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There are numerous techniques reported in literature and commonly used to reconstruct the medial sided soft tissue constraints. Flattening or developmental dysplasia of the trochlea leads to loss of normal patellar tracking and can predispose to lateral patellar dislocation with flexion. Because the knee is flexed in dislocation, the patella impacts upon the weightbearing surface of the lateral femoral condyle. Techniques for quantifying trochlear dysplasia with MRI have been standardized and shown to be accurate and reproducible in assessing lateral trochlear inclination, facet asymmetry, and trochlear depth8,9. Lateral patellar dislocation. 2000; 216:858-864. In addition, symptomatic knees may demonstrate normal engagement between the patella and trochlea beyond 30 of flexion. Kamel S, Kanesa-Thasan R, Dave J et al. is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. These two structures blend with each other and are difficult to separate on imaging. Sports Med Arthrosc 15:5760, Nam EK, Karzel RP (2005) Mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation: a medium-term follow-up. official website and that any information you provide is encrypted Knee Surg Sports Traumatol Arthrosc 14:235240, Article Radiology 263:469474, Subhawong TK, Eng J, Carrino JA, Chhabra A (2010) Superolateral Hoffas fat pad edema: association with patellofemoral maltracking and impingement. Early diagnosis is essential, as chronic maltracking will lead to patellofemoral cartilage damage and osteoarthritis [3]. The patella remains laterally shifted (blue arrow) and an osteochondral injury of the medial patella (arrowheads) is apparent. Insights Imaging 10, 65 (2019). Both MRI and ultrasound are accurate imaging modalities in the detection of MPFL injuries [5, 50, 51]. Bookshelf Distal neurovascular examination also needs to be performed [16]. The AIUM Practice Parameter for the Performance of the Musculoskeletal Both knees are scanned simultaneously. (PDF) Magnetic Resonance Imaging Characteristics of the Medial 2020;49(6):1642-50. Please enable it to take advantage of the complete set of features! It is not until beyond 90 of flexion that the odd facet engages the medial femoral condyle and plays a role in load sharing along with lateral facet [6, 7]. A bone bruise occurs anterior to this site of impaction as the patella reduces with knee extension. Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. 2010. 1Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 149 Sangil-dong, Gangdong-gu, Seoul 134-727, Korea. There is edema of the medial patella and of the lateral femoral condyle (arrow), consistent with bone contusion due to recent lateral patellar dislocation. 5. Post WR, Teitge R, Amis A (2002) Patellofemoral malalignment: looking beyond the viewbox. 2). Correspondence to The anatomic relationship between the resultant force from the quadriceps and the line of pull of the patellar tendon is termed the Q angle and is normally 1015 of valgus [11]. Various parameters can be used in assessing and predicting the presence of patellar maltracking. The knee then was flexed 30, 60, 90, and 120, and the transducer recorded changes in tension within the lateral patellofemoral . During this dislocation phase of injury, shearing forces can damage the articular surfaces of either the patella or the lateral femoral condyle. The deep layer is comprised of the lateral patellofemoral ligament, patellotibial band and transverse ligament. The technique has been refined, and a better understanding of the anatomical features of both the origin and insertion of the ligament onto the patella has made the operation more reproducible (Fig. Discussion. PubMed Central (9a) The Insall-Salvati Index is determined by dividing the length of the patellar tendon (PT) by the length of the patella (PL). At less than 30 of flexion, asymptomatic knees may demonstrate physiologic patellar tilt or subluxation. The patellar tendon may tear when the knee is bent and the foot planted, like when landing from a jump or . All authors (ZJ, PJ, KSR, MLS, GD) contributed to the study design, drafted the work, and revised it critically for final submission. Skeletal Radiol 38:785790, Campagna R, Pessis E, Biau DJ et al (2012) Is superolateral Hoffa fat pad edema a consequence of impingement between lateral femoral condyle and patellar ligament? Femoral avulsion of the MPFL is a predictor of chronic instability and may be a surgical indication in some patients with acute injury. Crossref, Medline, Google Scholar; 32 Starok M, Lenchikl L, Trudell D, Resnick D. Normal patellar retinaculum: MR and sonographic imaging with cadaveric correlation. Trochlear depth=[(a+b)/2]c, Lateral trochlear inclination measurement on axial MRI. In one MRI study, 76% of cases of prior lateral patellar dislocation showed medial retinacular injury at its patellar insertion and 30% at its midsubstance, and injury of the femoral origin of the MPFL was identified in 49% of the cases [49]. Pedersen ME, DaCambra MP, Jibri Z, Dhillon S, Jen H, Jomha NM. Patellar tilt assessment. Medial patellofemoral ligament injury patterns and associated pathology On the other hand, frank patellar dislocation is a significant risk factor in the development of patellofemoral osteoarthritis with an incidence of 49% at 25years after the patellar dislocation incident in comparison with 8% in a control group without a dislocation history [60]. Additionally, return to sport can be as low as 45%, leaving many patients searching for further management options [12]. In acute patellar dislocation, CT may demonstrate osseous impaction or fractures of the medial margin of the patella (with or without involvement of the articular surface) and/or the lateral surface of the lateral femoral condyle and intraarticular fragments. Knee Surg Sports Traumatol Arthrosc 15:13011314, Tom A, Fulkerson JP (2007) Restoration of native medial patellofemoral ligament support after patella dislocation. Int J Sports Med 29:359365, Smith TO, Walker J, Russell N (2007) Outcomes of medial patellofemoral ligament reconstruction for patellar instability: a systematic review. Springer Nature. Management of Patellofemoral Pain Syndrome | AAFP Significantly greater lateral patellar displacement and tilt was found in osteoarthritis patients compared to a control group [3]. The common peroneal nerve can be localized in the popliteal fossa or identified posterior to the biceps femoris tendon and followed as it courses around the fibular neck. The typical injury pattern is a tear of the medial patellofemoral ligament (MPFL) and bone bruises of the patella and the lateral femoral condyle. Direct impact to the front of the knee from a fall or other blow is a common cause of tears. The mechanism is commonly a non-contact twisting injury of the lower extremity with the knee extended and external rotation of the foot and is perceived as the knee giving way. The patella will often self-reduce by reflexic contraction of the quadriceps muscles. Distally, it attaches to the tibial tubercle via the patellar tendon. AIM: To describe the sonographic appearances of the medial retinacular (MPFR) complex of the knee in patients with acute and recurrent patellar dislocation.MATERIALS AND METHODS: Thirty patients were scanned within 2-4 weeks of an acute episode of lateral patellar dislocation. Courtesy of Daniel Bodor, MD, Radsource. Additionally, complex injuries to bone, cartilage, and ligaments may occur. The lateral retinaculum or lateral canthus is a complex integration of a number of structures. The medial patellofemoral ligament is composed of a transverse (T) component arising between the adductor tubercle and medial epicondyle and an oblique decussation that originates from the medial collateral ligament (MCL). 7,14 While plain radiography is an important tool to diagnose APD, magnetic resonance imaging (MRI . The patella becomes unstable and undergoes a transient, violent lateral displacement. It can not only detect any underlying morphological risk factors but also look for structural damage associated with maltracking including patellofemoral articular cartilage loss, osteochondral defects, or damage to the medial patellar stabilizers [4, 5]. A Focal Defect at the Lateral Patellar Retinaculum on Clinical Knee MRI Am J Sports Med 33:220230, Nikku R, Nietosvaara Y, Aalto K, Kallio PE (2005) Operative treatment of primary patellar dislocation does not improve medium-term outcome: a 7-year follow-up report and risk analysis of 127 randomized patients. Immobilization Regime Following Lateral Patellar Dislocation: A Systematic Review and Meta-Analysis of the Current Evidence Base. A focused history of the mechanism, number, and circumstances of instability to date is essential. The trochlear depth is calculated by measuring the mean of the maximum anteroposterior (AP) distance of the medial and lateral femoral condyles minus the distance between the deepest point of the trochlear groove and the line paralleling the posterior femoral condyles surfaces (Fig. (20a) A fat-suppressed proton density-weighted sagittal image in a patient following patellar dislocation reveals an osteochondral injury with a chondral defect (arrows) at the lateral weightbearing surface of the lateral femoral condyle, a finding seen in only 5% of patients. The patellar apprehension test is used to assess for lateral instability and is positive when pain or discomfort occurs with lateral translation of the patella. Am J Sports Med 14:117120, Smith TO, Donell S, Song F, Hing CB (2015) Surgical versus non-surgical interventions for treating patellar dislocation. 21 Patellar dislocation not only has a high recurrence rate 51 but also readily causes articular cartilage damage, osteochondral fractures, and patellofemoral arthritis, which can ultimately lead to motor dysfunction and pain. (21a) A corresponding anterior coronal slice reveals the large displaced osteochondral fragment (arrow) that occurred as a result of this injury. Knee 13:2631, McNally EG (2001) Imaging assessment of anterior knee pain and patellar maltracking. AJR Am J Roentgenol 167:339341, Caton JH, Dejour D (2010) Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. and transmitted securely. The conditions are presented anatomicallyanterior, lateral, medial, or posteriorwith common etiologies, history and physical exam findings, and diagnosis and treatment options for each (see Table, page 28). Bethesda, MD 20894, Web Policies Yu JS, Goodwin D, Salonen D, Pathria MN, Resnick D, Dardani M, Schweitzer M. AJR Am J Roentgenol. A commonly used one is the InsallSalvati ratio of patellar tendon length: patellar length. It can be difficult to determine the deepest part of the trochlear groove when assessing the TT-TTG in the presence of trochlear dysplasia; therefore, an alternative method for assessing tibial tubercle position was proposed measuring the distance in reference to the posterior cruciate ligament and not to the trochlea (tibial tubercle-posterior cruciate ligament distance [TT-PCL]), with proposed pathologic threshold of 21mm [42, 43]. Epub 2011 Nov 9. At the time the article was last revised Mohamed Saber had Thawait SK, Soldatos T, Thawait GK, Cosgarea AJ, Carrino JA, Chhabra A. Skeletal Radiol. J Knee Surg 19:307316, Gonaives MB, Jnior LH, Soares LF, Gonaives TJ, Dos Santos RL, Pereira ML (2011) Medial patellofemoral ligament reconstruction to treat recurrent patellar dislocation. Open Orthop J. Duke Radiology Case Review. eCollection 2015. These parameters can be evaluated using dynamic MRI [29]. A typical bone bruise is seen within the anterolateral aspect of the lateral femoral condyle (asterisk). Some controversy exists regarding whether female gender is a definite risk factor for patellar instability with certain studies identifying a 33% increased likelihood of first-time dislocation as well as three times high re-dislocation rates than males, whereas others have found roughly equal rates [2, 12,13,14]. Do a thorough work-up of the patient at the clinic to determine the need for a redesign total knees arthroplasty (Figs. The objective of this paper was to describe the anatomy of the stifle joint (Articulatio genus) of the pampas deer (Ozotoceros bezoarticus, Linnaeus, 1758) by dissection and imaging studies. Acta Orthop Belg 72:6571, Panagopoulos A, van Niekerk L, Triantafillopoulos IK (2008) MPFL reconstruction for recurrent patella dislocation: a new surgical technique and review of the literature. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. We confirm that this article is not under consideration for publication elsewhere and that the authors did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. MR findings were correlated with clinical, surgical, and arthroscopic findings. 7). The TT-TG distance can be influenced by the degree of knee flexion (reduces with flexion), and it is also smaller upon weight bearing [41]. Burks RT, Desio SM, Bachus KN, Tyson L, Springer K. Spritzer CE, Courneya DL, Burk DL Jr, Garrett WE, Strong JA. Radiology 189:905907, Warren LF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee: an anatomical analysis. A Focal Defect at the Lateral Patellar Retinaculum on Clinical Knee MRI Hemarthrosis is rare in lateral patellar sleeve fractures, as the lateral pole is not as vascularized as the inferior pole of the patella that has the most important blood supply of patella [5 ]. A ratio equal or more than 1.2 indicates patella alta [35] (Fig. The VMO is active, not only in full extension but also at 30 degrees and up to 100 degrees of flexion. The injuries involved the medial retinacular ligament in 16 of 17 patients and the medial and lateral retinacular ligament in one patient. PTI of less than 12.5% suggests the presence of patella alta. Eur J Trauma Emerg Surg. 4. Google Scholar, Nakagawa S, Kadoya Y, Kobayashi A, Tatsumi I, Nishida N, Yamano Y (2003) Kinematics of the patella in deep flexion. Before Unauthorized use of these marks is strictly prohibited. MRI and operative studies have revealed that it is almost . PubMed The .gov means its official. statement and Methods: We compared 361 treated cases of aneurysm occlusion after subarachnoid hemorrhage from 1997 to 2003 with 281 cases from 2006 to 2014. Tibial tubercletrochlear groove distance (TT-TG) assessment. In the setting of osseous patellar malalignment, an osseous procedure such as tibial tubercle transfer osteotomy can be performed (Fig. Twenty-six pelvic limbs were used for gross dissection, and four stifle regions from two animals were used for radiography and magnetic resonance imaging (MRI). The transverse stabilizers include the medial and lateral retinaculum, the vastus medialis and lateralis muscles, the ilio-tibial band, and the medial patellofemoral ligament (MPFL). As is typical, a bone bruise extends anteriorly (arrowheads) from the site of the chondral defect. The vastus medialis oblique (VMO) provides active stability of the patella. Cochrane Database Syst Rev 2:CD008106, Woo R, Busch MT (1998) Management of patellar instability in children. Google Scholar, Sanders TG, Paruchuri NB, Zlatkin MB (2006) MRI of osteochondral defects of the lateral femoral condyle: incidence and pattern of injury after transient lateral dislocation of the patella. The superficial layer originates from the lowest fibers of the iliotibial band and from an extension of vastus lateralis fascia. Operative lateral retinaculum release is indicated in refractory cases. Subjective: Pain and tenderness on structure (lateral side of patella) (Juhn). Imaging plays a vital role in detecting not only the secondary damage but also subtle early features that can raise the suspicion for the presence of this entity. Am J Sports Med 38:181188, Ali S, Bhatti A (2007) Arthroscopic proximal realignment of the patella for recurrent instability: report of a new surgical technique with 1 to 7 years of follow-up. Skeletal Radiol 30:484495, Tsujimoto K, Kurosaka M, Yoshiya S, Mizuno K (2000) Radiographic and computed tomographic analysis of the position of the tibial tubercle in recurrent dislocation and subluxation of the patella. Am J Sports Med. In acute traumatic lateral patellar dislocation, it is not only the patella that dislocates. The lateral patellar retinaculum is a fibrous expansion comprising of superficial and deep layers. However, the use of this method is not widespread. Patellofemoral friction syndrome: MRI findings of an - Eurorad 8600 Rockville Pike (12a) At an axial image 3 cm proximal to the femoral-tibial joint space, the lengths of the medial and lateral trochlear facets are obtained. AJR Am J Roentgenol 1997; 168:1493-1499. b The patella tilt angle is measured between the posterior condylar line (dashed line) and the maximal patella width (solid line). Clin Orthop Relat Res 144:1626, Elias DA, White LM, Fithian DC (2002) Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. It is therefore helpful in surgical planning. Lateral patellar dislocation | Radiology Reference Article The most obvious presentation of patellar maltracking is that of the first time lateral patellar instability or recurrent instability thereafter. PubMedGoogle Scholar. Unable to process the form. The lateral trochlear articular surface is usually more prominent than its medial portion. The oblique decussation of the MPFL blends with fibers of the superficial MCL. government site. A Focal Defect at the Lateral Patellar Retinaculum on Clinical Knee MRI Am J Sports Med 2009 37: 2355-2362. PubMed Central Because as noted above, the femoral bone bruise occurs as the patella moves forward during reduction, bone bruises at the lateral femoral condyle always course anteriorly from the site of any femoral chondral injury that may be present. [Nov;2019 . J Bone Joint Surg Br 87:3640, Wechter J, Macalena J, Arendt EA (1994) Lateral patella dislocations: history, physical exam, and imaging. Am J Sports Med 32:11141121, Tsavalas N, Katonis P, Karantanas AH (2012) Knee joint anterior malalignment and patellofemoral osteoarthritis: an MRI study. Elsevier, Philadelphia, Buckens CF, Saris DB (2010) Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. The above video demonstrates the mechanism of injury in patellar dislocation. Sonographic Appearances of Medial Retinacular Complex Injury in (19a) The corresponding STIR coronal image reveals the large displaced osteochondral fragment (arrow) at the lateral aspect of the lateral femoral condyle. Other structures combine to form the region referred to as the medial retinaculum (MR) more anteriorly. Lateral patellar dislocation results in bone contusion at the medial patella and along the lateral aspect of the lateral femoral condyle. FOIA Knee Surg Sports Traumatol Arthrosc 26:27332742, Hingelbaum S, Best R, Huth J, Wagner D, Bauer G, Mauch F (2014) The TT-TG Index: a new knee size adjusted measure method to determine the TT-TG distance. The MCL is beneath the deep crural fascia (layer 1), from which it is separated by a variable amount of fat (Fig. The MPFL is also stripped from the femoral attachment (long arrow). 1-B).Determine the possibility of a difficult knee revelation (following the medial parapatellar arthrotomy) owed to limited knee flexion, a lack of patellar mass, and patella baja when view on a lateral knee radiograph. PubMed As an example, although the InsallSalvati ratio is one of the most commonly used methods and does not depend on the degree of knee flexion, it is affected by the patellar shape particularly its inferior point and measurement does not change after tibial tubercle distalization procedure [25]. 30 Correctly diagnosing APD can be difficult as the displaced patella usually relocates spontaneously, with fewer than 10% of patients presenting with fixed lateral dislocation. Although you may feel that being asked to make the specific diagnosis of lateral patellar dislocation from a single image is unrealistic, the coronal view in fact reveals a classic and highly characteristic appearance, allowing the diagnosis to be made with confidence. Trochleoplasty is rarely performed in this country and is reserved for significant dysplasias or when other surgical options have been insufficient in restoring patellofemoral stability. Epidemiology Patellar dislocation accounts for ~3% of all knee injuries and is commonly seen in those individuals who participate in sports activities. also supported our data in a magnetic resonance imaging (MRI) study of 82 patients with the diagnosis of lateral patella dislocation and found that 76% of medial retinacular/MPFL disruption occurred at its patellar insertion site, 49% occurred at the femoral attachment site, 30% showed injury of the MPFL at mid-substance, and 48% . By using this website, you agree to our Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Most commonly the patella tracks outwards (laterally) so the muscles on the inside of the thigh need strengthening. Dr. Frederick Buechel, Jr. MD answered. The Insall-Salvati index is the most widely accepted measurement and is easily performed on radiographs and MRI examinations. PubMed It has been shown that damage to the medial patellar stabilizers including medial patellar retinaculum and the medial patellofemoral ligament (MPFL) injuries are prevalent in 70100% of cases of lateral patellar dislocation [5, 27, 49,50,51]. A sliver of fluid undermines a moderately thickened and scarred MPFL at the medial femoral condyle attachment consistent with a chronic partial stripping tear (arrowheads). As the knee progresses through greater flexion, the contact surface becomes more proximal on the patella. et al. Knee Surg Sports Traumatol Arthrosc 22:26552661, Seitlinger G, Scheurecker G, Hgler R, Labey L, Innocenti B, Hofmann S (2012) Tibial tubercle-posterior cruciate ligament distance: a new measurement to define the position of the tibial tubercle in patients with patellar dislocation. 4 Sanders TG, Morrison WB, Singleton BA, Miller MD, Cornum KG. It is a geometric abnormality of the trochlear groove that affects its shape and depth mainly at its superior part, which can result in abnormal tracking of the patella along the trochlea. An increased tibial tubercletrochlear groove (TT-TG) indicates a lateralized tibial tuberosity, or a medialized trochlear groove [38]. Trochlear geometry, including slope of the lateral wall and depth, is an important factor. MRI has been found to be 85%-92% sensitive for diagnosing MPFL injury (Seeley, 2013). The injury typically occurs from a twisting event with the knee in mild flexion (less than 30). Because of the transient and brief nature of lateral patellar dislocations, the diagnosis is frequently unrecognized by both patients and clinicians.1 Pain is often described as medial because of soft tissue injuries that occur to the medial retinaculum and/or MPFL.