Relationship between patellofemoral joint morphology and chondromalacia patella.

BACKGROUND: For the normal functioning of the patellofemoral joint (PF), the relationship between the patella and the trochlear groove must be compatible. PURPOSE: To investigate the relationship between patellofemoral joint morphology (PFM) and patellar chondromalacia. MATERIAL AND METHODS: Overall, 136 knees of patients aged 20-55 years examined between March 2020 and March 2021 were included in this study. In all patients, trochlear sulcus angle, trochlear sulcus depth, trochlear facet asymmetry, patella alta (Insall-Salvati [IS] index), and patellar facet asymmetry were measured. Of these cases, 66 knees with an abnormality detected in any of the measurements for PFM were included in the case group. Moreover, 70 knees with demonstrating normal PFM measurements were included in the control group. RESULTS: The incidence and grade of chondromalacia was higher in the case group than in the control group (P < 0.001). Between the patients with and without chondromalacia trochlear sulcus angle (mean = 138.25° ± 10.02° vs. 132.58° ± 7.24°; P = 0.001), IS index (mean = 1.25 ± 0.21 vs. 1.16 ± 0.15; P = 0.014), patellar facet asymmetry (mean = 0.77 ± 0.09 vs. 0.73 ± 0.12; P = 0.039), trochlear sulcus depth (mean = 5.39 ± 1.42 mm vs. 6.27 ± 1.04 mm; P < 0.001), and trochlear facet asymmetry (mean = 0.67 ± 0.11 vs. 0.71 ± 0.09; P = 0.023) measurements, there was a significant difference. CONCLUSION: The presence of at least one of the measures indicating pathology in PFM is associated with the presence and severity of chondromalacia.

Medial Patellofemoral Reconstruction Techniques for Patellar Instability.

The medial patellofemoral complex (MPFC) is the term used to describe the primary soft tissue stabilizer of the patella, which consists of fibers that attach to the patella (medial patellofemoral ligament, or MPFL), and the quadriceps tendon (medial quadriceps tendon femoral ligament, or MQTFL). Despite the variability of its attachment on the extensor mechanism, the midpoint of this complex is consistently at the junction of the medial quadriceps tendon with the articular surface of the patella, indicating that either patellar or quadriceps tendon fixation can be used for anatomic reconstruction. Multiple techniques exist to reconstruct the MPFC, including graft fixation on the patella, quadriceps tendon, or both structures. Various techniques using several graft types and fixation devices have all reported good outcomes. Regardless of the location of fixation on the extensor mechanism, elements critical to the success of the procedure include anatomic femoral tunnel placement, avoiding placing undue tension on the graft, and addressing concurrent morphological risk factors when present. This infographic reviews the anatomy and techniques for the reconstruction of the MPFC, including graft configuration, type, and fixation, while addressing common pearls and pitfalls in the surgical treatment of patellar instability.

Editorial Commentary: Patellofemoral Instability Results in Osteoarthritis, and Nonanatomic Surgery and Surgical Over-constraint May Also Cause Osteoarthritis.

When we are looking at the stars, we are in fact looking back in time. This is because it takes years for the light from the stars to reach us. In similar fashion, when we are evaluating data on osteoarthritis after patellofemoral surgery, we need to consider what kind of procedure was performed. Furthermore, it is extremely important to answer the question of whether the patellofemoral instability itself or the surgical procedure is causing the arthritis. Recent evidence suggests that recurrent patellofemoral instability is causing cartilage degeneration and stopping this process via surgical restoration of the anatomy and biomechanics of the patellofemoral joint may significantly reduce the risk of osteoarthritis. Shear loading of the cartilage can be detrimental. An instability event elicits inflammatory markers that are shown to induce arthritis. On the other hand, there is the argument that over-constraint may lead to arthritis owing to an increase in cartilage loading. Another argument is that surgery may not fully restore the patellofemoral anatomy. Appropriate patient selection and continuous evolution of our surgical procedures are key elements toward successful management of patellofemoral instability.

Sulcus depth, congruence angle, Wiberg index, TT-TG distance, and CDI are strong predictors of recurrent patellar dislocation.

PURPOSE: To characterize patellofemoral morphology, determine radiological cutoff values based on computed tomography (CT) images, and clarify predominant anatomic risk factors in young patients with recurrent patellar dislocation (RPD). METHODS: A total of 212 knees (age 23.0 ± 5.3 years, female: male = 110:102) with CT-confirmed RPD were enrolled for analysis. The control group was matched by age and sex (2:1). Patellofemoral and trochlear morphology, patellofemoral alignment, and other parameters were assessed by CT. Standardized methods were used for measurements. Receiver operating characteristic (ROC) curves and the areas under the ROC curve (AUCs) were used to assess accuracy in diagnosing RPD. The index of union (IU) was employed to identify a cutoff value for risk. A binary logistic regression model (Forward, LR) was constructed, and standardized coefficients were calculated to compare the relative strength of different predictors. Factors included in the model were employed to calculate distributions in the studied population. RESULTS: The majority of measurements showed a significant difference between the RPD and control groups when comparing mean values. The AUC value was favorable for sulcus depth and significantly better than that for other trochlear morphology parameters (P < 0.0001). Cutoff values were 0.58 for the Wiberg index, 153.3° for the sulcus angle, 3.6 mm for the sulcus depth, 1.94 for the trochlear width ratio, 16.2° for the lateral trochlear inclination, 17.2° for the patellar lateral tilt, 25.5° for the congruence angle, 1.2 for the patellar height [Caton-Deschamps index (CDI)], 6.1° for the knee rotation, and 16.4 mm for the tibial tubercle-trochlear groove (TT-TG) distance. A binary logistic regression model (χ2 = 20.826, P = 0.008) including the Wiberg index, sulcus depth, congruence angle, patellar height (CDI), and TT-TG distance was constructed for RPD (P ≤ 0.015), which showed excellent diagnostic performance, as indicated by an AUC of 0.989 (95% CI, 0.979 to 0.998). Sulcus depth showed the strongest relationship with RPD, followed by the congruence angle and Wiberg index, as indicated by the standardized coefficients - 1.43, 1.02, and 0.97, respectively. Eighty-seven percent of the RPD population had sulcus depth ≤ 3.6 mm. CONCLUSIONS: This study provides a systematic reference of cutoff values based on CT data. The combination of five anatomic risk factors (sulcus depth, congruence angle, Wiberg index, TT-TG distance, and CDI) may be an excellent predictor of RPD as initial risk assessment. Sulcus depth, as the most frequently observed anatomic risk factor, showed the best diagnostic performance among trochlear morphological parameters and the strongest relationship with RPD, followed by the congruence angle and Wiberg index. In clinical practice, the sulcus depth, congruence angle, Wiberg index, TT-TG distance, and CDI with the proposed cutoff values can be used in combination to evaluate RPD. When assessing trochlear morphology, sulcus depth is recommended as the best radiological parameter. LEVEL OF EVIDENCE: Level III.

Axial orientation of the femoral trochlea is superior to femoral anteversion for predicting patellar instability.

PURPOSE: The femoral anteversion angle is considered to be the same as femoral torsion; however, the femoral anteversion angle is strongly influenced by the femoral posterior condylar morphology. It remains unclear whether the femoral anteversion angle and axial orientation of the femoral trochlea can predict patellar instability. This study aimed to redefine the femoral inherent torsion, verify whether the femoral anteversion angle reflects the femoral inherent torsion, and compare the validity and calculate the cut-off values of the femoral anteversion angle and femoral trochlear axial orientation for predicting patellar instability. METHODS: Seventy-three patients with patellar instability and 73 matched controls underwent computed tomography to measure the femoral anteversion angle, femoral inherent torsion, and femoral trochlear axial orientation. Pearson's product moment correlation coefficients and linear regression were calculated to determine correlations between measurements. Receiver operating characteristic curves and nomograms were plotted to evaluate the predictive validity of the femoral anteversion angle and femoral trochlear axial orientation for patellar instability. RESULTS: All measurements showed excellent intra- and inter-observer reliability. Compared with the control group, the patellar instability group had a significantly larger femoral anteversion angle (25.4 ± 6.4° vs. 20.2 ± 4.5°) and femoral inherent torsion (18.3 ± 6.7° vs. 15.8 ± 3.4°), and significantly smaller femoral trochlear axial orientation (58.1 ± 7.3° vs. 66.9 ± 5.1°). The femoral anteversion angle and femoral trochlear axial orientation had area under the receiver operating characteristic curve values of 79 and 84%, respectively, and cut-off values of 24.5° and 62.7°, respectively. The calibration curve and decision curve analysis showed that the femoral trochlear axial orientation performed better than the femoral anteversion angle in predicting patellar instability. There was a strong correlation between the femoral anteversion angle and femoral inherent torsion (r > 0.8). Linear regression analysis of the femoral inherent torsion with the femoral anteversion angle as the prediction variate showed moderate goodness-of-fit (adjusted R2 = 0.69). CONCLUSION: The femoral anteversion angle moderately reflects the femoral inherent torsion. The femoral trochlear axial orientation is better than the femoral anteversion in predicting patellar instability in terms of predictive efficiency, consistency with reality, and net clinical benefit. These findings warn orthopaedists against overstating the role of the femoral anteversion angle in patellar instability, and suggest that the femoral trochlear axial orientation could aid in identifying at-risk patients and developing surgical strategies for patellar instability. LEVEL OF EVIDENCE: III.

Patellar shift ratio (PSR) is the optimal measurement for characterising lateral patellar shift and a reliable predictor of recurrent patellar dislocation.

PURPOSE: To propose a new measurement, the patellar shift ratio (PSR), for characterising lateral patellar shift; to determine its diagnostic accuracy in predicting recurrent patellar dislocation (RPD); and to identify the effect of patellar tilt and morphology on shift measurements. METHODS: Variables including the PSR, bisect offset (BSO), BSO adjusted by trigonometric analysis, linear patellar displacement (LPD) distance and congruence angle were measured on axial computed tomography (CT). Furthermore, PSR was classified into grades determined by the threshold generated by receiver operating characteristic (ROC) curves. Youden's index was used to identify the ideal threshold on the curve. The area under the ROC curve (AUC) values and likelihood ratios were calculated to assess diagnostic performance in predicting RPD. Correlation analysis was conducted to identify the effects of lateral tilt and the Wiberg index on lateral shift. Intra- and interobserver reliability were evaluated using the intraclass correlation coefficient. RESULTS: The study included 54 RPD patients and 54 controls matched by sex and age. The threshold for PSR was 24.3% (sensitivity, 96.30%; specificity, 85.19%). AUCs were categorised as excellent for all protocols (P < 0.001). The positive likelihood ratio of the PSR for predicting RPD was 6.50. PSR was categorised in terms of lateral trochlear quadrants consisting of 25% increments. Lateral patellar tilt showed a strong positive correlation with BSO (P < 0.001); moderate correlations with PSR, LPD distance and adjusted BSO (P ≤ 0.001); and a weak correlation with congruence angle (P = 0.034). The Wiberg index presented a positive moderate correlation with BSO (P < 0.001), while no correlation was found with PSR, LPD distance, or congruence angle (n.s.). All parameters showed good repeatability (intraobserver) and reproducibility (interobserver). CONCLUSIONS: The PSR showed excellent diagnostic performance as indicated by likelihood ratios, measurement accuracy (being relatively resistant to the effects of tilt and the Wiberg index), and intra- and interobserver reliability. The optimal PSR threshold for predicting RPD risk was 24.3%, and the grade of PSR (normal, 1-4) was also a reliable and easily calculated predictor of RPD. This quantifying method to characterise lateral patellar shift is an alternative useful method for clinical assessments of RPD patients and for research on patellofemoral congruence. LEVEL OF EVIDENCE: Level III.

Surgery for patellar dislocation has evolved towards anatomical reconstructions with assessment and treatment of anatomical risk factors.

PURPOSE: Increasing knowledge on the treatment of patellar dislocation has resulted in the development of new surgical techniques for patella stabilisation. National incidence and trends in surgery for patellar dislocation were examined using data from the Finnish National Hospital Discharge Register (NHDR). The hypothesis was that an increased understanding of the pathophysiology of patellar instability has increased the popularity of reconstructing damaged structures and modification of anatomical risk factors. METHODS: Data from the years 1997-2016 were collected from the NHDR database using ICD-10 diagnostic codes and the Nomesco Classification of Surgical Procedures (NCSP) codes. Surgical procedures were categorised into subgroups representing the main surgical approaches of patellar dislocation. Total incidence of surgery for patellar dislocation and change in incidence during the study period were calculated. RESULTS: A total of 9702 operations for patellar dislocation were performed during the study period. Median (IQR) patient age at time of primary surgery was 23 (18-34) years. The total incidence of surgeries remained stable across the study period at of 8.9 per 100,000 person-years. Incidences of ligament reconstruction, femoral osteotomies and osteochondral fragment reimplantation operations multiplied during the study period. Ligament reconstruction procedures were the most performed operations at the end of the study period. CONCLUSION: The incidence of surgical procedures for patellar dislocation remained unchanged during the years 1997-2016. Ligament reconstruction procedures increased in popularity. Surgical techniques have shifted towards the reconstruction of damaged structures and the modification of congenital anatomical risk factors for patellar dislocation. Diversified surgical techniques have enabled the tailoring and combining of stabilizing procedures according to the patient's individual anatomy.

Radiographic Reference Points Do Not Ensure Anatomic Femoral Fixation Sites in Medial Patellofemoral Ligament Reconstruction: A Quantified Anatomic Localization Method Based on the Saddle Sulcus.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is one of the main treatments for lateral patellar translation. Based on intraoperative true lateral radiographs, the accepted methods for femoral MPFL tunnel location are potentially inaccurate. Direct assessment of anatomic characteristics during surgery through palpation of the anatomic landmarks involving the saddle sulcus might help eliminate tunnel malposition. HYPOTHESIS: The saddle sulcus is a reliable osseous landmark where the MPFL attaches for tunnel placement. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 9 fresh-frozen unpaired human cadaveric knees were dissected; MPFL insertion point and relative osseous structures were marked. Three-dimensional images and transformed true lateral radiographs were obtained for analysis; 3 previously reported radiographic reference points for MPFL femoral tunnel placement were determined on all images and compared with the anatomic insertion. RESULTS: A saddle sulcus consistently existed where the MPFL was attached, located at 11.7 ± 5.9 mm from the apex of the adductor tubercle (AT) to the medial epicondyle (ME), 62.8% of the average distance between the apexes of the AT and ME, and 5.6 ± 2.8 mm perpendicular-posterior to the border connecting the AT and ME. The reported radiographic reference points were located at average distances of 6.2 ± 3.2 mm (Schöttle method), 5.9 ± 2.3 mm (Redfern method), and 7.3 ± 6.6 mm (Fujino method) from the saddle sulcus center on the true lateral radiographs. CONCLUSION: The saddle sulcus was a reliable landmark where the MPFL was anatomically attached, located approximately 12 mm from the AT to the ME (approximately 60% along a line from the AT to the ME) and 6 mm perpendicular-posterior to the border connecting the apexes of the AT and ME. Additionally, the saddle sulcus position presented variability on the femoral aspect of different knees. All of the average direct distances from the sulcus to the reference radiographic points exceeded 5 mm, and tunnel localizations on a true lateral radiograph were inaccurate. CLINICAL RELEVANCE: This study demonstrates the potential precise position of the saddle sulcus, according to the ME and AT, as a reliable anatomic landmark for MPFL femoral tunnel location. Radiographic reference points were not accurate during MPFL reconstruction. Direct palpation of the landmarks might be effective for femoral MPFL tunnel placement.

Preoperative patellofemoral anatomy affects failure rate after isolated patellofemoral inlay arthroplasty.

PURPOSE: To analyze whether preoperative patellofemoral anatomy is associated with clinical improvement and failure rate after isolated patellofemoral arthroplasty (PFA) using a modern inlay-type trochlear implant. METHODS: Prospectively collected 24 months data of patients treated with isolated inlay PFA (HemiCAP® Wave, Arthrosurface, Franklin, MA, USA) between 2009 and 2016, and available digitalized preoperative imaging (plain radiographs in three planes and MRI) were retrospectively analyzed. All patients were evaluated using the WOMAC score, Lysholm score, and VAS pain. Patients revised to TKA or not achieving the minimal clinically important difference (MCID) for the total WOMAC score or VAS pain were considered failures. Preoperative imaging was analyzed regarding the following aspects: Tibiofemoral OA, patellofemoral OA, trochlear dysplasia (Dejour classification), patellar height (Insall-Salvati index [ISI]; Patellotrochlear index [PTI]), and position of the tibial tuberosity (TT-TG and TT-PCL distance). RESULTS: A total of 41 patients (61% female) with a mean age of 48 ± 13 years could be included. Fifteen patients (37%) were considered failures, with 5 patients (12%) revised to TKA and 10 patients (24%) not achieving MCID for WOMAC total or VAS pain. Failures had a significantly higher ISI, and a significantly lower PTI. Furthermore, the proportion of patients with a pathologic ISI (> 1.2), a pathologic PTI (< 0.28), and without trochlear dysplasia were significantly higher in failures. Significantly greater improvements in clinical outcome scores were observed in patients with a higher preoperative grade of patellofemoral OA, ISI ≤ 1.2, PTI ≥ 0.28, TT-PCL distance ≤ 21 mm, and a dysplastic trochlea. CONCLUSION: Preoperative patellofemoral anatomy is significantly associated with clinical improvement and failure rate after isolated inlay PFA. Less improvement and a higher failure rate must be expected in patients with patella alta (ISI > 1.2 and PTI < 0.28), absence of trochlear dysplasia, and a lateralized position of the tibial tuberosity (TT-PCL distance > 21 mm). Concomitant procedures such as tibial tuberosity transfer may, therefore, be considered in such patients. LEVEL OF EVIDENCE: Level III, retrospective analysis of prospectively collected data.

Femoral Origin Anatomy of the Medial Patellofemoral Complex: Implications for Reconstruction.

PURPOSE: To report the shape and orientation of the medial patellofemoral complex (MPFC) footprint on the medial femur and describe the difference between the proximal (medial quadriceps tendon femoral ligament, MQTFL) and distal (medial patellofemoral ligament, MPFL) fibers. METHODS: In 20 cadaveric knees, the MPFC footprint on the medial femur was exposed. Images of the medial femur were analyzed using ImageJ software. The length and width of the MPFC footprint were described to the nearest 0.1 mm; the angle of its long axis was described relative to the axis of the femoral shaft (0.1°). The footprint's most proximal and distal margins were described in relation to the adductor tubercle and medial epicondyle. The differences between each were compared using paired t tests. RESULTS: 17 knees from 10 cadavers were included in this study. The MPFC footprint had a length of 11.7 ± 1.8 mm and a width of 1.7 ± 0.4 mm. The long axis of the footprint was at an angle 14.6° ± 16.6° anterior to the axis of the femoral shaft. The most proximal (MQTFL) fibers originated 7.4 ± 3.8 mm anterior and 1.8 ± 4.7 mm distal to the adductor tubercle and 4.1 ± 2.9 mm posterior and 8.4 ± 5.6 mm proximal to the medial epicondyle. The most distal (MPFL) fibers originated 4.9 ± 4.2 mm anterior and 12.7 ± 4.3 mm distal to the adductor tubercle, as well as 7.1 ± 2.4 mm posterior and 0.5 ± 5.6 mm distal to the medial epicondyle. The distal margin of the femoral MPFC footprint was 10.9 ± 1.7 mm distal (p < .001) and 2.6 ± 3.2 mm more posterior (p = .005) than the proximal margin. CONCLUSIONS: The femoral footprint of the MPFC has a length almost 7 times greater than its width, with the distal margin being 10.9 mm distal and 2.6 mm posterior to the proximal margin. CLINICAL RELEVANCE: This differential anatomy within the femoral origin suggests that MPFL and MQTFL reconstruction may require separate positions of femoral fixation to recreate the anatomy of these fibers.

Patella-patellar tendon angle and lateral patella-tilt angle decrease patients with chondromalacia patella.

PURPOSE: The aim of the present study was to evaluate the effect of patellofemoral joint morphology and patellar alignment (lateral patellar tilt and sagittal patellar tilt) on the presence and stage of CP, and identify the differences between sexes. METHODS: MRI of 243 patients [146 men (60.1%)] were evaluated retrospectively. Patients were grouped as normal group without chondromalacia, group with mild chondromalacia (grades 1-2) and group with severe chondromalacia (grades 3-4). Sagittal patellofemoral alignment was assessed by the angle between the patella and patellar tendon (P-PTA), and the angle between the quadriceps tendon and patella (Q-PA). Patellar tilt was assessed by lateral patellar tilt angle (LPTA). In addition, patellofemoral joint morphology was evaluated by measuring trochlear depth (TD), trochlear sulcus angle (TSA) and patella angle (PA). RESULTS: P-PTA, Q-PA, LPTA and TD values were significantly lower in patients with severe chondromalacia than in patients with both normal and mild chondromalacia (P < 0.001). TSA values were significantly higher in patients with severe chondromalacia than those with both normal and mild chondromalacia (P < 0.001). TSA was higher and TD was lower in women compared to men (P < 0.001). LPTA and P-PTA were lower in women compared to men, and the difference was significant. There was no difference in PA between the two sexes. CONCLUSIONS: Patellar cartilage degeneration increases with trochlear dysplasia. There is a strong correlation between patellar malalignment (lateral patellar tilt and sagittal patellar tilt) and chondromalacia patella. Women are more prone to developing CP than men.

Differential Contributions of the Quadriceps and Patellar Attachments of the Proximal Medial Patellar Restraints to Resisting Lateral Patellar Translation.

PURPOSE: To define the contributions of the of the medial patellofemoral ligament (MPFL) and medial quadriceps tendon femoral ligament (MQTFL) to lateral patellar translation as the knee moves through a 90° arc of motion. METHODS: Six pairs of bilateral cadaveric knee specimens (12 knees) were dissected and potted in perfect lateral position using fluoroscopy. An eye screw was placed in the midpoint on the lateral aspect of the patella. Each knee underwent testing in 4 conditions after sequential sectioning: intact, lateral retinacular release, randomized MQTFL or MPFL sectioning, and complete proximal medial patellar restraint (PMPR) sectioning. With a custom machined jig, all knees were tested at 0, 10, 20, 30, 45, 60, and 90° of flexion on an MTS machine with 20N of lateral patellar force applied and displacement recorded. RESULTS: PMPR extensor mechanism insertion on all specimens was identified 50% on the quadriceps tendon and 50% on the proximal aspect of the medial patella. Isolated MPFL sectioning resulted in significantly increased lateral displacement compared to the lateral release state at all flexion angles tested except 0°. There was significantly increased lateral patellar displacement with complete sectioning compared with isolated proximal sectioning at all degrees of knee flexion except 0°. However, complete sectioning following isolated MPFL sectioning did not demonstrate significance at any angle. CONCLUSIONS: Compared with the MQTFL, the MPFL is primarily responsible for resistance to lateral patellar translation throughout a 0° to 90° arc of motion. The MPFL provides a similar resistance to lateral patellar displacement as the fully intact PMPR; however, the MQTFL may contribute to resistance in full extension. CLINICAL SIGNIFICANCE: Proximal medial patellar restraint reconstruction techniques involving both the patellar and quadriceps insertion have been described; however, the unique contributions of the native anatomy to lateral patellar restraint have not been investigated.

Medial Patellofemoral Ligament Isometry in the Setting of Patella Alta.

PURPOSE: To investigate alterations in technique for medial patellofemoral ligament (MPFL) reconstruction in the setting of patella alta and describe the effect of these alterations on MPFL anatomometry. METHODS: Ten cadaveric knees were used. Four candidate femoral attachment sites of MPFL were tested. The attachment sites were Schottle's point (SP), 5 mm distal to SP, 5 mm proximal to SP, and 10 mm proximal to SP. A suture anchor was placed at the upper 40% of the medial border of the patella with the emanating suture used to simulate the reconstructed ligament. MPFL maximum length change was calculated through a range of motion between 0° and 110°. Recordings at all 4 candidate femoral attachments sites were repeated after a flat tibial tubercle osteotomy and transfer to achieve alta as measured by the Caton-Deschamps Index (CDI) of 1.3, 1.4, and 1.5. RESULTS: The 10 specimens had an average CDI of 0.99, range 0.87 to 1.16. In the native tibial tubercle condition, SP was more isometric through 20° to 70° range of motion, or anatomometric, than any other candidate femoral attachment location. With patella alta with a CDI of 1.3 and 1.4, attachment site 5 mm proximal to SP exhibited more anatomometry than SP. With patella alta with a CDI of 1.5, attachment site 10 mm proximal to SP exhibited more anatomometry than SP. CONCLUSIONS: Increased patella alta significantly alters MPFL anatomometry. With increasing degrees of patella alta, more proximal candidate femoral attachment sites demonstrate decreased change in length compared with SP. None of the varied femoral attachments produced anatomometry over the entirety of the flexion range from 20° to 70°, suggesting that in cases of significant patella alta, proximalization the femoral attachment site of MPFL reconstruction may be necessary to achieve an anatomometric MPFL reconstruction. CLINICAL RELEVANCE: A standardized, isolated MPFL reconstruction may be prone to failure in the setting of patella alta, given the anisometry demonstrated. Alternative femoral attachment sites for MPFL reconstruction should be considered in these patients.

Healthy knees have a highly variable patellofemoral alignment: a systematic review.

PURPOSE: There is still lack of knowledge regarding the variability of patellofemoral alignment in healthy, non-osteoarthritic knees, without patellofemoral instability. Therefore, a systematic review of the existing literature was performed to evaluate the variability of patellofemoral alignment. METHODS: Patellofemoral alignment of the knee was defined by the following parameters: sulcus angle (SA), femoral trochlear depth (FTD), patellar tilt angle (PTA), lateral patellofemoral angle (LPFA), lateral femoral trochlear inclination (LFTI) and tibial tubercle-trochlear groove distance (TT-TG). The electronic databases MEDLINE and EMBASE were searched from database inception to search date (January 11, 2019) and screened for relevant studies. The PRISMA guidelines were followed. Articles reporting PF alignment measurements of healthy knees in patients between 15 years and 47 years were included. RESULTS: A total of 15 studies met the inclusion criteria. The studies reported mean values and standard deviations for the SA between 118.7° ± 7 and 168°; for the FTD between 3.4 mm ± 1.1 and 7.1 mm ± 1.8; for the PTA between 0.7° ± 4.99 and 17.05° ± 4.3; for the LPFA between 6.26° ± 4.1 and 11.1° ± 4.0; for the LFTI between 16.3° ± 2.8 and 22.1° ± 1.9; and for the TT-TG between 9.8 mm ± 4.6 and 17.3 mm ± 5.3. CONCLUSION: Patellofemoral alignment in the healthy knee is extremely variable. A more precise knowledge of the complex relationship between the patella and the trochlea may help to better diagnose PF disorders and eventually help in selecting the correct therapy. Furthermore, standardised imaging protocols and measurement techniques for patellofemoral parameters are needed. LEVEL OF EVIDENCE: III.

Sagittal patellar flexion angle: a novel clinically validated patellar height measurement reflecting patellofemoral kinematics useful throughout knee flexion.

PURPOSE: Patellar height measurements on lateral radiographs are dependent on knee flexion which makes standardisation of measurements difficult. This study described a plain radiographic measurement of patellar sagittal height which reflects patellofemoral joint kinematics and can be used at all degrees of flexion. METHODS: The study had two parts. Part one involved 44 normal subjects to define equations for expected patellar position based on the knee flexion angles for three new patellar height measurements. A mixed model regression with random effect for individual was used to define linear and polynomial equations for expected patellar position relating to three novel measurements of patella height: (1) patellar progression angle (trochlea), (2) patellar progression angle (condyle) and (3) sagittal patellar flexion. Part two was retrospective and involved applying these measurements to a surgical cohort to identify differences between expected and measured patellar position pre- and post-operatively. RESULTS: All three measurements provided insight into patellofemoral kinematics. Sagittal patellar flexion was the most useful with the least residual error, was the most reliable, and demonstrated the greatest detection clinically. CONCLUSIONS: Clinically applied radiographic measurements have been described for patellar height which reflect the sagittal motion of the patella and can be used regardless of the degree of flexion in which the radiograph was taken. The expected sagittal patellar flexion linear equation should be used to calculate expected patellar height. LEVEL OF EVIDENCE: IV.

Femoral Anteversion Is Related to Tibial Tubercle-Trochlear Groove Distance in Patients with Patellar Dislocation.

PURPOSE: To evaluate the potential relationship between the tibial tubercle-trochlear groove (TT-TG) distance and the femoral anteversion of different segments of the femur in patients with patellar dislocation. METHODS: A total of 60 patients with a diagnosis of patellar dislocation were included in our study. Patients with previous knee surgeries, previous fractures, or lack of necessary radiologic examinations were excluded from our study. The data of computed tomography scanning within a week before the surgery was used to measure the TT-TG distance, total anteversion, proximal anteversion, diaphyseal anteversion, distal anteversion, and tibial torsion. All the data were obtained from the picture archiving and communication system (PACS) workstation. The Pearson correlation analysis was performed to confirm the potential relationship between TT-TG distance and femoral anteversion of different segments. The intraclass correlation coefficient was used to assess the interobserver reliability of measurements. RESULTS: The TT-TG distance was significantly correlated with the diaphyseal anteversion (r = -0.305, P = 0.008) and distal anteversion (r = 0.365, P = 0.004). The total anteversion was associated with proximal anteversion (r = 0.392, P = 0.02) and diaphyseal anteversion (r = 0.631, P < 0.001). The intraclass correlation coefficient showed the measurements of included parameters were presented with excellent agreement. CONCLUSION: Our study showed that patients with high diaphyseal anteversion and distal anteversion tend to had a higher TT-TG distance but the value of total and proximal femoral anteversion were independent of the value of TT-TG distance. LEVEL OF EVIDENCE: Level IV therapeutic case series.

Concepts of the Distal Medial Patellar Restraints: Medial Patellotibial Ligament and Medial Patellomeniscal Ligament.

The important medial patellar ligamentous restraints to lateral dislocation are the proximal group (the medial quadriceps tendon femoral ligament and the medial patellofemoral ligament) and the distal group [medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML)]. The MPTL patellar insertion is at inferomedial border of patella and tibial insertion is in the anteromedial tibia. The MPML originates in the inferomedial patella, right proximal to the MPTL, inserting in the medial meniscus. On the basis of anatomy and biomechanical studies, the MPTL and MPML are more important in 2 moments during knee range of motion: terminal extension, when it directly counteracts quadriceps contraction. In a systematic review on MPTL reconstructions 19 articles were included detailing the clinical outcomes of 403 knees. All were case series. Overall, good and excellent outcomes were achieved in >75% of cohorts in most studies and redislocations were <10%, with or without the association of the medial patellofemoral ligament. The MPTL is a relevant additional tool to proximal restraint reconstruction in select patient profiles; however, more definitive clinical studies are necessary to better define surgical indications.

Why and Where to Move the Tibial Tubercle: Indications and Techniques for Tibial Tubercle Osteotomy.

Patellofemoral disorders including pain and instability are common orthopedic problems, particularly in the adolescent population. Patellofemoral pain is usually anterior, poorly localized, and diffuse. Because of its multifactorial etiology, patellofemoral pain can be clinically challenging to diagnose and manage. With regards to instability, predisposing factors include trochlear dysplasia, patella alta, patellar tilt, and an elevated tibial tuberosity and trochlea groove distance. Initially, nonoperative management is recommended to treat patellofemoral maladies such as overload, maltracking, and acute first-time dislocations. However, tibial tubercle transfer (TTT) is commonly used to address cases of symptomatic malalignment and overload and recurrent patellar instability. The tubercle can be translated in multiplanar directions to correct patellar height, maltracking associated with instability, and to offload chondral defects. A thorough understanding of the anatomy and biomechanics of the patellofemoral joint is essential for optimizing results after TTT. Individualizing the direction and degree of tubercle transfer on the basis of patient parameters is critical to producing successful long-term results after surgery. This article will review the indications for performing a TTT and highlight the various techniques.

When is Trochleoplasty a Rational Addition?

Trochlear dysplasia has been recognized as a dominant anatomic risk factor in patients with recurrent patellar instability. Sulcus-deepening trochleoplasty is a very effective and powerful procedure for correcting trochlear dysplasia and, specifically, eliminating the supratrochlear spur. However, it must be emphasized that trochleoplasty is not appropriate for patients with mild trochlear dysplasia or those without a large supratrochlear spur or bump. We discuss the characteristics and classification of trochlear dysplasia and discuss specific indications for sulcusdeepening trochleoplasty.

Descriptive and dynamic study of the medial patellofemoral ligament (MPFL).

PURPOSE: The goal of this study was to evaluate the anatomy of the medial patellar retinaculum and the medial patellofemoral ligament (MPFL) to provide an anatomical validation of a pediatric reconstruction technique. METHODS: Fifteen knees were dissected to study the MPFL and its relationship with the medial patellar retinaculum and the femoral insertion of the medial collateral ligament (MCL). The distances between the insertions of the MPFL of eight knees, and the patellar insertion of the MPFL and the femoral insertion of the MCL of four knees, were measured during the flexion to evaluate the isometricity of the native and reconstructed MPFL. RESULTS: The medial patellar retinaculum includes four structures: the fascia, fibrous expansions of the vastus muscles, the MPFL and the medial patellomeniscal ligament. The femoral insertion of the MPFL was located just behind the femoral insertion of the MCL in 12 knees. During flexion, the distance between the insertion on the upper patella and the femoral insertion of the MPFL increased while the distance between the insertion on the lower patella and the femoral insertion of the MPFL decreased. The variation in the distances measured during the flexion was greater between the MPFL insertions (nsup = 6.5 mm, ninf = 6.5 mm) than between the patellar insertion of the MPFL and the femoral insertion of the MCL (n'sup = 2.5 mm, n'inf = 5.75 mm). CONCLUSION: The MPFL is not isometric. Even though the results were obtained from knees of elderly specimens, this study demonstrates reconstruction of the MPFL should take into account its anatomy and biomechanical role in the knee.