1
|
Wu CC. Patellar malalignment: A common disorder associated with knee pain. Biomed J 2023; 46:100658. [PMID: 37678711 PMCID: PMC10550501 DOI: 10.1016/j.bj.2023.100658] [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: 05/18/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023] Open
Abstract
Pain-associated knee joint disorders are common in daily life. Practically, knee pain should be divided into the origin from the isolated tibiofemoral (TF), isolated patellofemoral (PF) joint, or a combination thereof. The TF joint controls the actions of level walking, while the PF joint controls knee flexion-extension. Owing to its sufficient inherent stability, non-traumatic disorders of the isolated TF joint in young individuals are uncommon. In contrast, because of its insufficient inherent stability, non-traumatic disorders of the isolated PF joint are common in young individuals. Patellar malalignment (PM) associated with knee pain is common in all age groups, and the most common predisposing factor is imbalanced peripatellar soft-tissue tension. The outward forces acting on the patella are caused by pulling from the quadriceps femoris during knee flexion to extension (manifested by the quadriceps angle [Q-angle]), and sliding backward of the iliotibial band (ITB) during knee extension to flexion. Once the muscle power of the vastus medialis (especially the vastus medialis obliquus [VMO]) decreases, which lowers the counteracting effect against outward forces, the patella displaces or rotates laterally. The reduced contact surface between the patella and the femoral condyle significantly increases the compressive pressure and injures the articular cartilage. Subsequently, progressive PF degeneration occurs. Although other factors may also cause PM, they are relatively uncommon. In principle, nonsurgical treatment of PM should be considered first, while surgical treatment should follow established indications. Some nonsurgical techniques are currently widely used that feature high satisfaction rates. Surgical techniques are continuously being developed, and their success rates have gradually improved. This study aimed to review the current literature for relevant studies and report related publications of the author's institution to emphasize the universality and importance of PM management. Conceptually, simply focusing on problems of the TF joint cannot treat all knee disorders.
Collapse
Affiliation(s)
- Chi-Chuan Wu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
2
|
Bozzo I, Laverdière C, Corban J, Ge S, Pauyo T, Bernstein M. Equation predicting tibial-tuberosity to trochlear-groove distance following supratubercle osteotomy: Radiographic proof of concept. Clin Biomech (Bristol, Avon) 2023; 102:105892. [PMID: 36652877 DOI: 10.1016/j.clinbiomech.2023.105892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/13/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Supratubercle tibial rotational osteotomies are useful in patellar stabilizing procedures with high tibial-tuberosity to trochlear-groove distance caused by excessive external tibial torsion. An investigation determined one degree of internal tibial rotation results in 0.68 mm reduction of tibial-tuberosity to trochlear-groove distance, but did not account for anatomical variability. METHODS This is a radiographic proof of concept for equation validation. We compared two different derived equations, a complex four-variable and simplified two-variable equation, to the literature relationship and true measured value from CT imaging. Bilateral pre-operative CTs of 37 patients, evaluated for malalignment, were reviewed retrospectively. We virtually simulated derotations of five, ten and fifteen degrees, and compared the reduction in tibial-tuberosity to trochlear-groove distance measured radiologically from CTs to the one predicted by our equation. FINDINGS The difference between the true change in tibial-tuberosity to trochlear-groove distance and that obtained using our four-variable was statistically insignificant for all derotation angles (p > 0.05), and the two-variable equation it was statistically insignificant for five and fifteen degrees of derotation (p > 0.05). Conversely, the true values were statistically different from those found using the published relationship (p < 0.05 for all). INTERPRETATION This new equation accounts for individual patient anatomy, for a more accurate relationship between internal rotation of the distal segment of the tibia and the subsequent decrease in the tibial-tuberosity to trochlear-groove distance. The change was overestimated using the linear relationship, which may result in under correction. Future studies will assess true post-operative distance change following osteotomy.
Collapse
Affiliation(s)
- Isabella Bozzo
- Faculty of Medicine, McGill University, 3605 Rue de la Montagne, Montréal, Québec H3G 2M1, Canada.
| | - Carl Laverdière
- Division of Orthopaedic Surgery, McGill University Health Center, Montreal General Hospital Site, 1650 Cedar Ave, Montreal, Quebec H3G 1A4, Canada
| | - Jason Corban
- Division of Orthopaedic Surgery, McGill University Health Center, Montreal General Hospital Site, 1650 Cedar Ave, Montreal, Quebec H3G 1A4, Canada
| | - Susan Ge
- Division of Orthopaedic Surgery, McGill University Health Center, Montreal General Hospital Site, 1650 Cedar Ave, Montreal, Quebec H3G 1A4, Canada
| | - Thierry Pauyo
- Division of Orthopaedic Surgery, McGill University Health Center, Montreal General Hospital Site, 1650 Cedar Ave, Montreal, Quebec H3G 1A4, Canada; Shriners Hospital for Children-Canada, 1003 Decarie Blvd, Montreal, Québec H4A 0A9, Canada
| | - Mitchell Bernstein
- Division of Orthopaedic Surgery, McGill University Health Center, Montreal General Hospital Site, 1650 Cedar Ave, Montreal, Quebec H3G 1A4, Canada; Shriners Hospital for Children-Canada, 1003 Decarie Blvd, Montreal, Québec H4A 0A9, Canada
| |
Collapse
|
3
|
Patellofemoral Instability Part I: Evaluation and Nonsurgical Treatment. J Am Acad Orthop Surg 2022; 30:e1431-e1442. [PMID: 36037281 DOI: 10.5435/jaaos-d-22-00254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/04/2022] [Indexed: 02/01/2023] Open
Abstract
Patellofemoral instability (PFI) is a prevalent cause of knee pain and disability. It affects mostly young females with an incidence reported as high as 1 in 1,000. Risk factors for instability include trochlear dysplasia, patella alta, increased tibial tubercle-to-trochlear groove distance, abnormal patella lateral tilt, and coronal and torsional malalignment. Nonsurgical and surgical options for PFI can treat the underlying causes with varied success rates. The goal of this review series was to synthesize the current best practices into a concise, algorithmic approach. This article is the first in a two-part review on PFI, which focuses on the clinical and radiological evaluation, followed by nonsurgical management. The orthopaedic surgeon should be aware of the latest diagnostic protocol for PFI and its nonsurgical treatment options, their indications, and outcomes.
Collapse
|
4
|
Biz C, Stecco C, Crimì A, Pirri C, Fosser M, Fede C, Fan C, Ruggieri P, De Caro R. Are Patellofemoral Ligaments and Retinacula Distinct Structures of the Knee Joint? An Anatomic, Histological and Magnetic Resonance Imaging Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031110. [PMID: 35162134 PMCID: PMC8834464 DOI: 10.3390/ijerph19031110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
There is disagreement regarding the description of the patellofemoral ligaments (PFLs), considered by some authors as capsular thickening and by others as independent ligaments. It was hypothesised that the PFLs and retinacula are structures with different histological features. The aim of this study was to describe the stabilising structures of the patella in detail and to determine if the PFLs and retinacula are different and separable structures from a macroscopic, microscopic and imaging viewpoint. An anatomical study was performed on eight knees from five cadavers (mean age, 56.2 years; range, 35–63 years), and a histological study was conducted on specimens from nine patients having a mean age of 65 years (range 35–84 years) who had undergone surgical knee procedures. The imaging study was based on 100 MRIs (96 patients). The mean age was 46 years (range 16–88), and the study analysed the capsular-ligamentous structures. In the medial compartment, the layers and structures were as follows: superficial layer, medial retinaculum; intermediate layer, Medial Collateral Ligament (MCL), Posterior Oblique Ligament (POL) and Medial Patellofemoral Ligament (MPFL); deep layer, deep part of the MCL and joint capsule. In the lateral compartment, the layers and structures were the following: superficial layer, lateral retinaculum; intermediate layer, Lateral Collateral Ligament (LCL) and Lateral Patellofemoral Ligament (LPFL); deep layer, joint capsule. All of the knees examined presented a clearly distinguishable MPFL and LPFL separable from the capsular layer. Histological study: there was a higher density of nerve fibres in retinacula compared to ligaments (p = 0.0034) and a higher content of elastic fibres in retinacula (p < 0.0005). In imaging, there was no difference between medial and lateral retinaculum thickness (p > 0.05). In conclusion, both the lateral and medial compartment can be described using the three-layer scheme. PFLs and retinacula are separate structures both macroscopically and according to imaging analysis. The retinacula respond to their specific function with a higher nerve fibre content and higher number of elastic fibres compared to the ligaments.
Collapse
Affiliation(s)
- Carlo Biz
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
- Correspondence: ; Tel.: +39-049-8213239
| | - Carla Stecco
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Alberto Crimì
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
| | - Carmelo Pirri
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Michele Fosser
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
| | - Caterina Fede
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Chenglei Fan
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| | - Pietro Ruggieri
- Orthopaedics and Orthopaedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padua, 35128 Padova, Italy; (A.C.); (M.F.); (P.R.)
| | - Raffaele De Caro
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy; (C.S.); (C.P.); (C.F.); (C.F.); (R.D.C.)
| |
Collapse
|
5
|
Abstract
Optimal treatment of patients with patellofemoral trochlear dysplasia and recurrent patellar instability requires in-depth understanding of this complex structural anomaly. An extensive review of the literature suggests that dysplasia occurs as a result of aberrant forces applied to the patellofemoral joint in the majority of cases. Evidence supports surgical stabilization that reconstructs the medial patellofemoral and/or medial quadriceps tendon-femoral ligament without added trochleoplasty in the majority of patients with trochlear dysplasia and recurrent patellar instability. Adding tibial tubercle transfer distally, medially, or anteromedially in those who need it to treat specific deficits in alignment or articular cartilage can be beneficial in selected patients with trochlear dysplasia and recurrent patellar instability. Trochleoplasty may be appropriate in those few cases in which permanent stable patellofemoral tracking cannot be restored otherwise, but the indications are not yet clear, particularly as trochleoplasty adds risk to the articular cartilage. Improved understanding of imaging techniques and 3-dimensional reproductions of dysplastic patellofemoral joints are useful in surgical planning for patients with recurrent patellar instability and trochlear dysplasia.
Collapse
Affiliation(s)
- Benjamin J Levy
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Surgery, UConn Health, Farmington, Connecticut, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John P Fulkerson
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Surgery, Yale University, New Haven, Connecticut, USA
| |
Collapse
|
6
|
Maas KJ, Warncke ML, Leiderer M, Krause M, Dust T, Frings J, Frosch KH, Adam G, Henes FOG. Diagnostic Imaging of Patellofemoral Instability. ROFO-FORTSCHR RONTG 2021; 193:1019-1033. [PMID: 33773517 DOI: 10.1055/a-1348-2122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Throughout the literature, patellofemoral instability (PI) is defined as an increased risk of re-/luxation of the patella within the patellofemoral joint (PFJ). In most patients it is caused by traumatic patella luxation or the existence of a range of predisposing anatomic risk factors leading to an unphysiological movement sequence within the PFJ also known as patellofemoral maltracking. In order to provide an individualized therapy approach, clinical and radiological evaluation of those risk factors of variable magnitude becomes essential. Diagnostic imaging such as magnetic resonance imaging (MRI), plain radiography, and computed tomography (CT) are straightforward diagnostic tools in terms of evaluation and treatment of PI. METHOD In this review we performed a precise analysis of today's literature concerning the radiological evaluation of anatomic risk factors leading to PI. The purpose of the review is to present a logical compilation of the different anatomical risk factors causing PI and provide a straight overview of valuable radiological imaging techniques. RESULTS AND CONCLUSION PI is frequently based on a multifactorial disposition. The most relevant predisposing risk factors are trochlea dysplasia, rupture of the medial patellofemoral ligament (MPFL), patella alta, abnormal tibial tubercle to trochlea groove distance (TT-TG), femoral torsion deformities, and genu valgum. Although plain X-rays may provide basic diagnostic value, cross-sectional imaging (MRI, CT) is the standard radiological tool in terms of evaluation and detection of severity of predisposing anatomic variants leading to PI. KEY POINTS · Based on today's literature, PI is characterized as an increased risk of patella re-/luxation within the PFJ.. · Underlying anatomic risk factors of variable magnitude mark the pathological cause of PI.. · Modern diagnostic imaging (MRI and CT) permits straightforward diagnosis of the typical features in terms of PI.. · To provide an individualized therapy approach, precise radiological evaluation and determination of the severity of predisposing anatomic anomalies are essential.. CITATION FORMAT · Maas KJ, Warncke ML, Leiderer M et al. Diagnostic Imaging of Patellofemoral Instability. Fortschr Röntgenstr 2021; 193: 1019 - 1033.
Collapse
Affiliation(s)
- Kai-Jonathan Maas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Lennart Warncke
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Leiderer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Krause
- Department Trauma Surgery and Orthopedics, UKE, Hamburg, Germany
| | - Tobias Dust
- Department Trauma Surgery and Orthopedics, UKE, Hamburg, Germany
| | - Jannik Frings
- Department Trauma Surgery and Orthopedics, UKE, Hamburg, Germany
| | | | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank Oliver Gerhard Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
7
|
Leite CBG, Santos TP, Giglio PN, Pécora JR, Camanho GL, Gobbi RG. Tibial Tubercle Osteotomy With Distalization Is a Safe and Effective Procedure for Patients With Patella Alta and Patellar Instability. Orthop J Sports Med 2021; 9:2325967120975101. [PMID: 33553451 PMCID: PMC7829522 DOI: 10.1177/2325967120975101] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Tibial tubercle osteotomy with concomitant distalization for the treatment of
patellar instability remains controversial, as it may cause anterior knee
pain and chondral degeneration. Purpose: To evaluate radiographic, clinical, and functional outcomes in patients who
had patellar instability with patella alta and underwent tibial tubercle
osteotomy with distalization (TTO-d) as well as medial patellofemoral
ligament reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were 25 patients (31 cases) (mean age at surgery, 28.7
years; range, 14-33 years) with patellar instability and patella alta who
underwent TTO-d with minimum 1-year follow-up. The Caton-Deschamps index
(CDI), tibial tubercle–trochlear groove (TT-TG) distance, and amount of
distalization were assessed. Clinical and functional variables included
J-sign, anterior knee pain, apprehension test, Tegner activity level, and
Kujala score. Results: The mean follow-up period was 2.62 years. The mean TT-TG was 16.15 mm (range,
7-24 mm); the mean CDI changed from 1.37 (1.25-1.7) preoperatively to 1.02
(0.9-1.12) postoperatively (P = .001); and the mean amount
of tibial tubercle distalization was 8.80 mm (range, 4-16 mm). Lateral
release (22 cases; 71.0%), medialization of tibial tubercle (17 cases;
54.8%), and autologous chondrocyte implantation (4 cases; 12.9%) were other
associated procedures. The J-sign improved in 30 cases (96.8%;
P = .001), and there was a complete resolution of
anterior knee pain in 22 cases (71.0%; P = .001). An
exploratory analysis showed that patellar cartilage defect severity was
correlated with persistent pain (P = .005). The
apprehension test became negative in all cases (P = .001).
The median Kujala score increased from 52 to 77 (P = .001),
and the median Tegner activity level improved from 3 to 4
(P = .001). No cases of osteotomy nonunion were
reported. One case (3.2%) of patellar instability recurrence and 3 cases
(6.5%) with painful hardware were observed. Conclusion: TTO-d resulted in good radiographic, clinical, and functional outcomes
providing proper patellar stability to patients with patella alta. TTO-d
appears to be a safe and efficient procedure with low complication rates,
providing an additional tool for the personalized treatment of patellar
instability.
Collapse
Affiliation(s)
- Chilan B G Leite
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Társis P Santos
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Pedro N Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José R Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gilberto L Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Riccardo G Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|