lateral patellar compression syndrome with arthroscopic vedio

1. Lateral Patellar
Compression syndrome
Prepared by:
Dr.Amanj Mohsin Mustafa
4th
year candidate at KBMS
Supervised by :
Dr abdulkader alany

2. Overview
• Anatomy and Biomechanics
• Definition
• Causes of lateral compression
• Sign and symptom
• Examination
• Radiological finding and measurements
• Treatment
• Summmary
• Take home message
• Reference

3. Anatomy
• largest sesamoid bone in body,sits in
femoral trochlea
• asymmetrical oval with its apex directed
distally

5. Biomechanics
• Aid knee for extension
• Increase lever arm
• Stress disturbution
• Bears greatets load
• 0.5 B. W with normal walking
• 7 times B. w during squating
• 20 times during jumping

7. Definition
• Improper tracking of patella in trochlear
groove but with out presence of
instability is often associated with
overload & increased pressure on
lateral facet due to pathologic lateral soft-
tissue restraints
• Chronic anterior knee pain

8. Causes
1.tight lateral retinaculum leads to excessive
lateral tilt without excessive patellar mobility
2.Miserable Triad
is a term used for anatomic characteristics that
lead to an increased Q angle and an
exacerbation of patellofemoral dysplasia.
•  femoral anteversion
•  genu valgum
•  external tibial torsion / pronated feet

10. Sign and symptom
• Anterior Knee pain that is out of
proportion with physical examination
• pain with stair climbing & descending
• theatre sign (pain with sitting for long
periods of time)

11. • Pain & tenderness at lateral side of
patella & some time on medial side
because tension on medial retinaculum
• Patients deny instability or crepitus

12.  Physical exam• Look:
• Supine:
any muscle waisting, scar , discoloration
Sitting with 90 knee:
any deformity , swelling
Standing :
for any valgus ,external tibial torsion
Walking : again for deformity and rotation

13. Feel :
tenderness usually at lateral side of patella
present
Movement:
Active movement
Passive movement

14. Tests :
• Measurement Q-angle by standing
• Apprehension test for patella
• inability to evert the lateral edge of the patella
• Palm of the patella to check for articular
surface

18. Radiological findings and
measurements
1. X-Ray : Merchant view

19. Radiological findings and
measurements
1. X-Ray : Sunrise view

25. measurements for Trochlear dysplasia
usually we have to know about such
condition to exclude trochlear
dysplasia

26. D angle 145
Sulcus angle

27. 0.8- 2.9 mm normal

30. Normal range less than 20mm

31. Normal range less than 20mm

32. MRI findings

35. MRI findings

36. Treatment
• Nonoperative
• indications
mainstay of treatment & should be done
for extensive period of time
• Technique
• therapy should emphasize vastus
medialis strengthening & closed chain
short arc quadriceps exercises

39. Operative
• arthroscopic lateral release
• objective evidence of lateral tilting (neutral
or negative tilt)( no subluxation)
• pain refractory to extensive rehabilitation
• inability to evert lateral edge of patella

40. • ideal candidate has no symptoms of
instability
• medial patellar glide of less than one
quadrant
• lateral patellar glide of less than three
quadrants

41. Laproscopic Release case
• Pre op

43. Release

44. Post release

46. Pre op MRI
4-7-2015

47. Post op MRI
26-7-2016

48. Approach to Distal
Realignment
1. objective anatomic malalignment has
been diagnosed
2. nonoperative treatment has failed.
3. If dislocations have occurred, one must
consider whether stabilization of patella
might be needed by medial
patellofemoral ligament imbrication or
reconstruction, along with correction of
underlying malalignment.

49. patellar realignment surgery
• Soft tissue procedures:
(Skeletally immature)
1)the Roux-Goldthwait procedure
in which lateral half of patellar tendon is
detached distally, passed behind medial
half of tendon, and sutured to pes
anserinus insertion,

50. • this procedure is no longer
recommended.

51. 2.Galeazzi semitendinosus tenodesis :

52. Bony Procedures
• Maquet (tubercle anteriorization)
• indicated only for distal pole lesions
• Elevate about 1.2 cm which has
significant effect on decreasing joint
force but care should be taken for more
elevation because there is risk of skin
necrosis

53. • Anterior elevation of tibial tuberosity,
enhances efficiency of quadriceps by
increasing lever arm while decreasing
patellofemoral joint reaction force.
• increasing angle between vector of
quadriceps pull & patellar tendon
decreases joint reaction force.

55. • Elmslie-Trillat (medialization)
• indicated only for instability with lateral
translation (not isolated lateral tilt)
• avoid if medial patellar facet arthrosis

56. technique classically combines lateral
release, medial capsular reefing, and
medial displacement of bony insertion of
patellar tendon with distal displacement
titrated according to degree of patella
alta measured preoperatively.

58. • Fulkerson alignment surgery (tubercle
anteriorization & medialization)
• Indications (controversial)
1. lateral and distal pole lesions
2.increased Q angle
• contraindications
superior medial O.A

59. • Laboratory evaluation of this concept in a
cadaver model with increased lateral
facet overload induced by alteration of
proximal vector of quadriceps showed
excellent reduction of lateral facet
pressure.

60. • study reported a 30% reduction in lateral facet
pressure with anteriorization of 8.8 mm &
medialization of 8.4 mm,
• 65% relief after additional anteromedialization to
14.8/8.4 mm.
• By 20 to 30 degrees of knee flexion, reduction &
equalization of medial & lateral facet pressure were
noted, with greater reduction in more anteriorized
group

64. Complications
• 1.skin necrosis
• 2.Fracture
• 3.Compartment syndrome

65. Take Home Message
1.Patellofemoral joint (PFJ) disorders is
(black hole of orthopaedics).
2.Anterior Knee pain is common complain
and always don’t forget to exclude
patella pathology.

66. Take Home Message
3.Don’t accept Knee MRI with out axial
view specialy in cases with AKP.
4. With arthroscopy never forget to check
for patellar tracking
5.When ever see patient with chronic knee
pain and stable patella think about LPCS

67. Reference
1.Insall & Scott Surgery of the Knee
(FIFTH EDITION) 2012
2. CAMPBELL’S OPERATIVE ORTHOPAEDICS
(TWELFTH EDITION) 2013
3.Postgraduate Orthopaedics:
The Candidate’s Guide to the FRCS (Tr & Orth)
Examination (Second edition) 2012
4.Measurements and Classifications in
Musculoskeletal Radiology (2014)
5. Orthobullet 2015

68. 6. A systematised MRI approach to evaluating the
patellofemoral joint
Published in final edited form as:
Skeletal Radiol. 2011 April ; 40(4): 375–387.
doi:10.1007/s00256-010-0909-1
• 7. Diagnosis and Treatment of Lateral Patellar
Compression Syndrome
Michael G. Saper, D.O., A.T.C., C.S.C.S., and David A.
Shneider, M.D.