Download Patellofemoral Pain

Patellofemoral Pain
William R. Beach, M.D.
Raymond Y. Whitehead, M.D.
Anatomy and Biomechanics
• Arthicular surface
– 2-facets with a central ridge
• Passive stabilizers
– Patellar tendon
– Lateral retinaculum
– Medial patellofemoral ligament
• Static checkrein
• Resist lateral translation
• Dynamic stabilizers
– Quadriceps muscle
History
• Pain
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Character
Location
Onset
Intensity
Exacerbation
Remittance
• Effusion
• Trauma
– Subluxation
– Dislocation
History
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Previous treatment
Other joint involvement (gout, R.A.)
Litigation
Worker’s compensation
Psychological components
Physical Examination
• Alignment
– Varus/valgus
– Rotational
• Q-angle
– Norms – male(10º) and female(15º)
– Flexion angle
• Tubercle-sulcus angle
• Extensor mechanism
– Patellar alta vs. baja
• Hamstring tightness
Physical Examination
• Patellofemoral crepitus
• Patellar tracking
– J-sign
– Apprehension
• Lateral retinaculum
– Tenderness
– Tilt
– Patellar mobility
• Quad strength
– IT band friction synd.
– Pes anserinus bursitis
Radiographic Evaluation
• AP, lateral and axial
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Varus/valgus alignment
Accessory ossification centers
Osteochondral fractures
Patellar relationship
• Alta
• Baja
Radiographic Evaluation
• Merchant axial
– 45 deg and 30 caudal tilt
– Normal patella – no tilt or subluxation beyond 15-20
deg of flexion
Radiographic Evaluation
• Sulcus angle
– Angle formed by the trochlear ridges
– Mean - 138º
medial
lateral
Radiographic Evaluation
• Congruence angle
– Angle formed by bisecting the sulcus angle and central
patellar ridge
– Mean = -6º +/- 6º (central ridge should lie medial to the
bisector)
medial
lateral
Radiographic Evaluation
• 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
Radiographic Evaluation
• Lateral patellofemoral angle
• Line parallel to the lateral facet and a line drawn
across the posterior femoral condyles
• Angle formed will normally be open laterally (>8º)
• If open medially suggest patellar tilt
Computed Tomography
• Precise midpatellar transverse images parallel to
both femoral condyles
• Images at 15, 30 and 45 degrees of flexion
• Normal standing alignment – maintain rotational
and angular alignment
• Normal patellar tracking = patella centered in the
trochlea without tilt at 15º of flexion
• Visually the easiest way to determine tilt and
subluxation
Computed Tomography
• Patellar tilt angle
– angle between line along lateral facet of the patella and
line along posterior condyles
– normal > 12º
Computed Tomography – 0°
Computed Tomography – 15°
Computed Tomography – 30°
Computed Tomography – 45°
Computed Tomography – 60°
Magnetic Resonance Imaging
• Less helpful than CT
• Assess bone and cartilage lesions
Bone Scan
• Occult fracture
• Painful bipartite patella
• Increased uptake with patellar tendonitis
• Avoid electrocautery for revision release
Conservative Treatment
• Goal – reduce symptoms, improve quad
strength and endurance
• Short arc quads – reduce patellofemoral
load and friction
• Quad stretching
• Hamstring stretching
• Pelvic tilt – stretch hip extensors and
abductors
Conservative Treatment
• Patellar mobility exercises – lateral
retinaculum stretching
• Aerobic conditioning
• NSAIDS
• Bracing/McConnell taping
– Patellar cut-out brace
– J-pad
Surgical Treatment
• Arthroscopy
– Lateral release
– VMO Plication
• Tibial tubercleplasty
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Elmslie-Trillat – medial
Maquet – anterior
Fulkerson – anterior/medial
Roux-Goldthwaite – open growth plate
• Patellectomy
Arthroscopy and Lateral Release +/Arthroscopic VMO Plication
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Debridement of the articular surface
Result of patellar malalignment/maltracking
Lateral release for isolated patellar tilt
Lateral release alone is insufficient for subluxation
Arthroscopy and Lateral Release +/Arthroscopic VMO Plication
• Technique
– Lateral release from muscle to the anterolateral portal
• Avoid the lateral portion of the quad tendon
• Electocautery for primary release
Arthroscopic VMO Plication
• Technique
– Arthroscope in the lateral portal
– Thru and thru #2 panacryl suture on a large curved
needle
– Sutures from 2 – 4 o’clock
– Small incision to tie the sutures
– Flex the knee to 90º to assure proper suture placement
Tibial Tubercleplasty
• Indication
– Elmslie-Trillat – for subluxation without arthrosis
– Maquet – for primary athrosis
– Fulkerson – for subluxation and arthrosis
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Best for patellar lesion, distal lateral facet
Medialization realigns extensor mechanism
Anteriorization unloads the articular cartilage
Lateral release should always be performed
Fulkerson Anteromedial Tibial
Tubercle Transfer
Fulkerson Anteromedial Tibial
Tubercle Transfer
Fulkerson Anteromedial Tibial
Tubercle Transfer
Fulkerson Anteromedial Tibial
Tubercle Transfer
Fulkerson Anteromedial Tibial
Tubercle Transfer
Fulkerson Anteromedial Tibial
Tubercle Transfer
Fulkerson Anteromedial Tibial
Tubercle Transfer
Fulkerson Anteromedial Tibial
Tubercle Transfer
Patellectomy
– Last resort
– Extensive articular damage of the patella and
unremitting pain
– Patella must have satisfactory alignment