The medial patellar retinaculum and MPFL are best seen on MRI on the axial fluid-sensitive sequences. 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. Patellar maltracking: an update on the diagnosis and treatment strategies, https://doi.org/10.1186/s13244-019-0755-1, http://creativecommons.org/licenses/by/4.0/. 2). It runs obliquely and transversely and inserts on the patella and the patellar tendon, and is composed of two layers. The latter distinction is important to recognize among both radiologists and surgeons. Sports Med Arthrosc 15:6871, Longo UG, Rizzello G, Ciuffreda M et al (2016) Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures for the management of patellar dislocation: systematic review and quantitative synthesis of the literature. Prevalence of Lateral Patellofemoral Maltracking and Associated Complications in Patients with Osgood Schlatter Disease. Traumatic lateral patellar dislocation is a common injury among young, athletic individuals and is generally transient in nature. A small osseous avulsion (arrowhead) is seen in this region. These morphological risk factors can be assessed using methods similar to those on MRI as detailed in the prior sections of this article. Several methods have been used to assess patella alta. Because of the transient and brief nature of lateral patellar dislocations, the diagnosis is frequently unrecognized by both patients and clinicians. Distally, it attaches to the tibial tubercle via the patellar tendon. Techniques of Medial Retinacular Repair and Reconstruction - LWW AJR Am J Roentgenol 194:721727, Kalichman L, Zhang Y, Niu J et al (2007) The association between patellar alignment and patellofemoral joint osteoarthritis features--an MRI study. A Focal Defect at the Lateral Patellar Retinaculum on Clinical Knee MRI Thus, imaging at positions both less than and greater than 30 can be used to avoid missing maltracking that might be captured at only certain degrees of flexion [64]. Patellar sleeve avulsion fracture in a patient with Sinding-Larsen The lateral patellar retinaculum presents a superficial layer attached medially to the patella and patellar ligament, and extending laterally to the iliotibial band and vastus lateralis muscle fascia (Fig. 2010 Aug;36(4):353-60. doi: 10.1007/s00068-010-9165-2. These parameters can be evaluated using dynamic MRI [29]. LTI < 11 degrees indicates dysplasia. Surgical indications following patellar dislocation include the presence of a chondral or osteochondral body, significant rupture of the medial stabilizers most importantly the MPFL, a persistent laterally subluxed patella, or a second dislocation injury in a patient with malalignment or dysplasia. All authors read and approved the final manuscript. Am J Sports Med 32:11141121, Tsavalas N, Katonis P, Karantanas AH (2012) Knee joint anterior malalignment and patellofemoral osteoarthritis: an MRI study. Advantages of CT over plain radiography include its cross-sectional capability and ability to generate multiplanar reformations. Magnetic Resonance Imaging Characteristics of the Medial Patellofemoral Ligament Lesion in Acute Lateral Patellar Dislocations Considering Trochlear Dysplasia, Patella Alta, and Tibial Tuberosity-Trochlear Groove Distance For first-time dislocators without intra-articular loose bodies or chondral injury, a trial of nonoperative therapy is indicated. Femoral condylar chondral injuries occur during the dislocation phase due to impaction shearing forces of the patella upon the flexed femur, typically occurring at the weightbearing surface. (19a) The corresponding STIR coronal image reveals the large displaced osteochondral fragment (arrow) at the lateral aspect of the lateral femoral condyle. 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. These two structures blend with each other and are difficult to separate on imaging. (18a) A 13-year-old female following acute patellar dislocation. 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. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 5). The longitudinal stabilizer is the extensor mechanism itself, which is comprised of the quadriceps tendon proximally and the patellar tendon distally. 6 Cone R. Patella Alta and Baja. The lateral patellar retinaculum is a fibrous expansion comprising of superficial and deep layers. 2002 Dec;225(3):736-43. doi: 10.1148/radiol.2253011578. 23,29,37 The causative factors of . There is agreement, however, that the MPFL is almost always injured with lateral patellar dislocations4. Patellar Dislocation (Acute) | Pediatric Orthopaedic Society of - POSNA Duke Radiology Case Review. the patellar retinaculum at the dynamic examination (Fig. Clin J Sport Med 15:6266, Colvin AC, West RV (2008) Patellar instability. b Trochlear dysplasia (9 inclination), Facet asymmetry assessment for trochlear dysplasia on axial MRI. Adjunctive treatments such as knee aspiration and patellar stabilizing braces have been proposed to decrease swelling and enable early range of motion; however, there is no conclusive evidence for their use [71]. Lateral Patellar Retinaculum Tension in Patellar Instability Early detection particularly in the stage preceding the development of significant cartilaginous loss and osteoarthritis is critical. Trauma itself rarely causes patellofemoral dislocations without predisposing factors such as trochlear dysplasia, patella alta and lateralization of the tibial tuberosity. Surgical management of patellar instability should be guided on an individual patient basis depending on history, physical examination, and radiologic findings as outlined above. (PDF) Magnetic Resonance Imaging Characteristics of the Medial 9). 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]. Lateral Retinaculum - an overview | ScienceDirect Topics Reference article, Radiopaedia.org (Accessed on 02 May 2023) https://doi.org/10.53347/rID-27273, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":27273,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/lateral-patellar-dislocation/questions/2391?lang=us"}, Case 14: transient lateral patellar dislocation, see full revision history and disclosures, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, Ahlback classification system in assessing osteoarthritis of the knee joint, Kellgren and Lawrence system for classification of osteoarthritis, anterior cruciate ligament mucoid degeneration, MRI grading system for meniscal signal intensity, medial retinacular abnormalities (ranging from strain to complete disruption) with adjacent periligamentous edema and hemorrhage, lateral displacement of patella (not necessarily seen in transient dislocation), medial patellar contusion +/- corresponding lateral femoral condyle contusion, direct trauma to lateral knee:normally no patellar contusion. TT-TG is a reflection of the clinically measured Q angle. James M. Provenzale, Rendon C. Nelson, Emily N. Vinson. Normal = 0.8 to 1.2. 1995 Jan;164(1):135-9. doi: 10.2214/ajr.164.1.7998526. 1997 Jan;168(1):117-22. doi: 10.2214/ajr.168.1.8976933. J Pediatr Orthop 37:484490, Parikh SN, Lykissas MG, Gkiatas I (2018) Predicting risk of recurrent patellar dislocation. Federal government websites often end in .gov or .mil. The conditions are presented anatomicallyanterior, lateral, medial, or posteriorwith common etiologies, history and physical exam findings, and diagnosis and treatment options for each (see Table, page 28). PubMed Recurrent dislocations and chronic patellofemoral joint instability will lead to significant cartilage damage and severe arthritis if left untreated. Nontraumatic Knee Pain: A Diagnostic & Treatment Guide The MPFL is also stripped from the femoral attachment (long arrow). Management of Patellofemoral Pain Syndrome | AAFP Rev Chir Orthop Reparatrice Appar Mot 76:4554, CAS Acute lateral patellar dislocation at MR imaging: injury patterns of Patellar fractures are the most common cause of disruption of the extensor mechanism, six times as frequent as soft tissue injuries such as quadriceps or patellar tendon rupture [ 3 ]. (Figs.1-A 1-A also and1-B). Lateral Retinacular Release - Surgery Information The discrimination between low-grade and high-grade dysplasia is important because prognosis and treatment may depend upon the severity of trochlear dysplasia. It can be divided into nonoperative and operative management. AJR Am J Roentgenol. An inclination angle of less than 11 indicates trochlear dysplasia [32]. There are several different techniques described in the literature to assess patella alta and many of these are reviewed in detail in the MRI Web Clinic, August 20106. Axial PDFS MR image showing MPFL disruption (open arrow) and trochlear dysplasia (arrowheads). By altering the insertion point of the patellar tendon, these procedures affect the timing and position of patellar engagement in the trochlea and have the ability to biomechanically offload damaged distal articular cartilage, thereby reducing pain and increasing stability simultaneously. The VMO is active, not only in full extension but also at 30 degrees and up to 100 degrees of flexion. (6a) A more distal T1-weighted image reveals fibers of the oblique decussation of the MPFL which blend with the medial collateral ligament (MCL). Am J Sports Med 38:181188, Ali S, Bhatti A (2007) Arthroscopic proximal realignment of the patella for recurrent instability: report of a new surgical technique with 1 to 7 years of follow-up. J Orthop Sports Phys Ther 2017;47(10):815. doi:10.2519/ jospt.2017.6616 . Reconstruction of the medial patellofemoral ligament for treatment of patellar instability. 6. If the lateral retinaculum tendon is tight enough to pull the patella out of the trochlear groove, a lateral release procedure can loosen the tissue and correct the patellar malalignment. This distance is the trochlear sulcus depth (TD). (12a) At an axial image 3 cm proximal to the femoral-tibial joint space, the lengths of the medial and lateral trochlear facets are obtained. Clin Sports Med 21:521546 x, Article {"url":"/signup-modal-props.json?lang=us"}, Shetty A, Saber M, Rasuli B, et al. MR imaging of patellar retinacular ligament injuries - PubMed Am J Sports Med 45:10121017, Pedersen ME, DaCambra MP, Jibri Z, Dhillon S, Jen H, Jomha NM (2015) Acute osteochondral fractures in the lower extremities - approach to identification and treatment. Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. National Library of Medicine Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. The images should be scrutinized for the presence of chondral or osteochondral injury, especially if displaced as an intra-articular body, as this may affect surgical management. The most important soft tissue passive stabilizers involved in patellofemoral dislocation injuries have traditionally been referred to as the MPFL and the medial retinaculum. Methods: We compared 361 treated cases of aneurysm occlusion after subarachnoid hemorrhage from 1997 to 2003 with 281 cases from 2006 to 2014. Levy B, Tanaka M, Fulkerson J. Arthroscopy 23:305311, Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S (1990) Lateral release of the patella: indications and contraindications. Lateral patellar retinaculum | Radiology Reference Article Observer Agreement on the Dejour Trochlear Dysplasia Classification: A comparison of true lateral radiographs and axial magnetic resonance images. Unauthorized use of these marks is strictly prohibited. Curr Rev Musculoskelet Med 11:253260, Article The lateral patellar retinaculum can also be assessed in this position. 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. On the other hand, frank patellar dislocation is a significant risk factor in the development of patellofemoral osteoarthritis with an incidence of 49% at 25years after the patellar dislocation incident in comparison with 8% in a control group without a dislocation history [60]. A thorough examination of the knee is then performed including presence of effusion, localization of pain, assessment of patellar translation, patellar apprehension, presence of a J sign (visual lateralization of the patella as it disengages from the trochlea when extending the knee), and a measurement of the Q angle along with ligamentous and meniscal testing. It is therefore recommended that radiologists include measurement of TT-TG in reports on patients who undergo MRI for patellar instability. For CT evaluation of the patellofemoral joint, patients are positioned supine, with mild external rotation of up to 15 with padding as needed to facilitate a relaxed state of the quadriceps musculature. Normal TD > 5.2mm. ADVERTISEMENT: Supporters see fewer/no ads. AJR Am J Roentgenol. Diederichs G, Issever A, Scheffler S. MR Imaging of Patellar Instability: Injury Patterns and Assessment of Risk Factors. Kamel S, Kanesa-Thasan R, Dave J et al. (5a) An axial T1-weighted image demonstrates the low blending fibers of the VMO and transverse MPFL at their attachment along the upper patella. In general realignment surgery such as tibial tubercle transfer should be strongly considered in patients with TT-TG > 15mm (borderline) and typically should be performed in patients with TT-TG > 20mm. At the time the article was created Pereshin Moodaley had no recorded disclosures. Discussion. et al. Additionally, return to sport can be as low as 45%, leaving many patients searching for further management options [12]. Radiology 187:205212, Jibri Z, Martin D, Mansour R, Kamath S (2012) The association of infrapatellar fat pad oedema with patellar maltracking: a case-control study. Lateral patellar dislocation is a common clinical entity with a characteristic MR appearance. 11 Lind M, Jakobsen B, Lund B, et al. Check for errors and try again. The pages that follow contain general guidance on the diagnosis and treatment of chronic nontraumatic knee pain. 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]. PTI of less than 12.5% suggests the presence of patella alta. MRI and CT are superior modalities in looking for predisposing factors associated with patellar maltracking [26,27,28]. Understanding the biomechanics of these joints is essential to investigating and appropriately treating patellofemoral joint pathology. With knee extension and subsequent reduction, the patella bounces back into position and in doing so, the medial patella impacts against the non-weightbearing anterolateral aspect of the lateral femoral condyle, resulting in the characteristic marrow edema pattern. The radiograph can be helpful in the acute presentation in detecting fractures in the setting of lateral (often transient) patellar dislocation. Migliorini F, Marsilio E, Cuozzo F, Oliva F, Eschweiler J, Hildebrand F, Maffulli N. Life (Basel). Objective: This prospective study is designed to detect changes in the treatment of ruptured intracranial aneurysms over a period of 17 years. 2012;40(4):837-844. In patients without osseous malalignment, MPFL reconstruction and plication of the medial restraints is reported to decrease re-dislocation rates to 5%. What is the treatment for a patellar retinaculum tear? The typical injury pattern is a tear of the medial patellofemoral ligament (MPFL) and bone bruises of the patella and the lateral femoral condyle. The main morphological features associated with patellar maltracking are trochlear dysplasia, lateralization of the tibial tuberosity, patella alta, and lateral patellar tilt. The ratio of the medial to the lateral facet length defines trochlear facet asymmetry (MT/LT) *100%. This short surgical video demonstrates an arthroscopic lateral release as seen from inside the knee. There are a number of MRI features of trochlear dysplasia including reduction in the trochlear depth, lateral trochlear inclination, and facet asymmetry. Eur Radiol 22:418428, Sonin AH, Pensy RA, Mulligan ME, Hatem S (2002) Grading articular cartilage of the knee using fast spin-echo proton density-weighted MR imaging without fat suppression. Magn Reson Med Sci 17:195202, Elias DA, White LM (2004) Imaging of patellofemoral disorders. The two features are associated with patellar maltracking. Sports Health 3:170174, Stensdotter AK, Hodges PW, Mellor R, Sundelin G, Hger-Ross C (2003) Quadriceps activation in closed and in open kinetic chain exercise. Femoral osteochondral injuries, when present, typically involve the lateral weightbearing surface. Patellar maltracking occurs as a result of an imbalance in the dynamic relationship between the patella and trochlea. PubMed Stretching a Lateral Retinaculum of the Knee | livestrong Twenty-seven knees in 21 patients were studied and the mean age of the patients at surgery was 19 years. The most accepted indication for surgical management of patellar instability is the presence of a large displaced osteochondral fracture or loose body. 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. This protocol can help in evaluating for osseous integrity, morphology, and patellofemoral alignment [63] (Fig. Open Orthop J 9:463474, Article AIM: To describe the sonographic appearances of the medial retinacular (MPFR) complex of the knee in patients with acute and recurrent patellar dislocation.MATERIALS AND METHODS: Thirty patients were scanned within 2-4 weeks of an acute episode of lateral patellar dislocation. Open Orthop J. Twenty-six pelvic limbs were used for gross dissection, and four stifle regions from two animals were used for radiography and magnetic resonance imaging (MRI). Magnetic Resonance Imaging Findings After Acute Patellar Dislocation in Imaging of patellar fractures | Insights into Imaging | Full Text 1997 Jun;168(6):1493-9. doi: 10.2214/ajr.168.6.9168713. Complete dislocation of the knee: spectrum of associated soft-tissue injuries depicted by MR imaging. no financial relationships to ineligible companies to disclose. Knee Surg Sports Traumatol Arthrosc 14:707712, Ahmad M, Janardhan S, Amerasekera S, Nightingale P, Ashraf T, Choudhary S (2019) Reliability of patellotrochlear index in patellar height assessment on MRI-correction for variation due to change in knee flexion. It is a geometric abnormality of the trochlear groove that affects its shape and depth mainly at its superior part, which can result in abnormal tracking of the patella along the trochlea. Epub 2011 Nov 9. Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Thawait SK, Soldatos T, Thawait GK, Cosgarea AJ, Carrino JA, Chhabra A. Skeletal Radiol. The injured retinaculum had an indistinct, irregular appearance associated with edema and hemorrhage. A buckle transducer was clamped on the lateral patellofemoral ligament and the transducer was calibrated to zero with the knee at full extension. In our experience, injuries to the transverse band most often involve the femoral attachment, whereas injuries to the oblique decussation and associated medial retinacular structures are more common at the patellar attachment. PMID: 9168713. Am J Sports Med. A patient with acute first-time transient patellar dislocation without osteochondral lesions and severe risk factors for redislocation is generally treated conservatively. Bone Contusion Patterns of the Knee at MR Imaging - RadioGraphics They include: pain with compression of patella and moderate lateral facet tenderness, inability to evert the lateral edge of the patella, mainstay of treatment and should be done for extensive period of time, closed chain short arc quadriceps exercises, pain refractory to extensive rehabilitation, ideal candidate has no symptoms of instability, medial patellar glide of less than one quadrant, lateral patellar glide of less than three quadrants, only elevate 1 cm or else risk of skin necrosis, indicated only for instability with lateral translation (not isolated lateral tilt), viewing through superior portal will show medial facet does not articulate with trochlea at 40 degrees of knee flexion, postoperatively the patella should be able to be, patellar instability with medial translation, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Proximal Tibiofibular Joint Ganglion Cysts, Pre-Participation Physical Exam in Athlete, Concussions (Mild Traumatic Brain Injury).
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