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Gobbi RG, Cavalheiro CM, Giglio PN, Hinckel BB, Camanho GL. Patellar Tilt and Patellar Tendon-Trochlear Groove Angle Present the Optimum Magnetic Resonance Imaging Diagnostic Reliability for Patients With Patellar Instability. Arthroscopy 2023; 39:2339-2351. [PMID: 37116551 DOI: 10.1016/j.arthro.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/04/2023] [Accepted: 04/08/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE To describe, in controls and in a population with patellar instability, magnetic resonance imaging values of measurements representing major associated factors for patellar instability (patellar height, trochlear dysplasia, and extensor mechanism alignment), as well as their cutoff values. METHODS In total, 323 knee magnetic resonance imaging scans, 142 with patellar instability and 181 controls without patellofemoral complaints (anterior cruciate, medial collateral ligament, meniscus ruptures or normal) were evaluated. Means, normality values in the control population, ideal cutoff values through receiver operating characteristic curves analysis, and interobserver reliability (intraclass correlation coefficient) were described for a series of measurements. RESULTS All measurements were statistically different in control and instability patients, except for the patellotrochlear index and tibial tuberosity to posterior cruciate ligament distance. The interobserver intraclass correlation coefficient was good or excellent (above 0.75) only for the patellotrochlear index, patellar tendon-trochlear groove (PTTG) angle, and patellar tilt. The optimal cutoff value for each measurement was: PTTG angle ≥25.3o with sensitivity (S) of 70% and specificity (E) of 89%, patellar tilt ≥16o (S: 69% and E: 84%), trochlear sulcus angle ≥153o (S: 75% and E: 76%), Carrillon ≤12.8o (S: 62% and E: 87%), PTTG distance ≥11mm (S: 71% and E: 78%), Caton-Deschamps index ≥1.23 (S: 72% and E: 76%) and trochlear bump ≥3.95 mm (S: 76% and E: 65%). CONCLUSIONS Caton-Deschamps index (≥1.23), trochlear sulcus angle (≥153o), ventral prominence of the trochlea (≥3.95 mm), PTTG distance (≥11 mm), PTTG angle (≥25.3o), Carrillon angle (≤12.8o), and patellar tilt (≥16o) presented better diagnostic performance for patellar instability. Patellotrochlear index and tibial tuberosity to posterior cruciate ligament distance were not related to patellar instability. The interobserver reliability of the factors related to patellar instability was excellent only for the PTTG angle and lateral patellar tilt. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; Hcor, São Paulo, Brazil.
| | - Camila Maftoum Cavalheiro
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Pedro Nogueira Giglio
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Betina Bremer Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, U.S.A
| | - Gilberto Luis Camanho
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Bae K, Aldosari AM, Kang MS. The Difference in Tibial Tuberosity to Trochlear Groove Distance Between CT and MRI Arises From the Degree of Knee Flexion During Imaging. J Pediatr Orthop 2023; 43:e761-e768. [PMID: 37493032 DOI: 10.1097/bpo.0000000000002481] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Tibial tuberosity to trochlear groove distance (TT-TG) has been reported to have different values according to imaging modalities, usually higher in computed tomography (CT) than in magnetic resonance imaging (MRI). This difference is thought to be caused by the degree of knee flexion during imaging, but few studies have aimed to elucidate the cause. METHODS Five hundred eight patients with knee CT or MRI performed between ages of 6 to 16 years without underlying diseases affecting the musculoskeletal system were included. This study was conducted in 2 statistical ways. (1) Propensity score matching was performed for the imaging modality, and the bony TT-TG was compared between the 2 matched groups. (2) A regression model was fitted with 484 patients with either CT or MRI (a training set), and validation of the fitted model was performed with 24 patients with both CT and MRI simultaneously taken within a week (a test set). The predicted TT-TG values were compared with the measured values. RESULTS (1) Eighty-one patients were successfully matched by propensity score (all the standardized mean differences < 0.1) for each modality. In the matched patients, there was no significant difference in TT-TG according to the imaging modality (11.3 ± 3.7 mm for CT, 10.4 ± 3.8 mm for MRI, P = 0.126). (2) For the model fitting, different linear models were fitted before and after 10 degrees of knee flexion angle because there was a sharp change in TT-TG when the knee flexion angle was <10 degrees. The predicted TT-TG values did not significantly differ from the measured values (10.2 ± 4.3 mm vs. 9.0 ± 5.1 mm, P = 0.124). CONCLUSIONS This study is the first to statistically prove that the difference between TT-TG in MRI and CT originates from the different degrees of knee flexion. In addition, although more studies are needed, authors recommend imaging to be performed with the knee flexed at least 10 degrees for more reliable measurements because TT-TG changes sharply if the knee flexion angle is <10 degrees. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kunhyung Bae
- Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Songpa-gu
- Department of Orthopedic Surgery, Hanyang University Hospital, Hanyang University College of Medicine, Seongdong-gu, Seoul, Republic of Korea
| | - Amaal Mohammed Aldosari
- Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Songpa-gu
- Department of Orthopedic Surgery, Alnoor Specialist Hospital, Makkah, Makkah, Saudi Arabia
| | - Michael Seungcheol Kang
- Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Songpa-gu
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Leite CBG, Hinckel BB, Ribeiro GF, Giglio PN, Santos TP, Bonadio MB, Arendt E, Gobbi RG. Medial patellofemoral ligament reconstruction in skeletally immature patients without correction of bony risk factors leads to acceptable outcomes but higher failure rates. J ISAKOS 2023; 8:189-196. [PMID: 36924824 DOI: 10.1016/j.jisako.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/29/2023] [Accepted: 02/25/2023] [Indexed: 03/15/2023]
Abstract
OBJECTIVES To report outcomes and re-dislocation rates of medial patellar stabilizers reconstruction without bone procedures for correction of anatomical risk factors for patellar instability in skeletally immature patients; to compare isolated medial patellofemoral ligament (MPFL) reconstruction to combined MPFL and medial patellotibial ligament (MPTL) reconstruction in this population. METHODS Patients with open physis and bone abnormalities including patella alta and/or increased tibial tubercle-trochlear groove (TT-TG) distance and/or trochlear dysplasia underwent MPFL reconstruction, either isolated or associated with MPTL reconstruction. Preoperative, 1-year follow-up and the latest follow-up (5 years minimum) data were collected. Radiological and clinical evaluations were conducted, with special attention to failure rate. Comparison of results from isolated MPFL and combined MPFL/MPTL reconstructions was performed. RESULTS Twenty-nine patients were included, 19 in the isolated MPFL group (median 14 years old; follow-up 5.8 ± 1.7 years) and 10 in the combined MPFL/MPTL group (median 13.5 years old; follow-up 5.2 ± 1.4 years). Kujala and Tegner scores increased over time, although without statistically significant differences between the two groups at the latest follow-up (p = 0.840 and p > 0.999, respectively). During follow-up, 5 of 19 (26.3%) isolated MPFL and 2 of 10 (20%) MPFL/MPTL reconstructions experienced recurrence of patellar dislocation (p > 0.999). Trochlear dysplasia type D (p = 0.028), knee rotation (p = 0.009) and lateral patellar tilt angle (p = 0.003) were associated with patellar instability recurrence. The isolated MPFL group showed increased laxity on physical exam at the latest follow-up compared to the 1-year follow-up (patellar glide test (p = 0.002), patellar tilt test (p = 0.042) and subluxation in extension (p = 0.019). This increased laxity was not observed in the MPFL/MPTL group (p > 0.999). Comparing both groups, the glide test was significantly better in the combined MPFL/MPTL group in comparison to the isolated MPFL reconstruction group at the latest follow-up (p = 0.021). CONCLUSION MPFL reconstruction in isolation or combined with MPTL reconstruction in skeletally immature patients with additional uncorrected anatomical patellofemoral abnormalities leads to acceptable clinical outcomes within a minimum of 5 years follow-up, although has a high failure rate of 24.1%. Addition of a MPTL reconstruction to the MPFL may result in decreased patellar laxity on physical exams, as demonstrated by better patellar glide test, patellar tilt test and subluxation in extension. LEVEL OF EVIDENCE Level III; retrospective cohort study.
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Affiliation(s)
- Chilan Bou Ghosson Leite
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Betina Bremer Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI 48180, USA.
| | - Gabriel Fernandes Ribeiro
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Pedro Nogueira Giglio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Tarsis Padula Santos
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Marcelo Batista Bonadio
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
| | - Elizabeth Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN 55454, USA
| | - Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP 05403-010, Brazil
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Hansen P, Harving M, Øhlenschlæger T, Brinch S, Lavard P, Krogsgaard M, Boesen M. Comparison between conventional MRI and weight-bearing positional MRI reveals important differences in radiological measurements of the patellofemoral joint. Skeletal Radiol 2023:10.1007/s00256-023-04304-9. [PMID: 36877225 DOI: 10.1007/s00256-023-04304-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE To compare radiological measurements of the patellofemoral joint (PFJ) morphology and measurement reproducibility across the following scanning modalities: (a) 3 T supine MRI, (b) 0.25 T supine MRI and (c) standing 0.25 T MRI. METHODS Forty patients referred to MRI of the knee were scanned by high field 3 T MRI in supine position and low field 0.25 T positional (pMRI) in supine and standing positions. Radiological measurements for assessment of femoral trochlear morphology, patellar tracking, patellar height and knee flexion angle were compared across scanning situations by one-way repeated-measures ANOVA. Measurement reliability and agreement were assessed by calculation of ICC, SEM and MDC. RESULTS Patellar tracking differed across scanning situations, particularly between 3.0 T supine and 0.25 T standing position. Mean differences are the following: patella bisect offset (PBO): 9.6%, p ≤ 0.001; patellar tilt angle (PTA): 3.1°, p ≤ 0.001; tibial tuberosity-trochlear groove distance (TT-TG): 2.7 mm, p ≤ 0.001). Measurements revealed slight knee joint flexion in supine and slight hyperextension in the standing position (MD: 9.3°, P ≤ 0.001), likely related to the observed differences in patellar tracking. Reproducibility was comparable across MRI field strengths. In general, PBO, PTA and TT-TG were the most robust measurements in terms of reproducibility and agreement across scanning situations (ICC range: 0.85-0.94). CONCLUSION Significant differences in important patellofemoral morphology measurements were observed between supine and standing MRI scanning positions. These were unlikely due to physiological factors such as changes in joint loading but rather induced by slight differences in knee flexion angle. This emphasises the need to standardise knee positioning during scanning, particularly for weight-bearing positional MRI before clinical use.
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Affiliation(s)
- Philip Hansen
- Musculoskeletal Imaging Research Unit Copenhagen, Department of Radiology, Bispebjerg-Frederiksberg Hospital, Nielsine Nielsens vej 41A, DK-2400, Copenhagen, NV, Denmark.
| | - Mette Harving
- Department of Radiology, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Tommy Øhlenschlæger
- Institute of Sports Medicine Copenhagen, IOC Research Center Copenhagen, Bispebjerg-Frederiksberg Hospital, Nielsine Nielsens vej 11, DK-2400, Copenhagen, NV, Denmark
| | - Signe Brinch
- Musculoskeletal Imaging Research Unit Copenhagen, Department of Radiology, Bispebjerg-Frederiksberg Hospital, Nielsine Nielsens vej 41A, DK-2400, Copenhagen, NV, Denmark
| | - Peter Lavard
- Section for Sports Traumatology M51, IOC Research Center Copenhagen, Bispebjerg-Frederiksberg Hospital, Nielsine Nielsens vej 3, DK-2400, Copenhagen, NV, Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology M51, IOC Research Center Copenhagen, Bispebjerg-Frederiksberg Hospital, Nielsine Nielsens vej 3, DK-2400, Copenhagen, NV, Denmark
| | - Mikael Boesen
- Musculoskeletal Imaging Research Unit Copenhagen, Department of Radiology, Bispebjerg-Frederiksberg Hospital, Nielsine Nielsens vej 41A, DK-2400, Copenhagen, NV, Denmark
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Abstract
PURPOSE Patellofemoral instability is a common acute knee injury seen in the pediatric population. First-time patellar dislocations usually undergo conservative management, but ~15% to 80% of patients experience recurrent instability. This study aims to develop a prediction model using radiographic parameters of the patellofemoral joint seen on computed tomography scans in different degrees of knee flexion, to determine the risk of recurrence after the first episode of patellofemoral instability. METHODS A 12-year retrospective case-control study was performed. All patients in a single institution aged 18 years or younger who had a computed tomography patellar tracking scan performed for patellar instability were included. Predictors included in the score were determined through backward logistic regression and compared using receiver operating characteristic curve analysis. RESULTS This study revealed that recurrent dislocation in first-time patellofemoral dislocation could be accurately predicted using the prediction score that consisted of age, tibial tubercle-trochlear groove distance and congruence angle at 10- and 20-degree flexion. The sensitivity of the score was 100% and specificity was 73.3%. Three diagnostic zones were identified and used to categorize patients into low-, intermediate-, and high-probability groups. CONCLUSION This study presented a scoring system that incorporated radiographic knee kinematics in the risk assessment for recurrent patellofemoral instability for patient stratification. The scoring system could guide the decision for early surgical intervention after the first-episode patellofemoral dislocation for patients at high risk of recurrent patellofemoral dislocation.
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Migliorini F, Pilone M, Eschweiler J, Marsilio E, Hildebrand F, Maffulli N. High Rates of Damage to the Medial Patellofemoral Ligament, Lateral Trochlea, and Patellar Crest After Acute Patellar Dislocation: Magnetic Resonance Imaging Analysis. Arthroscopy 2022; 38:2472-2479. [PMID: 35157964 DOI: 10.1016/j.arthro.2022.01.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary outcome of interest of this study was to determine the frequency, location, and extent of chondral injuries and medial patellofemoral ligament (MPFL) tears, along with the rate of loose bodies, in the knee after acute primary patellar dislocation. The secondary outcome of interest was to conduct a multivariate analysis to investigate whether the presence of pathoanatomic abnormalities, including structural differences in the knees of the patients, is associated with the features of the lesions. METHODS Patients who underwent magnetic resonance imaging after primary acute patellar dislocation were identified from our institutional databases. We analyzed a total of 175 magnetic resonance imaging scans of patients aged between 14 and 25 years who were eligible for inclusion. RESULTS Chondral damage to the medial facet of the patella was present in 36 patients; patellar crest, 78 patients; and lateral patellar facet, 28 patients. One patient presented with chondral defects in the medial trochlear facet, whereas 118 patients showed chondral defects in the lateral trochlear facet. Loose bodies were present in 142 patients. A total of 161 patients (92%) showed MPFL damage. The patellar portion was affected in 119 patients. Of the patients, 28 showed a partially damaged MPFL (<50%), 42 showed MPFL damage greater than 50%, and 49 presented with a complete tear of the MPFL. MPFL lesions were observed on the femoral side in 42 patients. Fourteen patients presented with an avulsion fracture on the patellar side; 28 patients, on the femoral side. CONCLUSIONS The MPFL was injured in 92% of 175 patients after a first-time acute patellar dislocation. Chondral damage was most frequent at the patellar crest, followed by the lateral femoral epicondyle. No association was found between patella alta, the sulcus angle, the Q angle, the tibial tubercle-trochlear groove distance, trochlear and patellar dysplasia, and soft-tissue damage. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Marco Pilone
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | - Jörg Eschweiler
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Emanuela Marsilio
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy; Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London, England; School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, England
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Shah NS, Kyriakedes JC, Liu RW. An MRI-based Study to Investigate If the Patella is Truly Centred between the Femoral Condyles in the Coronal Plane. Strategies Trauma Limb Reconstr 2022; 17:63-67. [PMID: 35990177 PMCID: PMC9357791 DOI: 10.5005/jp-journals-10080-1561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background An AP knee radiograph is considered adequate if the patella is centred between the femoral condyles. Our previous studies demonstrated a tendency for lateral patellar deviation on an AP view orthogonal to the posterior femoral condyles. However, findings were based on cadaveric samples limited by the lack of soft tissue effects on patellar positioning. Materials and methods After excluding those with deformity or damage to osseous or ligamentous structures, 106 knee MRI scans were randomly selected. Patellar centring was calculated as a percentage of total distal femoral intercondylar width and represented how lateral the centre of the patella is located with respect to the midpoint of the femoral condyles. Multiple regression analysis was performed to determine the relationship between patellar centring and age, gender, anatomic lateral distal femoral angle (aLDFA), medial proximal tibial angle (MPTA) and tibial tuberosity to trochlear groove (TT-TG) distance. Results There were 35 males and 71 females included in the study with a mean age of 29 ± 14 years. Mean patellar centring was 8 ± 4%. There was a statistically significant correlation between TT-TG distance and positive (lateral) patellar centring (standardised β = 0.36, p <0.01). There were no associations between aLDFA and MPTA with patellar centring. Conclusion This study demonstrates that the patella is rarely perfectly centred and is usually positioned slightly laterally within the femoral condyles in an AP view orthogonal to the posterior aspect of the femoral condyles. The use of supine MRI scans makes this data relevant to a patient on the operating room table. How to cite this article Shah NS, Kyriakedes JC, Liu RW. An MRI-based Study to Investigate If the Patella is Truly Centred between the Femoral Condyles in the Coronal Plane. Strategies Trauma Limb Reconstr 2022;17(2):63–67.
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Affiliation(s)
- Nihar S Shah
- Division of Pediatric Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- Nihar S Shah, Division of Pediatric Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America, Phone: +3098307469, e-mail:
| | - James C Kyriakedes
- Division of Pediatric Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - Raymond W Liu
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, Ohio, United States of America
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The Tibial Tubercle-Trochlear Groove Distance/Trochlear Dysplasia Index Quotient Is the Most Accurate Indicator for Determining Patellofemoral Instability Risk. Arthroscopy 2022; 38:1608-1614. [PMID: 34450216 DOI: 10.1016/j.arthro.2021.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary aim of our study was to evaluate diagnostic accuracy of the tibial tubercle-trochlear groove (TT-TG) distance relative to associated quotients produced from trochlear width (TT-TG distance/TW) and trochlear dysplasia index (TT-TG distance/TDI) for detecting patellofemoral instability. Secondary aims included identifying thresholds for risk and comparing differences between cases and controls. METHODS Consecutive sampling of electronic medical records produced 48 (21 males, 27 females) patellofemoral instability cases (19 ± 7 years old) and 79 (61 males, 18 females) controls (23 ± 4 years old) who had a history of isolated meniscal lesion, as evaluated by magnetic resonance imaging. Standardized methods were employed with measurements executed in a blinded and randomized manner. A receiver operating characteristic curve assessed accuracy by area under the curve (AUC). The index of union (IU) was employed to identify a threshold for risk. Two-sample t-tests examined group differences. P < .05 denoted statistical significance. RESULTS The AUC values were .69 (.60, .79) for TT-TG distance, .81 (.73, .88) for TT-TG distance/TW, and .85 (.78, .91) for TT-TG distance/TDI. Thresholds were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. Cases demonstrated statistically significant (P < .001) greater values for each measure compared with controls: TT-TG distance (15.8 ± 4.2 mm vs 12.9 ± 3.6 mm, [1.4, 4.3]); TT-TG distance/TW (.51 ± .24 vs .31 ± .09, [.13, .27]); TT-TG distance/TDI (3.07 ± 1.55 vs 1.7 ± .7, [.9, 1.84]). CONCLUSION The TT-TG distance, TT-TG distance/TW, and TT-TG distance/TDI measures were 69%, 81%, and 85%, respectively, accurate for determining patellofemoral instability risk. Thresholds for risk were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. The thresholds reported in this study may help in advancing clinical decision-making. LEVEL OF EVIDENCE Level III, diagnostic retrospective comparative observatory trial.
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Gobbi RG, Videira LD, Dos Santos AA, Saruhashi MB, Lucarini BR, Fernandes RJR, Giglio PN, Pécora JR, Camanho GL, Hinckel BB. Anatomical Risk Factors for Anterior Cruciate Ligament Injury Are Not Important As Patellar Instability Risk Factors in Patients with Acute Knee Injury. J Knee Surg 2022; 35:676-683. [PMID: 32942334 DOI: 10.1055/s-0040-1716504] [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] [Indexed: 02/07/2023]
Abstract
To compare in magnetic resonance imaging the anatomical risk factors for anterior cruciate ligament (ACL) injury and patellar dislocation among patients who suffered acute knee injury, 105 patients with acute knee injury resulting in 38 patellar dislocations (patella group), 35 ACL injuries (ACL group), and 32 meniscus or medial collateral ligament injuries (control group) were included. These groups were compared for risk factors for patellar dislocation (patellar height, trochlear dysplasia, and quadriceps angle of action) and for ACL injury (intercondylar width, posterior inclination of tibial plateaus, and depth of the medial plateau). Univariate analysis found statistically significant differences (p < 0.05) between the patella and ACL groups in patellar height (Caton-Deschamps [CD] 1.23 vs. 1.07), trochlear facet asymmetry (55 vs. 68%), PTTG (13.08 vs. 8.01 mm), and the patellar tip and trochlear groove (PTTG) angle (29.5 vs. 13.71 degrees). The patella group also differed from control in medial plateau inclination (4.8 vs. 1.87 degrees), patellar height (CD 1.23 vs 1.08), trochlear facet asymmetry (55 vs. 69%), lateral trochlear inclination (17.11 vs. 20.65 degrees), trochlear depth (4.1 vs. 6.05 mm), PTTG (13.08 vs. 9.85 mm), and the PTTG angle (29.5 vs. 17.88 degrees). The ACL and control groups were similar in all measures. Multivariate analysis found the following significant determinants between the Patella and Control groups: patellar height (CD index, odds ratio [OR]: 80.13, p = 0.015), trochlear anatomy (asymmetry of facets M/L, OR: 1.06, p = 0.031) and quadriceps action angle (PTTG angle, OR: 1.09, p = 0.016); between the ACL and control groups: PTTG angle (OR: 0.936, p = 0.04) and female gender (OR: 3.876, p = 0.032); and between the patella and ACL groups, the CD index (OR: 67.62, p = 0.026), asymmetry of the M/L facets (OR: 1.07, p = 0.011) and PTTG angle (OR: 1.16, p < 0.001). In conclusion, in patients with acute knee injury, the anatomical factors patellar height, trochlear dysplasia, and quadriceps angle of action were related to the occurrence of patellar dislocation. None of the anatomical factors studied was related to the occurrence of anterior cruciate ligament injury.
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Affiliation(s)
- Riccardo Gomes Gobbi
- Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Livia Dau Videira
- Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Marcello Barni Saruhashi
- Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Pedro Nogueira Giglio
- Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Ricardo Pécora
- Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gilberto Luis Camanho
- Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Wu ZK, Dai ZZ, Sha L, Li H, Li TC, Zhang ZM, Li H. Diagnostic Performance of MRI Versus CT in the Evaluation of Intra-articular Osteochondral Fracture in Pediatric Patients With Acute Traumatic Lateral Patellar Dislocation. Orthop J Sports Med 2022; 10:23259671221083585. [PMID: 35356311 PMCID: PMC8958689 DOI: 10.1177/23259671221083585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Evaluation of intra-articular osteochondral fractures in children with acute traumatic lateral patellar dislocation (LPD) is important for determining treatment options. Purpose: To (1) compare the diagnostic accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) for evaluating intra-articular osteochondral fractures; (2) compare the interpretation of CT and MRI images between radiologists and pediatric orthopaedic surgeons (POS); and (3) investigate any clinical factors influencing the accuracy of CT and MRI evaluations. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We reviewed 35 knees in 35 patients (mean age, 12.2 ± 1.2 years; 12 boys and 23 girls) who were treated arthroscopically for acute traumatic LPD; 71% of the patients had patellar fractures, 54% had femoral fractures, and 60% had free osteochondral fracture fragments. All presurgical MRI and CT images were reviewed by POS who were blinded to both the reports of the radiologists and surgical records. We compared the accuracy of CT and MRI in diagnosing intra-articular osteochondral fractures against the arthroscopic findings and compared the interpretation of the images by the POS (MRI-O, CT-O) with those of the radiologists (MRI-R, CT-R). Results: There was no significant difference in diagnostic accuracy between CT and MRI for overall intra-articular osteochondral fractures by the POS or the radiologists; however, the CT-O images had a higher diagnostic specificity (84.2% vs 69.6%; P < .001) and sensitivity (88.1% vs 70.1%; P < .001) versus the MRI-R images. Regarding free fracture fragments, the CT-R images had a higher diagnostic accuracy than the MRI-R images (73.5% vs 47.1%; P = .026). When backed by clinical data, the MRI-O images had greater diagnostic accuracy (78.7% vs 60.3%; P = .001) and sensitivity (88.1% vs 30.7%; P = .021) but lower specificity compared with the MRI-R images, and the CT-O images had similar diagnostic accuracy but greater sensitivity than the CT-R images (70.1% vs 52.2%; P < .001). The diagnostic accuracy of MRI-O images was lower for children under 12 years versus children 12 years and over (67.5% vs 83.3%; P = .040). Conclusion: Compared with MRI, CT scans had better diagnostic performance in the evaluation of intra-articular osteochondral fractures in pediatric patients with acute traumatic LPD. Clinical data enhanced the diagnostic sensitivity of MRI and CT but decreased the specificity of MRI. MRI evaluations remain challenging for both POS and radiologists.
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Affiliation(s)
- Zhen-Kai Wu
- Department of Pediatric Orthopaedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Zhen-Zhen Dai
- Department of Pediatric Orthopaedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Lin Sha
- Department of Pediatric Orthopaedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Hao Li
- Department of Pediatric Orthopaedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Tai-Chun Li
- Department of Pediatric Orthopaedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Zi-Ming Zhang
- Department of Pediatric Orthopaedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Hai Li
- Department of Pediatric Orthopaedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
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Krishnan H, Eldridge JD, Clark D, Metcalfe AJ, Stevens JM, Mandalia V. Tibial tuberosity-trochlear groove distance: does it measure up? Bone Jt Open 2022; 3:268-274. [PMID: 35321559 PMCID: PMC8965791 DOI: 10.1302/2633-1462.33.bjo-2021-0107] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor; however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability. Cite this article: Bone Jt Open 2022;3(3):268–274.
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Affiliation(s)
| | | | - Damian Clark
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Andrew J. Metcalfe
- Warwick Medical School, University of Warwick, University Hospitals of Coventry and Warwickshire, Coventry, UK
| | | | - Vipul Mandalia
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
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12
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MRI signal and morphological alterations of the suprapatellar fat pad in asymptomatic subjects: are these normal variants? Skeletal Radiol 2022; 51:1995-2007. [PMID: 35426502 PMCID: PMC9381489 DOI: 10.1007/s00256-022-04055-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/23/2022] [Accepted: 04/01/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To study the prevalence of suprapatellar fat pad (SPFP) MR alterations in asymptomatic subjects, in relation to a wide range of clinical/imaging parameters, including muscle performance tests and physical activity data. MATERIALS AND METHODS We prospectively included 110 asymptomatic subjects as part of a cohort study. Inclusion criteria were no knee pain in the last year. Exclusion criteria were any medical/surgical history of a knee disorder. Subjects underwent knee and low-dose posture radiographs [EOS®], 3 T MRI, clinical examination including muscle performance tests, and physical activity monitoring. The presence/absence of SPFP alterations (hyperintensity and mass effect) were assessed through consensus reading on fluid-sensitive sequences. Differences between groups of knees with SPFP alterations and controls were tested for a total of 55 categorical/continuous clinical/imaging parameters, including SPFP relative-T2-signal, trochlear/patellar/lower-limb morphologic measurements. Wilcoxon-rank-sum and chi-square tests were used to compare groups of patients. The histological correlation was obtained in a cadaveric specimen. RESULTS SPFP alterations were common in asymptomatic subjects: hyperintensity 57% (63/110) and mass effect 37% (41/110), with 27% (30/110) showing both. Among the 55 imaging, clinical, or activity parameters tested, only increased patellar tilt angle (p = 0.02) and TT-TG distance (p = 0.03) were statistically different between groups of SPFP alterations and controls. The histological correlation showed more abundant connective tissue in SPFP compared to the prefemoral fat pad. CONCLUSIONS SPFP hyperintensity and mass effect are common MRI findings in asymptomatic knees, and they are not related to most imaging, clinical, and activity parameters. Care should be taken not to overcall them pathological findings as they most likely represent normal variants.
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Camanho GL, Gobbi RG, Andrade MHD. Complicações funcionais do tratamento da instabilidade patelar com reconstrução do ligamento femoropatelar medial com terço medial do tendão patelar com acompanhamento mínimo de 5 anos. Rev Bras Ortop 2021; 57:308-313. [PMID: 35652011 PMCID: PMC9142260 DOI: 10.1055/s-0041-1729570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 11/03/2020] [Indexed: 10/24/2022] Open
Abstract
Resumo
Objetivo Avaliar complicações maiores após um mínimo de 5 anos de acompanhamento após luxação aguda ou recidivante da patela tratada com reconstrução do ligamento femoropatelar medial (LFPM) com terço medial do tendão patelar, com ou sem medialização da tuberosidade anterior da tíbia (TAT) associada.
Métodos Um total de 50 pacientes foram incluídos, com acompanhamento mínimo de 5 anos. Os pacientes foram avaliados em relação à ocorrência de complicações como rigidez articular, recidiva de luxação patelar ou instabilidade subjetiva relatada pelos pacientes, e incapacidade de retorno ao nível prévio de atividades físicas.
Resultados O acompanhamento médio foi de 8,9 ± 2,6 anos, com mínimo de 6 e máximo de 15 anos; 64% dos pacientes eram mulheres, com média de idade de 27 ± 11,2 anos; 24% dos pacientes foram submetidos a osteotomia da TAT para medialização concomitantemente; e 46% eram casos agudos. Foram constatados apenas 9 maus resultados (18%), todos decorrentes de recidiva da luxação (12%) e de queixa de instabilidade subjetiva (6%), ocorridos entre 36 e 60 meses de acompanhamento. Não ocorreram outras complicações. Dentre os maus resultados, cinco ocorreram em casos de luxação aguda, e quatro em casos recidivantes, e apenas um havia sido submetido a osteotomia da TAT.
Conclusão A reconstrução do LFPM com terço medial do tendão patelar, associada ou não à osteotomia de medialização da TAT, é uma alternativa no tratamento da instabilidade patelar aguda ou crônica, com falha de apenas 18% em acompanhamento mínimo de 5 anos. Além disso, é um tratamento seguro, sem apresentar outras complicações.
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Affiliation(s)
- Gilberto Luis Camanho
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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14
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Abstract
Patellar instability is a broad term that encompasses patellar dislocation, patellar subluxation, and patellar instability. Although both functional and anatomic considerations contribute to symptoms of patellar instability, the most important are thought to be patella alta, trochlear dysplasia, and lateralization of the tibial tubercle. In patients with a history suspicious for prior patellar dislocation, careful evaluation of MRI and radiographic studies can reveal characteristic findings. The most common methods to address patellofemoral instability are medial patellofemoral ligament reconstruction and tibial tubercle osteotomy with either anteromedialization or medialization. Less commonly trochleoplasty is indicated as well. Patients may be treated with one of or a combination of these techniques, each of which has specific indications and complications.
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Affiliation(s)
- Erin McCrum
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA.
| | - Kyle Cooper
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA
| | - Jocelyn Wittstein
- Department of Orthopaedic Surgery, Duke Health Heritage, Duke University School of Medicine, 3000 Rogers Road, Wake Forest, Durham, NC 27587, USA
| | - Robert J French
- Division of Musculoskeletal Imaging, Department of Radiology, Duke University Medical Center, Duke University Hospital, Box 3808, Durham, NC 27710, USA
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15
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Li Z, Liu G, Tian R, Kong N, Li Y, Li Y, Wang K, Yang P. The patellofemoral morphology and the normal predicted value of tibial tuberosity-trochlear groove distance in the Chinese population. BMC Musculoskelet Disord 2021; 22:575. [PMID: 34162383 PMCID: PMC8223279 DOI: 10.1186/s12891-021-04454-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/08/2021] [Indexed: 01/11/2023] Open
Abstract
Background Our objective was to obtain normal patellofemoral measurements to analyse sex and individual differences. In addition, the absolute values and indices of tibial tuberosity-trochlear groove (TT-TG) distances are still controversial in clinical application. A better method to enable precise prediction is still needed. Methods Seventy-eight knees of 78 participants without knee pathologies were included in this cross-sectional study. A CT scan was conducted for all participants and three-dimensional knee models were constructed using Mimics and SolidWorks software. We measured and analysed 19 parameters including the TT-TG distance and dimensions and shapes of the patella, femur, tibia, and trochlea. LASSO regression was used to predict the normal TT-TG distances. Results The dimensional parameters, TT-TG distance, and femoral aspect ratio of the men were significantly larger than those of women (all p values < 0.05). However, after controlling for the bias from age, height, and weight, there were no significant differences in TT-TG distances and anterior-posterior dimensions between the sexes (all p values > 0.05). The Pearson correlation coefficients between the anterior femoral offset and other indexes were consistently below 0.3, indicating no relationship or a weak relationship. Similar results were observed for the sulcus angle and the Wiberg index. Using LASSO regression, we obtained four parameters to predict the TT-TG distance (R2 = 0.5612, p < 0.01) to achieve the optimal accuracy and convenience. Conclusions Normative data of patellofemoral morphology were provided for the Chinese population. The anterior-posterior dimensions of the women were thicker than those of men for the same medial-lateral dimensions. More attention should be paid to not only sex differences but also individual differences, especially the anterior condyle and trochlea. In addition, this study provided a new method to predict TT-TG distances accurately. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04454-8.
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Affiliation(s)
- Zhe Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Guanzhi Liu
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Run Tian
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Ning Kong
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Yue Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Yiyang Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Kunzheng Wang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China
| | - Pei Yang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, People's Republic of China.
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16
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Clinical Improvement Is Achieved Following Tibial Tubercle Distomedialization for Patellar Maltracking and Patella Alta Without Instability. Arthrosc Sports Med Rehabil 2021; 3:e845-e853. [PMID: 34195653 PMCID: PMC8220615 DOI: 10.1016/j.asmr.2021.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 01/27/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose To determine short-term patient-reported outcomes following distomedial tibial tubercle transfer (TTT) in patients with patellar maltracking and patella alta without instability. Methods A single-surgeon case series study was performed on patients receiving distomedial TTT for the indication of patellar maltracking and patella alta without instability, after nonresponse to conservative treatment. Patient-reported outcomes were assessed preoperatively and at 3-, 6-, 12-, and 24-month follow-up using Kujala, Knee injury and Osteoarthritis Outcome Score (KOOS), and visual analog scale (VAS) pain scores. Generalized estimating equations analyses were performed to study improvement over time. Minimal clinically important differences obtained from literature were used to determine clinical relevance. Results A total of 40 patients were included. Eight patients were lost to follow-up; thus, outcomes of 32 patients were analyzed. Mean follow-up was 22 months, median age was 21 years, and 75% were female. Mean Kujala score increased pre- to postoperatively from 55 ± 12 to 79 ± 16 (P < .001), KOOS from 48 ± 14 to 79 ± 15 (P < .001), and VAS from 64 ± 17 to 25 ± 21 (P < .001), respectively. Eighty-four percent had clinical improvement of Kujala score, 91% of KOOS, and 78% of VAS score. A plateau phase in pain reduction was reached at 3 months, and in functional improvement at 6 months follow-up, after which no further significant improvement was observed. Complication rate was 3% and removal of hardware rate was 72%. Conclusions: In this case series study, distomedial TTT led to clinically relevant functional improvement and pain reduction in patients with patellar maltracking and patella alta without instability. However, the removal of hardware rate was high (72%). Level of Evidence Level IV, therapeutic case series.
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17
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Dong C, Zhao C, Li M, Fan C, Feng X, Piao K, Hao K, Wang F. Accuracy of tibial tuberosity-trochlear groove distance and tibial tuberosity-posterior cruciate ligament distance in terms of the severity of trochlear dysplasia. J Orthop Surg Res 2021; 16:383. [PMID: 34130707 PMCID: PMC8204520 DOI: 10.1186/s13018-021-02527-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/08/2021] [Indexed: 01/25/2023] Open
Abstract
Purpose Increased tibial tubercle-trochlear groove distance (TT-TG) was proposed as one of the main risk factors for patellofemoral instability (PFI). The increased TT-TG distance indicated externalization of the tibial tubercle with the reference of the trochlear groove. However, in the case of severe trochlear dysplasia, the reference point on the trochlear groove was indistinct, and the accuracy of TT-TG was controversial. The purpose of this study was to evaluate the accuracy of TT-TG and TT-PCL in consideration of the mild and severe trochlear dysplasia. Methods From 2015 to 2020, MRI findings of consecutive knee joints with PFI symptoms diagnosed in our hospital were retrospectively analyzed. All knees with trochlear dysplasia were diagnosed by longitudinal MRI scan and lateral radiograph. The knees were classified according to the four-type classification system described by Dejour et al. Twenty cases of type A (mild trochlear dysplasia); 20 cases of type B, C, and D (severe trochlear dysplasia); and 20 cases of normal type were selected and divided into normal group (normal trochlea), mild group (type A), and severe group (type B, type C, type D). Tibial tubercle-trochlear groove distance (TT-TG), tibial tubercle-posterior cruciate ligament distance (TT-PCL), and the Dejour classification of trochlear dysplasia were assessed by 2 experienced orthopedics. The reliability of TT-TG distance and TT-PCL distance was tested by intraclass correlation coefficients (ICCs). Results Comparing the differences between TT-TG and TT-PCL in the normal, mild, and severe groups, the TT-TG and TT-PCL in the mild and severe groups show different meanings (normal, 8.83 ± 3.62 mm vs. 8.44 ± 4.57 mm, P > 0.05; mild, 17.30 ± 4.81 mm vs. 20.09 ± 5.05 mm, P < 0.05; severe, 10.79 ± 4.24 mm vs. 12.31 ± 5.43 mm, P > 0.05). The Pearson correlation coefficient of TT-TG and TT-PCL measurements of trochlear dysplasia were r = 0.480 (mild group, P = 0.032) and r = 0.585 (severe group, P < 0.001). The intra-observer ICCs of TT-TG were r = 0.814 (mild group) and r = 0.739 (severe group). The inter-observer ICCs of TT-TG were r = 0.810 (mild group) and r = 0.713 (severe group). In the normal knee, the Pearson correlation coefficient of TT-TG and TT-PCL was r = 0.787(P < 0.001), the intra-observer ICC of TT-TG was r = 0.989, and the inter-observer ICC of TT-TG was r = 0.978. Conclusion Compared with the mild trochlear dysplasia, the inter-observer and intra-observer correlations of TT-TG measurements decreased in the group of severe dysplastic trochlea (inter-observer ICC, 0.810 vs. 0.713; intra-observer ICC, 0.814 vs. 0.739). In the present study, the determination of TT-TG and TT-PCL distance are of great significance for patients with low-grade trochlear dysplasia. And TT-PCL, without referring to the abnormal trochlear groove, is an effective indicator to measure the lateralization of tibial tuberosity in patients with severe dysplastic trochlea.
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Affiliation(s)
- Conglei Dong
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Chao Zhao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Ming Li
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Chongyi Fan
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Xunkai Feng
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Kang Piao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Kuo Hao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Fei Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China.
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White AE, Otlans PT, Horan DP, Calem DB, Emper WD, Freedman KB, Tjoumakaris FP. Radiologic Measurements in the Assessment of Patellar Instability: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:2325967121993179. [PMID: 34095324 PMCID: PMC8142007 DOI: 10.1177/2325967121993179] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/19/2020] [Indexed: 01/27/2023] Open
Abstract
Background: Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings across multiple studies. Purpose: To review the different imaging measurements used to evaluate patellar instability and to assess the prevalence of each measure and its utility in predicting instability. We focused on reliability across imaging modalities and between patients with and without patellar instability. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a systematic review of the literature using the PubMed, SCOPUS, and Cochrane databases. Each database was searched for variations of the terms “patellar instability,” “patellar dislocation,” “trochlear dysplasia,” “radiographic measures,” “computed tomography,” and “magnetic resonance imaging.” Studies were included if they were published after May 1, 2009, and before May 1, 2019. A meta-analysis using a random effects model was performed on several measurements, comparing instability and control groups to generate pooled values. Results: A total of 813 articles were identified, and 96 articles comprising 7912 patients and 106 unique metrics were included in the analysis. The mean patient age was 23.1 years (95% CI, 21.1-24.5), and 41% were male. The tibial tubercle–trochlear groove (TT-TG) distance was the most frequently included metric (59 studies), followed by the Insall-Salvati ratio and Caton-Deschamps index (both 26 studies). The interobserver intraclass correlation coefficients were excellent or good for the TT-TG distance and Insall-Salvati ratio in 100% of studies reporting them; however, for the Caton-Deschamps index and Blackburne-Peel ratio, they were excellent or good in only 43% and 40% of studies. Pooled magnetic resonance imaging values for TT-TG distance (P < .01), Insall-Salvati ratio (P = .01), and femoral sulcus angle (P = .02) were significantly different between the instability and control groups. Values for tibial tubercle–posterior cruciate ligament distance (P = .36) and Caton-Deschamps index (P = .09) were not significantly different between groups. Conclusion: The most commonly reported measurements for evaluating patellar instability assessed patellar tracking and trochlear morphology. The TT-TG distance was the most common measurement and was greater in the patellar instability group as compared with the control group. In addition, the TT-TG, tibial tubercle–posterior cruciate ligament, and patellar tendon–trochlear groove distances were highly reproducible measurements for patellar tracking, and the Insall-Salvati ratio had superior reproducibility for assessing patellar height.
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Affiliation(s)
- Alex E White
- Hospital for Special Surgery, New York, New York, USA
| | - Peters T Otlans
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dylan P Horan
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Daniel B Calem
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - William D Emper
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fotios P Tjoumakaris
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Gupta H, Kataria H, Batta NS, Yadav S, Jain V. Assessment of validity and reliability of femoral shaft-patellar tendon angle measured on MRI. Skeletal Radiol 2021; 50:927-936. [PMID: 33026478 DOI: 10.1007/s00256-020-03636-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Clinically measured Quadriceps angle (Q-angle) has low reliability. Measurement of angle between femoral shaft and patellar tendon (FSPT angle) on routine knee MRI was described in this study to represent the lateral vector forces of quadriceps mechanism. The cross-sectional study was designed to compare this angle between subjects with objective patellofemoral instability (PFI) versus those without PFI, to assess its reliability, and to assess its validity in terms of its ability to differentiate between PFI and non-PFI subjects using the "Receiver Operating Characteristic" (ROC) curve. MATERIALS AND METHODS MRI scans of 20 subjects with PFI and 20 without PFI were obtained. FSPT angle was measured in each MRI by three different raters. In addition, the clinical Q-angle was also measured in the control group. RESULTS The FSPT angle was significantly higher in PFI group as compared with the non-PFI group (p < 0.001). It had substantial inter-rater reliability of 0.82 (95% CI = 0.67-0.92) in the non-PFI group and 0.89 (95% CI = 0.78-0.95) in the PFI group. Test-retest reliability was more than 0.90. The AUC for the ROC curve was 0.86 (95% CI = 0.74-0.97). The clinical Q-angle measured in non-PFI subjects had inter-rater reliability of only 0.48 (95% CI = 0.21-0.72), and showed a fair correlation of 0.58 with the MRI angle. CONCLUSION Measurement of FSPT angle was described on MRI with substantial intra-rater and inter-rater reliability. The angle was significantly higher in PFI versus non-PFI subjects and also showed a good ability to differentiate between these two groups in the ROC curve.
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Affiliation(s)
- Himanshu Gupta
- Department of Sports Injury Centre, VMMC & Safdarjung Hospital, New Delhi, 110029, India.
| | - Himanshu Kataria
- Department of Sports Injury Centre, VMMC & Safdarjung Hospital, New Delhi, 110029, India
| | | | - Sunil Yadav
- Department of Sports Injury Centre, VMMC & Safdarjung Hospital, New Delhi, 110029, India
| | - Vineet Jain
- Department of Sports Injury Centre, VMMC & Safdarjung Hospital, New Delhi, 110029, India
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20
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Aivazoglou LU, Toma MK, Arruda PHC, Ormond Filho AG, Guimarães JB, Silva FD. A ressonância magnética do joelho usando a bobina de corpo é equivalente à TC na medição da distância TT-ST: Removendo o viés sistemático. Rev Bras Ortop 2021; 57:82-88. [PMID: 35198113 PMCID: PMC8856859 DOI: 10.1055/s-0040-1718511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/06/2020] [Indexed: 12/02/2022] Open
Abstract
Objective
To compare magnetic resonance imaging (MRI) using a body coil with computed tomography (CT) in measuring the tibial tubercle-trochlear groove distance (TT-TG) and the patellar tendon-cartilaginous trochlear groove (PT-CTG) distances, and evaluate interrater reliability.
Methods
The study group consisted of 34 knees from 17 asymptomatic subjects with no history of knee pathology, trauma or surgery. A low-dose CT scan and an axial T1-weighted MRI sequence of the knees were performed with rigorous standardization of the positioning with full extension of the knees and parallel feet. Two musculoskeletal radiologists performed the measurements independently. The reliability of the TT-TG and PT-CTG distances on CT (17.1 ± 4.2 mm and 17.3 ± 4.2 mm) and of MRI (16.2 ± 3.7 mm and 16.5 ± 4.1 mm) was assessed by intraclass correlation coefficient (ICC [2,1]) and Bland-Altman graphs, as well as the interrater reliability for both methods.
Results
Good reliability and agreement was observed between CT and MRI measurements for TT-TG and PT-CTG, with an ICC of 0.774 (
p
< 0.001) and 0.743 (
p
< 0.001), respectively, and no systematic bias was observed. The interrater reliability was excellent for all measurements on both imaging methods.
Conclusion
This was the first study that compared MRI using a body coil with CT in measuring the TT-TG distance, with the potential clinical implication that the CT in this clinical setting could be avoided.
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Affiliation(s)
| | - Mariana Kei Toma
- Departamento de Radiologia, Grupo Fleury Medicina e Saúde, São Paulo, SP, Brasil
| | | | | | | | - Flávio Duarte Silva
- Departamento de Radiologia, Grupo Fleury Medicina e Saúde, São Paulo, SP, Brasil
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21
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Optimizing Outcomes in Articulating (Kissing) Patellofemoral Joint Osteochondral Lesions: Case Report and Review of the Literature. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202103000-00010. [PMID: 33986226 DOI: 10.5435/jaaosglobal-d-20-00085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 02/05/2021] [Indexed: 11/18/2022]
Abstract
A 32-year-old woman with bipolar patellofemoral chondral lesions caused by traumatic patella dislocation underwent autologous chondrocyte implantation with concomitant tibial tubercle osteotomy and MPFL reconstruction. At 1- and 2-year follow-ups, the patient had returned to all previous activities with considerable improvement in all patient-reported outcome scores. This is an encouraging treatment option for a historically difficult therapeutic problem.
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22
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Dai ZZ, Sha L, Zhang ZM, Liang ZP, Li H, Li H. Comparing the Tibial Tuberosity-Trochlear Groove Distance Between CT and MRI in Skeletally Immature Patients With and Without Patellar Instability. Orthop J Sports Med 2021; 9:2325967120973665. [PMID: 33553445 PMCID: PMC7844456 DOI: 10.1177/2325967120973665] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/20/2020] [Indexed: 01/25/2023] Open
Abstract
Background: The tibial tubercle–trochlear groove (TT-TG) distance was originally described for computed tomography (CT), but it has been measured on magnetic resonance imaging (MRI) in patients with patellar instability (PI). Whether the TT-TG measured on CT versus MRI can be considered equivalent in skeletally immature children remains unclear. Purpose: To investigate in skeletally immature patients (1) the effects of CT versus MRI imaging modality and cartilage versus bony landmarks on consistency of TT-TG measurement, (2) the difference between CT and MRI measurements of the TT-TG, and (3) the difference in TT-TG between patients with and without PI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively identified 24 skeletally immature patients with PI and 24 patients with other knee disorders or injury but without PI. The bony and cartilaginous TT-TG distances on CT and MRI were measured by 2 researchers, and related clinical data were collected. The interrater, interperiod (bony vs cartilaginous), and intermethod (CT vs MRI) reliabilities of TT-TG measurement were assessed with intraclass correlation coefficients. Results: The 48 study patients (19 boys, 29 girls) had a mean age of 11.3 years (range, 7-14 years). TT-TG measurements had excellent interrater reliability and good or excellent interperiod reliability but fair or poor intermethod reliability. TT-TG distance was greater on CT versus MRI (mean difference, 4.07 mm; 95% CI, 2.6-5.5 mm), and cartilaginous distance was greater than bony distance (mean difference, 2.3 mm; 95% CI, 0.79-3.8 mm). The TT-TG measured on CT was found to increase with the femoral width. Patients in the PI group had increased TT-TG distance compared with those in the control group, regardless of landmarks or modality used (P > .05 for all). Conclusion: For skeletally immature patients, the TT-TG distance could be evaluated on MRI, regardless of whether cartilage or bony landmarks were used. Its value could not be interchanged with CT according to our results; however, further research on this topic is needed.
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Affiliation(s)
- Zhen-Zhen Dai
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Lin Sha
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Zi-Ming Zhang
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Zhen-Peng Liang
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Hao Li
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Hai Li
- Department of Pediatric Orthopedics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
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23
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Xu Z, Zhang H, Yan W, Qiu M, Zhang J, Zhou A. Validating the Role of Tibial Tubercle-Posterior Cruciate Ligament Distance and Tibial Tubercle-Trochlear Groove Distance Measured by Magnetic Resonance Imaging in Patients With Patellar Dislocation: A Diagnostic Study. Arthroscopy 2021; 37:234-242. [PMID: 32949633 DOI: 10.1016/j.arthro.2020.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To (1) compare these parameters between patients with patellar dislocation and healthy individuals on magnetic resonance imaging measurements, (2) validate the diagnostic capacity of the tibial tubercle-posterior cruciate ligament (TT-PCL) distance and tibial tubercle-trochlear groove (TT-TG) distance, (3) define the pathologic threshold values of these parameters for tibial tubercle osteotomy indication, and (4) compare these values with those of previous studies. METHODS Seventy patients with patellar dislocation and 70 healthy volunteers were identified. The inter- and intraobserver reliability values were determined using Bland-Altman analysis and the intraclass correlation coefficient (ICC). The diagnostic capacity of the parameters was evaluated using receiver operating characteristic curves and the area under the receiver operating characteristic curve. The data of the control group were used to determine the pathologic threshold values of the measurements. Logistic regression analysis was performed with these pathologic threshold values. RESULTS Significant differences in the TT-PCL distance (P = .01) and TT-TG distance (P < .001) were found between the study group (21.48 ± 3.18 and 12.91 ± 3.80, respectively) and the control group (20.07 ± 2.99 and 8.46 ± 3.16, respectively). Both the TT-PCL distance and TT-TG distance had excellent inter- and intraobserver agreement, with inter-ICCs >0.915 and intra-ICCs >0.932, respectively. However, the TT-TG distance had a higher area under the receiver operating characteristic curve than did the TT-PCL distance (0.820 vs 0.627). The pathologic threshold value of the TT-PCL distance was 24.76 mm. The pathologic threshold value of the TT-TG distance was 13.64 mm. Subjects with a TT-TG distance of >13.64 mm had a greater risk for patellar dislocation, with an odds ratio of 14.02 (95% confidence interval 4.00-49.08, P < .001). CONCLUSIONS Both the TT-PCL distance and TT-TG distance can be measured reliably by magnetic resonance imaging; however, the TT-TG distance has a better diagnostic capacity than does the TT-PCL distance. LEVEL OF EVIDENCE Retrospective cohort study (diagnosis); Level of evidence, I.
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Affiliation(s)
- Zijie Xu
- Department of Orthopedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Zhang
- Department of Orthopedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenlong Yan
- Department of Orthopedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Man Qiu
- Endoscopic Center, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Zhang
- Department of Orthopedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Aiguo Zhou
- Department of Orthopedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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24
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Mo KMC, Cho KYF, Au KYA, Lee KYG, Cheng HMJ. Establishing the reference value for tibial tubercle-trochlear groove distance on MRI in Southern Chinese population and its correlation with age, sex, height, weight and size: A multi-centre study. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720969706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: The first objective of this study is to determine the reference Tibial Tubercle-Trochlear Groove (TT-TG) distance on MRI in Southern Chinese population. The second objective is to investigate the correlation between TT-TG distance and (i) age, (ii) sex, (iii) height, (iv) weight and (v) Body Mass Index (BMI) respectively. Method: Three hundred MRI knees performed in two different centres between August 2017 and October 2018 were included. All patients were prospectively recruited after MRI referral from Orthopaedics department. The TT-TG distances were measured by two radiologists independently. Measurement reliability was assessed using intraclass correlation coefficient (ICC). One sample t-test was used to compare the results between this study and other published studies. Spearman’s rank correlation coefficient was used to determine correlations between the TT-TG distance and age, sex, height, weight and BMI respectively. Result: There was no statistical significance between the mean of TT-TG distances from the two radiologists ( P-value = 0.32). The measurement reliability was excellent (ICC = 0.922 ± 0.02). The mean of averaged TT-TG distance was 8.32 ± 0.33 mm (range 2.01 to 17.48 mm). There were no statistical significant differences in means of TT-TG distance between laterality and gender. There were statistically significant correlations between (i) TT-TG distance and age ( p-value = 0.009), and (ii) TT-TG distance and height ( p-value = 0.014). Conclusion: The reference TT-TG distance on MRI in Southern Chinese population was 8.32 ± 0.33 mm. Statistically significant correlations were established between (i) TT-TG distance and age; and (ii) TT-TG distance and height.
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Affiliation(s)
- Kwun Man Cyrus Mo
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
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25
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Schröder FF, Post CE, van Raak SM, Simonis FFJ, Wagenaar FCBM, Huis In't Veld RMHA, Verdonschot N. The diagnostic potential of low-field MRI in problematic total knee arthroplasties - a feasibility study. J Exp Orthop 2020; 7:59. [PMID: 32737621 PMCID: PMC7394973 DOI: 10.1186/s40634-020-00274-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/15/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose Low-field MRI, allowing imaging in supine and weight-bearing position, may be utilized as a non-invasive and affordable tool to differentiate between causes of dissatisfaction after TKA (‘problematic TKA’). However, it remains unclear whether low-field MRI results in sufficient image quality with limited metal artefacts. Therefore, this feasibility study explored the diagnostic value of low-field MRI concerning pathologies associated with problematic TKA’s’ by comparing low-field MRI findings with CT and surgical findings. Secondly, differences in patellofemoral parameters between supine and weight-bearing low-field MRI were evaluated. Methods Eight patients with a problematic TKA were scanned using low-field MRI in weight-bearing and supine conditions. Six of these patients underwent revision surgery. Scans were analysed by a radiologist for pathologies associated with a problematic TKA. Additional patellofemoral and alignment parameters were measured by an imaging expert. MRI observations were compared to those obtained with CT, the diagnosis based on the clinical work-up, and findings during revision surgery. Results MRI observations of rotational malalignment, component loosening and patellofemoral arthrosis were comparable with the clinical diagnosis (six out of eight) and were confirmed during surgery (four out of six). All MRI observations were in line with CT findings (seven out of seven). Clinical diagnosis and surgical findings of collateral excessive laxity could not be confirmed with MRI (two out of eight). Conclusion Low-field MRI shows comparable diagnostic value as CT and might be a future low cost and ionizing radiation free alternative. Differences between supine and weight-bearing MRI did not yield clinically relevant information. The study was approved by the Medical Research Ethics Committees of Twente (Netherlands Trial Register: Trial NL7009 (NTR7207). Registered 5 March 2018, https://www.trialregister.nl/trial/7009).
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Affiliation(s)
- Femke F Schröder
- OCON, centre for orthopaedic surgery, Geerdinksweg 141 postbus 546, 7550, AM, Hengelo, The Netherlands. .,University of Twente, Faculty of Engineering Technology, Biomechanical Engineering, postbus 217 7500 AE, Enschede, The Netherlands.
| | - Corine E Post
- OCON, centre for orthopaedic surgery, Geerdinksweg 141 postbus 546, 7550, AM, Hengelo, The Netherlands.,University of Twente, Faculty of Engineering Technology, Biomechanical Engineering, postbus 217 7500 AE, Enschede, The Netherlands.,Orthopaedic Research Laboratory, Radboud University Medical Center, postbus, 9101 6500, HB, Nijmegen, The Netherlands
| | - Sjoerd M van Raak
- Department of Radiology, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609PP, Almelo, The Netherlands
| | - Frank F J Simonis
- University of Twente, Faculty of science and technology, Magnetic Detection and Imaging, postbus 217 7500 AE, Enschede, The Netherlands
| | | | | | - Nico Verdonschot
- University of Twente, Faculty of Engineering Technology, Biomechanical Engineering, postbus 217 7500 AE, Enschede, The Netherlands.,Orthopaedic Research Laboratory, Radboud University Medical Center, postbus, 9101 6500, HB, Nijmegen, The Netherlands
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26
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Gupta H, Batta NS, Kataria H, Batra V, Upadhyay AD, Jain V, Mishra P, Goel N. A Comparison of the Reliability of the Patellar Tendon-Trochlear Groove (PTTG) Distance and the Tibial Tuberosity-Trochlear Groove (TTTG) Distance Measured on MRI. Malays Orthop J 2020; 14:34-41. [PMID: 32296480 PMCID: PMC7156171 DOI: 10.5704/moj.2003.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Introduction: An increased tibial tuberosity-trochlear groove (TTTG) distance is used for deciding a treatment plan in patello-femoral instability (PFI). The centre of the patellar tendon and the chondral trochlear groove can be directly visualised on MRI, and measured, giving the patellar tendon-trochlear groove (PTTG) distance. A study was designed to compare the inter-rater and the test-retest reliabilities of PTTG and TTTG measurements in MRI of patients without PFI and in a group with PFI. Materials and Methods: This cross-sectional reliability study was done on archival MRI films of 50 patients without patellar instability and 20 patients with patellar instability. TTTG and PTTG distances were independently measured by two orthopaedic surgeons and two radiologists. A hybrid PTTG measurement with bony landmarks on the femoral side and the patellar tendon landmark on the tibial side, was used to estimate the influence of the differences in the femoral and tibial landmarks on the difference in reliabilities. The intra-class correlation coefficient (ICC) was calculated for all four raters, as well as separately for each rater. Results: The PTTG distance had a higher inter-rater reliability (ICC=0.86, 95% CI=0.79-0.92) compared to the TTTG distance (ICC=0.70, 95% CI=0.59-0.80) in patients without PFI. Similar trends were seen in patients with PFI (0.83 vs 0.66). The inter-rater reliability for the hybrid PTTG distance was found to lie in between the TTTG and PTTG. Conclusions: The MRI-based PTTG distance had better inter-rater reliability compared with the MRI-based TTTG distance.
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Affiliation(s)
- H Gupta
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - N S Batta
- Department of Radiodiagnosis, Mahajan Imaging, New Delhi, India
| | - H Kataria
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - V Batra
- Department of Radiodiagnosis, Mahajan Imaging, New Delhi, India
| | - A D Upadhyay
- Department of Biostatistics, All India Institute Of Medical Sciences, New Delhi, India
| | - V Jain
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - P Mishra
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - N Goel
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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27
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Kejriwal R, Annear P. Arthroscopic assessment of patella tracking correlates with recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc 2020; 28:876-880. [PMID: 31079162 DOI: 10.1007/s00167-019-05532-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 05/02/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE For recurrent lateral patellar instability surgical algorithm, an arthroscopic assessment of patellar tracking can aid with the decision of adding a tibial tubercle transfer procedure based on knee flexion angle at which patella centrally engages in its groove. Tibial tubercle-trochlear groove distance is variable in normal values and has discrepancies between imaging modalities. The aims of our study were to assess correlation of arthroscopic patellar tracking technique with recurrent patellar instability, and to assess the accuracy and reproducibility of this technique. METHODS 157 patients were evaluated, 64 control patients with no patellar instability, and 93 patients with recurrent patellar instability. This included 57 consecutive knee arthroscopy procedures evaluated for accuracy and reproducibility of our technique. The technique involved low flow arthroscopy and anterolateral viewing portal. Patients' knees were extended from a flexed position of 120°, and paused when the patella disengaged from its groove. The KFA was then estimated by the primary surgeon, and compared with a goniometer measurement. The assisting surgeon, blinded to the primary surgeon measurements, repeated this process. For the primary outcome, goniometer readings for KFA from the primary surgeon were used to correlate with patellar instability diagnosis. RESULTS Patients with patellar instability had a mean KFA of 118° compared to 44°for patients without patellar instability (p < 0.001). The mean difference between goniometer reading and estimation of KFA by each surgeon was 5° (p < 0.001) with intra-class correlation of 0.99. The mean difference between the two surgeons' goniometer readings was 8° (p < 0.001) with intra-class correlation of 0.99. CONCLUSION This study confirms arthroscopic assessment of patella tracking is accurate, reproducible, and a knee flexion angle of greater than 44° correlates with patellar instability diagnosis. Patella tracking can be used as an adjunct or an alternative assessment method to tibial tubercle-trochlear groove distance to determine the need for tibial tubercle transfer in patellar stabilisation surgery. LEVEL OF EVIDENCE Prospective Cohort Study, Level III.
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Affiliation(s)
- Ritwik Kejriwal
- Taranaki Base Hospital, 87 Vivian St, New Plymouth, 4310, New Zealand.
| | - Peter Annear
- Perth Orthopaedic and Sports Medicine Centre, Perth, Australia
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28
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A robust and semi-automatic quantitative measurement of patellofemoral instability based on four dimensional computed tomography. Med Eng Phys 2020; 78:29-38. [PMID: 32115353 DOI: 10.1016/j.medengphy.2020.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/02/2020] [Accepted: 01/23/2020] [Indexed: 11/21/2022]
Abstract
Patellofemoral instability is a motion related disease, featured as the patella dislocating from the trochlear groove. Four dimensional computed tomography (4DCT) enables full assessment of the patellofemoral movement. Nevertheless, the quantitative measurements of patellofemoral instability are still under research and currently of limited practical use. The aim of this study is to develop a robust and semi-automatic workflow to quantitatively describe the patellofemoral movement in a patient group of eight suffering from patellofemoral instability. The initial results show agreement with manual observations of the tibial tubercle - trochlear groove (TT-TG) distance in routine practice, and the possibility to evaluate both TT-TG distance and patellar centre - trochlear groove (PC-TG) distance dynamically during active flexion-extension-flexion movement of the knee.
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29
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Nielsen TG, Miller LL, Mygind-Klavsen B, Lind M. A simple rehabilitation regime improves functional outcome in patients with patellafemoral pain after 12 month. J Exp Orthop 2020; 7:5. [PMID: 32034562 PMCID: PMC7007455 DOI: 10.1186/s40634-020-00223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/03/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The purpose of the present study was to investigate the effects of a 3-month multimodal intervention including patient education, a simple hip exercise program, footwear adjustment, and foot orthoses to reduce symptoms in patients with patellafemoral pain (PFP). METHODS Patients were diagnosed based on a physical examination, patient symptoms and ruled out intra-articular knee pathologies by MRI. Patients were educated on PFP and participated in a 3-month exercise program; shoes with solid heel-caps were recommended, and custom made orthoses with arch support were recommended to patients with foot pronation. The Anterior Knee Pain Scale (AKPS) and the pain numeric rating scale (NRS) were used to evaluate the outcomes of the intervention and collected at baseline, 3 and 12-months follow-ups. RESULTS Sixty-five patients (age 18 years (9-32)) were included in a consecutive prospective cohort. The AKPS score improved from 71 ± 24 to 89 ± 9 (p < 0.01) at 12 months follow up. The NRS-rest and NRS-activity improved from 3 to 0 (p < 0.01) and 7 to 3 (p < 0.01) respectively. 78% of the patients clinically improved (i.e., demonstrated a > 10-point improvement (minimal clinically important difference (MCID))) considering the AKPS; and 76% and 73% clinically improved (i.e., demonstrated (MCID) a ≥ 2-point improvement) in their NRS-rest and NRS-activity, respectively. No patients experienced a decrease in their AKPS score or an increase in their NRS-rest and NRS-activity scores at 12-months. CONCLUSION A 3-month PFP multimodal treatment strategy focusing on patient education, footwear adjustment, orthoses, and simple hip muscle exercises significantly improved functional outcomes and reduced pain at a 12 month follow-up.
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Affiliation(s)
- Torsten Grønbech Nielsen
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Lene Lindberg Miller
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Bjarne Mygind-Klavsen
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Martin Lind
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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30
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Kamada S, Shiota E, Yamashita T, Kiyama T, Saeki K, Maeyama A, Yamamoto T. Patellar Dislocation in a Patient with Kabuki Syndrome with Severe Mental Retardation: A Case Report. Prog Rehabil Med 2019; 4:20190012. [PMID: 32789259 DOI: 10.2490/prm.20190012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/03/2019] [Indexed: 11/09/2022] Open
Abstract
Background Kabuki syndrome is a rare congenital syndrome. Individuals with Kabuki syndrome have intellectual disabilities, often combined with skeletal anomalies and joint laxity. We herein report the first case of rehabilitation after reconstruction of the medial patellofemoral ligament in a patient with Kabuki syndrome. Case A 27-year-old woman with Kabuki syndrome and severe intellectual disability fell during an epileptic seizure. The right patella dislocated and then spontaneously reduced; similar episodes occurred repeatedly. Reconstruction of the medial patellofemoral ligament and lateral retinacular release were performed. Despite an intensive rehabilitation protocol, the patient's activities of daily living (ADL) did not quickly improve postoperatively because of her severe intellectual impairment and unwillingness to participate in rehabilitation exercises. About 3 months postoperatively, staff encouraged the patient to transfer from a wheelchair to a car, and she was able to get into the car with a little assistance. Subsequently, the patient's ADL gradually improved. By approximately 1 year postoperatively, the patient was able to ambulate independently for a few meters. Discussion The patient was thought to be interested in cars and in going for drives. Rehabilitation training for ADL improvement in patients with severe developmental disorders should include activities that the patients consider interesting.
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Affiliation(s)
- Satoshi Kamada
- Department of Rehabilitation Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Etsuji Shiota
- Department of Rehabilitation Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Toshiyuki Yamashita
- Department of Rehabilitation Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Takahiko Kiyama
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kazuhiko Saeki
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Akira Maeyama
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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31
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Tibial Tubercle-Trochlear Groove Distance Is a Reliable and Accurate Indicator of Patellofemoral Instability. Clin Orthop Relat Res 2019; 477:1450-1458. [PMID: 31094842 PMCID: PMC6554121 DOI: 10.1097/corr.0000000000000711] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial tubercle-trochlear groove (TT-TG) distance is a measurement generally made on CT scans that is commonly used to quantify the risk of patellofemoral instability (PFI); however, its interrater reliability and accuracy as an indicator of PFI in patients is poorly characterized. QUESTIONS/PURPOSES The purposes of our study were (1) to primarily analyze interrater reliability of the TT-TG distance among orthopaedists with varied experience as measured by MRI, (2) to secondarily compare TT-TG distances between PFI and control groups, and (3) to determine an accurate TT-TG distance threshold indicative of PFI. METHODS The electronic medical records of a senior fellowship-trained orthopaedic sports medicine surgeon were surveyed between 2012 and 2016 for patients who had experienced at least one episode of patellar subluxation or dislocation, who reported no other knee-related history, and who underwent MRI due to persistent PFI signs and symptoms. The records of 48 PFI patients (23 males, 25 females; 19 ± 4 years of age) were compared with 83 controls (60 males, 23 females; 31 ± 8 years of age) having no history of PFI, presenting with an isolated meniscal lesion as determined from MRI and treated by the same orthopaedist during this time. All records meeting study criteria were consecutively included to offset selection bias of the retrospective analysis. Two sports medicine fellows, one who had just completed orthopaedic residency training, and another with a year of experience after residency, and a sports medicine subspecialist with more than 15 years of experience in practice independently recorded TT-TG distance, indicative of tibial tubercle lateralization relative to the femoral trochlea, to the nearest millimeter (mm) in a blinded and randomized fashion. Intraclass correlation coefficient computed interrater reliability accompanied by standard error of measurement (SEM); a one-tailed, two-sample t-test analyzed group differences with accompanying effect size per Cohen's d; receiver operating characteristic (ROC) curve determined accuracy and threshold for PFI risk. A p value < 0.05 denoted statistical significance. RESULTS Interrater reliability was excellent, at 0.93 (95% confidence interval [CI], 0.84-0.97; SEM = 0.6 mm) for PFI patients and 0.95 (95% CI, 0.91-0.97; SEM = 0.4 mm) for controls. Distance was greater (95% CI, 2-5; p < 0.001) in PFI patients (14 ± 4 mm; range = 7-24 mm) than controls (10 ± 3 mm; range = 3-19 mm) with an effect size of 1 (95% CI, 0.3-2). Area under the ROC curve was 0.75 (95% CI, 0.66-0.83) and threshold was 13 mm (sensitivity = 0.52, 1-specificity = 0.25), suggesting the measure is a fairly accurate indicator of risk and values of 13 mm or greater are better suited to rule in PFI. Respective positive and negative likelihood ratios of 2 and 0.6 at this threshold confirm that this distance yields a small increase in probability for PFI and a minimal decrease in probability for risk; specifically, a 13-mm TT-TG distance is two times more likely to be found in patients with PFI. Furthermore, this threshold is estimated to increase a correct PFI diagnosis by approximately 15%. CONCLUSIONS The MRI-specific TT-TG distance, based on a single measurement using cartilaginous-tendon landmarks within a standardized trochlear range, is reliable as performed by orthopaedists of varied experience. Patients with PFI display a 4-mm greater distance than controls, which may represent a difference large enough for clinicians to discern in practice using MRI. A 13-mm TT-TG distance is two times more likely seen in patients with PFI. However, this threshold increases a correct PFI diagnosis by only about 15%; therefore, clinical decision-making should not be influenced by this criterion alone and instead used in conjunction with other relevant variables. LEVEL OF EVIDENCE Level IV, diagnostic study.
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Özdemir M, Kavak RP. Chondromalacia Patella among Military Recruits with Anterior Knee Pain: Prevalence and Association with Patellofemoral Malalignment. Indian J Orthop 2019; 53:682-688. [PMID: 31673166 PMCID: PMC6804383 DOI: 10.4103/ortho.ijortho_655_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to investigate the frequency of chondromalacia patella (CMP) and to evaluate its relation with trochlear morphometric and patellofemoral alignment measurements as well as with edema in superolateral region of Hoffa's fat pad (SHFP) in military recruits with anterior knee pain (AKP). MATERIALS AND METHODS Knee magnetic resonance imaging examinations of 288 military recruits with AKP were retrospectively evaluated. Patellar cartilage lesions were graded using modified Noyes system. Quantitative measurements of trochlear morphology (sulcus angle, trochlear sulcus depth, and lateral trochlear inclination [LTI]) and patellofemoral alignment (patellar translation [PT], lateral patellofemoral angle (LPA), Insall-Salvati index, and tibial tuberosity-trochlear groove distance) were made. The SHFP region was assessed for the presence of edema. Mean values of measurements in knees with and without CMP and in knees with early and advanced stage CMP were compared. RESULTS We found CMP in 169 (58.7%) patients. Patients with CMP demonstrated a significantly greater sulcus angle (P = 0.012), smaller LTI (P = 0.004), greater PT (P = 0.01), smaller LPA (P = 0.036), greater Insall-Salvati ratio (P = 0.034), and higher incidence of SHFP edema (P = 0.001) compared to those without CMP. While none of the measurements were associated with the severity of cartilage damage, the incidence of SHFP edema was significantly correlated with the severity of CMP (P = 0.001). CONCLUSION CMP is a common disorder among military recruits with AKP. Patellofemoral malalignment is an important contributory factor in the development of CMP, and the presence of edema in SHFP may be a strong indicator of underlying severe CMP in this population.
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Affiliation(s)
- Meltem Özdemir
- Department of Radiology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey,Address for correspondence: Dr. Meltem Özdemir, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Department of Radiology, Ziraat Mah, Şehit Ömer Halisdemir Cad. No: 20, Altıdağ/Ankara, Turkey. E-mail:
| | - Rasime Pelin Kavak
- Department of Radiology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Injuries of the adolescent girl athlete: a review of imaging findings. Skeletal Radiol 2019; 48:77-88. [PMID: 30123946 DOI: 10.1007/s00256-018-3029-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 07/03/2018] [Accepted: 07/09/2018] [Indexed: 02/02/2023]
Abstract
With the rising participation of girls in sports at both the recreational and elite levels, there has also been increased awareness of injuries common in this athlete population. Anatomic differences between boys and girls cause girl athletes to be predisposed to certain injuries. Certain behavioral patterns, such as eating disorders, also cause problems specific to girl athletes that may result in injury. Imaging plays a large role in diagnosis and ongoing management, but there has been only scant literature dedicated to the specific topic of imaging in girl athletes. The purpose of this article is to review the imaging findings and recommendations for injuries and other conditions affecting the adolescent girl athlete. This article first provides an overview of the key anatomic differences between boys and girls, including both static and dynamic factors, as well as non-anatomic differences, such as hormonal factors, and discusses how these differences contribute to the injury patterns that are seen more typically in girls. The article then reviews the imaging findings in injuries that are commonly seen in girl athletes. There is also a discussion of the "female athlete triad," which consists of osteoporosis, disordered eating, and amenorrhea, and the role of imaging in this condition.
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Patellar tracking should be taken into account when measuring radiographic parameters for recurrent patellar instability. Knee Surg Sports Traumatol Arthrosc 2018; 26:3593-3600. [PMID: 29159672 DOI: 10.1007/s00167-017-4795-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 11/08/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE To date, many radiographic parameters on patellar instability have their measurements taken statically, and have not been studied in various degrees of flexion according to the patellar tracking. There are also limited data regarding the use of these parameters in predicting recurrent patellar dislocation. The current study aims to review the radiographic parameters of the patellofemoral joint in different degrees of knee flexion and to correlate them with the presence of recurrent instability. METHODS A 10-year retrospective study was conducted on all patients who had computed tomography patellar-tracking scan done for patellar instability when aged 18 years or younger. The computed tomography patellar-tracking scans were performed with the knee in extension, 10° flexion, and 20° flexion. The axial radiographic parameters were evaluated at the patellar equator, roman arch, and distal patellar pole. Sagittal and coronal parameters were noted. Radiographic parameters were then correlated with recurrent patellar instability. RESULTS The femoral sulcus angle and trochlear groove depth at the distal patellar pole in 10° knee flexion (p value 0.04 and 0.03, respectively) and patellar equator in 20° knee flexion (p value 0.02 and 0.03, respectively) had the most significant clinical correlations with recurrent instability on multivariate analysis. Other radiographic parameters found to have significant clinical correlation on univariate analysis include the patellar tilt angle, congruence angle, femoral sulcus angle, trochlear groove depth, and Wiberg's classification. CONCLUSIONS As per the knee dynamics, axial radiographic parameters had the most significant correlation with recurrent patellar instability when measured at the distal patellar pole in 10° knee flexion and at the patellar equator in 20° knee flexion. Future axial radiographic evaluation of patellofemoral instability should then be performed at these degrees of knee flexion and axial cuts. Trochlear dysplasia, as measured by the femoral sulcus angle and trochlear groove depth, was the most significant predictor of recurrent patellar instability in the skeletally immature. Wiberg's classification was also a novel factor found to have clinical correlation with patellofemoral instability. LEVEL OF EVIDENCE III.
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Suomalainen JS, Regalado G, Joukainen A, Kääriäinen T, Könönen M, Manninen H, Sipola P, Kokki H. Effects of knee flexion and extension on the tibial tuberosity-trochlear groove (TT-TG) distance in adolescents. J Exp Orthop 2018; 5:31. [PMID: 30116908 PMCID: PMC6095936 DOI: 10.1186/s40634-018-0149-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/09/2018] [Indexed: 01/16/2023] Open
Abstract
Background Measurement of the tibial tubercle–trochlear groove (TT–TG) distance is used to assess patellofemoral instability and rotation. Since patellofemoral instability and acute patellar dislocation are common among adolescents, it is important to clarify the relationship between TT–TG distance and various flexion and extension angles in asymptomatic children. The purpose of the present study was to determine how knee flexion and extension influence TT–TG-distance values measured using 3D imaging in an anatomic axial plane among asymptomatic adolescents. Methods We performed magnetic resonance imaging (MRI) of 26 knees in 13 adolescents (8 boys and 5 girls) of 11–17 years of age, with no known patellofemoral disorders. Imaging was performed with 3.0 T MRI with the knee at four separate angles of flexion between 0° and 30°. Measurements were made by two independent blinded raters. Results The mean TT–TG distance in millimetres was 11.1–0.29 × the angle in degrees. TT–TG distance decreased with greater flexion, showing a mean decrease of 0.29 mm (SD, 0.04) per degree of increased flexion (p < 0.001). We found significant inter-observer (Pearson’s r = 0.636, p = 0.03) and intra-observer (Pearson’s r = 0.792, p ≤ 0.001) correlations. TT–TG values were not significantly correlated with age, length, weight, or body mass index. The rate of TT–TG change (change between consecutive TT–TG values/change between consecutive angles) was significantly negatively correlated with length (p = 0.014), weight (p = 0.004), and body mass index (p = 0.025). Conclusions Our data revealed that TT–TG distance assessed in the anatomic axial plane decreased with greater flexion in adolescent. Moreover, this effect of knee angle was stronger in smaller subjects. These findings support the need for a standardized protocol for TT–TG distance measurement in adolescents.
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Affiliation(s)
| | - Gideon Regalado
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Antti Joukainen
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Tommi Kääriäinen
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
| | - Mervi Könönen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Manninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Petri Sipola
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, P.O. BOX 100, FI-70029 KYS, Kuopio, Finland.
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When and How Far to Move the Tibial Tuberosity in Patients With Patellar Instability. Sports Med Arthrosc Rev 2018; 25:78-84. [PMID: 28459750 DOI: 10.1097/jsa.0000000000000146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The many factors contributing to patellar instability have led to various surgical techniques that are used commonly today. When surgery is deemed necessary, the operation should be tailored to the patient's specific pathoanatomy. Patients with malalignment can often be stabilized by moving the tibial tuberosity to a more medial, anteromedial, or distal position. Subsequent changes in the forces acting on the patellofemoral joint will depend on the direction and distance of the tuberosity repositioning. When planning tuberosity osteotomies, it is crucial to understand how to use clinical and imaging modalities to measure and quantify tuberosity position accurately to achieve the desired degree of realignment.
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Tibial tuberosity to trochlear groove distance and its association with patellofemoral osteoarthritis-related structural damage worsening: data from the osteoarthritis initiative. Eur Radiol 2018; 28:4669-4680. [DOI: 10.1007/s00330-018-5460-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/22/2018] [Accepted: 04/03/2018] [Indexed: 12/29/2022]
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Burke CJ, Kaplan D, Block T, Chang G, Jazrawi L, Campbell K, Alaia M. Clinical Utility of Continuous Radial Magnetic Resonance Imaging Acquisition at 3 T in Real-time Patellofemoral Kinematic Assessment: A Feasibility Study. Arthroscopy 2018; 34:726-733. [PMID: 29273250 PMCID: PMC6080599 DOI: 10.1016/j.arthro.2017.09.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patellar instability with magnetic resonance imaging analysis using continuous real-time radial gradient-echo (GRE) imaging in the assessment of symptomatic patients and asymptomatic subjects. METHODS Symptomatic patients with suspected patellofemoral maltracking and asymptomatic volunteers were scanned in real time by a radial 2-dimensional GRE sequence at 3 T in axial orientation at the patella level through a range of flexion-extension. The degree of lateral maltracking, as well as the associated tibial tubercle-trochlear groove distance and trochlea depth, was measured. Patellar lateralization was categorized as normal (≤2 mm), mild (>2 to ≤5 mm), moderate (>5 to ≤10 mm), or severe (>10 mm). The patellofemoral cartilage was also assessed according to the modified Outerbridge grading system. RESULTS The study included 20 symptomatic patients (13 women and 7 men; mean age, 36 ± 12.8 years) and 10 asymptomatic subjects (3 women and 7 men; mean age, 33.1 years). The mean time to perform the dynamic component ranged from 3 to 7 minutes. Lateralization in the symptomatic group was normal in 10 patients, mild in 1, moderate in 8, and severe in 1. There was no lateral tracking greater than 3 mm in the volunteer group. Lateral maltracking was significantly higher in symptomatic patients than in asymptomatic subjects (4.4 ± 3.7 mm vs 1.5 ± 0.71 mm, P = .007). Lateral tracking significantly correlated with tibial tubercle-trochlear groove distance (r = 0.48, P = .006). There was excellent agreement on lateral tracking between the 2 reviewers (intraclass correlation coefficient, 0.979; 95% confidence interval, 0.956-0.990). CONCLUSIONS The inclusion of a dynamic radial 2-dimensional GRE sequence is a rapid and easily performed addition to the standard magnetic resonance imaging protocol and allows dynamic quantitative assessment of patellar instability and lateral maltracking in symptomatic patients. With a paucity of reported data using this technique confirming that these results reach clinical significance, future work is required to determine how much lateral tracking is clinically significant. LEVEL OF EVIDENCE Level III, case control.
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Affiliation(s)
- Christopher J Burke
- Department of Radiology, NYU Hospital for Joint Diseases, New York, New York, U.S.A..
| | - Daniel Kaplan
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York, U.S.A
| | - Tobias Block
- NYU Center for Biomedical Imaging, New York, New York, U.S.A
| | - Gregory Chang
- NYU Center for Biomedical Imaging, New York, New York, U.S.A
| | - Laith Jazrawi
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York, U.S.A
| | - Kirk Campbell
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York, U.S.A
| | - Michael Alaia
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York, U.S.A
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Gulati A, McElrath C, Wadhwa V, Shah JP, Chhabra A. Current clinical, radiological and treatment perspectives of patellofemoral pain syndrome. Br J Radiol 2018; 91:20170456. [PMID: 29303366 DOI: 10.1259/bjr.20170456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Anterior knee pain in active young adults is commonly related to patellofemoral pain syndrome, which can be broadly classified into patellar malalignment and patellar maltracking. Imaging is performed to further elucidate the exact malalignment and maltracking abnormalities and exclude other differentials. This article details the role of the stabilizers of the patellofemoral joint, findings on conventional and multimodality imaging aiding in patellofemoral pain syndrome diagnosis and characterization, and current perspectives of various treatment approaches.
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Affiliation(s)
- Aishwarya Gulati
- 1 Department of Radiology, Dr Gulati Imaging Institute , Hauz Khas, New Delhi , India
| | - Christopher McElrath
- 2 Department of Orthopaedic Surgery, UT Southwestern Medical Center , Dallas, TX , United States
| | - Vibhor Wadhwa
- 3 Department of Radiology, University of Arkansas for Medical Sciences , Little Rock, AR , United States
| | - Jay P Shah
- 2 Department of Orthopaedic Surgery, UT Southwestern Medical Center , Dallas, TX , United States
| | - Avneesh Chhabra
- 2 Department of Orthopaedic Surgery, UT Southwestern Medical Center , Dallas, TX , United States.,4 Department of Radiology, UTSouthwestern Medical Center , Dallas, TX , United States
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Hinckel BB, Gobbi RG, Kihara Filho EN, Demange MK, Pécora JR, Rodrigues MB, Camanho GL. Why are bone and soft tissue measurements of the TT-TG distance on MRI different in patients with patellar instability? Knee Surg Sports Traumatol Arthrosc 2017; 25:3053-3060. [PMID: 27034087 DOI: 10.1007/s00167-016-4095-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/15/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE To determine whether the tibial tuberosity-to-trochlear groove distance (TT-TG) and patellar tendon-to-trochlear groove distance (PT-TG) are equal, whether the bony and cartilaginous points coincide in the trochlea, and whether the insertion of the PT coincides with the most anterior point of the TT in patients with patellar instability. METHODS Fifty-three MRI scans of patients with patellar instability were examined. TT-TG and PT-TG were measured by three examiners in 31 knees. Additionally, the bone-cartilage distance in the trochlea [trochlear cartilage to trochlear bone (TC-TB)] and the distance between the mid-point of the PT insertion and the most anterior point of the TT (PT-TT) were measured by one examiner. The intraclass correlation coefficient was used to evaluate the reliability of the measurements between the three examiners. The relationships between the measurements were determined, the means of the measurements were calculated, and the correlations between PT-TG and TT-TG, PT-TT, and TC-TB were assessed. RESULTS The ICC was above 0.8. PT-TG was 3.7 mm greater than TT-TG. The TC and TB coincided in 73 % of cases, and the mean TC-TB was 0.3 mm. The PT was lateral to the TT in 94 % of the cases, and the mean PT-TT was 3.4 mm. The Pearson's correlation coefficients between PT-TG and TT-TG, PT-TT, and TC-TB were 0.946, 0.679, and 0.199, respectively. CONCLUSION TT-TG underestimated PT-TG, primarily due to the lateralization of the PT insertion relative to the most anterior point of the TT. CLINICAL RELEVANCE our study shows that in patients with patellar instability, there are differences in the absolute values of TT-TG and PT-TG, as previously reported for patients without patellar instability. Hence, normal cut-off values based on case-control studies of TT-TG cannot be equivalently used when measuring PT-TG to indicate TT medialization in patients with patellar instability. It is also important to note that the clinical outcomes cannot be directly compared between patients evaluated using TT-TG versus PT-TG measurements. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Betina B Hinckel
- Department of Orthopaedics and Traumatology, Institute of Orthopaedics and Traumatology, University of São Paulo, Ovídio Pires de Campos St, 333, 2nd Floor, Cerqueira César, São Paulo, SP, 5403-010, Brazil
| | - Riccardo G Gobbi
- Department of Orthopaedics and Traumatology, Institute of Orthopaedics and Traumatology, University of São Paulo, Ovídio Pires de Campos St, 333, 2nd Floor, Cerqueira César, São Paulo, SP, 5403-010, Brazil.
| | - Eduardo N Kihara Filho
- Department of Musculoskeletal Radiology, University of São Paulo, São Paulo, SP, 55403-010, Brazil
| | - Marco K Demange
- Department of Orthopaedics and Traumatology, Institute of Orthopaedics and Traumatology, University of São Paulo, Ovídio Pires de Campos St, 333, 2nd Floor, Cerqueira César, São Paulo, SP, 5403-010, Brazil
| | - José Ricardo Pécora
- Department of Orthopaedics and Traumatology, Institute of Orthopaedics and Traumatology, University of São Paulo, Ovídio Pires de Campos St, 333, 2nd Floor, Cerqueira César, São Paulo, SP, 5403-010, Brazil
| | - Marcelo B Rodrigues
- Department of Musculoskeletal Radiology, University of São Paulo, São Paulo, SP, 55403-010, Brazil
| | - Gilberto Luis Camanho
- Department of Orthopaedics and Traumatology, Institute of Orthopaedics and Traumatology, University of São Paulo, Ovídio Pires de Campos St, 333, 2nd Floor, Cerqueira César, São Paulo, SP, 5403-010, Brazil
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Carlson VR, Boden BP, Shen A, Jackson JN, Yao L, Sheehan FT. The Tibial Tubercle-Trochlear Groove Distance Is Greater in Patients With Patellofemoral Pain: Implications for the Origin of Pain and Clinical Interventions. Am J Sports Med 2017; 45:1110-1116. [PMID: 28056523 PMCID: PMC6010059 DOI: 10.1177/0363546516681002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The distance between the tibial tubercle (TT) and trochlear groove (TT-TG distance) is known to be greater in patients with patellar instability. However, the potential role and prevalence of pathological TT-TG distances in a large cohort of skeletally mature patients with isolated patellofemoral pain (PFP) are not clear. PURPOSE To determine if the mean TT-TG distance is greater in patients with PFP, who lack a history of patellar dislocations, knee trauma, or osteoarthritis, relative to healthy controls. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 50 knees (38 patients) with PFP and 60 knees (56 controls) without PFP formed the basis of this study. Magnetic resonance imaging was used to determine the TT-TG distance from 3-dimensional static scans. RESULTS The cohort with PFP demonstrated a significantly greater mean TT-TG distance relative to asymptomatic controls (13.0 vs 10.8 mm, respectively; P = .001). Among the cohort with PFP, 15 knees (30%) demonstrated TT-TG distances ≥15 mm, and 3 knees (6%) demonstrated TT-TG distances ≥20 mm. CONCLUSION Most adult patients with isolated PFP have elevated TT-TG distances compared with controls, which likely contributes to the force imbalance surrounding the knee.
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Affiliation(s)
- Victor R. Carlson
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, NIH, Bethesda, Maryland
| | - Barry P. Boden
- The Orthopaedic Center, A Division of CAO, Rockville, Maryland
| | - Aricia Shen
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, NIH, Bethesda, Maryland
| | - Jennifer N. Jackson
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, NIH, Bethesda, Maryland
| | - Larry Yao
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, NIH, Bethesda, Maryland
| | - Frances T. Sheehan
- Functional and Applied Biomechanics Section, Department of Rehabilitation Medicine, NIH, Bethesda, Maryland
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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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Yin L, Chen C, Duan X, Deng B, Xiong R, Wang F, Yang L. Influence of the image levels of distal femur on the measurement of tibial tubercle-trochlear groove distance--a comparative study. J Orthop Surg Res 2015; 10:174. [PMID: 26568198 PMCID: PMC4645479 DOI: 10.1186/s13018-015-0323-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 11/08/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The purpose of the present study was to determine whether the image levels of the distal femur affected the measurement of the tibial tubercle-trochlear groove (TT-TG) distance. METHODS Thirty sets of computer tomography (CT) images and 30 sets of MR images of the knee were evaluated. The TT-TG distance was quantified at multiple image levels in 1.5-mm increments, covering the proximodistal range of the trochlear groove. The CT measurement was based on osseous landmarks; the magnetic resonance imaging (MRI) measurement was based on cartilaginous and osseous landmarks. RESULTS The average TT-TG distances measured with CT, with MRI based on cartilaginous landmarks, and with MRI based on osseous landmarks were 15.74 mm (SD 3.83 mm), 12.8 mm (SD 5.67 mm), and 12.36 mm (SD 5.58 mm), respectively. No significant difference was found across image levels in the CT measurement and the MRI measurement upon osseous landmarks (P = 0.64, P = 0.11); yet, the difference was significant in the MRI measurement upon cartilaginous landmarks (P < 0.01). Large deviation was found between levels in individual subjects in all the three sorts of measurement. The proximal levels were the most variable, while the mid levels were the least variable. CONCLUSIONS Measurements of the TT-TG distance are not identical across the levels of the distal femur. Cautions should be taken when specific image slices were selected for evaluation.
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Affiliation(s)
- Li Yin
- Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, 30 Gaotanyan St., Shapingba, Chongqing, 400038, People's Republic of China.
| | - Cheng Chen
- Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, 30 Gaotanyan St., Shapingba, Chongqing, 400038, People's Republic of China.
| | - Xiaojun Duan
- Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, 30 Gaotanyan St., Shapingba, Chongqing, 400038, People's Republic of China.
| | - Bing Deng
- Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, 30 Gaotanyan St., Shapingba, Chongqing, 400038, People's Republic of China.
| | - Ran Xiong
- Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, 30 Gaotanyan St., Shapingba, Chongqing, 400038, People's Republic of China.
| | - Fuyou Wang
- Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, 30 Gaotanyan St., Shapingba, Chongqing, 400038, People's Republic of China.
| | - Liu Yang
- Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, 30 Gaotanyan St., Shapingba, Chongqing, 400038, People's Republic of China.
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Hinckel BB, Gobbi RG, Kihara Filho EN, Demange MK, Pécora JR, Camanho GL. Patellar Tendon-Trochlear Groove Angle Measurement: A New Method for Patellofemoral Rotational Analyses. Orthop J Sports Med 2015; 3:2325967115601031. [PMID: 26535396 PMCID: PMC4622295 DOI: 10.1177/2325967115601031] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: The tibial tubercle–trochlear groove (TT-TG) is used as the gold standard for patellofemoral malalignment. Purpose: To assess 3 patellar tendon–trochlear groove (PT-TG) angle measurement techniques and the PT-TG distance measurement (tendinous cartilaginous TT-TG) as predictors of patellar instability. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Three PT-TG angle measurements and the PT-TG distance were measured in 82 participants with patellar instability and 100 controls using magnetic resonance imaging (MRI). Measurement landmarks were the line tangent to the posterior femoral condyles, the deepest point of the trochlea, the transepicondylar line, and the patellar tendon center. All measurements were recorded once by 1 examiner, and the measurements were recorded twice by 2 examiners in a random group of 100 knees. Mean values and standard deviations (SDs) were obtained. Normality cutoff values were defined as 2 and 3 SDs above the mean in the control group. The sensitivity, specificity, and positive likelihood ratio (LR+) were calculated. Inter- and intrarater reliability were assessed based on the intraclass correlation coefficient (ICC). Results: The measurements from the patellar instability and control groups, respectively, for angle 1 (16.4° and 8.4°), angle 2 (31° and 15.6°), angle 3 (30.8° and 15.7°), PT-TG distance (14.5 and 8.4 mm), and patellar tilt (21.1° and 7.5°) were significantly different (P < .05). The angle measurements showed greater sensitivity, specificity, and LR+ than the PT-TG distance. Inter- and intrarater ICC values were >0.95 for all measurements. Conclusion: The PT-TG angle and the PT-TG distance are reliable and are different between the patellar instability and control groups. PT-TG angles are more closely associated with patellar instability than PT-TG distance. Clinical Relevance: PT-TG angle measurements show high reliability and association with patellar instability and can aid in the assessment of extensor mechanism malalignment. A more sensitive and specific evaluation of extensor mechanism malalignment can improve patient care by preventing both redislocation and abnormal tracking of overlooked malalignment and complications of unnecessary tibial tuberosity medialization.
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Affiliation(s)
- Betina B Hinckel
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Riccardo G Gobbi
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Eduardo N Kihara Filho
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Marco K Demange
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - José Ricardo Pécora
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Gilberto Luis Camanho
- Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil
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