patellofemoral disease

11/3/2014 Professor Freih Abuhassan-

University of Jordan

1

Patellofemoral Pain Syndrome

Patellofemoral Pain

Syndrome

Freih Odeh Abu Hassan

FRCS (Eng.), FRCS (Tr. & Orth.)

Professor of Orthopedics

Universit y of Jordan

11/3/2014 2Professor Freih Abuhassan-


A- Anatomy B-Assessment

C-Acute dislocation

D-Breakdown of disorders

1-PF malalignment (e or e out articular

degeneration)

2-PF instability e out static malalignment

3-Articular degeneration e out malalign.

4- Unstable Patella after TKR



• Thickest articular cartilage in the body

–Up to 5mm at central ridge

• Joint reaction forces ( X of B.Wt)

–0.5 level walking

–3.3 stair climbing

–7.8 squats

A-PF Basics and Anatomy



Patellar Stabilizers

=Soft Tissue

=Bony



Passive stabilizers

–Patellar tendon

–Retinaculum(Med. & Lat.)

–MPFL +VMO

Dynamic stabi.

–Quadriceps



• Geometry of the patella &

trochlea.

– Hypoplastic trochlea (flat)

• Angle of pull of the

quadriceps (Q-angle)

Bony stabilizers



MRI of Normal MPFL



Proper assessment

1-Pain–Character, Location, Onset, Intensity,

Exacerbation, Remittance

2-Effusion

3-Trauma–Subluxation

–Dislocation11/3/2014 9Professor Freih Abuhassan-


4-Previous treatment

5-Other joint involvement

6-Litigation

7-Worker’s compensation

8-Psychological components



Symptoms•Pain Anterior knee

•Pain after sitting (movie sign)

•Pain ascending stairs

•Popping & clicking

•Pseudo-locking

•Instability - Giving Way

The patellar pain are aggravated by flexed

knee activities as sitting, climbing, squatting



Physical Examination

• Alignment : Varus/valgus, Rotational(Ext. tibial torsion, Femoral anteversion)

• Patellofemoral crepitus

• Patellar tracking

–J-sign, Apprehension

• Lateral retinaculum

–Tenderness, Tilt, Patellar mobility

. Compression test chondromalacia11/3/2014 12Professor Freih Abuhassan-


• Quad strength (VMO)

– IT band friction synd., Pes anserinus bursitis

• Q-angle: N – Male(10º) , Female(15º)

• Tubercle-sulcus angle

• Extensor mechanism: alta vs. baja

• Patellar/femoral dysplasia

• Hamstring tightness



Radiographic Evaluation

Weight-bearing=AP extension view

=AP 45° flexion (Rosemberg)

=Lateral view in 30° of flexion



• Merchant axial– 45 deg and 30 caudal tilt



• Sulcus angle– Angle formed by the trochlear ridges

= Sulcus angle 140° (+ 5)



• Congruence angle– Angle formed by bisecting the sulcus angle

and central patellar ridge

– Mean = -6º +/- 6º (central ridge should lie medial to the bisector)



4-Lateral patellofemoral angle (> 13°)



Dynamic CT Scan:

0°, 15°, 30° and 45° knee flexion

More accurate bec. the post. condyles

of femur are more precise reference.

=Tilt angle

=Subluxation

=Congruence angle11/3/2014 19Professor Freih Abuhassan-


MRI scan = Status of the lateral retinaculum

(thickening), MPFL & cartilage

=Injuries in the PF joint.



Torn MPFL

Chondral inj.

lateral edema

Chondral inj.



• Subluxation Central patellar ridge is lateral to the bisector of the sulcus angle.

• Tilt Patella centered in the trochlea but the medial facet is elevated away from the trochlea



Arthroscopic evaluation1- Confirms the Dx of patellar subluxation

2- Classification of articular lesion

(size, severity and location)

3- Helps to quantify lateral malalignment -

tracking

°90°45°011/3/2014 24Professor Freih Abuhassan-


4-Treatment of associated pathologies

Patellar fracture secondary to luxation



5-Reevaluation of patellar tracking after

open proximal realignment



• Usually presents to ED after twisting injury

• Often hemarthrosis, Fat !!

• 40% risk of osteochondral injury

• Most often underlying alignment issues

B-Acute Dislocation



Dislocation lesions

• Medial tear

• Medial patellar chondral injury

• Lateral femoral edema



• Acute Dislocation

Flex the hip & gradually extend the knee to

reduce If x-ray changes, fat in joint, or

crepitus Scope.

Conservative R/–Cast for 3 W in extension, brace for

6 W Brace at the 1st return to sport.

–Physical therapy (proprioception)

Treatment



SurgeryEarly !!!! chronic pain and arthrofibrosis

Late (50% will need surgery)

=In recurrent cases

=Correct malalignments

• Chronic– Treat pain, alignment or instability issues as needed



• C/O = Pain or Mechanical issues.

1-Patellofemoral Malalignment

–NSAIDS

–Physical therapy• Mainstay

• several months before aggressive measures

• Avoid aggressive quad strengthening.

Conservative treatment



–Patellar tracking braces

–Avoidance of offending activities



Patellar tilt

Surgical treatment

Lateral release–Patella should evert to 70-90°

–May need proximal or distal realignment as well



1-Hauser procedure.– Posteriomedial tibial tubercle transfer

– Increases DJD due to joint reaction forces

– Contraindicated

Distal Realignment



2-Elmslie-TrillatMedial and distal transfer

– Originally included medial tightening and

lateral release, but not necessary.

– Much better than Hauser

–Avoid if significant degenerative changes



=Increased “Q” angle

=Recurrent lateral subluxation

=Skeletally mature patients

Indications



3-Fulkerson

–Anteromedial transfer.

–Use for combination of chondralchanges and malalignment.

–Oblique cut.

–Large surface area for healing.

–Good for distal and lateral chondrosis.



• Usually indicative of soft tissue injury.

• Conservative treatment .=Overall limb strengthing, =VMO strength,

= avoidance of foot overpronation

• Examine arthroscopically

• Surgery proximal realignment

procedure with or without lateral release

2-Dynamic Instability without Static

Malalignment



Proximal realignment

=After dislocation for torn MPFL

=Patella fails to centralize after lateral release

=Skeletally imature patients

=Abnormal VMO

=Dynamic lateral subluxation without overall

malalignment

Indications

Severe OAContraindication11/3/2014 45Professor Freih Abuhassan-


Mainly arthroscopic



Mini-open advancement



=Lateral release

=Imbrication of medial capsule

=Advancement of VMO (distal and laterally)

MPFL reconstruction



• Chondral changes on the patella correlate

poorly with pain

• Underlying bony changes are better indicator

• Assess location of chondral damage

• Check alignment carefully

3-Articular Degeneration without

Malalignment



Articular degeneration



1 2

3 411/3/2014 52Professor Freih Abuhassan-


–Avoid aggressive PT

–Stop offending activities

–Stay within “envelope of function”

Treatment

• Arthroscopic debridement/chondroplasty



Conclusion

1- Proper assessment and radiology.

2-Always conservative first.

3-Lateral release must be complete .

4-Documented patellar tilt and minimal

articular cartilage.

5-Check malalignments.

6- Fulkerson procedure more consistant

results



Unstable Patella after TKR

1-Component malpositioning,(internal malrotation of the femoral or

tibial components)

2- Limb malalignment,

3-Prosthetic design,

4-Improper patellar preparation,

5-Soft-tissue imbalance.



Major malposition of components

implant revision.

No malposition proximal

realignments

(lateral release with lateral advancement of

the vastus medialis obliquus muscle)



patellofemoral disease

Health & Medicine

patellar pain

disorders1pf malalignment

patella trochlea

ap extension view

squatsapf basics

jordanpatellar stabilizers

jordana anatomy bassessmentc

flexion rosemberg