Disorders of the Patellofemoral Joint: Diagnosis and Management

140 Pages·2019·8.05 MB·English

by  E. Carlos Rodríguez-Merchán, Alexander D. Liddle

Disorders of the
Patellofemoral Joint
Diagnosis and Management
E. Carlos Rodríguez-Merchán
Alexander D. Liddle
Editors
123
Disorders of the Patellofemoral Joint
E. Carlos Rodríguez- Merchán
Alexander D. Liddle
Editors
Disorders of the
Patellofemoral Joint
Diagnosis and Management
Editors
E. Carlos Rodríguez-Merchán Alexander D. Liddle
Department of Orthopaedic Surgery University College London Institute
La Paz University Hospital of Orthopaedics
Madrid London
Spain UK
ISBN 978-3-030-12441-0 ISBN 978-3-030-12442-7 (eBook)
https://doi.org/10.1007/978-3-030-12442-7
© Springer Nature Switzerland AG 2019
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Preface
Pathologies of the patellofemoral joint are common and affect a diverse group
of patients, from children with patellar instability to sports people with trau-
matic dislocations and cartilage defects and elderly patients with patellofem-
oral osteoarthritis. In spite of this, for many years, the patellofemoral joint
has been poorly understood. As orthopaedic surgeons, the interventions that
we have available to treat patients with patellofemoral pathologies have until
recently been limited, and outcomes have been uncertain.
Happily, times are changing. Since the turn of the century, unprecedented
steps have been made in increasing our understanding of the patellofemoral
joint in normal and pathological states. Anatomical and physiological studies
have helped us to understand patellofemoral morphology and function.
Improvements in imaging have improved diagnosis and planning of surgical
treatments. New procedures, such as trochleoplasty and medial patellofemo-
ral ligament reconstruction, have been introduced and have demonstrated
reliable results, and new implants have been introduced, improving outcomes
in patellofemoral arthroplasty. A large and growing body of evidence exists to
guide us in the treatments we offer and to improve the information available
to patients; traditional interventions such as lateral retinacular release and
patellectomy have been shown not to have the efficacy to justify their wide-
spread use. The progress that has been made in recent years in the under-
standing and treatment of the patellofemoral joint is arguably greater than in
any other topic in hip and knee surgery.
As a result of this pace of change, the clinician who treats disorders of the
patellofemoral joint should be equipped with the latest evidence. The tradi-
tional use of simple and universal techniques for treating patellofemoral
problems has been overtaken by a more patient-centred, a la carte method of
treatment based on the patient’s anatomy, physiology and functional demands.
As a result, surgeons need to be familiar with a large and growing range of
techniques.
The aim of this book is to aid surgeons in providing the best, evidence-
based treatments for patients presenting with patellofemoral disorders. We
have aimed to cover the breadth of the topic from assessment and imaging of
adults and children with patellofemoral pathology to management of acute
and chronic patellofemoral conditions. We have covered a range of traditional
and novel techniques, including methods of nonoperative management, joint
preserving surgery and arthroplasty. Each chapter has been produced by
authors with direct experience of the condition and its management, and a
v
vi Preface
thorough overview of the evidence for each intervention is presented. We
hope that this book will help surgeons to provide the best, evidence-based
treatments for patients with disorders of the patellofemoral joint.
Madrid, Spain E. C. Rodríguez-Merchán
London, UK A. D. Liddle
Contents
1 Examination of the Patellofemoral Joint . . . . . . . . . . . . . . . . . . . 1
Luke Jones, Adam Fell, and Simon Ball
2 Imaging of the Patellofemoral Joint . . . . . . . . . . . . . . . . . . . . . . . 7
Carlos A. Encinas-Ullán and E. Carlos Rodríguez-Merchán
3 Acute Patellar Instability in Children . . . . . . . . . . . . . . . . . . . . . . 25
Stephen Ng Man Sun and Sally J. Tennant
4 Acute Lateral Patellar Dislocation in Adults . . . . . . . . . . . . . . . . 31
Alfonso Vaquero-Pintado and E. Carlos Rodríguez-Merchán
5 Recurrent Lateral Dislocation of the Patella in Children . . . . . . 37
Luis Moraleda-Novo and Primitivo Gómez-Cardero
6 Risk Factors and Demographics for Recurrent
Lateral Dislocation of the Patella in Adults . . . . . . . . . . . . . . . . . 59
E. Carlos Rodríguez-Merchán, Carlos A. Encinas-Ullán, and
Alexander D. Liddle
7 Nonoperative Treatment of Patellofemoral Problems:
The Role of Physical Medicine and Rehabilitation . . . . . . . . . . . 67
Hortensia De la Corte-Rodriguez and
Juan M. Roman-Belmonte
8 Cartilage Defects of the Patellofemoral Joint . . . . . . . . . . . . . . . . 81
Yaser Ghani and James Donaldson
9 Patellofemoral Instability: Lateral Release . . . . . . . . . . . . . . . . . 89
Alexander D. Liddle and E. Carlos Rodríguez-Merchán
10 Patellofemoral Instability: Proximal Realignment and
Trochleoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Maureen Monda and Antony Palmer
11 Patellofemoral Instability: Distal Realignment . . . . . . . . . . . . . . 101
Suroosh Madhanipour, Kostas Michail, and Sam Oussedik
12 Patellofemoral Instability: Medial Patellofemoral
Ligament (MPFL) Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . 109
E. Carlos Rodríguez-Merchán, Carlos Encinas- Ullán, and
Primitivo Gómez-Cardero
vii
viii Contents
13 Patellofemoral Osteoarthritis: Intra-articular Injections . . . . . . 117
Juan S. Ruiz-Pérez and E. Carlos Rodríguez-Merchán
14 Patellofemoral Osteoarthritis: Partial Lateral Patellar
Facetectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
E. Carlos Rodríguez-Merchán and Alexander D. Liddle
15 Patellofemoral Osteoarthritis: Patellofemoral Arthroplasty . . . 129
Farhad Iranpour, Arash Aframian, and Justin P. Cobb
16 Patellectomy in Patellofemoral Joint Problems . . . . . . . . . . . . . . 135
Alfonso Vaquero-Picado and E. Carlos Rodríguez-Merchán
1
Examination of the Patellofemoral
Joint
Luke Jones, Adam Fell, and Simon Ball
1.1 Introduction as isolated from the overall diagnostic process.
The history will reveal common presentations
Despite its apparent simplicity, the patellofemo- (typically pain, giving way and swelling) and will
ral joint exhibits a wide variety of pathology with therefore narrow the potential differential diag-
several potentially causative or contributory fac- nosis and allow the clinician to focus on specific
tors. The examination of the joint can therefore aspects of the examination.
be challenging and must consider those factors Despite this, we suggest that a thorough clini-
intrinsic to the joint as well as those related to cal examination be performed on each patient,
other parts of the body. The joint behaves differ- allowing the examiner to gain more experience in
ently in different positions and has both static and assessing the subtle examination findings associ-
dynamic elements that add to its complexity. In ated with the joint. Here, we outline a structured
addition, patellofemoral joint examination find- examination technique that should be performed
ings are often subtle and poorly reproducible, in a systematic manner. We use this examina-
reinforcing the impression that only an expert can tion structure in our outpatient clinics to allow
adequately assess it. clear documentation of findings and to facilitate
Of course, there is no substitute for experi- communication between clinicians of differing
ence—the clinician must take every opportunity experience.
to examine patients in order to understand what The patient is examined in three stages: stand-
is normal and what lies outside this range. The ing, sitting and supine. In each of the first two
clinician should realise that most tests have poor stages, inspection is performed both statically
sensitivity and therefore utilise several differ- and dynamically. In the third stage, palpation
ent examination techniques to assess the same and special tests are performed. We believe this
aspect of the joint. The examination should be structured examination to be the most efficient
used to confirm or refute the diagnosis made from method of assessing the patellofemoral joint.
the clinical history and guide the use of special- There is of course flexibility to perform palpation
ist investigations. It should never be thought of and special tests in the first two stages. Although
L. Jones (*) · A. Fell · S. Ball
Department of Orthopaedics and Trauma,
Chelsea and Westminster Hospital, London, UK
e-mail: [email protected];
[email protected]; [email protected]
© Springer Nature Switzerland AG 2019 1
E. C. Rodríguez-Merchán, A. D. Liddle (eds.), Disorders of the Patellofemoral Joint,
https://doi.org/10.1007/978-3-030-12442-7_1
2 L. Jones et al.
the examination manoeuvres may be adjusted At this stage, a brief assessment of leg length
according to individual patients, it is advised to discrepancy is made with the feet flat on the
perform it in a systematic manner to avoid miss- ground and the knees fully extended. The tilt of
ing key findings. the pelvis is noted from the height of the iliac
crests. Next, the relative heights of the patel-
lae are noted from their topographical anatomy:
1.2 Standing patella alta is associated with instability, whereas
patella baja is associated with chondromala-
The patient’s lower limbs are exposed, with the cia patellae. From the side, an inability to fully
patient wearing high shorts or briefs to allow extend the knee is assessed—this is associated
inspection of the pelvic position. The feet must with patellofemoral arthrosis. Hyperextension of
be uncovered. the knee (recurvatum) may indicate a generalised
hyperlaxity, in which case at the Beighton scores
is determined. Here, a score of 1 is allocated to
1.2.1 Static Examination the ability to bend the thumb to the radial side of
the forearm; a score of 1 is allocated to the ability
An initial examination of the patient for the “five to extend the fifth finger beyond 90°. A score of
Ss” (symmetry, skin changes (bruising and red- 1 is allocated for the ability to hyperextend the
ness), scars (surgical and posttraumatic), sinuses knee and elbow. Each side is assessed to gener-
(indicating infection), soft tissue swelling) is per- ate a score of 8, and a further 1 point is allocated
formed with the patient standing with both feet to the ability to place the hands flat on the floor
flat on the ground and the feet slightly apart. The with the legs straight. A total score of 4 or more
examiner kneels in front of the patient, and the indicates generalised hypermobility [1].
patient is asked to turn 90° to their right on four Whilst standing, the posture of the feet can be
occasions, until a 360-degree inspection has been assessed. Excessive pronation can be seen if the
performed. Firstly, an inspection of overall align- patient is standing in a relaxed position or dur-
ment is performed to assess for varus or valgus ing normal walking or running. A flattening of
alignment. Genu valgum indicates a larger later- the medial longitudinal arch can indicate exces-
ally directed force across the patella which may sive forefoot pronation, which is associated with
lead to maltracking and patella subluxation. This internal tibial torsion, and a valgus deformity of
is formally measured by the Q angle—a mea- the knee. Both of these can increase the stress on
surement of the angle formed by the intersec- the periarticular soft tissues and may cause ante-
tion of the line drawn from the anterior superior rior knee pain [2]. Fortunately, the simple use of
iliac spine (ASIS) to the midpoint of the patella orthotics can eliminate this.
and the extension of a line drawn from the tib-
ial tuberosity to the midpoint of the patella. A
greater Q angle in women (15–18°) compared to 1.2.2 Dynamic Examination
men (12°) may partly explain higher incidences
of patellofemoral pain in women due to a larger The patient is then asked to walk, and the gait is
valgus vector. The Q angle must be interpreted observed from the front and behind whilst walk-
with caution—a laterally subluxated patella will ing forwards and then backwards, on the heel
reduce the value, whilst an internally rotated hip and the toes. The latter two elements are general
will artificially increase it. An assessment of the assessment of lower limb function and the L5 and
presence of increased femoral anteversion is then S1 motor nerve roots in particular. Assessment of
made by inspecting the orientation of the patel- the gait whilst walking backwards is a way to
lae—an inward pointing or “winking” patella assess the patient who is suspected of exaggerat-
confirms this, as does tibial external rotation and ing symptoms as it is difficult to artificially induce
a compensatory hind foot valgus. a limp whilst walking backwards [3]. A limping