patellar tracking controlled the patellofemoral...

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The Patellofemoral JointJOHN R. GREEN, III, M.D.DEPARTMENT OF ORTHOPAEDICS UNIVERSITY OF TEXAS HEALTH SAN ANTONIO

Patellar Tracking Controlled by the Quadriceps

Quadriceps inhibition Pain Inflammation Joint effusion

www.jospt.org/doi/pdf/10.2519/jospt.1998.28.5.307 by KE Wilk - 1998/

Quadriceps Balance Lateral Patella Force

Dynamic Q-angle Proximal

Femoral adductionHip internal rotation

DistalPronationTibial internal rotation

http://www.patellofemoral.org/pfoe/images/02_11.jpg Fulkerson http://www.jgphysiocoach.co.uk/common-culprits-of-non-traumatic-knee-injuries-the-hip/

Merchant Classification

SOURCE: Merchant AC: The classification of patellofemoral disorders. Arthroscopy 4:235, 1988.


Initial Treatment:Anatomic Disruption Precluding Quadriceps

Balance? Yes = Surgery

Fracture Quadriceps rupture Patellar tendon rupture Patella dislocation*

Loose body

No = Rehabilitation Everything else

Patella Stabilization From Above

Hip Abduction, extension, and external rotation

Core Quadriceps

VMO From below

Foot and ankle control Over the counter orthotic for pes planus

Eliminate Quadriceps Inhibition

Ice NSAIDs Taping Bracing Aspirate/inject effusion

Rehabilitation Goals

Reduce inflammation Restore motion Regain strength Recover proprioception Resume functional activities Return to sports


Rehabilitation Goals Acute Phase

Reduce inflammationRest IceCompressionElevation

Re-establish quadriceps control

Images courtesy of Dr. Green’s personal files


Early Continue reduction of

pain and swelling Restore motion Resume normal gait



Intermediate Regain strength Recover

proprioception



Advanced Resume functional activities Return to sports

Image courtesy of Dr. Green’s personal files


First Time Traumatic Patellar Dislocation

What’s the pathology? Associated problems Early surgery Non-operative management Technical pearls

Patella Dislocation

Valgus rotation mechanism MPFL

Patella, mid-substance, femoral Medial patella

Contusion, chondral, osteochondral Lateral trochlea

Contusion, chondral, osteochondral

Decision Making History

Previous subluxation Physical exam

MCL, ACL Alignment, Q-angle Straight leg raise

X-rays Osteochondral fracture* Alta, tilt, subluxation, trochlea hypoplasia

MRI Loose body*, MPFL @ patella*, VMO tear*

Non-operative Management RICE Brace in extension

Quadriceps control NSAIDs Straight leg raises (VMO)


Rehabilitation Brace Physical therapy (2/3 success)

VMOTaping, e-stim, biofeedback

Hip abductor and core Foot

Early Surgery Osteochondral fractures Loose bodies MPFL @ patella

VMO attachment

Lateral Release

The only operation that the literature does not support for patella instability

Recurrent Instability

MPFL reconstruction Tibial tubercle

transfer

Saggin, Paulo Renato Fernandes MD*; Saggin, Jose Idílio MD*; Dejour, David MD† ‘Imaging in Patellofemoral Instability: An Abnormality-based Approach’ Sports Medicine & Arthroscopy Review: September 2012 - Volume 20 - Issue 3


MPFL Reconstruction Keys

Schottle’s point Repair tension Avoid large patella

tunnels Early ROM

Schöttle PB, Schmeling A, Rosenstiel N, Weiler A. ‚ Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction.‘Am J Sports Med. 2007 May;35(5):801-4. Epub 2007 Jan 31.

Tibial Tubercle Transfer Tips Horizontal or anterior

Elmslie – Trillat vs Fulkerson (can unload distal lateral patellar cartilage)

Alexis Chiang Colvin, MD1; Robin V. West, MD2, ‘Patellar Instability’ The Journal of Bone & Joint Surgery, Volume 90, Issue 12 Current Concepts Review | December 01, 2008 J Bone Joint Surg Am, 2008 Dec 01;90(12):2751-2762

Tibial Tubercle Transfer Tips

Size matters Keep medial soft

tissue intact Osteotome Fixation

Chronic TendinopathyJumper’s Knee

Exercise program (stretch/strengthen) Transverse friction massage Augmented soft tissue mobilization (ASTM) Iontophoresis Extracorporeal shock wave PRP Percutaneous ultrasound tenotomy (Tenex) Surgical debridement


What’s New?

The Infrapatellar plica: A Major cause of chronic adolescent anterior knee pain, relieved by arthroscopic resection. Tom Smallman accepted by Arthoscopy

Infrapatellar Plica (IPP)

Infrapatellar Plica Tethers Fat Pad tight in full extension and full flexion Arthroscopic view

Longitudinal fissure in distal trochlea


Results

49 knees 64 month follow-up Lysholm Score improved 39 to 83

41/49 Good/excellent 3/49 Fair 5/49 Poor

No one got worse with the surgery

Summary

VMO balances lateral patella force Surgery for anatomic disruptions precluding balance Rehabilitation for all the rest

VMO, hip, core, foot stabilization First time patella dislocation

Rehabilitation Early surgery for fractures, loose bodies, MPFL off patella (VMO)

Infrapatellar plica maybe cause of adolescent anterior knee pain that does not get better with rehabilitation

Thank You ?


Lateral Patellofemoral Angle

Normally opens laterally Measure of tilt

Saggin, Paulo Renato Fernandes MD*; Saggin, Jose Idílio MD*; Dejour, David MD† ‘Imaging in Patellofemoral Instability: An Abnormality-based Approach’, Sports Medicine & Arthroscopy Review: September 2012 - Volume 20 - Issue 3

Congruence Angle DSulcus Angle C-A-B

Congruence angle (subluxation) Sulcus angle (trochlea hypoplasia)


Patella Alta Measurements


Trochlea hypoplasia clues on lateral x-ray

Saggin, Paulo Renato Fernandes MD*; Saggin, Jose Idílio MD*; Dejour, David MD† ‘Imaging in PatellofemoralInstability: An Abnormality-based Approach’, Sports Medicine & Arthroscopy Review: September 2012 - Volume 20 - Issue 3


TT-TG Distance

CT overlay of tibial tubercle and trochlea


patellar tracking controlled the patellofemoral...

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