lateral patellar retinaculum injury radiology

Patellar maltracking occurs as a result of an imbalance in the dynamic relationship between the patella and trochlea. Each of the mentioned assessment methods of patella alta has its own advantages and limitations. Radiology. Clinical History: A 23 year-old female presents with medial knee pain following a twisting injury. 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]. Biomechanical evaluation of lateral patellar dislocations. 1. MRI can provide valuable information regarding the status of such repairs in patients who experience recurrent dislocation following surgery. 4). It takes a very strong force to tear the patellar tendon. In addition, symptomatic knees may demonstrate normal engagement between the patella and trochlea beyond 30 of flexion. An inclination angle of less than 11 indicates trochlear dysplasia [32]. Sports Med Arthrosc Rev 25:7277, Gillespie H (2012) Update on the management of patellar instability. In a series of 474 patients with anterior knee pain, patellar tilt or subluxation was present in 40% of the cases on axial MRI [46]. The deep layer of the lateral retinaculum contains thickenings that form ligaments providing stabilizing support to the patella. 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? The primary aim of surgery is to repair the knee damage and to correct the anomalies that are predisposing to chronic instability. 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]. 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]. High resolution magnetic resonance imaging of the patellar retinaculum: normal anatomy, common injury patterns . Lateral patellar tilt is a sensitive marker for patellar instability [45]. 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. Patella alta assessment. Injury. What is the diagnosis? Early detection particularly in the stage preceding the development of significant cartilaginous loss and osteoarthritis is critical. 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. In order for the patella to engage with the femoral trochlea, a higher degree of flexion than normal is needed. Radiographics. First, a line is drawn paralleling the posterior femoral condyles surfaces. Surgical repair is most commonly directed to MPFL reconstruction and to distal realignment in the subset of patients who have significant osseous malalignment. Skeletal Radiol. Edema and thickening compatible with tears of the MPFL and medial retinaculum (red arrows) are apparent both anteriorly and posteriorly. (1a) A single fat-suppressed proton density-weighted coronal image is provided. The natural history. Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella Injury to the medial retinaculum, MPFL, and VMO may be identified at MR imaging after acute LPD. Patella alta persists in this patient. The authors would like to sincerely thank Cheryl Kreviazuk for all her efforts in the submission process. Lateral release and medial imbrication on their own are generally insufficient, but can be used to augment an MPFL repair or reconstruction or, if there is osseous misalignment, used in conjunction with a bony procedure particularly if there is recurrent instability or demonstrable lateral patellar tilt [73,74,75,76,77,78]. It is the percentage of the medial (a) to the lateral (b) trochlear facet length (a/b100%). Bethesda, MD 20894, Web Policies The latter distinction is important to recognize among both radiologists and surgeons. It is composed of Lockwood's ligament (inferior suspensory ligament), the lateral extension or horn of the levator aponeurosis, the continuations of the pretarsal and preseptal muscles, and the check ligament of the lateral rectus muscle. Disadvantages of CT compared to MRI include the use of ionizing radiation, which reduced soft tissue contrast resulting in limited evaluation of the cartilage, tendons, ligaments, muscles, and internal structures of the knee [64]. 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. 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. Knee Surg Sports Traumatol Arthrosc 2:1926, Jaquith BP, Parikh SN (2017) Predictors of recurrent patellar instability in children and adolescents after first-time dislocation. Am J Sports Med 18:359365, Lattermann C, Toth J, Bach BR Jr (2007) The role of lateral retinacular release in the treatment of patellar instability. Lateral patellar compression syndrome is the improper tracking of the patella in the trochlear groove generally caused by a tight lateral retinaculum. 5 Carrillon Y, Abidi H, Dejour D, et al. The medial patellofemoral ligament (MPFL) is a condensation of the medial capsule of the knee joint. The medial patellar retinaculum is part of the anterior third of the medial joint capsule. 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. (Figs.1-A 1-A also and1-B). Alimorad Farshchian M. D.. Farshchian's Orthopedic Regenerative Series. The convex articular surface of the patella places it at risk for chondral injury in either the dislocation or the reduction phases of injury. Understanding the biomechanics of these joints is essential to investigating and appropriately treating patellofemoral joint pathology. no financial relationships to ineligible companies to disclose. TT-TG assessment has its own limitations. (4a) This 3D graphic view of the medial knee with the crural fascia and sartorius (S) muscle incised and reflected demonstrates the main medial contributors to patellar stability. Medial patellar chondral injuries may occur during either the dislocation or reduction phases of injury. In these patients, a triad of findings that included focal impaction injuries involving the lateral femoral condyle, osteochondral injuries of the medial patellar facet, and injuries of the medial retinacular ligament were seen. The tight structures of the knee such as the lateral retinaculum need to be stretched and mobilized. government site. 2011;39(8):1756-1761. Oper Tech Sports Med 6:247258, Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. There is agreement, however, that the MPFL is almost always injured with lateral patellar dislocations4. 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. Infrapatellar (Hoffas) fat pad impingement is recognized as a cause of anterior knee pain. Thawait SK, Soldatos T, Thawait GK, Cosgarea AJ, Carrino JA, Chhabra A. Skeletal Radiol. Skeletal Radiology 39:7, 675-682. Objective: The purpose of this study is to retrospectively investigate the frequency of a focal defect at the lateral patellar retinaculum on knee MRI and to determine the variables that are significantly associated with the defect. Surgical management of patellar instability should be guided on an individual patient basis depending on history, physical examination, and radiologic findings as outlined above. 3. Epub 2010 Mar 8. Falls. California Privacy Statement, ADVERTISEMENT: Supporters see fewer/no ads. 3 Dirim B, Haghighi P, Trudell D et al. Insights Imaging 10, 65 (2019). The radiograph can be helpful in the acute presentation in detecting fractures in the setting of lateral (often transient) patellar dislocation. These are most often found at the inferomedial patella or the lateral femoral condyle [49, 61, 62]. A ratio equal or more than 1.2 indicates patella alta [35] (Fig. At less than 30 of flexion, asymptomatic knees may demonstrate physiologic patellar tilt or subluxation. Kim et al. Magnetic Resonance Cholangiopancreatography MRI PREMIUM Digestive system Illustrations PREMIUM CT axial male abdomen and pelvis CT PREMIUM CT peritoneal cavity CT PREMIUM MRI female pelvis MRI PREMIUM Female pelvis 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. Would you like email updates of new search results? 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. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Am J Knee Surg 13:8388, Izadpanah K, Weitzel E, Vicari M et al (2014) Influence of knee flexion angle and weight bearing on the Tibial Tuberosity-Trochlear Groove (TTTG) distance for evaluation of patellofemoral alignment. J Orthop Sports Phys Ther 2017;47(10):815. doi:10.2519/ jospt.2017.6616 . Abnormalities of the medial retinaculum and MPFL are seen in 82-100% of MRI examinations following patellar dislocation. (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. official website and that any information you provide is encrypted 2. In the setting of osseous patellar malalignment, an osseous procedure such as tibial tubercle transfer osteotomy can be performed (Fig. 1997 Jun;168(6):1493-9. doi: 10.2214/ajr.168.6.9168713. 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. Before The patients are then J-braced for 3 to 6 months for all sports activities. Operative lateral retinaculum release is indicated in refractory cases. The most obvious presentation of patellar maltracking is that of the first time lateral patellar instability or recurrent instability thereafter. Knee Surg Sports Traumatol Arthrosc 22:23882395, Escala JS, Mellado JM, Olona M, Gin J, Sauri A, Neyret P (2006) Objective patellar instability: MR-based quantitative assessment of potentially associated anatomical features. Clin Orthop Relat Res 471:26412648, Laurin CA, Dussault R, Levesque HP (1979) The tangential x-ray investigation of the patellofemoral joint: x-ray technique, diagnostic criteria and their interpretation. Similar 2-year results in 125 randomized patients. 1995 Jan;164(1):135-9. doi: 10.2214/ajr.164.1.7998526. Yu JS, Goodwin D, Salonen D, Pathria MN, Resnick D, Dardani M, Schweitzer M. AJR Am J Roentgenol. Physical therapy is directed to increasing range of motion and to strengthening the VMO and quadriceps muscles. Arthroscopy 35:537543, Mountney J, Senavongse W, Amis AA, Thomas NP (2005) Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction. PubMed Knee Surg Sports Traumatol Arthrosc 15:13011314, Tom A, Fulkerson JP (2007) Restoration of native medial patellofemoral ligament support after patella dislocation. 1Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 149 Sangil-dong, Gangdong-gu, Seoul 134-727, Korea. Structures such as the iliotibial band, fibular collateral ligament, and biceps femoris tendon are readily apparent on MRI and are easy to identify. These morphological risk factors can be assessed using methods similar to those on MRI as detailed in the prior sections of this article. Jibri, Z., Jamieson, P., Rakhra, K.S. This is often secondary to an underlying structural abnormality. Identifying edema at the superolateral aspect of Hoffas fat pad on MRI should prompt the reporting radiologist to look for features of patellar maltracking. At the time the article was created Pereshin Moodaley had no recorded disclosures. A 2015 Cochrane Review concluded that there is no significant increase in functional scores between nonoperative and operative management; however, surgical management does result in a significantly lower risk of recurrent dislocation at the cost of surgical complications [19]. In: West RV, Colvin AC (eds) The patellofemoral joint in the athlete. The patellar tendon may tear when the knee is bent and the foot planted, like when landing from a jump or . 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). (1a) A single fat-suppressed proton density-weighted coronal image. 3). (13a) A line is drawn between the cortex of the lateral trochlear facet on the most superior axial image showing cartilage. 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. (9a) The Insall-Salvati Index is determined by dividing the length of the patellar tendon (PT) by the length of the patella (PL). Diederichs G, Issever A, Scheffler S. MR Imaging of Patellar Instability: Injury Patterns and Assessment of Risk Factors. (21a) A corresponding anterior coronal slice reveals the large displaced osteochondral fragment (arrow) that occurred as a result of this injury. Perpendicular to this baseline, trochlear depth is calculated by measuring the mean of the maximum AP distance of the medial (a) and lateral (b) femoral condyles minus the distance between the deepest point of the trochlear groove and the line paralleling the posterior condylar surfaces (c). Am J Orthop (Belle Mead NJ) 46:290300, Dejour H, Walch G, Neyret P, Adeleine P (1990) Dysplasia of the femoral trochlea. Rev Chir Orthop Reparatrice Appar Mot 76:4554, CAS Lateral patellar compression syndrome is the improper tracking of the patella in the trochlear groove generally caused by a tight lateral retinaculum. Usually, young individuals, particularly women, suffer the consequences of this disorder [2]. a Axial CT image demonstrating MPFL reconstruction (arrow heads). 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. 2 Baldwin JL. The lateral retinaculum appears as a hyperechoic band originating from the iliotibial band and the vastus lateralis muscle. 3). On the other hand, there are static MRI measurements that are routinely used as indicators of patellofemoral alignment during knee movement [30, 31]. CT of both knees in 20 flexion demonstrating bilateral shallow trochlear groove (arrows) compatible with dysplasia and bilateral lateral patellar subluxation and lateral tilt. Gross anatomy The superficial layer originates from the lowest fibers of the iliotibial band and from an extension of vastus lateralis fascia. Another method is the CatonDeschamps index. Other indicated structures: gracilis (G), semitendinosus (ST), and adductor magnus (AM) tendons. Patella alta is considered an important factor in patellar instability. The knee then was flexed 30, 60, 90, and 120, and the transducer recorded changes in tension within the lateral patellofemoral . Am J Sports Med 16:244249, Hawkins RJ, Bell RH, Anisette G (1986) Acute patellar dislocations. Patellar maltracking is a disorder that often affects the young active individuals. Chronic fat impingement can result in chronic inflammation and fat pad hypertrophy. Imaging, particularly MRI, plays a vital role in the assessment of patellar maltracking. A lateral patellar sleeve fracture can be misdiagnosed The clinical evaluation can be more challenging in the absence of a dislocation history, and in this scenario, imaging can have a critical role. Post WR, Teitge R, Amis A (2002) Patellofemoral malalignment: looking beyond the viewbox. The patella remains laterally shifted (blue arrow) and an osteochondral injury of the medial patella (arrowheads) is apparent. Knee 10:215220, Terry GC, Hughston JC, Norwood LA (1986) The anatomy of the iliopatellar band and iliotibial tract. This short surgical video demonstrates an arthroscopic lateral release as seen from inside the knee. 2010. Patellar tracking refers to the dynamic relationship between the patella and trochlea during knee motion [1]. Lateral patellar dislocation refers to lateral displacement followed by dislocation of the patella due to disruptive changes to the medial patellar retinaculum. The deep layer is comprised of the lateral patellofemoral ligament, patellotibial band and transverse ligament. It is therefore helpful in surgical planning. The pattern of bone bruising seen in a transient lateral patellar dislocation is easy to understand if one considers the mechanism of injury. There are a number of MRI features of trochlear dysplasia including reduction in the trochlear depth, lateral trochlear inclination, and facet asymmetry. b Trochlear dysplasia (9 inclination), Facet asymmetry assessment for trochlear dysplasia on axial MRI. Despite non-operative management, recurrent patellar instability occurs in between 15 and 45% of patients [17,18,19,20]. 2006;187(5):1332-7. The MPFL is best seen on axial MRI on the slice just distal to the VMO.

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