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MPFL. PFJ Instability2015


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MPFL. PFJ Instability2015

  1. 1. Professor Deiary F Kader Department of Sport, Exercise, Northumbria University, Newcastle Knee Surgeon, Nuffield Hospital, Newcastle upon Tyne PATELLOFEMORAL JOINT INSTABILITY PostGrad Orth Deiary Kader
  2. 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. 3. PLAN Presentation Frank dislocation Subluxation Symptomatic instability Pain due to mal-tracking
  4. 4. PATELLAR DISLOCATION Re-dislocation rate First Time 17-20% Second Time 44%-71% High dissatisfaction following conservative Rx
  5. 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. 6. PATELLAR STABILITY DETERMINED BY – Soft Tissue 0-300 Muscles Ligaments MPFL (at 200-300) – Bone morphology >300
  7. 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. 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. 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. 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. 11. Many potential problems • Crude measure • How it is measured? – Flexion, Extension – Standing, Sitting, Supine – Muscle relaxed/tense • No standard method Q- Angle
  12. 12. IMAGING OF THE PATELLOFEMORAL JOINT AP and Lateral Knee x-ray Merchant’s view MRI Axial view CT Rotational Profile Merchant’s
  13. 13. Trochlea dysplasia Blumensaat's line Normal Trochlea Depth NORMAL
  14. 14. MEASURING PATELLA HEIGHT Caton – Deschamps index =1.2 Blackburne-peel index = 1.12 PostGrad Orth Deiary Kader
  15. 15. MPFL injury Patella pain Articular Damage MRI SCAN
  16. 16. 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)
  17. 17. 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
  18. 18. 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
  19. 19. TREATMENT OF PATELLA INSTABILITY Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait
  20. 20. Med Epicondyle Add Tubercle Patella MPFL PostGrad Orth Deiary Kader
  21. 21. PostGrad Orth Deiary Kader
  22. 22. BONY TUNNEL PostGrad Orth Deiary Kader
  23. 23. MX OF PATELLA INSTABILITY Patellofemoral Instability with Malalignment Distal Realignment tibial tubercle transfer Combined MPFL Recon
  24. 24. FULKERSON'S TECHNIQUE OF ANTEROMEDIALIZATION A steeper osteotomy plane will produce more anteriorization along with medialization
  25. 25. OTHER PATELLOFEMORAL PROBLEMS Patella Alta – Distal transfer (Distalization) Trochlea Dysplasia – Trochloplasty PostGrad Orth Deiary Kader
  26. 26. 1.4 cm Patella alta
  28. 28. TAKE HOME MESSAGE The approach to patellar instability should be individualised and tailored to each patient’s symptoms, anatomy and physical demands
  29. 29. PostGrad Orth Deiary Kader
  30. 30. 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
  31. 31. TREATMENT SUMMARY MPFL Reconstruction (very popular >80%) Tib Tub Medialisation on the decline Tib Tub Distalisation excellent procedure Trochleoplasty Distal femoral Osteotomy
  32. 32. 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