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Lateral patellar compression syndrome
Lateral patellar compression syndrome is caused by improper tracking of the patella in the femoral trochlear groove without instability. It is associated with increased pressure on the lateral facet due to tight lateral soft tissues. Patients present with chronic anterior knee pain that is exacerbated by activities like stairs and sitting. Examination reveals tenderness over the lateral patella. Treatment begins with physical therapy focusing on vastus medialis strengthening. For refractory cases, arthroscopic lateral release can provide relief by correcting the lateral tilt.
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Lateral patellar compression syndrome
- 1. Lateral Patellar Compression syndrome Preparedby: Dr.Amanj Mohsin Mustafa 4th year candidate at KBMS Supervised by : Dr abdulkader alany
- 2. Overview • Anatomy andBiomechanics • Definition • Causes of lateral compression • Sign and symptom • Examination • Radiological finding and measurements • Treatment • Summmary • Take home message • Reference
- 3. Anatomy • largest sesamoidbone in body,sits in femoral trochlea • asymmetrical oval with its apex directed distally
- 5. Biomechanics • Aid kneefor 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 trackingof 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 retinaculumleads 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 usuallyat lateral side of patella present Movement: Active movement Passive movement
- 14. Tests : • MeasurementQ-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 Trochleardysplasia usually we have to know about such condition to exclude trochlear dysplasia
- 26. D angle 145 Sulcusangle
- 27. 0.8- 2.9 mmnormal
- 30. Normal range lessthan 20mm
- 31. Normal range lessthan 20mm
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- 36. Treatment • Nonoperative • indications mainstayof 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 lateralrelease • 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 candidatehas no symptoms of instability • medial patellar glide of less than one quadrant • lateral patellar glide of less than three quadrants
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- 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 procedureis no longer recommended.
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- 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 elevationof 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 combineslateral 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 alignmentsurgery (tubercle anteriorization & medialization) • Indications (controversial) 1. lateral and distal pole lesions 2.increased Q angle • contraindications superior medial O.A
- 59. • Laboratory evaluationof 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 reporteda 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.Patellofemoraljoint (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’taccept 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 & ScottSurgery 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 systematisedMRI 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.