2. Isolated Avulsion Fracture of Patellar Attachment of Medial CAS Skeletal Radiol 41:925931, Wittstein JR, Bartlett EC, Easterbrook J, Byrd JC (2006) Magnetic resonance imaging evaluation of patellofemoral malalignment. (7a) A coronal T1-weighted image at the level of the patella demonstrates blending of fibers of the VMO with the MPFL superiorly. Despite the presence of numerous detailed anatomical dissection and MRI based studies of the anatomy2,3, there is much variability in the description of these structures within the literature. Evaluation of both of these soft tissue structures is critical when one examines a MRI following lateral patellar dislocation, as the extent of soft-tissue injury influences the use of operative repair. At the time the article was created Pereshin Moodaley had no recorded disclosures. The contralateral side may serve as an internal control or may also have anatomic factors predisposing to maltracking. Identifying edema at the superolateral aspect of Hoffas fat pad on MRI should prompt the reporting radiologist to look for features of patellar maltracking. Distal neurovascular examination also needs to be performed [16]. 4). Int Orthop. As is typical, a bone bruise extends anteriorly (arrowheads) from the site of the chondral defect. 2000; 216:858-864. Between 15 and 45% of patients will develop recurrent patellar instability after acute dislocation, which is both functionally limiting and painful [17,18,19,20]. This can provide a road map of developing a treatment strategy that would be primarily aimed at stabilizing the patellofemoral joint and halt the progression of cartilage loss. Injury. HHS Vulnerability Disclosure, Help MeSH Knee Surg Sports Traumatol Arthrosc 14:264272, McNally EG, Ostlere SJ, Pal C, Phillips A, Reid H, Dodd C (2000) Assessment of patellar maltracking using combined static and dynamic MRI. Depends on how bad: Small tears are observed and heal. Trochlear depth of less than 3 mm on MRI has a sensitivity of 100% and a specificity of 96% for trochlear dysplasia.10. Zaid Jibri. An association has been demonstrated between patellofemoral cartilage damage and patellar maltracking. [Nov;2019 . Check for errors and try again. These parameters can be evaluated using dynamic MRI [29]. 8 Lippacher S, Dejour S, Elsharkawi M, et al. Axial PDFS left knee MR image, demonstrating the method used for the measurement of trochlear depth. Radiology 216:582585, Ward SR, Terk MR, Powers CM (2007) Patella alta: association with patellofemoral alignment and changes in contact area during weight-bearing. They include: pain with compression of patella and moderate lateral facet tenderness, inability to evert the lateral edge of the patella, mainstay of treatment and should be done for extensive period of time, closed chain short arc quadriceps exercises, pain refractory to extensive rehabilitation, ideal candidate has no symptoms of instability, medial patellar glide of less than one quadrant, lateral patellar glide of less than three quadrants, only elevate 1 cm or else risk of skin necrosis, indicated only for instability with lateral translation (not isolated lateral tilt), viewing through superior portal will show medial facet does not articulate with trochlea at 40 degrees of knee flexion, postoperatively the patella should be able to be, patellar instability with medial translation, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Proximal Tibiofibular Joint Ganglion Cysts, Pre-Participation Physical Exam in Athlete, Concussions (Mild Traumatic Brain Injury). Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete. A lateral patellar sleeve fracture can be misdiagnosed (6a) A more distal T1-weighted image reveals fibers of the oblique decussation of the MPFL which blend with the medial collateral ligament (MCL). In eight of 17 patients, the mechanism of injury was a patellar tendon tear (n = 1) or valgus hyperextension (n = 7). 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]. What is the treatment for a patellar retinaculum tear? The degree of patellar tilt can be evaluated by measuring the patella tilt angle, which is the angle between the posterior condylar line and the maximal patella width line [47] (Fig. This procedure involves removal of cancellous bone beneath the trochlea followed by fixation of the articular surface [88, 89]. PMID: 9168713. Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. PubMed Radiology 225:736743, Kirsch MD, Fitzgerald SW, Friedman H, Rogers LF (1993) Transient lateral patellar dislocation: diagnosis with MR imaging. 1993;161(1):109-13. Epub 2010 Mar 8. Various parameters can be used in assessing and predicting the presence of patellar maltracking. Google Scholar, Diederichs G, Issever AS, Scheffler S (2010) MR imaging of patellar instability: injury patterns and assessment of risk factors. A buckle transducer was clamped on the lateral patellofemoral ligament and the transducer was calibrated to zero with the knee at full extension. The convex articular surface of the patella places it at risk for chondral injury in either the dislocation or the reduction phases of injury. Failure to identify or treat injury to the patellar retinaculum is associated with recurrent patellar instability and contributes to significant morbidity. Manage cookies/Do not sell my data we use in the preference centre. Courtesy of Daniel Bodor, MD, Radsource. Flattening or developmental dysplasia of the trochlea leads to loss of normal patellar tracking and can predispose to lateral patellar dislocation with flexion. All authors read and approved the final manuscript. These prevailing anatomic indices feature prominently into the probability of recurrence, and understanding their variability and pathophysiology is critical to successful management of these patients. It is the percentage of the medial (a) to the lateral (b) trochlear facet length (a/b100%). 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. Patellar fractures are the most common cause of disruption of the extensor mechanism, six times as frequent as soft tissue injuries such as quadriceps or patellar tendon rupture [ 3 ]. Pediatric Lateral Patellar Retinacular Sleeve Avulsion - JOSPT A thorough examination of the knee is then performed including presence of effusion, localization of pain, assessment of patellar translation, patellar apprehension, presence of a J sign (visual lateralization of the patella as it disengages from the trochlea when extending the knee), and a measurement of the Q angle along with ligamentous and meniscal testing. Springer Nature. 5. 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. However, the patella starts to engage with the trochlea by 30 and is typically completely engaged by 45. Another study noted an association between abnormal trochlear morphology and high-grade patellofemoral cartilage damage [58]. On the other hand, the PTI is significantly altered with knee flexion [37]. Because the diagnosis of lateral patellar dislocation is often unsuspected, MR provides valuable diagnostic information in such cases. Rev Bras Ortop 46:160164, LeGrand AB, Greis PE, Dobbs RE, Burks RT (2007) MPFL reconstruction. Transient lateral patellar dislocation. This site needs JavaScript to work properly. As a common knee injury, patellar dislocation has a mean annual incidence of 5.8 in 100,000 people and is more prevalent in women. Advantages of CT over plain radiography include its cross-sectional capability and ability to generate multiplanar reformations. Features that may predispose to patellar dislocation and/or patellar maltracking and can be evaluated with CT include patellar and trochlear morphology and the alignment between the two structures. Gross anatomy The superficial layer originates from the lowest fibers of the iliotibial band and from an extension of vastus lateralis fascia. Patients with patella alta may also benefit from tibial tuberosity advancement. Bone bruise in acute traumatic patellardislocation: volumetric magnetic resonance imaging analysis with follow-up mean of 12 months. The patella itself is shaped as an inverted triangle and is embedded in the quadriceps tendon, making it the largest sesamoid bone in the body [6]. Surgical repair is most commonly directed to MPFL reconstruction and to distal realignment in the subset of patients who have significant osseous malalignment. The distance from the tibial tubercle to the trochlear groove (TT-TG) provides a quantitative evaluation of excessive lateralization of the tibial tuberosity.7, (10a) Axial image of the knee with superimposition of the tibial tubercle from another slice (yellow outline). 0000293749 00000 n Injury 4:126130, 1972. Imaging assessment can start with the radiograph including anteroposterior and lateral views of the knee and skyline view of the patella. Am J Orthop (Belle Mead NJ) 46:290300, Dejour H, Walch G, Neyret P, Adeleine P (1990) Dysplasia of the femoral trochlea. 2. One of the more common MPFL reconstruction procedures uses a single hamstring tendon graft passed through the medial intermuscular septum at the adductor magnus insertion fixed by an anchor in the femoral condyle and sutured or anchored to the superomedial pole of the patella11. AJR 2008: 191:490-498. Tibial tubercletrochlear groove distance (TT-TG) assessment. Advantages of CT over MRI include the reduced cost, larger gantry diameter allowing to fit larger patients, faster acquisition with less potential for claustrophobia, fewer absolute and relative contraindications related to implanted devices, and better cortical bone definition. The patella has 4 different planes of motion: flexionextension, mediallateral rotation, mediallateral patellar tilt, and mediallateral patellar shift. 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. This distance is the trochlear sulcus depth (TD). Osteochondral injuries of the inferomedial patella are seen in up to 70% of patellofemoral dislocations. 2 Baldwin JL. Additionally, MRs ability to delineate the extent of injury and predisposing factors is important in patient care and surgical planning. Military Health System Europe > Clinics > Grafenwoehr Army - TRICARE Patellar sleeve avulsion fracture in a patient with Sinding-Larsen It runs obliquely and transversely and inserts on the patella and the patellar tendon, and is composed of two layers. Patellar tilt assessment. (1a) A single fat-suppressed proton density-weighted coronal image. Lateral patellar dislocation. PFA of 0 or if it opens medially (negative value) is considered abnormal indicating lateral patellar tilt [27, 48]. Guidelines and Gamuts in Musculoskeletal Ultrasound. Lateral patellar compression syndrome is the improper tracking of the patella in the trochlear groove generally caused by a tight lateral retinaculum. Lateral patellar dislocation results in bone contusion at the medial patella and along the lateral aspect of the lateral femoral condyle. 1835 31 - 40 27 30.0 41 - 50 22 24.4 50 + 4 4.4 Total 90 100.0 Age Distribution Number Percent Sex Female 19 21.1 Male 71 78.9 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). Of course, if medial soft tissue restraints are disrupted at the first dislocation, the loss of such restraints makes future dislocations more likely. The injured retinaculum had an indistinct, irregular appearance associated with edema and hemorrhage. Complete dislocation of the knee: spectrum of associated soft-tissue injuries depicted by MR imaging. Cookies policy. ADVERTISEMENT: Supporters see fewer/no ads. Figure 1: ligaments (Gray's illustrations), View Pereshin Moodaley's current disclosures, see full revision history and disclosures, posterior suprapatellar (prefemoral or supratrochlear) fat pad, anterior suprapatellar (quadriceps) fat pad, accessory anterior inferior tibiofibular ligament, superficial posterior tibiotalar ligament, superficial posterior compartment of the leg (calf), accessory extensor digiti secundus muscle, descending branch of the lateral circumflex. Created for people with ongoing healthcare needs but benefits everyone. 1997 Jan;168(1):117-22. doi: 10.2214/ajr.168.1.8976933. The two features are associated with patellar maltracking. Osteochondral fractures are common in acute or recurrent transient lateral patellar dislocation, seen in up to 70% of cases. On T2-weighted MR images, sprain is depicted as thickening of retinaculum with signal intensity signifying edema and hemorrhage (Fig. Patellar Tendon Tear - OrthoInfo - AAOS J Bone Joint Surg Am 89:17491755, PubMed 7,14 While plain radiography is an important tool to diagnose APD, magnetic resonance imaging (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. From 10 to 20 of flexion, the patella engages the trochlear groove with the contact area being the inferior most portion of the medial and lateral facets. A bone bruise at the anterolateral aspect of the lateral femoral condyle is also apparent (arrowheads). no financial relationships to ineligible companies to disclose. MRI Web Clinic, August 2010. https://radsource.us/patella-alta-and-baja/. The site is secure. This short surgical video demonstrates an arthroscopic lateral release as seen from inside the knee. Patellar tilt can also be assessed using the patellofemoral angle (PFA).
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