AJR Am J Roentgenol. 9). Epidemiology Patellar dislocation accounts for ~3% of all knee injuries and is commonly seen in those individuals who participate in sports activities. It has been suggested that fat impingement occurs between the lateral femoral condyle and the posterior aspect of the patellar tendon [54]. The MPFL is attached to the region of the adductor tubercle or medial femoral epicondyle extending deep to the vastus medialis obliquus (VMO) and attaching to the superior two thirds of the patella [52]. Early detection particularly in the stage preceding the development of significant cartilaginous loss and osteoarthritis is critical. Curr Sports Med Rep 11:226231, Jain NP, Khan N, Fithian DC (2011) A treatment algorithm for primary patellar dislocations. This is measured on the sagittal MRI images at the point where the patella is at its greatest length. 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. AJR 2008: 191:490-498. 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. Surgical management procedures can broadly be categorized as soft tissue procedures (lateral release, medial imbrication, and MPFL repair or reconstruction) and bony procedures (tibial tubercle transfer procedures and trochleoplasty). 4 Sanders TG, Morrison WB, Singleton BA, Miller MD, Cornum KG. Operative lateral retinaculum release is indicated in refractory cases. The site is secure. Characterization of the type of medial restraint injury is crucial for surgical planning. (6a) A more distal T1-weighted image reveals fibers of the oblique decussation of the MPFL which blend with the medial collateral ligament (MCL). (28a) A sagittal proton density-weighted image demonstrates the typical hardware location in a patient status post medialization of the tibial tuberosity (arrow). 2023 BioMed Central Ltd unless otherwise stated. b Axial MRI at the level of the tibial tuberosity. Additionally, MRs ability to delineate the extent of injury and predisposing factors is important in patient care and surgical planning. Sports Med Arthrosc 15:6871, Longo UG, Rizzello G, Ciuffreda M et al (2016) Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures for the management of patellar dislocation: systematic review and quantitative synthesis of the literature. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Lateral Patellar Compression Syndrome. Less than 3-mm trochlear depth is indicative of trochlear dysplasia [24]. 6. Distances between 15 and 20 mm are borderline, and distances of more than 20 mm indicate significant lateralization of the tuberosity.5. Would you like email updates of new search results? Radiographics. Medial retinacular complex injury in acute patellar dislocation: MR LTI < 11 degrees indicates dysplasia. Pathology (1a) A single fat-suppressed proton density-weighted coronal image. Kamel S, Kanesa-Thasan R, Dave J et al. At the time the article was last revised Joel Hng had PubMed Persistent abnormalities of patellar alignment and abnormalities of trochlear morphology are also common, and should be carefully described. 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. 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. MRI and operative studies have revealed that it is almost . AJR Am J Roentgenol 169:211215, Buchner M, Baudendistel B, Sabo D, Schmitt H (2005) Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment. Arthroscopy 23:305311, Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S (1990) Lateral release of the patella: indications and contraindications. Lateral trochlear inclination is another quantitative method to diagnose trochlear dysplasia. Lateral Retinaculum - an overview | ScienceDirect Topics Am J Sports Med 45:10121017, Pedersen ME, DaCambra MP, Jibri Z, Dhillon S, Jen H, Jomha NM (2015) Acute osteochondral fractures in the lower extremities - approach to identification and treatment. J Bone Joint Surg Am 89:17491755, PubMed {"url":"/signup-modal-props.json?lang=us"}, Shetty A, Saber M, Rasuli B, et al. Understanding the biomechanics of these joints is essential to investigating and appropriately treating patellofemoral joint pathology. 2 Baldwin JL. Sports Med Arthrosc Rev 15:7277, Mikashima Y, Kimura M, Kobayashi Y, Miyawaki M, Tomatsu T (2006) Clinical results of isolated reconstruction of the medial patellofemoral ligament for recurrent dislocation and subluxation of the patella. Lateral patellar dislocation | Radiology Reference Article Radiology 187:205212, Jibri Z, Martin D, Mansour R, Kamath S (2012) The association of infrapatellar fat pad oedema with patellar maltracking: a case-control study. Clin Sports Med 21:521546 x, Article 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. 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). Patellofemoral Pain Syndrome - OrthoInfo - AAOS Diagnosis is made clinically with pain with compression of the patella and moderate lateral facet tenderness and sunrise knee radiographs will often show patellar tilt in the lateral direction. However, the patella starts to engage with the trochlea by 30 and is typically completely engaged by 45. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Crossref, Medline, Google Scholar; 32 Starok M, Lenchikl L, Trudell D, Resnick D. Normal patellar retinaculum: MR and sonographic imaging with cadaveric correlation. The Anterolateral Ligament of the Knee: MRI Appearance, Association TT-TG is a reflection of the clinically measured Q angle. 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. no financial relationships to ineligible companies to disclose. 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. Google Scholar, Fithian DC, Paxton EW, Stone ML et al (2004) Epidemiology and natural history of acute patellar dislocation. (27a) Axial and (27b) coronal fat suppressed proton density-weighted images in a patient who experienced recurrent patellar dislocation following surgery. Another study noted an association between abnormal trochlear morphology and high-grade patellofemoral cartilage damage [58]. A bone bruise occurs anterior to this site of impaction as the patella reduces with knee extension. The medial patellar retinaculum is part of the anterior third of the medial joint capsule. Kirsch M, Fitzgerald S, Friedman H, Rogers L. Transient Lateral Patellar Dislocation: Diagnosis with MR Imaging. J Comput Assist Tomogr 2001; 25:957-962. Complete disruption and avulsion are seen as discontinuity of ligament fibers with associated edema [50]. 4. The patellofemoral joint has two primary functions; firstly, it acts as an anatomic pulley to provide mechanical advantage for the extensor mechanism and, secondly, to reduce friction between the extensor mechanism and the femur. 2. Axial PDFS MR image showing MPFL disruption (open arrow) and trochlear dysplasia (arrowheads). The patellar dislocations were clinically unsuspected in the initial evaluation of eight of these nine patients. A trochlear depth of < 3mm indicates dysplasia. The marrow edema and medial patellofemoral ligament (MPFL) injury pattern above are virtually pathognomonic of a transient lateral patellar dislocation, as little else will cause such an appearance. 9). Surgical repair is most commonly directed to MPFL reconstruction and to distal realignment in the subset of patients who have significant osseous malalignment. 25a) Axial proton density-weighted images at initial injury (left) and 5 months later demonstrate progression of medial retinacular and MPFL scarring (arrows) in this patient with trochlear dysplasia and chronic patellofemoral instability with a history of multiple prior dislocations. Frequently underdiagnosed, the patellofemoral friction syndrome, also called Hoffa's fat cushion compression syndrome, is mainly represented by 2 characteristic symptoms, which are mainly found in women (especially if they present obesity or rapid weight gain, as in pregnancy): patellofemoral pain and instability in the patellar . The vastus medialis oblique (VMO) provides active stability of the patella. Transient lateral patellar dislocation. a Axial PDFS right knee MR image at the level of the trochlear groove. Facet asymmetry is determined by calculating the percentage of the medial to the lateral femoral facet length (Fig. Guidelines and Gamuts in Musculoskeletal Ultrasound. The lateral patellar retinaculum can also be assessed in this position. As with the anatomy, there is considerable variability in both the surgical and radiology literature regarding the location of soft tissue injuries in patients following patellar dislocation. A facet ratio of < 40% indicates dysplasia. Patella instability in children and adolescents. 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. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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]. 2006;187(5):1332-7. b Trochlear dysplasia (9 inclination), Facet asymmetry assessment for trochlear dysplasia on axial MRI. A ratio equal or more than 1.2 indicates patella alta [35] (Fig. Unable to process the form. 28 Please enable it to take advantage of the complete set of features! 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]. The lateral retinaculum or lateral canthus is a complex integration of a number of structures. 2015 Sep 30;9:463-74. doi: 10.2174/1874325001509010463. An increased tibial tubercletrochlear groove (TT-TG) indicates a lateralized tibial tuberosity, or a medialized trochlear groove [38]. All authors read and approved the final manuscript. Observer Agreement on the Dejour Trochlear Dysplasia Classification: A comparison of true lateral radiographs and axial magnetic resonance images. Google Scholar, Pfirrmann CW, Zanetti M, Romero J, Hodler J (2000) Femoral trochlear dysplasia: MR findings. They are best indicated in isolation in the setting of recurrent instability with minimal underlying osseous malalignment (normal TT-TG, minimal trochlear dysplasia). It is a ratio between the patellar tendon length (along the inner surface of the tendon) and the diagonal patellar height [27]. Skeletal Radiol 48:387393, Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J (2006) The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. 2002 Dec;225(3):736-43. doi: 10.1148/radiol.2253011578. is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. Patellofemoral friction syndrome: MRI findings of an - Eurorad Distally, it attaches to the tibial tubercle via the patellar tendon. Am J Sports Med 14:117120, Smith TO, Donell S, Song F, Hing CB (2015) Surgical versus non-surgical interventions for treating patellar dislocation. Most, however, agree regarding the importance of the MPFL and its role as the strongest restraint to lateral patellar displacement. Various parameters can be used in assessing and predicting the presence of patellar maltracking. 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. Int Orthop. (1a) A single fat-suppressed proton density-weighted coronal image is provided. 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. It can be divided into nonoperative and operative management. Initial diagnosis is key to a successful outcome, as these injuries are easily overlooked on plain radiographs with poor results well documented from delayed management. This is often secondary to an underlying structural abnormality. However, in the case of acute, focal, lateral patellar pain, a lateral patel - lar sleeve avulsion should be considered and may necessitate advanced imaging for optimal evaluation. Laxity of the medial stabilizers will lead to increasing instability over time. Pedersen ME, DaCambra MP, Jibri Z, Dhillon S, Jen H, Jomha NM. The axial proton density-weighted image reveals a large osteochondral shearing injury involving the mid to medial patella (arrowheads). In full extension, the patella has little to no contact with the trochlear groove and, therefore, is in a position of higher risk for instability. Patella alta persists in this patient. The most important soft tissue passive stabilizers involved in patellofemoral dislocation injuries have traditionally been referred to as the MPFL and the medial retinaculum. It should be noted that these procedures are mostly contraindicated in the patient with open physes due to growth arrest of the tibial tubercle apophysis. MRI has been found to be 85%-92% sensitive for diagnosing MPFL injury (Seeley, 2013). MR findings were correlated with clinical, surgical, and arthroscopic findings. Additionally, complex injuries to bone, cartilage, and ligaments may occur. 2012;40(4):837-844. Springer Nature. The patella becomes unstable and undergoes a transient, violent lateral displacement. A focused history of the mechanism, number, and circumstances of instability to date is essential. Rheumatology (Oxford) 46:13031308, Sanders TL, Pareek A, Johnson NR, Stuart MJ, Dahm DL, Krych AJ (2017) Patellofemoral arthritis after lateral patellar dislocation: a matched population-based analysis. PubMed Division of Sports Trauma, Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark. Traumatic dislocations are commonly associated with other injuries including that of the MPFL, meniscal pathology, and osteochondral fractures of the femur or patella [15, 16]. (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. 2010 Aug;36(4):353-60. doi: 10.1007/s00068-010-9165-2. Background Lateral Patella dislocations are common injuries seen in the active and young adult populations. 20,61 This is attributable to a medial retinacular injury, specifically, avulsion or tearing of the medial patellofemoral ligament. Rev Chir Orthop Reparatrice Appar Mot 76:4554, CAS However, in the setting of osseous malalignment, MPFL reconstruction alone leads to higher rates of recurrent instability. Normal TD > 5.2mm. Edema is also present medially in the region of the MPFL and medial retinaculum (arrowheads). 6 Cone R. Patella Alta and Baja. Careers. The osteocartilaginous anatomy of the patellofemoral joint provides additional static stabilization to the joint. 1997 Jun;168(6):1493-9. doi: 10.2214/ajr.168.6.9168713. Am J Sports Med. Thus, to assess for maltracking specifically, a multi-stage CT with a variable number of repeated acquisitions at variable degrees of flexion can also be performed [57]. Sonographic Appearances of Medial Retinacular Complex Injury in Traumatic lateral patellar dislocation is a common injury among young, athletic individuals and is generally transient in nature. Bone bruises at the anterolateral aspect of the lateral femoral condyle and at the inferomedial patella are the most constant findings in patients who have sustained a recent patellar dislocation. The patella remains laterally shifted (blue arrow) and an osteochondral injury of the medial patella (arrowheads) is apparent. PubMed Central The MPFL plays a significant role in the stabilization of the medial aspect of the patella.Especially during the early stages of knee flexion, the MPFL is a critical component in patellar tracking and stability within the trochlear groove. PubMed J Knee Surg 28:303309, Hevesi M, Heidenreich MJ, Camp CL et al (2019) The recurrent instability of the patella score: a statistically based model for prediction of long-term recurrence risk after first-time dislocation. [Nov;2019 . AJR Am J Roentgenol 161:109113, Lance E, Deutsch AL, Mink JH (1993) Prior lateral patellar dislocation: MR imaging findings. Methods MRI studies taken at one imaging site between January, 2007 to January, 2008 with the final diagnosis of patella . 1997 Jan;168(1):117-22. doi: 10.2214/ajr.168.1.8976933. Patients with patella alta may also benefit from tibial tuberosity advancement. An association has been demonstrated between patellofemoral cartilage damage and patellar maltracking. Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete. Usually, young individuals, particularly women, suffer the consequences of this disorder [2]. High resolution magnetic resonance imaging of the patellar retinaculum: normal anatomy, common injury patterns . PubMed 3. Lateral patellar compression syndrome is the improper tracking of the patella in the trochlear groove generally caused by a tight lateral retinaculum. Risk factors for recurrent instability include female sex, family history of patellar instability, and various anatomic risk factors such as patella alta, increased femoral anteversion, external tibial rotation, genu valgum, trochlear dysplasia, increased tibial tubercletrochlear groove (TT-TG) distance, and patellar tilt [13, 21,22,23]. 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% . 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]. Femoral condylar chondral injuries occur during the dislocation phase due to impaction shearing forces of the patella upon the flexed femur, typically occurring at the weightbearing surface. High resolution magnetic resonance imaging of the patellar retinaculum Lateral patellar dislocation is a common clinical entity with a characteristic MR appearance. Inferiorly, components of the medial retinaculum blend with the patellar tendon. 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. Correspondence ML: [emailprotected] Submitted 07-19-2011. The literature in this field has been extremely heterogeneous, and this has made clinical guidelines difficult to produce. As the knee joint ranges from extension to flexion, the articular surface area of the patella is in contact with the femur changes. Reconstruction of the MPFL has recently become an increasingly popular procedure for recurrent lateral patellar instability. AJR Am J Roentgenol 195:13671373, Jarraya M, Diaz LE, Roemer FW, Arndt WF, Goud AR, Guermazi A (2018) MRI findings consistent with peripatellar fat pad impingement: how much related to patellofemoral maltracking? 23,29,37 The causative factors of . It is therefore helpful in surgical planning. Soft tissue changes may include effusion, thickening or disruption of the MPFL, and retinacular complex and regional edema. What is the treatment for a patellar retinaculum tear? 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]. The lateral patellar retinaculum is a fibrous expansion comprising of superficial and deep layers. Bull NYU Hosp Jt Dis 67:2229, Dupuy DE, Hangen DH, Zachazewski JE, Boland AL, Palmer W (1997) Kinematic CT of the patellofemoral joint. Patella alta assessment. a Sagittal PD knee MRI showing the method of assessing the InsallSalvati index, calculated as the ratio of the patellar tendon length at its inner aspect (white dashed line) to the greatest diagonal length of the patella (white line). Focal Defect at the LPR on Clinical Knee MRI and a Cadaveric Study Musculoskeletal Imaging Original Research. Become a Gold Supporter and see no third-party ads. Unable to load your collection due to an error, Unable to load your delegates due to an error. Recent literature does not encourage the use of lateral release, since this can increase patellar instability. Falls. 5 a-d). Findings typically associated with acute lateral patellar dislocation were also assessed and recorded (present or absent) including characteristic bone bruises and osteochondral injuries involving the patella, lateral trochlear facet, and lateral femoral condyle. (18a) A 13-year-old female following acute patellar dislocation. 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. (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.
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