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
–Dislocation

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 angle

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 evaluation
1- Confirms the Dx of patellar subluxation
2- Classification of articular lesion
(size, severity and location)
3- Helps to quantify lateral malalignment -
tracking
°90°45°0

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

Surgery
Early !!!! 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-Trillat
Medial 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 chondral
changes 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 4

–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 patellarpreparation,
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

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Patellofemoral disease