Patellofemoral Joint Instability Treatment Options
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Patellofemoral Joint Instability Treatment Options
- 1. Professor Deiary F Kader Department of Sport, Exercise, Northumbria University, Newcastle www.oasir.co.uk Knee Surgeon, Nuffield Hospital, Newcastle upon Tyne PATELLOFEMORAL JOINT INSTABILITY PostGrad Orth Deiary Kader
- 2. Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course Newcastle Upon Tyne 16-21 March 2015 • Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Nuffield Hospital Newcastle NGMV Charity
- 3. PLAN Presentation Frank dislocation Subluxation Symptomatic instability Pain due to mal-tracking
- 4. PATELLAR DISLOCATION Re-dislocation rate First Time 17-20% Second Time 44%-71% High dissatisfaction following conservative Rx
- 5. PFJ BIOMECHANICS Patellofemoral joint reaction force WALKING 0.5xBW STRAIGHT LEG RAISE 0.5xBW 0 DEG CYCLING: 1.2 × BW RISING FROM A CHAIR w ARMS: <3 × BW STAIRS (UP OR DOWN) 3.3xBW 60 DEG JOGGING & SQUAT–RISE 6xBW at 140 deg SQUAT–DESCENT 7.6x BW at 140 deg JUMPING UP TO 12 × BW Ff Ft Fj Trigonometry Fjf=Ff cos(angle/2) PostGrad Orth Deiary Kader
- 6. PATELLAR STABILITY DETERMINED BY – Soft Tissue 0-300 Muscles Ligaments MPFL (at 200-300) – Bone morphology >300
- 7. CAUSES OF PATELLA INSTABILITY • Soft Tissue • Global --HMS (Hyperlaxity) • Medial • MPFL Insufficiency • VMO dysplasia/VL dominance • Lateral -- ITB, Contracture Lat Ret • Osseous abnormalities • Patella alta/ morphology • Trochlea dysplasia • Lower limb Malalignment (Torsion or Genu Valgum) – Fem anteversion, Ext tibia torsion, foot pronation – Increased Q angle or TT:TG distance • Gait (Valgus thrust, Pelvis core muscles)
- 8. WHY THE PATELLA IS UNSTABLE Lower limb Malalignment?? – Femur, tibia or foot pronation Osseous abnormalities?? – Patella alta – Increased Q angle – Trochlea dysplasia Soft Tissue?? – HMS – MPFL Insufficiency – Muscle or ITB Gait ?? PostGrad Orth Deiary Kader
- 9. KNEE ASSESSMENT Leg Alignment Varus/valgus Soft tissue imbalance Ligament assessment (ACL,PCL, MCL, LCL) Meniscal assessment Medial/ Lateral compartment OA Hip , Spine, peripheral pulses Apprehension test
- 10. PATELLA ASSESSMENT Beighton Score0---9 Patella Alignment (Q Angle) Dislocation in extn (J Sign) Quads Bulk/ ITB (Ober's test) Hamstring Tightness Patella height Alta/Baja Patella Mobility (N@300=<1/2) Parapatellar tenderness Patella Apprehension PFJ Crepitus PFJ Compression (Clarke test) Trochlea Depth Normal (1380) – Shallow ,Flat , Convex , Cliff
- 11. Many potential problems • Crude measure • How it is measured? – Flexion, Extension – Standing, Sitting, Supine – Muscle relaxed/tense • No standard method Q- Angle
- 12. IMAGING OF THE PATELLOFEMORAL JOINT AP and Lateral Knee x-ray Merchant’s view MRI Axial view CT Rotational Profile Merchant’s
- 15. MEASURING PATELLA HEIGHT Caton – Deschamps index =1.2 Blackburne-peel index = 1.12 PostGrad Orth Deiary Kader
- 16. MPFL injury Patella pain Articular Damage MRI SCAN
- 17. ROTATIONAL PROFILE CT EVIDENCE BASED INTERVENTION 1. Femoral Anteversion N=50 -150 2. Knee rotation N=30 3. External Tibial torsion 250-300 4. TT:TG offset (N= 10-19mm) 5. Patella index 6. Patella Tilt (N=average QD&QC <200) 7. Trochlea Tilt (N>130) 8. Trochlea DepthNormal (1380+/- 60)
- 18. TRUE Q ANGLE, MEASUREMENT OF THE TIBIAL TUBEROSITY-TROCHLEAR GROOVE (TT/TG) DISTANCE Normally TT/TG = 2-9 mm pathologic measure is > 19 mm PostGrad Orth Deiary Kader
- 19. HOW USEFUL IS TT:TG • Large variation in normal value (patient size and height) • Poor interrater reliability 3-5mm measurement error – Trochlea ?deepest point of – Tib Tub bony landmark vs Central point of PT attachment 4mm • What condition? – Flexion or extension – Weight bearing 5mm • MRI or CT measurement
- 20. TREATMENT OF PATELLA INSTABILITY Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait
- 21. Med Epicondyle Add Tubercle Patella MPFL PostGrad Orth Deiary Kader
- 22. PostGrad Orth Deiary Kader
- 23. BONY TUNNEL PostGrad Orth Deiary Kader
- 24. MX OF PATELLA INSTABILITY Patellofemoral Instability with Malalignment Distal Realignment tibial tubercle transfer Combined MPFL Recon
- 25. FULKERSON'S TECHNIQUE OF ANTEROMEDIALIZATION A steeper osteotomy plane will produce more anteriorization along with medialization
- 26. OTHER PATELLOFEMORAL PROBLEMS Patella Alta – Distal transfer (Distalization) Trochlea Dysplasia – Trochloplasty PostGrad Orth Deiary Kader
- 31. TROCHELOPLASTY
- 32. TAKE HOME MESSAGE The approach to patellar instability should be individualised and tailored to each patient’s symptoms, anatomy and physical demands
- 33. PostGrad Orth Deiary Kader
- 34. 24 years old female doctor had a permanents dislocation of the patella Treated with 1. Lateral release 2. Tib Tub Medialisation 3. Tib Tub Distalisation 4. Trochleaoplasty 5. MPFL Reconstruction PostGrad Orth Deiary Kader
- 35. TREATMENT SUMMARY MPFL Reconstruction (very popular >80%) Tib Tub Medialisation on the decline Tib Tub Distalisation excellent procedure Trochleoplasty Distal femoral Osteotomy
- 36. THANK YOU
Editor's Notes
- Good after My name is Banaszkiewicz For this first section I will be taking you through examination of the hip I have no disclosures to make
- We often forget how much force goes through the PFJ. It can reach up tp 12 x body wt in jumping sports while cycling is very patella friendly
- It well documented that the Q angle is no reliable At what condition or position to
- Of course when there is bony malalignment