1
|
Tanaka MJ. Sagittal tibial tuberosity to trochlear groove distance measurements may reflect patellofemoral contact pressures. Arthroscopy 2024:S0749-8063(24)00479-1. [PMID: 38950641 DOI: 10.1016/j.arthro.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/03/2024]
Abstract
Tibial tubercle to trochlear groove (TTTG) distance is a commonly utilized measurement in the assessment of knees with patellar instability, representing malalignment in the form of tuberosity lateralization relative to the trochlear groove. More recently, the concept of the anteroposterior TTTG (AP-TTTG), renamed as the sagittal TTTG (sTTTG), has been studied as a measurement to assess the relationship between the two structures in a different direction, potentially representing patellofemoral contact pressures through its assessment in the sagittal plane. As we incorporate this measurement to capture how our surgical procedures can offload the joint and 'correct' the sTTTG distance, the utility of this measurement as a proxy for patellofemoral contact pressures will continue to grow, allowing us to better consider joint preservation in addition to stability in the management of patellar instability.
Collapse
Affiliation(s)
- Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A..
| |
Collapse
|
2
|
Retzky JS, Palhares GM, Uppstrom TJ, Hinkley P, Fletcher C, Gomoll AH, Strickland SM. Risk Factors for Atraumatic Medial Patellar Facet Lesions. Orthop J Sports Med 2024; 12:23259671241255681. [PMID: 38881850 PMCID: PMC11179489 DOI: 10.1177/23259671241255681] [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: 09/25/2023] [Accepted: 10/24/2023] [Indexed: 06/18/2024] Open
Abstract
Background Medial patellar facet lesions have been well-described in the setting of patellar instability. However, relatively little is known about risk factors for atraumatic medial patellar facet lesions. Purpose/Hypothesis To identify clinical and radiographic risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability. It was hypothesized that a posterior tibial tubercle relative to the trochlear groove would be a risk factor for atraumatic medial patellar facet lesions. Study Design Case-control study; Level of evidence, 3. Methods A total of 37 patients with atraumatic medial patellar facet lesions were matched by age, sex, and body mass index with 37 control patients without a history of patellofemoral dysplasia. Demographic and imaging characteristics were compared between groups. Plain radiography was used to evaluate Wiberg type, and magnetic resonance imaging was used to calculate Caton-Deschamps index, tibial tubercle-trochlear groove distance, trochlear facet asymmetry ratio, patellotrochlear index, sulcus depth, patellar bisect ratio, and tibial tubercle height. Statistically significant variables from univariate analysis were used as inputs to the multivariate regression model to assess independent risk factors. Results There were no differences between groups with respect to Wiberg type, Caton-Deschamps index, tibial tubercle-trochlear groove distance, sulcus depth, or patellotrochlear index (P > .05 for all). The medial facet lesion group had a larger medial trochlear facet (trochlear facet asymmetry ratio, 0.72 ± 0.11 vs 0.60 ± 0.09; P < .001), a more medial-lying patella in the trochlear groove (patellar bisect ratio, 0.57 ± 0.06 vs 0.55 ± 0.07; P = .035), and a more posterior tibial tubercle relative to the trochlear groove (tibial tubercle height, -3.13 ± 5.21 vs -0.23 ± 5.93 mm; P = .030) compared with the control group. Multivariate regression analysis identified trochlear facet asymmetry and tibial tubercle height as independent risk factors for medial patellar facet lesions (relative risk = 97.3 [95% CI, 14.9-635.1], P < .001 and relative risk = 0.95 [95% CI, 0.92-0.98], P = .004, respectively). Conclusion A relatively larger medial trochlear facet and a more posterior tibial tubercle relative to the trochlear groove were found to be risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability.
Collapse
Affiliation(s)
- Julia S Retzky
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, USA
| | - Guilherme M Palhares
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, USA
| | - Tyler J Uppstrom
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, USA
| | - Paige Hinkley
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, USA
| | - Connor Fletcher
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, USA
| | - Andreas H Gomoll
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, USA
| | - Sabrina M Strickland
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, USA
| |
Collapse
|
3
|
Uppstrom TJ, Fletcher CF, Green DW, Gomoll AH, Strickland SM. Decreased Effective Patellar Tendon Length following Distalization Tibial Tubercle Osteotomy without Patellar Tendon Tenodesis. Orthop J Sports Med 2024; 12:23259671241227201. [PMID: 38371997 PMCID: PMC10870814 DOI: 10.1177/23259671241227201] [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: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 02/20/2024] Open
Abstract
Background Distalization tibial tubercle osteotomy (TTO) is an effective treatment for improving patellar height in patients with patella alta associated with patellofemoral instability and cartilage lesions. The addition of a patellar tendon tenodesis has been suggested; nonetheless, concerns exist regarding possible increased patellofemoral cartilage stresses. Purpose To evaluate pre- and postoperative patellar tendon length and alignment parameters on magnetic resonance imaging (MRI), as well as patient-reported outcome measures (PROMs) after distalization TTO without patellar tendon tenodesis. Study Design Case series; Level of evidence, 4. Methods Twenty skeletally mature patients who underwent distalization TTO with or without anteromedialization at our institution between December 2014 and August 2021 were included. All patients underwent pre- and postoperative MRIs of the affected knee. The Caton-Deschamps index (CDI), the axial and sagittal tibial tubercle-trochlear groove (TT-TG) distances, the distances from the tibial plateau to the patellar tendon insertion and the tibial tubercle, and the patellar tendon length were assessed. PROMs included the International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale, the Kujala Anterior Knee Pain Scale, and the Veterans RAND 12-Item Health Survey mental and physical component scores. Results The mean patient age at surgery was 27.4 years (range, 14-42 years). Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11; P < .001) after distalization TTO. The distance from the tibial plateau to the patellar tendon insertion significantly decreased from 20.1 mm preoperatively to 17.9 mm postoperatively (P < .020), and the patellar tendon length decreased from 53.4 mm preoperatively to 46.0 mm postoperatively (P < .001). The patellar tendon insertion was not distalized after distalization TTO, likely because of scarring of the patellar tendon proximal to the osteotomy site. Patients demonstrated significant pre- to postoperative improvements on all PROMs (P≤ .024 for all ). There were 4 (20%) complications-2 cases of arthrofibrosis, 1 postoperative infection, and 1 osteotomy delayed union. Conclusion Distalization TTO without patellar tendon tenodesis was associated with improved radiographic outcomes and PROMs. It provides an additional tool for surgical management of patellofemoral pathology with associated patella alta.
Collapse
Affiliation(s)
- Tyler J. Uppstrom
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Connor F. Fletcher
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W. Green
- Department of Pediatric Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Andreas H. Gomoll
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | | |
Collapse
|
4
|
Andronic O, Helmy N, Kellner C, Graf DA. A decreased tibial tuberosity-trochlear groove distance is associated with lateral patellofemoral joint degeneration after implantation of medial fixed-bearing unicompartmental knee arthroplasty - a minimum five year follow-up. INTERNATIONAL ORTHOPAEDICS 2023; 47:2225-2233. [PMID: 37100957 DOI: 10.1007/s00264-023-05812-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/11/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE The influence of lateral patellofemoral osteoarthritis (PFOA) in medial unicompartmental knee arthroplasty (UKA) is controversial. Our aim was to identify radiographic factors that may lead to progressive PFOA after implantation of a fixed-bearing medial UKA and their impact on patient-reported outcomes (PROMs). METHODS A retrospective consecutive cohort of patients undergoing medial UKA with a minimum follow-up of 60 months between September 2011 and January 2017 was identified. All UKAs had a fixed-bearing design with cemented femoral and tibial components. PROMs included documentation of the Oxford Knee Score (OKS). The following radiographic parameters were evaluated on conventional radiographs and computer tomography (CT) scans: patella tilt angle, patella congruence angle, Caton-Deschamps index, medial and lateral patellofemoral degeneration (Kellgren-Lawrence Classification (KL)), mechanical anteroposterior axis, femoral torsion, tibial tuberosity to trochlear groove distance (TTTG), anteroposterior translation of the femoral component. A hierarchical multiple regression analysis and partial Pearson correlation analysis (SPSS) were used to evaluate for predictors of progression of lateral PFOA. RESULTS Forty-nine knees allowed PFOA assessment and had an average follow-up of 62 months (range 60-108). Twenty-three patients did not exhibit any progression of lateral PFOA. Twenty-two progressed with 1 stage, whereas four had progressed 2 stages according to the KL classification. TTTG negatively correlated with progressive lateral PFOA (r = - 0.436, p = 0.01). Progression of lateral PFOA did not correlate with OKS at last follow-up (p = 0.613). CONCLUSION A decreased TTGT correlated with radiographic progression of lateral PFOA after medial fixed-bearing cemented UKA. PFOA however did not influence PROMs at a minimum of five years postoperatively.
Collapse
Affiliation(s)
- Octavian Andronic
- Department of Traumatology and Orthopaedics, Bürgerspital Solothurn, Schöngrünstrasse, 42, Solothurn, Switzerland.
| | - Näder Helmy
- Department of Traumatology and Orthopaedics, Bürgerspital Solothurn, Schöngrünstrasse, 42, Solothurn, Switzerland
| | - Christoph Kellner
- Department of Traumatology and Orthopaedics, Bürgerspital Solothurn, Schöngrünstrasse, 42, Solothurn, Switzerland
| | - David Alexander Graf
- Department of Traumatology and Orthopaedics, Bürgerspital Solothurn, Schöngrünstrasse, 42, Solothurn, Switzerland
| |
Collapse
|
5
|
Sidharthan S, Strickland SM. Editorial Commentary: A Posterior Tibial Tubercle Relative to the Trochlear Groove Is Associated With Increased Risk of Patellofemoral Arthritis: The Sagittal Tibial Tubercle-Trochlear Groove Distance. Arthroscopy 2023; 39:1502-1504. [PMID: 37147077 DOI: 10.1016/j.arthro.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 05/07/2023]
Abstract
Arthritis of the patellofemoral compartment affects up to 24% of women and 11% of men over the age of 55 years who have symptomatic osteoarthritis of the knee. Patellofemoral cartilage lesions have been associated with several different geometric measures of patellar alignment, including the tibial tubercle-trochlear groove (TTTG) distance, trochlear sulcus angle, trochlear depth, and patellar height. Recently, there has been interest in the sagittal TTTG distance, which measures the position of the tibial tubercle with respect to the trochlear groove. This measurement is now being used in patients presenting with patellofemoral pain and/or cartilage pathology and may help guide surgical decision making as we gain more data on how changing the tibial tubercle alignment relative to the patellofemoral joint can improve outcomes. For now, there are not enough data to support isolated anteriorization tibial tubercle osteotomy in patients with patellofemoral chondral wear based on the sagittal TTTG distance. However, as we better understand geometric measures as risk factors for patellofemoral arthritis, realignment at a young age might be recommended as a preventative measure against end-stage osteoarthritis.
Collapse
|
6
|
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
|
7
|
A More Posterior Tibial Tubercle (Decreased Sagittal Tibial Tubercle-Trochlear Groove Distance) Is Significantly Associated With Patellofemoral Joint Degenerative Cartilage Change: A Deep Learning Analysis. Arthroscopy 2022; 39:1493-1501.e2. [PMID: 36581003 DOI: 10.1016/j.arthro.2022.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/23/2022] [Accepted: 11/30/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE To perform patellofemoral joint (PFJ) geometric measurements on knee magnetic resonance imaging scans and determine their relations with chondral lesions in a multicenter cohort using deep learning. METHODS The sagittal tibial tubercle-trochlear groove (sTTTG) distance, tibial tubercle-trochlear groove distance, trochlear sulcus angle, trochlear depth, Caton-Deschamps Index (CDI), and flexion angle were measured by use of deep learning-generated segmentations on a subset of the Osteoarthritis Initiative study with radiologist-graded PFJ cartilage grades (n = 2,461). Kruskal-Wallis H tests were performed to compare differences in PFJ morphology between subjects without PFJ osteoarthritis (OA) and those with PFJ OA. PFJ morphology was correlated with secondary outcomes of mean patellar cartilage thickness and mean patellar cartilage T2 relaxation time using linear regression models controlling for age, sex, and body mass index. RESULTS A total of 1,626 knees did not have PFJ OA, whereas 835 knees had PFJ OA. Knees without PFJ OA had an increased (anterior) sTTTG distance (mean ± standard deviation, 11.1 ± 12.8 mm) compared with knees with PFJ OA (8.4 ± 12.7 mm) (P < .001), indicating a more posterior tibial tubercle in subjects with PFJ OA. Knees without PFJ OA had a decreased sulcus angle (127.4° ± 7.1° vs 128.0° ± 8.4°, P = .01) and increased trochlear depth (9.1 ± 1.7 mm vs 9.0 ± 2.0 mm, P = .03) compared with knees with PFJ OA. Decreased patellar cartilage thickness was associated with decreased trochlear depth (β = 0.12, P = .002) and increased CDI (β = -0.07, P < .001). Increased patellar cartilage T2 relaxation time was correlated with decreased sTTTG distance (β = -0.08, P = .01), decreased sulcus angle (β = -0.12, P = .04), and decreased CDI (β = -0.12, P < .001). CONCLUSIONS PFJ OA, patellar cartilage thickness, and patellar cartilage T2 relaxation time were shown to be associated with the underlying geometries within the PFJ. This large longitudinal study highlights that a decreased sTTTG distance (i.e., a more posterior tibial tubercle) is significantly associated with PFJ degenerative cartilage change. LEVEL OF EVIDENCE Level III, retrospective comparative prognostic trial.
Collapse
|
8
|
Assessment of the reliability and validity of imaging measurements for patellofemoral instability: an updated systematic review. Skeletal Radiol 2022; 51:2245-2256. [PMID: 35794393 DOI: 10.1007/s00256-022-04110-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To provide an update on the reliability and validity of all radiological measures used to assess patients presenting with patellofemoral instability. METHODS A search of the CINHAL, EMBASE, MEDLINE, and SCOPUS databases and the Cochrane library was conducted. All studies assessing the validity, reliability, sensitivity, and specificity of radiological measures of the patellofemoral joints of patients with patellofemoral instability from 2010 onwards were considered for inclusion. Discrimination validity, inter- and intra-observer reliability, and the sensitivity and specificity of specific imaging measures were evaluated. RESULTS Seventy-three studies met the selection criteria and were included for analysis. We identified eight radiological measures in four categories with good reliability and validity: the tibial tubercle to trochlear groove distance, specific measures of patellar height (Blackburne-Peel index, Caton-Deschamps index and Insall-Salvati ratios), three measures of trochlear dysplasia (sulcus angle, trochlear depth, and lateral trochlear inclination), and the tibial tubercle to posterior cruciate ligament distance. No included studies examined the reliability and validity of patellofemoral instability ultrasound measures. CONCLUSION Our updated review demonstrated good inter- and intra-observer reliability and discrimination validity for the tibial tubercle-trochlear groove distance, specific patellar height, and trochlear dysplasia measures on MRI. The tibial tubercle to posterior cruciate ligament distance, an indirect measure of rotational asymmetry, was a valid and reliable measure on MRI. Due to a lack of assessments across more than one study, there are a variety of proposed measures with insufficient evidence to determine their validity, reliability, sensitivity, and specificity.
Collapse
|
9
|
MacLean IS, Southworth TM, Dempsey IJ, Naveen NB, Huddleston HP, Lansdown DA, Yanke AB. Interobserver Reliability and Change in the Sagittal Tibial Tubercle-Trochlear Groove Distance with Increasing Knee Flexion Angles. J Knee Surg 2022; 35:1571-1576. [PMID: 33932946 DOI: 10.1055/s-0041-1729547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The tibial tubercle-trochlear groove (TT-TG) distance is currently utilized to evaluate knee alignment in patients with patellar instability. Sagittal plane pathology measured by the sagittal tibial tubercle-trochlear groove (sTT-TG) distance has been described in instability but may also be important to consider in patients with cartilage injury. This study aims to (1) describe interobserver reliability of the sTT-TG distance and (2) characterize the change in the sTT-TG distance with respect to changing knee flexion angles. In this cadaveric study, six nonpaired cadaveric knees underwent magnetic resonance imaging (MRI) studies at each of the following degrees of knee flexion: -5, 0, 5, 10, 15, and 20. The sTT-TG distance was measured on the axial T2 sequence. Four reviewers measured this distance for each cadaver at each flexion angle. Intraclass correlation coefficients were calculated to determine interobserver reliability and reproducibility of the sTT-TG measurement. Analysis of variance (ANOVA) tests and Friedman's tests with a Bonferroni's correction were performed for each cadaver to compare sTT-TG distances at each flexion angle. Significance was defined as p < 0.05. There was excellent interobserver reliability of the sTT-TG distance with all intraclass correlation coefficients >0.9. The tibial tubercle progressively becomes more posterior in relation to the trochlear groove (more negative sTT-TG distance) with increasing knee flexion. The sTT-TG distance is a measurement that is reliable between attending surgeons and across training levels. The sTT-TG distance is affected by small changes in knee flexion angle. Awareness of knee flexion angle on MRI is important when this measurement is utilized by surgeons.
Collapse
Affiliation(s)
- Ian S MacLean
- Midwest Orthopaedics, Rush Orthopedic Surgery, Chicago, Illinois
| | | | - Ian J Dempsey
- Midwest Orthopaedics, Rush Orthopedic Surgery, Chicago, Illinois
| | - Neal B Naveen
- Midwest Orthopaedics, Rush Orthopedic Surgery, Chicago, Illinois
| | | | - Drew A Lansdown
- Midwest Orthopaedics, Rush Orthopedic Surgery, Chicago, Illinois
| | - Adam B Yanke
- Midwest Orthopaedics, Rush Orthopedic Surgery, Chicago, Illinois
| |
Collapse
|
10
|
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
|
11
|
Kaplan DJ, Mojica ES, Ortega PF, Triana J, Strauss EJ, Jazrawi LM, Gonzalez-Lomas G. Posterior tibial tubercle measured by the sagittal TT-TG distance correlates with increased risk for patellofemoral chondral lesions. Knee Surg Sports Traumatol Arthrosc 2022; 30:3733-3741. [PMID: 35513456 DOI: 10.1007/s00167-022-06988-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the variation in tibial tubercle sagittal alignment in patients with and without patellofemoral (PF) cartilage wear. METHODS This was a single-centre, retrospective review of patients that underwent a cartilage restoration procedure for isolated PF cartilage wear from 2014 to 2020. Patients were matched in a 1:2 ratio for age, sex and BMI to partial meniscectomy patients as controls. The sagittal TT-TG (sTT-TG) distance was measured on preoperative axial T2 magnetic resonance imaging (MRI) and was defined as the distance between a point at the nadir of the trochlear cartilage and the most anterior point of the tibial tubercle. RESULTS One hundred and forty patients (47 cartilage restoration, 94 meniscectomy) were included. Mean age, BMI, and height for the total cohort were 34.01 ± 8.7, 26.6 ± 6.4, and 173.0 ± 17.7 respectively, with 78 males (55%) and 63 females (45%). There were no significant differences between groups for age, BMI or sex (n.s). The cartilage restoration group (- 2.5 mm ± 5.9) was found to have a significantly more posterior (negative) sTT-TG compared to the meniscectomy group (1.72 mm ± 6.7) (p < 0.001). Interrater reliability was excellent (ICC = 0.931, p < 0.001). Patients with less than - 3.4 mm sTT-TG were 2.74 times more likely to have a cartilage restoration procedure compared to those with greater than - 3.4 mm (OR 2.7, 95% CI 1.3-5.85). Patients with < - 10 mm posterior translation were 13.7× (CI 1.6-111.1) more likely to have a cartilage restoration procedure. CONCLUSION Patients that underwent isolated cartilage restoration procedures had a significantly more posterior tibial tubercle than partial meniscectomy controls based on the sagittal TT-TG. The more posterior the tubercle, the more likely the patient had a cartilage restoration procedure. Surgeons should consider the sTT-TG measurement in patients presenting with anterior knee pain, particularly patellofemoral lesions. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Daniel J Kaplan
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA.
| | - Edward S Mojica
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Paola F Ortega
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Jairo Triana
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Eric J Strauss
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Laith M Jazrawi
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Guillem Gonzalez-Lomas
- Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Orthopaedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| |
Collapse
|
12
|
Geraghty L, Zordan R, Walker P, Chao TW, Talbot S. Patellar dislocation is associated with increased tibial but not femoral rotational asymmetry. Knee Surg Sports Traumatol Arthrosc 2022; 30:2342-2351. [PMID: 34850247 DOI: 10.1007/s00167-021-06813-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/17/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Patellar dislocation is associated with a range of anatomical abnormalities affecting the trochlea, extensor mechanism and the tibia. The relationship between patellofemoral instability and rotational abnormalities of the posterior condyles, trochlear groove and proximal tibia has not been adequately determined. This study aimed to identify the frequency and severity of anatomical risk factors to determine their relative contribution to patellofemoral instability. METHODS A retrospective morphological study was undertaken comparing multiple anatomical measurements with magnetic resonance imaging of 50 patients with patellofemoral instability to an age- and gender-matched Control group (n = 50). Several techniques were assessed measuring both femoral and tibial axial asymmetry. A new measurement, tibial rotational asymmetry, comparing a line between the midpoints of the collateral ligaments to the axis between the patellar tendon and posterior cruciate ligament, was assessed for its association with patellofemoral instability. RESULTS Compared to the controls, the patellofemoral instability group demonstrated a significant difference in tibial rotational asymmetry, with a mean of 2.9° (SD 3.2°) externally rotated vs - 1.6° (SD 2.2°) in the control group. Significant differences were also demonstrated regarding the sulcus angle, tibial tubercle-trochlear groove distance, tibial tubercle-posterior cruciate ligament distance, patellar size and the Insall-Salvati ratio. There were no differences between groups regarding the lengths of the posterior condyles, the heights of the trochlear ridges or lateralisation of the trochlear groove. Further analysis of the patellofemoral instability group revealed a subgroup of males with normal anatomy (7/50) and a subgroup of females with isolated patella alta (7/50). CONCLUSION Patellofemoral instability is associated with tibial rotational asymmetry due to lateralisation of the tibial tubercle. It is also associated with patella alta and reduced trochlear groove depth. The femoral axial shape is otherwise unchanged. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Liam Geraghty
- The Sports Medicine Practice Hobart, 36 Collins Street, Hobart, TAS, 7000, Australia.
- Department of Orthopaedic Surgery, Western Health, 160 Gordon Street, Footscray, VIC, 3011, Australia.
| | - Rachel Zordan
- Simon Talbot, 1/210 Burgundy Street, Heidelberg, VIC, 3084, Australia
- Honorary Senior Fellow, Melbourne Medical School, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Phoebe Walker
- Department of Orthopaedic Surgery, Western Health, 160 Gordon Street, Footscray, VIC, 3011, Australia
| | - Tat Woon Chao
- Department of Orthopaedic Surgery, Western Health, 160 Gordon Street, Footscray, VIC, 3011, Australia
| | - Simon Talbot
- Department of Orthopaedic Surgery, Western Health, 160 Gordon Street, Footscray, VIC, 3011, Australia
- Simon Talbot, 1/210 Burgundy Street, Heidelberg, VIC, 3084, Australia
| |
Collapse
|
13
|
Lansdown DA, Christian D, Madden B, Redondo M, Farr J, Cole BJ, Yanke AB. The Sagittal Tibial Tubercle-Trochlear Groove Distance as a Measurement of Sagittal Imbalance in Patients with Symptomatic Patellofemoral Chondral Lesions. Cartilage 2021; 13:449S-455S. [PMID: 31965819 PMCID: PMC8808873 DOI: 10.1177/1947603519900802] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective. To measure the sagittal alignment of the tibial tubercle through the sagittal tibial tubercle-trochlear groove (sTTTG) distance in patients with and without patellar chondral lesions. Design. Patients treated with patellofemoral cartilage restoration or repair procedures were retrospectively reviewed (group 1; N = 17). A control group of patients (group 2; N = 20) undergoing partial meniscectomy with normal patellar cartilage was included. An asymptomatic patellar chondrosis group (group 3; N = 15) was identified as patients undergoing partial meniscectomy with patellar cartilage wear. The sTTTG was measured on the preoperative axial T2 magnetic resonance imaging (MRI) sequence. The first point was the nadir of the anterior trochlear cartilage, and the second point was the anterior tibial tubercle. A line was drawn between these points, perpendicular to the posterior condylar axis. Comparisons were made between the 3 groups using analysis of variance testing with Bonferroni corrections. Significance was defined as P < 0.05. Results. The mean sTTTG was significantly more posterior in group 1 (5.9 ± 5.5 mm posterior to the trochlear groove) relative to group 2 (0.8 ± 5.3 mm posterior; P = 0.018). The mean value for group 3 (2.7 ± 5.3 mm posterior) fell between group 1 and 3 but was not significantly different from group 1 (P = 0.31) or group 2 (P = 0.89). There were no significant differences with regards to sulcus angle, Caton-Deschamps Index, TTTG, or knee flexion angle on the MRI scan. Conclusions. A more posteriorly positioned tibial tubercle was observed in patients with patellar cartilage lesions relative to those with intact patellar cartilage. Intermediate positioning was observed in patients with asymptomatic patellar chondral wear. Level of Evidence. Level 3 diagnostic study.
Collapse
Affiliation(s)
- Drew A. Lansdown
- Department of Orthopedic Surgery,
University of California, San Francisco, San Francisco, CA, USA,Drew A. Lansdown, Department of Orthopedic
Surgery, University of California, San Francisco, 1500 Owens Street, Suite 170,
San Francisco, CA 94158, USA.
| | - David Christian
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | - Brett Madden
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | - Michael Redondo
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | | | - Brian J. Cole
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| | - Adam B. Yanke
- Department of Orthopedic Surgery, Rush
University Medical Center, Chicago, IL, USA
| |
Collapse
|
14
|
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
|
15
|
Clark D, Metcalfe A, Eldridge J. Editorial. Knee 2019; 26:1159-1160. [PMID: 31864559 DOI: 10.1016/j.knee.2019.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/15/2019] [Accepted: 09/04/2019] [Indexed: 02/02/2023]
|