2023 Apr;47(4):973-981. doi: 10.1007/s00264-023-05707-y. Stretching this ligament keeps the patella in place and the ligament healthy. Division of Sports Trauma, Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark. Medial patellar. 4). This can provide a road map for formulating a treatment strategy that would be primarily aimed at stabilizing the patellofemoral joint to halt or slow the progression of articular cartilage loss. 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. Surgical realignment procedures include medialization of the tibial tubercle particularly in patients with a TT-TG distance greater than 20mm. Direct impact to the front of the knee from a fall or other blow is a common cause of tears. Imaging, particularly MRI, plays a vital role in the assessment of patellar maltracking. Am J Sports Med 16:244249, Hawkins RJ, Bell RH, Anisette G (1986) Acute patellar dislocations. A ratio > 1.3 indicates patella alta. Before 7). VMO dysplasia may play a role in patellofemoral instability. 2010. Fluid extending into the VMO myotendinous junction is generally seen in the setting of coexisting MPFL/retinacular tears. The above video demonstrates the mechanism of injury in patellar dislocation. Observer Agreement on the Dejour Trochlear Dysplasia Classification: A comparison of true lateral radiographs and axial magnetic resonance images. The decreased patellar contact area decreases stability particularly in shallow degrees of flexion and thus predisposes to lateral patellar subluxation. As is typical, a bone bruise extends anteriorly (arrowheads) from the site of the chondral defect. It can be divided into nonoperative and operative management. Tibial Tubercle Osteotomy to Aid Exposure for Revision Total Knee 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. The patella articulates with the trochlear groove of the anterior femur, which has corresponding lateral and medial patellar articular surfaces [6]. {"url":"/signup-modal-props.json?lang=us"}, Shetty A, Saber M, Rasuli B, et al. In the seven patients with hyperextension injuries, three had associated meniscal and cruciate ligament tears. Predisposing factors to patellofemoral dislocation include patella alta, excessive lateral distance between the tibial tubercle and trochlear groove and a congenitally shallow trochlear groove5, any of which significantly increase a patients likelihood for dislocation. The patients are then J-braced for 3 to 6 months for all sports activities. In the past two decades dissection studies have shown that it extends from the superomedial border of the patella to the femoral epicondyle, at or immediately above the adductor tubercle. Osteochondral injuries of the inferomedial patella are seen in up to 70% of patellofemoral dislocations. A small osseous avulsion (arrowhead) is seen in this region. MRI can provide valuable information regarding the status of such repairs in patients who experience recurrent dislocation following surgery. The angle between the two lines is the lateral trochlear inclination (LTI). Our study focus was to evaluate medial patellofemoral ligament (MPFL) injury patterns and associated knee pathology using Magnetic Resonance Imaging studies. 7). Pathology This site needs JavaScript to work properly. 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% . ANTERIOR KNEE PAIN PubMed J Pediatr Orthop 37:484490, Parikh SN, Lykissas MG, Gkiatas I (2018) Predicting risk of recurrent 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. The close association of the MR with the MCL is also apparent. Am J Sports Med 40:11191125, Boutris N, Delgado DA, Labis JS, McCulloch PC, Lintner DM, Harris JD (2018) Current evidence advocates use of a new pathologic tibial tubercle-posterior cruciate ligament distance threshold in patients with patellar instability. FOIA An inclination angle of less than 11 indicates trochlear dysplasia [32]. Methods MRI studies taken at one imaging site between January, 2007 to January, 2008 with the final diagnosis of patella . Lateral patellar dislocation refers to lateral displacement followed by dislocation of the patella due to disruptive changes to the medial patellar retinaculum. The TT-TG index is the TTTG/TT-TE ratio [44]. [Google Scholar] 6. 3). 2020;49(6):1642-50. At the time the article was created Pereshin Moodaley had no recorded disclosures. Medial Collateral Ligament (MCL) and Medial Supporting - Radiology Key 2. Lateral patellar retinaculum | Radiology Reference Article Early diagnosis is essential, as chronic maltracking will lead to patellofemoral cartilage damage and osteoarthritis [3]. Check for errors and try again. The Medial Patellofemoral Ligament (MPFL) is an hour-glass shaped ligament made of bands of retinacular tissue. 2 Baldwin JL. Google Scholar, Diederichs G, Issever AS, Scheffler S (2010) MR imaging of patellar instability: injury patterns and assessment of risk factors. 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. 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. (26a) An axial proton density-weighted image reveals trochlear dysplasia (line, indicating facet asymmetry and a shallow trochlear groove), ossification in the medial retinaculum and MPFL attachment anteriorly (short arrow) and diffuse scarring of the medial retinaculum (arrowheads)--these findings indicate chronic patellofemoral instability. b Axial MRI at the level of the tibial tuberosity. 8600 Rockville Pike Epub 2011 Nov 9. It has proven to be both sensitive and specific in the detection of hyaline cartilage abnormalities [4]. {"url":"/signup-modal-props.json?lang=us"}, Moodaley P, Hng J, Hacking C, et al. Thus, imaging at positions both less than and greater than 30 can be used to avoid missing maltracking that might be captured at only certain degrees of flexion [64]. 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]. Bull NYU Hosp Jt Dis 67:2229, Dupuy DE, Hangen DH, Zachazewski JE, Boland AL, Palmer W (1997) Kinematic CT of the patellofemoral joint. Distances between 15 and 20 mm are borderline, and distances of more than 20 mm indicate significant lateralization of the tuberosity.5. . Nine of 17 patients showed MR evidence of a patellar dislocation. The medial patellar retinaculum is part of the anterior third of the medial joint capsule. Acute patellar dislocation (APD) is a common injury in children, accounting for up to 16% of acute knee hemarthroses. 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. High resolution magnetic resonance imaging of the patellar retinaculum: normal anatomy, common injury patterns . PubMedGoogle Scholar. The knee is a complex synovial joint that can be affected by a range of pathologies: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Radiology 216:858864, Biedert RM, Tscholl PM (2017) Patella alta: a comprehensive review of current knowledge. Int Orthop 34:311316, Donell ST, Joseph G, Hing CB, Marshall TJ (2006) Modified Dejour trochleoplasty for severe dysplasia: operative technique and early clinical results. (13a) A line is drawn between the cortex of the lateral trochlear facet on the most superior axial image showing cartilage. In this section, we will emphasize the role of MRI and discuss how CT can also have value when assessing patellar maltracking. Google Scholar, Nakagawa S, Kadoya Y, Kobayashi A, Tatsumi I, Nishida N, Yamano Y (2003) Kinematics of the patella in deep flexion. 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 2010 Aug;36(4):353-60. doi: 10.1007/s00068-010-9165-2. The deep layer of the lateral retinaculum contains thickenings that form ligaments providing stabilizing support to the patella. Lateral dislocation may also occur, less commonly, as the result of a direct blow to the medial aspect of the knee. MR imaging of patellar retinacular ligament injuries - PubMed Medial retinacular complex injury in acute patellar dislocation: MR findings and surgical implications. Patellar tilt can also be assessed using the patellofemoral angle (PFA). Curr Sports Med Rep 11:226231, Jain NP, Khan N, Fithian DC (2011) A treatment algorithm for primary patellar dislocations. On the other hand, there are static MRI measurements that are routinely used as indicators of patellofemoral alignment during knee movement [30, 31]. 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]. (24a) Scarring of the medial stabilizers (asterisk) often leads to healing in a more superior and lateral location (long arrow) leading to persistent medial instability, laxity and malalignment even after the patella has been repositioned. 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. Another method is the CatonDeschamps index. Am J Sports Med. 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. Reconstruction of the medial patellofemoral ligament for treatment of patellar instability. A focused history of the mechanism, number, and circumstances of instability to date is essential. CAS Radiology. 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. This is an arthroscopic surgery ( a knee "scope" which is performed through 3 small incisions ( about inch each) around the knee. Identifying edema at the superolateral aspect of Hoffas fat pad on MRI should prompt the reporting radiologist to look for features of patellar maltracking. a Axial CT image demonstrating MPFL reconstruction (arrow heads). Courtesy of Daniel Bodor, MD, Radsource. Complete dislocation of the knee: spectrum of associated soft-tissue injuries depicted by MR imaging. Phys Ther 69:897901, Atkin DM, Fithian DC, Marangi KS, Stone ML, Dobson BE, Mendelsohn C (2000) Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. 3. MRI, given its superior soft tissue contrast and multi-planar capability, has emerged as the modality of choice in evaluating articular cartilage abnormalities. Patellar Dislocation (Acute) | Pediatric Orthopaedic Society of - POSNA The purpose of this article is to discuss the clinical and radiologic evaluation of patellar maltracking providing an update on the cross-sectional imaging assessment and also a synopsis of the management options. MR Imaging of Patellar Instability: Injury Patterns and Assessment of Acta Orthop Scand 68:419423, Deie M, Ochi M, Sumen Y, Adachi N, Kobayashi K, Yasumoto M (2005) A long-term follow-up study after medial patellofemoral ligament reconstruction using the transferred semitendinosus tendon for patellar dislocation. Trochlear depth of less than 3 mm on MRI has a sensitivity of 100% and a specificity of 96% for trochlear dysplasia.10. First, a line is drawn paralleling the posterior femoral condyles surfaces. PDF ORIGINAL RESEARCH Role of Magnetic Resonance Imaging in Evaluation of Although edema can be seen in other peripatellar fad pads on MRI, there is no clear association between patellar maltracking and prefemoral fat pad edema or with that at the suprapatellar fat pad [56]. Lateral patellar retinaculum. The knee is a complex joint with separate tibio-femoral and the patellofemoral articulations. Do a thorough work-up of the patient at the clinic to determine the need for a redesign total knees arthroplasty (Figs. However, patellofemoral tracking is a dynamic process with the spatial relationship between the articular surfaces varying depending on the position of the knee joint [57, 64]. The latter distinction is important to recognize among both radiologists and surgeons. This protocol can help in evaluating for osseous integrity, morphology, and patellofemoral alignment [63] (Fig. The injured retinaculum had an indistinct, irregular appearance associated with edema and hemorrhage. J Bone Joint Surg Am 85-A:12381242, Article 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]. Imaging, particularly MRI, can detect subtle features that could lead to the diagnosis, probably even more importantly when there is no clear history of patellar dislocation or before its development. :: KJR :: Korean Journal of Radiology (22a) In this patient with an acute first time patellar dislocation injury, typical bone bruises were not apparent. Peroneal Tendon Dislocation and Superior Peroneal Retinaculum Injury Patellar maltracking: an update on the diagnosis and treatment strategies, https://doi.org/10.1186/s13244-019-0755-1, http://creativecommons.org/licenses/by/4.0/. 2011;39(8):1756-1761. There are numerous techniques reported in literature and commonly used to reconstruct the medial sided soft tissue constraints. The lateral patellar retinaculum is less commonly injured than the medial patellar retinaculum, however it is often disrupted during surgery to correct abnormal lateral patellar tracking or dislocation 3. Therefore, the management of patellar maltracking remains controversial and decisions need to be made on an individual patient basis with surgical management being reserved for those patients with documented recurrent lateral patellar instability. Quinn described the MRI findings following acute patellar dislocation as contusion or impaction of the medial patellar facet and lateral femoral condyle, along with injury of the medial retinaculum and/or medial patellofemoral ligament (MPFL) (Quinn, 1993). In the setting of osseous patellar malalignment, an osseous procedure such as tibial tubercle transfer osteotomy can be performed (Fig. This results in a slightly superolateral direction of pull on the patella by the quadriceps. Usually, young individuals, particularly women, suffer the consequences of this disorder [2]. A bone bruise occurs anterior to this site of impaction as the patella reduces with knee extension. 23,29,37 The causative factors of . b The patella tilt angle is measured between the posterior condylar line (dashed line) and the maximal patella width (solid line). The patellar usually relocates, and the typical bone contusions are the key MRI features to diagnose transient lateral patellar dislocation (Fig. Failure to identify or treat injury to the patellar retinaculum is associated with recurrent patellar instability and contributes to significant morbidity. Radiographics 30:961981, Tscholl PM, Wanivenhaus F, Fucentese SF (2017) Conventional radiographs and magnetic resonance imaging for the analysis of trochlear dysplasia: the influence of selected levels on magnetic resonance imaging. Radiology 189:905907, Warren LF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee: an anatomical analysis. PDF Painful patellar swelling - dipot.ulb.ac.be The https:// ensures that you are connecting to the AJR Am J Roentgenol 161:109113, Lance E, Deutsch AL, Mink JH (1993) Prior lateral patellar dislocation: MR imaging findings. 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. J Bone Joint Surg Am Volume 90:27512762, Dixit S, Deu RS (2017) Nonoperative treatment of patellar instability. As the knee joint ranges from extension to flexion, the articular surface area of the patella is in contact with the femur changes. PubMed 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 ]. Rethy Chhem, Etienne Cardinal. Would you like email updates of new search results? The most important active stabilizer of the patella is the vastus medialis oblique (VMO). Traumatic lateral patellar dislocation is a common injury among young, athletic individuals and is generally transient in nature. 5. A tear of the reconstructed MPFL is indicated by fluid interrupting the fibers (27a, long arrow) (27b, arrowheads). Radiology 216:582585, Ward SR, Terk MR, Powers CM (2007) Patella alta: association with patellofemoral alignment and changes in contact area during weight-bearing. Knee Surg Sports Traumatol Arthrosc 14:707712, Ahmad M, Janardhan S, Amerasekera S, Nightingale P, Ashraf T, Choudhary S (2019) Reliability of patellotrochlear index in patellar height assessment on MRI-correction for variation due to change in knee flexion. The natural history. Seven of the nine patients with patellar dislocation injuries had frank osteochondral injuries. 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]. This distance is the trochlear sulcus depth (TD). Clipboard, Search History, and several other advanced features are temporarily unavailable. The site is secure. 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. Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. 1-31. Orthopedic Surgery 22 years experience. 8,12,18,28 In knees from cadavers, repair of the medial patellofemoral ligament is not only sufficient, but necessary to restore lateral patellar mobility to within a normal range. The average annual incidence for patellar dislocation injuries ranged between 5.8 and 7.0 per 100,000 person-years in the civilian population, and up to 29 per 100,000 person-years in the 10-17 year age . Inferiorly, components of the medial retinaculum blend with the patellar tendon. MRI Web Clinic, August 2010. https://radsource.us/patella-alta-and-baja/. Medial patellar chondral injuries may occur during either the dislocation or reduction phases of injury. The patella has 4 different planes of motion: flexionextension, mediallateral rotation, mediallateral patellar tilt, and mediallateral patellar shift. Additional passive stabilizers include the medial patellotibial ligament (MPTL) and the medial patellomeniscal ligament (MPML). MRI and CT are superior modalities in looking for predisposing factors associated with patellar maltracking [26,27,28]. Lateral patellar dislocation | Radiology Reference Article Several methods have been used to assess patella alta. Sonographic Appearances of Medial Retinacular Complex Injury in It is measured at the mid-point of the patella on the axial slices [48]. 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. TT-TG distance of more than 20mm is believed to be nearly always associated with patellar instability [27]. (27a) Axial and (27b) coronal fat suppressed proton density-weighted images in a patient who experienced recurrent patellar dislocation following surgery. The patella becomes unstable and undergoes a transient, violent lateral displacement. 1993;161(1):109-13. Correspondingly, the patella must shift slightly medially during early flexion to engage the trochlear groove. Less commonly, patients can also present after chronic patellar instability secondary to generalized ligamentous laxity with or without anterior knee pain. The goal of patellar instability treatment is to achieve a stable, functional, and pain-free knee and ultimately to halt or slow the development of osteoarthritis. Transient Lateral Patellar Dislocation - Radsource 6). Knee 13:2631, McNally EG (2001) Imaging assessment of anterior knee pain and patellar maltracking. When the knee moves slightly out of place or becomes tilted in the joint, it can cause tension and pain in the lateral retinaculum. 2012;40(4):837-844. Become a Gold Supporter and see no third-party ads. Because the diagnosis of lateral patellar dislocation is often unsuspected, MR provides valuable diagnostic information in such cases. Acute lateral patellar dislocation at MR imaging: injury patterns of Less than 3-mm trochlear depth is indicative of trochlear dysplasia [24]. (1a) A single fat-suppressed proton density-weighted coronal image. Primary traumatic patellar dislocation | Journal of Orthopaedic Surgery Zaid Jibri. Lateral Patellar Dislocation. Are you sure you want to trigger topic in your Anconeus AI algorithm? Both knees are scanned simultaneously. PubMed In general realignment surgery such as tibial tubercle transfer should be strongly considered in patients with TT-TG > 15mm (borderline) and typically should be performed in patients with TT-TG > 20mm. However, the use of this method is not widespread. Patellar maltracking: an update on the diagnosis and treatment Axial PDFS left knee MR image, demonstrating the method used for the measurement of trochlear depth. Less commonly, a direct laterally or medially orientated blow to the patella can precipitate dislocation. Lateral trochlear inclination is another quantitative method to diagnose trochlear dysplasia. A distance between the tibial tubercle and the trochlear groove of less than 15 mm is considered normal. A trochlear depth of < 3mm indicates dysplasia. In fact, most patellar maltracking occurs between extension and the first 30 of flexion. Patellofemoral Pain Syndrome Exercises - sports injury rehabilitation The primary aim of surgery is to repair the knee damage and to correct the anomalies that are predisposing to chronic instability. 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.
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