Download - Patellofemoral disorders
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What we should know about:
Patellofemoral disorders
AKRAM ALDAWOUDY, Mch.orth., FRCS
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Patellofemoral disorders
• Anatomy• Biomechanics• Pathology• Common clinical entities
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AnatomyThe patella
• Patella is the largest sesamoid bone• Thickest articular cartilage in the body
• Up to 5mm at central ridge• Articular surface is divided into the lateral
facet and the medial facet • Four different anatomical shapes probably
the result of the stress imposed on it.
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AnatomyThe trochlea
• Asymmetric medial and lateral facets, with the lateral facet little more prominent and more proximal
• The greater height of the lateral facet of the trochlea and the congruence between the sulcus and the ridge are important for stability and constitutes a structural bony stabilizer.
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AnatomyMedial Stabilizers
Medial retinaculum• Including medial patellofemoral ligament• MPFL runs from medial border of patella to
adductor tubercle• 75% restraining medial force • Vastus Medialis obliquus• Pulls at 55 to 70 degrees
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Anatomy Lateral Stabilizers
• Lateral retinaculum• Superficial attaches to ITB• Deep, 3 bands
• Connects to IT band, tibia, & lateral epicondyle• IT band moves posteriorly in flexion
• Contributes to tilt and subluxation• Vastus lateralis
• Main muscle inserts proximally at angle of 31 deg• Vastus lateralis obliquus
• Distinct distal portion from lateral intermuscular septum
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• The patalla pushes away the patellar tendon from the femorotibial contact point, increasing the patellar tendon moment arm (pulley action)
• Centralization of the divergent forces and transmit them in a frictionless way to the tibial tubercle
• Thichest articular cartilage, highiest compressive forces
Biomechanics
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Biomechanics
• Joint reaction forces, the result of the tension developing in the quadriceps and patellar tendons (multiples of body weight)
• 0.5 level walking• 3.3 stair climbing• 7.8 squats
• Patellofemoral contact areas, moves proximally and broadens with increasing flexion.
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• Patellofemoral contact pressure, ratio of patellofemoral reaction ferce to patellofemoral contact areas, most important
• Patellofemoral contact pressure increases with patellar malpositioning, as patellofemoral contact areas decrease
Biomechanics
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Angle of pull of the quadriceps (Q-angle)
Line drawn from ASIS to Mid-patella and Line drawn from mid-patella to tibial tubercleNormal Q angle= 15
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Pathology
• Traumatic: bony chondral ligamentous Merchant’s classification, sophisticated, though comprehensive
• Atraumatic, Insall classification
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Insall Classification
• Presence of cartilage damage chondromalacia Osteoarthritis osteochondritis dissicans• Variable cartilage damage
malalignement syndromes synovial plicae• Usually, normal cartilage
peripatellar causes: bursitis, tendinitis Overuse syndromes Reflex sympathetic dystrophy Patellar abnormalities
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Pathology
• Primary OA
• Pat fem maltraching
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Chondral Pathology
• Diagnosis• history: pain on getting to stairs and
on kneeling, clicking, age, trauma• Clin. exam: patellar squeeze,
tender undersurface, tend lat.retinaculum
• Imaging: plain probably enough, MRI ?!!!
ALWAYS LOOK FOR AN
UNDERLYING FACTOR
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Chondral Pathology
• Treatment: still a problem, especially in young pts. Depends on:• Age of the pt., age of the knee• Generalized or localized lesions• Underlying factor, Maltraching• Stage of the disease
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Chondral Pathology
• Conservative management should be always tried first
RestReduction of wt.Restriction of activitiesQuadriceps trainingNSAIDSPT
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Chondral Pathology
• Treatment:• Operative, DECECION CATIOUSLY TAKEN• Correction of the underlying
maltraching• Lateral retinacular release, may lead
to worse results ??!! • Articular cartilage management, from
cell to metal
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Chondral Pathology
• Arthroscopic debridement/chondroplasty• Microfracture• Chondral grafts• ACI
• Generally less successful than for condylar lesions
• Anterior Displacing Osteotomies• Fulkerson
• angled for less medialization• Maquet
• avoid huge grafts
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Chondral Pathology
• Patellectomy Mainly of historical interest• Patellofemoral arthroplasty Generally for older, lower demand patients Not as well proven as TKA• TKA Gold standard if coexistent femoral-tibial arthritis Reasonable in older, low demand patients with severe PF and some other compartment disease
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Maltraching
A- Acute dislocation:• Usually presents to A&E after an injury!! Easy
reduction• Often hemarthrosis
• If aspiration returns fat then suspect fracture• 40% risk of osteochondral injury
• Many missed on Xray• MRI better• Most often medial patellar facet and lateral
femur• Most often underlying alignment issues
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Maltraching
• Treatment of acute form:• Extend knee to reduce• If x ray changes, fat in joint, or crepitus
consider scope• Physical therapy• Primary repair of MPFL only in selected pts.
• 50% will probably need eventual surgery• Early interveniton may increase chronic
pain and arthrofibrosis
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Maltraching
B-The chronic form:• May present with pain and/or mechanical
symptoms• Medial and lateral patellar translationCompare medial to lateral and side to sideApprehension test
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Careful planning
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Maltraching
Consider:• Overall limb alignment, valgus knee, valgus heel,
femoral anteversion…• Trochlear geometry• Patellar tilt• Quadriceps function• Age, style of life …• Beware of hyperlaxity, bilaterality• Rotational alignment of the whole limb• Degree of sublaxation• Only dynamic instability !!!• Degree of articular cartilage pathology• J-sign, pat height
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Maltraching
• Radiology• Good quality x rays• Whole leg standing films• Tangential views• CT• MRI ??!!!
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Maltraching
Conservative treatment• Rest, Ice, NSAIDS• Physical therapy
• Should be tried for several months before more aggressive measures
• Avoid aggressive quad strengthening if pain important
• Patellar tracking braces• Avoidance of offending activities
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Maltraching
Surgical treatment: tailored for every pt. indiviually• Lateral release: Probably to be done with
lateral patellar compression syndrome• Distal realignment: Transfer, anterior, anteromedial, posteromedial (not done) Osteotomies, valgus knees
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Maltraching
• Proximal realignment: Trochleoplasty, Good results in well selected cases, open and recently !!! arthroscopic MPFL reconstruction “advancement”, commonly done now, different techniques, isolated gracilis graft or a strip of patellar tendon
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Take home message
• Patellofemoral joint disorders one of the very complex issues
• Look at the limb as a whole• Conservative measures always come first• Surgery may be devastating if not carefully
planned for• Lateral release over done ??!!• MPFL reconstruction coming to be a
standard procedure
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لكم الله شكر