lateral patellar retinaculum injury radiology

2012;40(4):837-844. lateral patellar retinacular sleeve, mak-ing this particular avulsion a rare oc-currence. J Bone Joint Surg Am 85-A:12381242, Article The Anterolateral Ligament of the Knee: MRI Appearance, Association (7a) A coronal T1-weighted image at the level of the patella demonstrates blending of fibers of the VMO with the MPFL superiorly. Check for errors and try again. eCollection 2015. In one MRI study, 76% of cases of prior lateral patellar dislocation showed medial retinacular injury at its patellar insertion and 30% at its midsubstance, and injury of the femoral origin of the MPFL was identified in 49% of the cases [49]. a Axial CT image demonstrating MPFL reconstruction (arrow heads). Treatment is nonoperative with physical therapy focusing on quadriceps stretching and strengthening. These morphological risk factors can be assessed using methods similar to those on MRI as detailed in the prior sections of this article. 1. . Springer Nature. 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 main morphological features associated with patellar maltracking are trochlear dysplasia, lateralization of the tibial tuberosity, patella alta, and lateral patellar tilt. Patients who experience multiple patellar dislocations are more likely to have anatomical variants of the trochlea, patellar alta, or tibial tubercle lateralization. Treatment of ruptured intracranial aneurysms yesterday and now a The posterior condylar line is drawn on the slice where the posterior femoral condyles are largest (dashed line). Become a Gold Supporter and see no third-party ads. High resolution magnetic resonance imaging of the patellar retinaculum: normal anatomy, common injury patterns, and pathologies. Accessibility The natural history. J Bone Joint Surg Br 87:3640, Wechter J, Macalena J, Arendt EA (1994) Lateral patella dislocations: history, physical exam, and imaging. As an example, although the InsallSalvati ratio is one of the most commonly used methods and does not depend on the degree of knee flexion, it is affected by the patellar shape particularly its inferior point and measurement does not change after tibial tubercle distalization procedure [25]. A trochlear depth of < 3mm indicates dysplasia. Sports Med Arthrosc Rev 25:7277, Gillespie H (2012) Update on the management of patellar instability. MR findings were correlated with clinical, surgical, and arthroscopic findings. A commonly used one is the InsallSalvati ratio of patellar tendon length: patellar length. AJR 2008: 191:490-498. A ratio > 1.3 indicates patella alta. Chondral and Soft Tissue Injuries Associated to Acute Patellar Dislocation: A Systematic Review. The injured retinaculum had an indistinct, irregular appearance associated with edema and hemorrhage. It acts as a powerful extensor of the knee. The injury typically occurs from a twisting event with the knee in mild flexion (less than 30). Am J Sports Med 14:117120, Smith TO, Donell S, Song F, Hing CB (2015) Surgical versus non-surgical interventions for treating patellar dislocation. 2011;39(8):1756-1761. 4 Sanders TG, Morrison WB, Singleton BA, Miller MD, Cornum KG. Lateral patellar compression syndrome is the improper tracking of the patella in the trochlear groove generally caused by a tight lateral retinaculum. Imaging of patellar fractures | Insights into Imaging | Full Text 23,29,37 The causative factors of . This site needs JavaScript to work properly. AJR Am J Roentgenol 161:109113, Lance E, Deutsch AL, Mink JH (1993) Prior lateral patellar dislocation: MR imaging findings. (Figs.1-A 1-A also and1-B). 2002 Dec;225(3):736-43. doi: 10.1148/radiol.2253011578. Because of the transient and brief nature of lateral patellar dislocations, the diagnosis is frequently unrecognized by both patients and clinicians.1 Pain is often described as medial because of soft tissue injuries that occur to the medial retinaculum and/or MPFL. Sonographic Appearances of Medial Retinacular Complex Injury in b Axial CT image showing tibial tuberosity transfer surgery with screw placement (arrow). Google Scholar, Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. Int Orthop. LTI < 11 degrees indicates dysplasia. The lateral retinaculum is a ligament that helps hold your patella, or kneecap, in place. More recently, the TT-TG index was developed, which takes knee size into account by assessing the proximaldistal distance between the entrance of the chondral trochlear groove (TE) and the tibial tuberosity (TT). MRI can provide valuable information regarding the status of such repairs in patients who experience recurrent dislocation following surgery. 5 a-d). Axial PDFS left knee MR image, demonstrating the method used for the measurement of trochlear depth. no financial relationships to ineligible companies to disclose. A Focal Defect at the Lateral Patellar Retinaculum on Clinical Knee MRI Patella instability in children and adolescents. Thawait SK, Soldatos T, Thawait GK, Cosgarea AJ, Carrino JA, Chhabra A. Skeletal Radiol. Although varied in presentation, successful management of all patients relies on thorough history taking, physical examination of the entire lower extremity, and appropriate imaging. For first-time dislocators without intra-articular loose bodies or chondral injury, a trial of nonoperative therapy is indicated. 1). 3). a Axial PDFS right knee MR image at the level of the trochlear groove. In this section, we will emphasize the role of MRI and discuss how CT can also have value when assessing patellar maltracking. The MPFL plays a significant role in the stabilization of the medial aspect of the patella.Especially during the early stages of knee flexion, the MPFL is a critical component in patellar tracking and stability within the trochlear groove. J Knee Surg 19:307316, Gonaives MB, Jnior LH, Soares LF, Gonaives TJ, Dos Santos RL, Pereira ML (2011) Medial patellofemoral ligament reconstruction to treat recurrent patellar dislocation. On the other hand, the PTI is significantly altered with knee flexion [37]. In the setting of osseous patellar malalignment, an osseous procedure such as tibial tubercle transfer osteotomy can be performed (Fig. Tibial Tubercle Osteotomy to Aid Exposure for Revision Total Knee Int Orthop 34:311316, Donell ST, Joseph G, Hing CB, Marshall TJ (2006) Modified Dejour trochleoplasty for severe dysplasia: operative technique and early clinical results. The above video demonstrates the mechanism of injury in patellar dislocation. provided a morphologic classification system for trochlear dysplasia describing four types [26,27,28]. Asymmetry of <40% suggests trochlear dysplasia [24]. This is the ratio between a line measured between the inferior margin of the patellar articular surface and the anterior aspect of the tibial plateau and the greatest length of the patellar articular surface. Patella alta is related to a long patellar tendon and is considered a major factor associated with reduced contact area at the patellofemoral joint and a major contributor to patellar instability [33]. Arthroscopy 23:305311, Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S (1990) Lateral release of the patella: indications and contraindications. Less common predisposing factors to be aware of include laterally tilted patella, VMO dysplasia and generalized joint laxity. Anatomical and radiology atlas of the abdomen and pelvis based on anatomical diagrams and cross-sectional CT and MRI imaging. Because the knee is flexed in dislocation, the patella impacts upon the weightbearing surface of the lateral femoral condyle. 2. 1-31. In the past two decades dissection studies have shown that it extends from the superomedial border of the patella to the femoral epicondyle, at or immediately above the adductor tubercle. First, a line is drawn paralleling the posterior femoral condyles surfaces. From this insertion, it extends posteriorly to blend with the lateral margin of the knee capsule and inferior surface of the lateral tibial condyle 1,2. Given the lack of history of direct trauma, a reliable diagnosis can be made. On T2-weighted MR images, sprain is depicted as thickening of retinaculum with signal intensity signifying edema and hemorrhage (Fig. A second line is drawn parallel to a line along the posterior femoral condyles. Prior lateral patellar dislocation: MR imaging findings. Risk factors for recurrent patellar dislocations include 5: The presence of an abnormal medial patellar retinaculum should suggest the diagnosis of transient lateral patellar dislocation 1. PMC 8600 Rockville Pike A bone bruise at the anterolateral aspect of the lateral femoral condyle is also apparent (arrowheads). The goal of patellar instability treatment is to achieve a stable, functional, and pain-free knee and ultimately to halt or slow the development of osteoarthritis. Military Health System Europe > Clinics > Grafenwoehr Army - TRICARE Knee Surg Sports Traumatol Arthrosc 15:13011314, Tom A, Fulkerson JP (2007) Restoration of native medial patellofemoral ligament support after patella dislocation. b Axial MRI at the level of the tibial tuberosity. J Comput Assist Tomogr 2001; 25:957-962. At the time the article was last revised Joel Hng had Predisposing factors to patellofemoral dislocation include patella alta, excessive lateral distance between the tibial tubercle and trochlear groove and a congenitally shallow trochlear groove5, any of which significantly increase a patients likelihood for dislocation. Incidence and concomitant chondral injuries in a consecutive cohort of primary traumatic patellar dislocations examined with sub-acute MRI. . Open Orthop J. e-Anatomy, the Anatomy of Imaging - IMAIOS The primary aim of surgery is to repair the knee damage and to correct the anomalies that are predisposing to chronic instability. Findings typically associated with acute lateral patellar dislocation were also assessed and recorded (present or absent) including characteristic bone bruises and osteochondral injuries involving the patella, lateral trochlear facet, and lateral femoral condyle. An inclination angle of less than 11 indicates trochlear dysplasia [32]. Facet asymmetry is determined by calculating the percentage of the medial to the lateral femoral facet length (Fig. Knee Surg Sports Traumatol Arthrosc 14:264272, McNally EG, Ostlere SJ, Pal C, Phillips A, Reid H, Dodd C (2000) Assessment of patellar maltracking using combined static and dynamic MRI. Patellar tilt assessment. It is the angle between a line tangential to the subchondral bone of the posterior aspect of the femoral condyles and a line along the lateral trochlear facet subchondral bone (Fig. CAS Depends on how bad: Small tears are observed and heal. RadioGraphics 2010; 30: 961-981. It is not until beyond 90 of flexion that the odd facet engages the medial femoral condyle and plays a role in load sharing along with lateral facet [6, 7]. 7). The clinical evaluation can be more challenging in the absence of a dislocation history, and in this scenario, imaging can have a critical role. James M. Provenzale, Rendon C. Nelson, Emily N. Vinson. Radiology 189:905907, Warren LF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee: an anatomical analysis. The adductor magnus tendon (AT) attaches to the adductor tubercle, which lies posterior and superior to the femoral attachment of the MPFL. Tibial tubercletrochlear groove distance (TT-TG) assessment. High resolution magnetic resonance imaging of the patellar retinaculum Patellar maltracking: an update on the diagnosis and treatment strategies. The lateral retinaculum or lateral canthus is a complex integration of a number of structures. Recurrent dislocations and chronic patellofemoral joint instability will lead to significant cartilage damage and severe arthritis if left untreated. The MPFL is attached to the region of the adductor tubercle or medial femoral epicondyle extending deep to the vastus medialis obliquus (VMO) and attaching to the superior two thirds of the patella [52]. Chronic fat impingement can result in chronic inflammation and fat pad hypertrophy. (2011) ISBN: 9780781778602 -. The knee then was flexed 30, 60, 90, and 120, and the transducer recorded changes in tension within the lateral patellofemoral . Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. Several methods have been used to assess patella alta. Knee 13:266273. 0000070933 00000 n 0000192215 00000 n 0000212094 00000 n 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]. What is the treatment for a patellar retinaculum tear? Specialists of neuroradiology and vascular neurosurgery decided over the modality assignment. Cookies policy. The knee is a complex synovial joint that can be affected by a range of pathologies: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. The transverse stabilizers include the medial and lateral retinaculum, the vastus medialis and lateralis muscles, the ilio-tibial band, and the medial patellofemoral ligament (MPFL). AJR Am J Roentgenol. Magnetic resonance imaging (MRI) is a vital tool in evaluating the potential cause(s) of anterior knee pain due to the complexity of the structure and biomechanics of the knee. The patellar retinaculum and the MPFL are seen on MRI as well-defined low-signal-intensity bands. 2015 Sep 30;9:463-74. doi: 10.2174/1874325001509010463. Fractures may be caused either by excessive force through the extensor mechanism or by a direct blow. 35 Dislocation typically occurs in the setting of internal rotation of the femur on a fixed, externally rotated tibia. The trochlear depth is calculated by measuring the mean of the maximum anteroposterior (AP) distance of the medial and lateral femoral condyles minus the distance between the deepest point of the trochlear groove and the line paralleling the posterior femoral condyles surfaces (Fig. Lastly, a sulcus-deepening procedure known as trochleoplasty may be indicated in the patient with significant trochlear dysplasia and recurrent instability. official website and that any information you provide is encrypted The injuries involved the medial retinacular ligament in 16 of 17 patients and the medial and lateral retinacular ligament in one patient. Femoral avulsion of the MPFL is a predictor of chronic instability and may be a surgical indication in some patients with acute injury. Background Lateral Patella dislocations are common injuries seen in the active and young adult populations. Seven of the nine patients with patellar dislocation injuries had frank osteochondral injuries. (1a) A single fat-suppressed proton density-weighted coronal image. 2012 Feb;41(2):137-48. doi: 10.1007/s00256-011-1291-3. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Diederichs G, Issever A, Scheffler S. MR Imaging of Patellar Instability: Injury Patterns and Assessment of Risk Factors. In full extension, the patella has little to no contact with the trochlear groove and, therefore, is in a position of higher risk for instability. Patellar sleeve avulsion (PSA) fractures are rare injuries that occur in in skeletally immature patients. The MPFL is also stripped from the femoral attachment (long arrow). 2. (27a) Axial and (27b) coronal fat suppressed proton density-weighted images in a patient who experienced recurrent patellar dislocation following surgery. PubMedGoogle Scholar. Figure 1: ligaments (Gray's illustrations), View Pereshin Moodaley's current disclosures, see full revision history and disclosures, posterior suprapatellar (prefemoral or supratrochlear) fat pad, anterior suprapatellar (quadriceps) fat pad, accessory anterior inferior tibiofibular ligament, superficial posterior tibiotalar ligament, superficial posterior compartment of the leg (calf), accessory extensor digiti secundus muscle, descending branch of the lateral circumflex. Laxity of the medial stabilizers will lead to increasing instability over time. Radiology 263:469474, Subhawong TK, Eng J, Carrino JA, Chhabra A (2010) Superolateral Hoffas fat pad edema: association with patellofemoral maltracking and impingement. Other indicated structures: gracilis (G), semitendinosus (ST), and adductor magnus (AM) tendons. Because as noted above, the femoral bone bruise occurs as the patella moves forward during reduction, bone bruises at the lateral femoral condyle always course anteriorly from the site of any femoral chondral injury that may be present. Clin Biomech (Bristol, Avon) 19:10401047, Horton MG, Hall TL (1989) Quadriceps femoris muscle angle: normal values and relationships with gender and selected skeletal measures. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Lateral Retinacular Release - Surgery Information 4). 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 ]. Patellar Dislocation (Acute) | Pediatric Orthopaedic Society of - POSNA Additionally, complex injuries to bone, cartilage, and ligaments may occur. Patellar tracking refers to the dynamic relationship between the patella and trochlea during knee motion [1]. Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella Injury to the medial retinaculum, MPFL, and VMO may be identified at MR imaging after acute LPD. Yu JS, Goodwin D, Salonen D, Pathria MN, Resnick D, Dardani M, Schweitzer M. AJR Am J Roentgenol. Knee 13:2631, McNally EG (2001) Imaging assessment of anterior knee pain and patellar maltracking. The anatomic relationship between the resultant force from the quadriceps and the line of pull of the patellar tendon is termed the Q angle and is normally 1015 of valgus [11]. There is a degree of variability in the literature about what is considered an abnormally high TT-TG. Insights Imaging 10, 65 (2019). Kamel S, Kanesa-Thasan R, Dave J et al. Kirsch M, Fitzgerald S, Friedman H, Rogers L. Transient Lateral Patellar Dislocation: Diagnosis with MR Imaging. Open Orthop J 9:463474, Article Medial retinacular complex injury in acute patellar dislocation: MR findings and surgical implications. Am J Knee Surg 13:8388, Izadpanah K, Weitzel E, Vicari M et al (2014) Influence of knee flexion angle and weight bearing on the Tibial Tuberosity-Trochlear Groove (TTTG) distance for evaluation of patellofemoral alignment. When the knee moves slightly out of place or becomes tilted in the joint, it can cause tension and pain in the lateral retinaculum. PubMed 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. Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete. Our study focus was to evaluate medial patellofemoral ligament (MPFL) injury patterns and associated knee pathology using Magnetic Resonance Imaging studies. also supported our data in a magnetic resonance imaging (MRI) study of 82 patients with the diagnosis of lateral patella dislocation and found that 76% of medial retinacular/MPFL disruption occurred at its patellar insertion site, 49% occurred at the femoral attachment site, 30% showed injury of the MPFL at mid-substance, and 48% . We confirm that this article is not under consideration for publication elsewhere and that the authors did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. 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. Acute patellar dislocation (APD) is a common injury in children, accounting for up to 16% of acute knee hemarthroses. 11 Lind M, Jakobsen B, Lund B, et al. quadricepsplasty rehab protocol Less commonly, patients can also present after chronic patellar instability secondary to generalized ligamentous laxity with or without anterior knee pain. In either case, careful search for possible displaced osteochondral fragments is necessary, as surgery is often indicated in such patients. ity. Elsevier, Philadelphia, Buckens CF, Saris DB (2010) Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. Patellar Tendon Tear - OrthoInfo - AAOS The clinical evaluation of patellar maltracking is often challenging, Imaging can detect subtle features that could lead to early diagnosis, Imaging can detect predisposing factors for patellar maltracking and associated structural changes, Management decisions are made on individual basis with imaging playing a vital role. Dr. Frederick Buechel, Jr. MD answered. Eleven gave a history of recurrent patellar dislocation. Levy B, Tanaka M, Fulkerson J. Despite non-operative management, recurrent patellar instability occurs in between 15 and 45% of patients [17,18,19,20]. 3). Am J Sports Med 16:244249, Hawkins RJ, Bell RH, Anisette G (1986) Acute patellar dislocations. The convex articular surface of the patella places it at risk for chondral injury in either the dislocation or the reduction phases of injury. The authors declare that they have no competing interests. Less commonly, a direct laterally or medially orientated blow to the patella can precipitate dislocation. 3. A bone bruise occurs anterior to this site of impaction as the patella reduces with knee extension. Objective: This prospective study is designed to detect changes in the treatment of ruptured intracranial aneurysms over a period of 17 years. The stability of the patella is dependent on both osseous anatomy and the integrity of longitudinal and transverse soft tissue stabilizers. 3. Medial patellofemoral ligament injury patterns and associated pathology Medial Patellofemoral Ligament (MPFL) - Physiopedia It was shown that certain features of patellar maltracking (increased sulcus angle, lateral patellar tilt, and a higher patellar tendon to patellar length ratio) are associated with cartilage loss and bone marrow lesions [59]. 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. PTI of less than 12.5% suggests the presence of patella alta. The most obvious presentation of patellar maltracking is that of the first time lateral patellar instability or recurrent instability thereafter. It is a major factor in patellar instability and was shown to be present in 85% of these patients [21]. Lateral Retinaculum - an overview | ScienceDirect Topics Soft tissue changes may include effusion, thickening or disruption of the MPFL, and retinacular complex and regional edema. Surgical management procedures can broadly be categorized as soft tissue procedures (lateral release, medial imbrication, and MPFL repair or reconstruction) and bony procedures (tibial tubercle transfer procedures and trochleoplasty). Both MRI and ultrasound are accurate imaging modalities in the detection of MPFL injuries [5, 50, 51]. Medial patellofemoral ligament injury patterns and associated pathology Am J Sports Med 32:11141121, Tsavalas N, Katonis P, Karantanas AH (2012) Knee joint anterior malalignment and patellofemoral osteoarthritis: an MRI study. These two structures blend with each other and are difficult to separate on imaging. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Persistent abnormalities of patellar alignment and abnormalities of trochlear morphology are also common, and should be carefully described. Are you sure you want to trigger topic in your Anconeus AI algorithm? sharing sensitive information, make sure youre on a federal Diagnosis is made clinically with pain with compression of the patella and moderate lateral facet tenderness and sunrise knee radiographs will often show patellar tilt in the lateral direction. Macroscopic Anatomy of the Stifle Joint in the Pampa's Deer An official website of the United States government. A facet ratio of < 40% indicates dysplasia. 1995 Jan;164(1):135-9. doi: 10.2214/ajr.164.1.7998526. 6). 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. In: West RV, Colvin AC (eds) The patellofemoral joint in the athlete. PubMed A Focal Defect at the Lateral Patellar Retinaculum on Clinical Knee MRI Unable to process the form. Guidelines and Gamuts in Musculoskeletal Ultrasound. TT-TG is a reflection of the clinically measured Q angle. Because of the transient and brief nature of lateral patellar dislocations, the diagnosis is frequently unrecognized by both patients and clinicians. From the inside of the knee the lateral retinaculum is incised, from the inside, allowing the kneecap to untilit itself. The authors would like to sincerely thank Cheryl Kreviazuk for all her efforts in the submission process. b The patella tilt angle is measured between the posterior condylar line (dashed line) and the maximal patella width (solid line). The patellar apprehension test is used to assess for lateral instability and is positive when pain or discomfort occurs with lateral translation of the patella. Springer, New York, pp 1529, Cash JD, Hughston JC (1988) Treatment of acute patellar dislocation.

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