematics at or near full extension and were written in English was conducted using Embase, PubMed, Scopus, and Web of Science up to September 2019. Cases were defined as patients with patellofemoral pain. Studies were eliminated if they lacked quantitative findings; had a primary aim to assess therapy efficacy; or included participants with osteoarthritis and/or previous trauma, pathology, or surgery. A quality assessment checklist was employed to evaluate each study. Meta-analyses were conducted to determine the influence of confounding variables on measures of patellofemoral kinematics. RESULTS Forty studies met the selection criteria, with quality scores ranging from 13% to 81%. Patient characteristics, data acquisition, and measurement methods were the primary sources of methodological variability. Active quadriceps significantly increased lateral shift (standardized mean difference [SMD]shift = 0.33; P = .0102) and lateral tilt (SMDtilt = 0.43; P = .006) maltracking. Individuals with pain secondary to dislocation had greater effect sizes for lateral maltracking than had those with isolated patellofemoral pain (ΔSMDshift = 0.71, P = .0071; ΔSMDtilt = 1.38, P = .0055). CONCLUSION This review exposed large methodological variability across the literature, which not only hinders the generalization of results, but ultimately mitigates our understanding of the underlying mechanism of patellofemoral pain. Although our meta-analyses support the diagnostic value of maltracking in patellofemoral pain, the numerous distinct methods for measuring maltracking and the limited control for cofounding variables across the literature prohibit defining a single quantitative profile. Compliance with specific standards for anatomic and outcome measures must be addressed by the scientific and clinical community to establish methodological uniformity in this field.
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Affiliation(s)
- Camila Grant
- Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Cameron N. Fick
- Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Judith Welsh
- National Institutes of Health Library, Office of Research Services, National Institutes of Health, Bethesda, Maryland, USA
| | - Jenny McConnell
- Centre for Health Exercise and Sports Medicine, University of Melbourne, Melbourne, Australia
| | - Frances T. Sheehan
- Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA,Address correspondence to Frances T. Sheehan, PhD, Department of Rehabilitation Medicine, National Institutes of Health, 6707 Democracy Blvd, Suite 856. Bethesda, MD 20817, USA ()
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Best MJ, Tanaka MJ, Demehri S, Cosgarea AJ. Accuracy and Reliability of the Visual Assessment of Patellar Tracking. Am J Sports Med 2020; 48:370-375. [PMID: 31913663 DOI: 10.1177/0363546519895246] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Abnormal patellar tracking is described as a "J-sign" when the patella exhibits excessive lateral displacement during active knee extension. PURPOSE To determine (1) the accuracy and reliability of the visual assessment of patellar tracking when viewed by surgeons with patellofemoral expertise and (2) whether surgeon experience (in years) correlates with the ability to accurately identify the presence and severity of patellar maltracking. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS Using a web-based assessment, 32 orthopaedic surgeon members of the International Patellofemoral Study Group determined the presence or absence of maltracking (≥2 quadrants of lateral translation) in 10 single-knee videos of patients with patellar instability during active knee extension (qualitative analysis). Surgeons then graded patellar tracking in 20 single-knee videos as follows: 0 (<1 patellar quadrant of lateral translation), 1 (1 to <2 quadrants), 2 (2 to <3 quadrants), or 3 (≥3 quadrants) (quantitative analysis). Responses were compared with a previously described grading system using patellar bisect offset measured with 4-dimensional computed tomography. We evaluated the association between number of years of surgeon experience and the ability to correctly identify and grade patellar tracking. A total of 22 surgeons repeated the survey 3 months later, and their answers were matched to the first survey, allowing for assessment of intraobserver reliability. RESULTS In the qualitative analysis, surgeons correctly identified videos as showing patellar maltracking 68% of the time (κ = 0.45). In the quantitative analysis, 53%, 51%, 48%, and 68% of surgeons correctly identified maltracking of grades 3, 2, 1, and 0, respectively (κ = 0.42). Surgeon experience did not correlate with ability to identify the presence (P = .59) or grade (P = .35) of patellar maltracking. Respondent answers from the second survey demonstrated inadequate intraobserver reliability (κ = 0.48). CONCLUSION Using visual assessment alone, surgeons correctly identified patellar maltracking in approximately two-thirds of videos and correctly graded patellar maltracking in half. Inter- and intraobserver reliability were inadequate to support the use of visual assessment alone for detecting the presence or grade of patellar maltracking. Surgeon experience did not correlate with ability to identify the presence or grade of patellar maltracking.
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Affiliation(s)
- Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Shadpour Demehri
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Andrew J Cosgarea
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Rosa SB, Ewen PM, Doma K, Ferrer JFL, Grant A. Dynamic Evaluation of Patellofemoral Instability: A Clinical Reality or Just a Research Field? A Literature review. Orthop Surg 2019; 11:932-942. [PMID: 31797563 PMCID: PMC6904628 DOI: 10.1111/os.12549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/02/2019] [Accepted: 09/09/2019] [Indexed: 12/15/2022] Open
Abstract
Patellofemoral instability (PFI) is one of the most disabling conditions in the knee, often affecting young individuals. Despite its not uncommon presentation, the underlying biomechanical features leading to this entity are not entirely understood. The suitability of classic physical examination manoeuvres and imaging tests is a matter of discussion among treating surgeons, and so are the findings provided by these means. A potential cause for this lack of consensus is the fact that, classically, the diagnostic approach for PFI has relied on statically obtained data. Many authors advocate for the study of this entity in a dynamic scenario, closer to the actual situation in which the instability episodes occur. In this literature review, we have compiled the available data from the last decades regarding dynamic evaluation methods for PFI and related conditions. Several categories are presented, grouping the related techniques and devices: physical examination, imaging modalities (ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT) and combined methods), arthroscopic evaluation, and others. In conclusion, although a vast number of quality studies are presented, in which comprehensive data about the biomechanics of the patellofemoral joint (PFJ) are described, this evidence has not yet reached clinical practice universally. Most of the data still stays in the research field and is seldom employed to assist a better understanding of the PFI cases and their ideal treatment targets.
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Affiliation(s)
- Sergio Barroso Rosa
- The ORIQL, Orthopaedic Research Institute of Queensland, Townsville (QLD), Australia.,Clinical Sciences Department, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Peter Mc Ewen
- The ORIQL, Orthopaedic Research Institute of Queensland, Townsville (QLD), Australia
| | - Kenji Doma
- The ORIQL, Orthopaedic Research Institute of Queensland, Townsville (QLD), Australia.,College of Healthcare Sciences, James Cook University, Townsville (QLD), Australia
| | - Juan Francisco Loro Ferrer
- Clinical Sciences Department, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Andrea Grant
- The ORIQL, Orthopaedic Research Institute of Queensland, Townsville (QLD), Australia
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Barzan M, Maine S, Modenese L, Lloyd DG, Carty CP. Patellofemoral joint alignment is a major risk factor for recurrent patellar dislocation in children and adolescents: a systematic review. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
ImportanceThe complex interplay of risk factors that predispose individuals to recurrent patellar dislocation is poorly understood, especially in paediatric patients who exhibit the most severe forms.ObjectiveThe primary aim of this study was to systematically review the current literature to characterise the lower limb alignment, patellofemoral morphology and soft tissue restraints of the patellofemoral joint (PFJ) through medical imaging measurements in paediatric recurrent patellar dislocators and age-matched control participants. The secondary aims were to synthesise the data to stratify the factors that influence PFJ stability and provide recommendations on the assessment and reporting of PFJ parameters in this patient population.Evidence reviewA systematic search was performed using CINAHL, the Cochrane Library, EMBASE, PubMed and Web of Science databases until June 2017. Two authors independently searched for studies that included typical children and adolescents who experienced patellar dislocation and also had direct measures of structural and dynamic risk factors. The methodological quality of the included studies was assessed through a customised version of the Downs and Black checklist. Weighted averages and SDs of measures that have been reported in more than one study were computed. A fixed-effects model was used to estimate the mean differences with 95% CIs regarding the association of recurrent patellar dislocation with patella alta, tibial tuberosity to trochlear groove (TT-TG) distance and bony sulcus angle.Findings20 of 718 articles met the inclusion criteria. Thirty-one risk factors were found; however, only 10 of these measurements had been assessed in multiple articles and only four had both dislocator and control population results. With respect to controls, patients with recurrent patellar dislocations had higher TT-TG distance (p<0.01) and higher bony sulcus angle (p<0.01).Conclusions and relevanceBased on the current scientific literature, increased TT-TG distances and bony sulcus angles predispose children and adolescents to recurrent patellar dislocation. Besides these measurements, studies reporting on recurrent patellar dislocation in children and adolescents should also include characterisation of lower limb alignment in coronal and axial planes and assessment of generalised ligamentous laxity.Level of evidenceSystematic review of prognostic studies, Levels II–IV.
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Effects of upright weight bearing and the knee flexion angle on patellofemoral indices using magnetic resonance imaging in patients with patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 2017; 25:2405-2413. [PMID: 26482535 DOI: 10.1007/s00167-015-3829-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 10/06/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE This study analysed the effects of upright weight bearing and the knee flexion angle on patellofemoral indices, determined using magnetic resonance imaging (MRI), in patients with patellofemoral instability (PI). METHODS Healthy volunteers (control group, n = 9) and PI patients (PI group, n = 16) were scanned in an open-configuration MRI scanner during upright weight bearing and supine non-weight bearing positions at full extension (0° flexion) and at 15°, 30°, and 45° flexion. Patellofemoral indices included the Insall-Salvati Index, Caton-Deschamp Index, and Patellotrochlear Index (PTI) to determine patellar height and the patellar tilt angle (PTA), bisect offset (BO), and the tibial tubercle-trochlear groove (TT-TG) distance to assess patellar rotation and translation with respect to the femur and alignment of the extensor mechanism. RESULTS A significant interaction effect of weight bearing by flexion angle was observed for the PTI, PTA, and BO for subjects with PI. At full extension, post hoc pairwise comparisons revealed a significant effect of weight bearing on the indices, with increased patellar height and increased PTA and BO in the PI group. Except for the BO, no such changes were seen in the control group. Independent of weight bearing, flexing the knee caused the PTA, BO, and TT-TG distance to be significantly reduced. CONCLUSIONS Upright weight bearing and the knee flexion angle affected patellofemoral MRI indices in PI patients, with significantly increased values at full extension. The observations of this study provide a caution to be considered by professionals when treating PI patients. These patients should be evaluated clinically and radiographically at full extension and various flexion angles in context with quadriceps engagement. LEVEL OF EVIDENCE Explorative case-control study, Level III.
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Diagnosis and Characterization of Patellofemoral Instability: Review of Available Imaging Modalities. Sports Med Arthrosc Rev 2017; 25:64-71. [DOI: 10.1097/jsa.0000000000000148] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Carlson VR, Boden BP, Sheehan FT. Patellofemoral Kinematics and Tibial Tuberosity-Trochlear Groove Distances in Female Adolescents With Patellofemoral Pain. Am J Sports Med 2017; 45:1102-1109. [PMID: 28029800 PMCID: PMC6006511 DOI: 10.1177/0363546516679139] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patellofemoral pain (PFP) is a prevalent disorder among female adolescents. Overuse is frequently cited as the cause of pain for this population. What is currently unclear, however, is if the patella demonstrates abnormal tracking patterns relative to the femoral trochlear groove in female adolescents with PFP. PURPOSE The aim of this case-control study was to determine if abnormal patellar tracking patterns are present in female adolescents with PFP. The secondary aim was to identify if an increased tibial tuberosity-trochlear groove (TT-TG) distance is associated with the observed kinematic patterns. STUDY DESIGN Controlled laboratory study. METHODS Twenty female adolescent knees from 12 patients with PFP and 20 age-matched female knees from 13 healthy controls were recruited for this study. Patellofemoral kinematics (eg, lateral patellar displacement) during a repetitive knee extension-flexion maneuver was quantified by dynamic cine phase-contrast magnetic resonance imaging (MRI). Static MRI scans were used to determine the TT-TG distance. RESULTS Relative to the control cohort, female adolescents with PFP demonstrated significantly greater lateral displacement at 10° (3.2 mm; P < .001), 20° (2.3 mm; P < .001), and 30° (1.7 mm; P = .014) of knee flexion. A subgroup within this cohort (7 knees from 5 patients) demonstrated extreme lateral maltracking >2 SDs of the mean of the control cohort. This subgroup also demonstrated a greater TT-TG distance relative to the controls (Δ = 4.2 mm; P = .001). CONCLUSION This study demonstrates abnormal lateral patellar displacement in the absence of patellar tilt in female adolescents with PFP. Because all adolescents from both cohorts participated in impact sports, it appears that rigorous athletic training alone is inadequate to produce symptoms in this population. Rather, PFP may derive from a combination of physical activity in the context of pathological kinematics. CLINICAL RELEVANCE Abnormal patellar tracking patterns and abnormal static alignment have been shown to contribute to the etiology of patellofemoral pain in adults. This study demonstrates that pathologic patellar tracking patterns are present in adolescent females with patellofemoral pain.
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Affiliation(s)
- Victor R. Carlson
- Functional and Applied Biomechanics, Department of Rehabilitation Medicine, NIH, Bethesda, MD, USA
| | | | - Frances T. Sheehan
- Functional and Applied Biomechanics, Department of Rehabilitation Medicine, NIH, Bethesda, MD, USA
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12
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Carlson VR, Boden BP, Shen A, Jackson JN, Alter KE, Sheehan FT. Patellar Maltracking Persists in Adolescent Females With Patellofemoral Pain: A Longitudinal Study. Orthop J Sports Med 2017; 5:2325967116686774. [PMID: 28210658 PMCID: PMC5302093 DOI: 10.1177/2325967116686774] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Patellofemoral pain is one of the most common conditions seen in sports medicine practices, particularly among adolescent females. However, the natural history of the underlying pathology in patellofemoral pain during puberty remains poorly understood. Purpose: The purpose of this longitudinal study is to assess changes in patellar maltracking patterns in subjects with patellofemoral pain as they mature from mid- to late adolescence. Study Design: Cohort study; Level of evidence, 3. Methods: Three-dimensional patellofemoral kinematic data were acquired during active knee extension-flexion using dynamic magnetic resonance imaging in 6 girls (10 knees; mean age, 14.0 years) with clinically diagnosed patellofemoral pain. The subjects then returned as late adolescents (mean age, 18.5 years) for follow-up scanning. Three-dimensional patellofemoral kinematic parameters were evaluated across the range of motion, but comparison between time points was restricted to 10° of flexion. Participation in impact and nonimpact physical activities, pain score based on the visual analog scale, and the anterior knee pain score were also compared across initial and follow-up visits. Results: All subjects reported improved patellofemoral pain symptoms at follow-up, and one subject reported complete resolution. However, relative to the initial visit, no differences were found in patellar maltracking. There was a decrease in hours engaged in impact physical activities for all subjects at follow-up. Conclusion: This study provides insight into the natural history of patellofemoral pain in adolescent females. The relatively unchanged patellofemoral maltracking across subjects suggests that potential anatomic and kinematic abnormalities contributing to patellofemoral pain during mid-adolescence persist during skeletal maturation. Symptom improvement for these subjects did not result from a change in patellofemoral tracking, but rather from other causes.
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Affiliation(s)
- Victor R Carlson
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Barry P Boden
- The Orthopaedic Center, A Division of CAO, Rockville, Maryland, USA
| | - Aricia Shen
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer N Jackson
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Katharine E Alter
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Frances T Sheehan
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, Maryland, USA
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Laugharne E, Bali N, Purushothamdas S, Almallah F, Kundra R. Variability of Measurement of Patellofemoral Indices with Knee Flexion and Quadriceps Contraction: An MRI-Based Anatomical Study. Knee Surg Relat Res 2016; 28:297-301. [PMID: 27894177 PMCID: PMC5134784 DOI: 10.5792/ksrr.16.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/02/2016] [Accepted: 09/20/2016] [Indexed: 10/31/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the impact of varying knee flexion and quadriceps activity on patellofemoral indices measured on magnetic resonance imaging (MRI). MATERIALS AND METHODS MRI of the knee was performed in 20 patients for indications other than patellar or patellofemoral pathology. Axial and sagittal sequences were performed in full extension of the knee with the quadriceps relaxed, full extension of the knee with the quadriceps contracted, 30° flexion of the knee with the quadriceps relaxed, and 30° flexion with the quadriceps contracted. Bisect offset, patella tilt angle, Insall-Salvati ratio and Caton-Deschamps index were measured. RESULTS With the knee flexed to 30° and quadriceps relaxed, the mean values of patellar tilt angle, bisect offset, Insall-Salvati ratio and Caton-Deschamps index were all within normal limits. With the knee extended and quadriceps contracted, the mean patellar tilt angle (normal value, <15°) was 14.6° and the bisect offset (normal value, <65%) was 65%, while the Caton-Deschamps index was 1.34 (normal range, 0.6 to 1.3). With the knee extended and quadriceps relaxed, the mean Caton-Deschamps index was 1.31. CONCLUSIONS MRI scanning of the knee in extension with the quadriceps contracted leads to elevated patellofemoral indices. MRI taken with the knee in 30° of flexion allows more reliable assessment of the patellofemoral joint and minimises the confounding effect of quadriceps contraction.
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Affiliation(s)
- Edward Laugharne
- Department of Orthopaedics, Royal Orthopaedic Hospital, Birmingham,
UK
| | - Navi Bali
- Department of Orthopaedics, Royal Orthopaedic Hospital, Birmingham,
UK
| | | | - Faris Almallah
- Department of Orthopaedics, Walsall Manor Hospital, Walsall,
UK
| | - Rik Kundra
- Department of Orthopaedics, Walsall Manor Hospital, Walsall,
UK
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Fujita Y, Tsuda E, Yamamoto Y, Naraoka T, Kimura Y, Sasaki S, Ishibashi Y. Quantitative analysis of dynamic patellar tracking in patients with lateral patellar instability using a simple video system. Knee 2016; 23:604-9. [PMID: 27169720 DOI: 10.1016/j.knee.2015.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/21/2015] [Accepted: 12/05/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND As patellar dislocation occurs during activity, it is more important to assess the behavior of the patellofemoral joint under dynamic conditions. The aim of this study was to compare patellar tracking between knees with and without patellar dislocation in patients with an unstable patella and healthy controls using a simple video technique. METHODS Twenty-three knees with patellar dislocation (dislocated group), 23 contralateral knees without dislocation (non-dislocated group), and 23 healthy knees (control group) were examined. Those with skin markers on anatomical landmarks were made to extend their knees actively, and skin markers were attached to the examiner's fingertips and the patella was followed by pinching. The knee during active knee extension was recorded with digital video cameras. The patella was tracked on imaging software, and the mediolateral patellar position (% patellar position: %PP) was calculated in reference to the knee width consecutively. RESULTS %PP was significantly different between the dislocated and control groups, from 30° (mean±SD: 58.9±6.2%, 54.6±4.7%) to 5° (64.2±5.2%, 55.2±5.2%). It was also significantly different between the non-dislocated and control groups, from 25° (58.9±7.1%, 54.5±4.6%) to 5° (63.8±6.5%, 55.2±5.2%). No significant difference in %PP was found between the dislocated and non-dislocated groups. CONCLUSION With the new video system, patellar tracking during active knee extension was successfully quantified. The tracking patterns were the same in knees with and without patellar dislocation, and the tracking in patients significantly differed from that in the controls at lower knee flexion angles. CLINICAL RELEVANCE The development of a quantitative examination technique for dynamic patellar tracking, which is easy to use and repeatedly applicable in a clinical situation, could help to follow-up the time-dependent changes and analyze the treatment effect on an unstable patella.
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Affiliation(s)
- Yuki Fujita
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan.
| | - Eiichi Tsuda
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Takuya Naraoka
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
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Ridley TJ, Bremer Hinckel B, Kruckeberg BM, Agel J, Arendt EA. Anatomical patella instability risk factors on MRI show sensitivity without specificity in patients with patellofemoral instability: a systematic review. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
OBJECTIVE The objective of our study as to assess several indexes relevant to patellofemoral instability (PFI) associated with femoral trochlear dysplasia as measured on oblique coronal MR images at three standardized reference levels. MATERIALS AND METHODS A total of 30 knee MRI examinations were selected as the study group of PFI patients. Sixty knee MRI examinations were included as a control group. MRI protocols included sagittal T2-weighted, axial proton density-weighted, and oblique coronal T2-weighted imaging. On a midline sagittal image, the following three levels of the femoral trochlear groove cartilage were determined: level 1 (one-fourth level of the trochlear groove in the midsagittal plane), level 2 (one-half level of the trochlear groove in the midsagittal plane), and level 3 (three-fourths level of the trochlear groove in the midsagittal plane). Three-level axial and oblique coronal images were selected using the sagittal image as a scout. Femoral trochlear indexes including the sulcus angle, sulcus depth, facet length, and trochlear groove area were measured on the axial and oblique coronal images. RESULTS Most indexes showed significant differences between the PFI and control groups in the axial and oblique coronal planes at all three levels (p < 0.05). Almost all indexes measured on the oblique coronal plane images were significantly different from those measured on the axial plane images (p < 0.05). Oblique coronal images showed little variability in the sulcus angle among the three levels in contrast to a marked decrease in the angle from the proximal to distal level on axial images. CONCLUSION Femoral trochlear indexes measured on oblique coronal knee MR images can be used to assess femoral trochlear dysplasia. Oblique coronal images showed less morphologic distortion of the distal femoral trochlear groove than axial images.
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Inter- and intra-rater reliability of patellofemoral kinematic and contact area quantification by fast spin echo MRI and correlation with cartilage health by quantitative T1ρ MRI. Knee 2016; 23:13-9. [PMID: 26746045 PMCID: PMC4762728 DOI: 10.1016/j.knee.2015.08.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/11/2015] [Accepted: 08/20/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patellar maltracking is a leading cause of patellofemoral pain syndrome (PFPS). The aim of this study was to determine the inter- and intra-rater reliability of a semi-automated program for magnetic resonance imaging (MRI) based patellofemoral kinematics. METHODS Sixteen subjects (10 with PFPS [mean age 32.3; SD 5.2; eight females] and six controls without PFPS 19 [mean age 28.6; SD 2.8; three females]) participated in the study. One set of T2-weighted, fat-saturated fast spin-echo (FSE) MRIs were acquired from each subject in full extension and 30° of knee flexion. MRI including axial T1ρ relaxation time mapping sequences was also performed on each knee. Following image acquisitions, regions of interest for kinematic MRI, and patellar and trochlear cartilage were segmented and quantified with in-house designed spline- based MATLAB semi-automated software. RESULTS Intraclass Correlations Coefficients (ICC) of calculated kinematic parameters were good to excellent, ICC > 0.8 in patellar flexion, rotation, tilt, and translation (anterior -posterior, medial -lateral, and superior -inferior), and contact area translation. Only patellar tilt in the flexed position and motion from extended to flexed state was significantly different between PFPS and control patients (p=0.002 and p=0.006, respectively). No significant correlations were identified between patellofemoral kinematics and contact area with T1ρ relaxation times. CONCLUSIONS A semi-automated, spline-based kinematic MRI technique for patellofemoral kinematic and contact area quantification is highly reproducible with the potential to help better understand the role of patellofemoral maltracking in PFPS and other knee disorders. LEVEL OF EVIDENCE Level IV.
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Biyani R, Elias JJ, Saranathan A, Feng H, Guseila LM, Morscher MA, Jones KC. Anatomical factors influencing patellar tracking in the unstable patellofemoral joint. Knee Surg Sports Traumatol Arthrosc 2014; 22:2334-41. [PMID: 25063490 DOI: 10.1007/s00167-014-3195-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/16/2014] [Indexed: 01/17/2023]
Abstract
PURPOSE The current study was performed to relate anatomical parameters to in vivo patellar tracking for pediatric patients with recurrent patellar instability. METHODS Seven pediatric patients with recurrent patellar instability that failed conservative treatment were evaluated using computational reconstruction of in vivo patellofemoral function. Computational models were created from high-resolution MRI scans of the unloaded knee and lower-resolution scans during isometric knee extension at multiple flexion angles. Shape matching techniques were applied to replace the low-resolution models of the loaded knee with the high-resolution models. Patellar tracking was characterized by the bisect offset index (lateral shift) and lateral tilt. Anatomical parameters were characterized by the inclination of the lateral ridge of the trochlear groove, the tibial tuberosity-trochlear groove distance, the Insall-Salvati index and the Caton-Deschamps index. Stepwise multivariable linear regression analysis was used to relate patellar tracking to the anatomical parameters. RESULTS The bisect offset index and lateral tilt were significantly correlated with the lateral trochlear inclination (p≤0.002) and TT-TG distance (p<0.05), but not the Insall-Salvati index or the Caton-Deschamps index. For both the bisect offset index and lateral tilt, the standardized beta coefficient, used to identify the best anatomical predictors of tracking, was larger for the lateral trochlear inclination than the TT-TG distance. CONCLUSION For this population, the strongest predictor of lateral maltracking that could lead to patellar instability was lateral trochlear inclination. LEVEL OF EVIDENCE Diagnostic study, Level II.
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Affiliation(s)
- Rahul Biyani
- Department of Orthopedic Surgery, Akron General Medical Center, Akron, OH, USA
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Fan ZY, Wang Y, Dong QR, Chen M, Jin ZG, Wang YG. Lateral patellar translation effects after arthroscopic partial meniscectomy of torn discoid lateral meniscus. Orthop Surg 2014; 6:38-41. [PMID: 24590992 DOI: 10.1111/os.12089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/11/2013] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To investigate the effects of arthroscopic partial meniscectomy of torn discoid lateral meniscus on patellar tracking. METHODS In all, 112 patients (112 knees) who underwent arthroscopic partial meniscectomy participated in the study. All subjects were examined with standing weight-bearing magnetic resonance imaging (MRI) preoperatively and one month postoperation. Axial-plane images through the maximum width of the patella and the maximum dorsal area of the femoral condyles were superimposed and the bisect offset index used to quantify patellar translation. Differences between pre- and postoperation in the bisect offset indexes were calculated and compared by Student's paired t-test. P < 0.05 was considered statistically significant. RESULTS Before surgery, the mean bisect offset index was 0.574 (0.437-0.692). One month postoperation, the mean bisect offset index was 0.622 (0.510-0.801). The postoperation bisect offset index increased by an average of 0.048 (-0.018 to 0.129) compared with the preoperation value; this difference is statistically significant result (t = 18.33, P < 0.01). CONCLUSION After arthroscopic partial meniscectomy, the patella translates more lateral to the femoral trochlear groove. These results suggest that arthroscopic partial meniscectomy may result in patellar maltracking.
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Affiliation(s)
- Zhi-ying Fan
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
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