Top

Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

21-11-2023 | Osteoarthrosis | KNEE

Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis

Authors: Simon Talbot, Rachel Zordan, Kyle Bennett, Francesca Sasanelli, Andrew Griffith, Noel Woodford, William L. Walter

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 12/2023

Abstract

Purpose

The purposes of this study are to, firstly, develop techniques to accurately identify extensor mechanism malalignment by measuring the alignment of the quadriceps tendon (QTA) with computerized tomography (CT) scans. Secondly, to investigate correlations between QTA and lower limb bony anatomical variations within a representative normal population. Lastly, to evaluate the clinical significance of QTA by establishing its potential connection with lateral facet patellofemoral joint osteoarthritis (LFPFJOA).

Method

CT scans were orientated to a mechanical axis reference frame and three techniques developed to measure the alignment of the quadriceps tendon. Multiple measurement of bony alignment from the hip to the ankle were performed on each scan. A series of 110 cadaveric CT scans were measured to determine normal values, reproducibility, and correlations with bony anatomy. Secondly, a comparison between 2 groups of 25 patients, 1 group with LFPFJOA and 1 group with isolated medial OA and no LFPFJOA.

Results

From the cadaveric study, it was determined that the alignment of the quadriceps tendon is on average 4.3° (SD 3.9) varus and the apex of the tendon is 9.1 mm (SD 7.7 mm) lateral to the trochlear groove and externally rotated 1.9° (SD 12.4°) from the centre of the femoral shaft. There was no association between the quadriceps tendon alignment and any other bony measurements including tibial tubercle trochlear groove distance (TTTG), coronal alignment, trochlear groove alignment and femoral neck anteversion. A lateralized QTA was significantly associated with LFPFJOA. QTA in the LFPFJOA group was 9.6° varus (SD 2.8°), 21.3 mm (SD 6.6) lateralised and 17.3° ER (SD 11°) compared to 5.5° (SD 2.3°), 10.7 mm (SD 4.9) and 3.3° (SD 7.2°), respectively, in the control group (p < 0.001). A significant association with LFPFJOA was also found for TTTG (17.2 mm (SD 5.7) vs 12.1 mm (SD 4.3), p < 0.01). Logistic regression analysis confirmed the QTA as having the stronger association with LFPFJOA than TTTG (AUC 0.87 to 0.92 for QTA vs 0.79 for TTTG).

Conclusion

These studies have confirmed the ability to accurately determine QTA on CT scans. The normal values indicate that the QTA is highly variable and unrelated to bony anatomy. The comparative study has determined that QTA is clinically relevant and a lateralised QTA is the dominant predictor of severe LFPFJOA. This deformity should be considered when assessing patella maltracking associated with patella osteoarthritis, patella instability and arthroplasty.

Level of evidence

III (retrospective cohort study).

Ferri R, Digennaro V, Panciera A, Bulzacki Bogucki BD, Cecchin D, Manzetti M et al (2023) Management of patella maltracking after total knee arthroplasty: a systematic review. Musculoskelet Surg 107(2):143–157CrossRefPubMed

Hinman RS, Crossley KM (2007) Patellofemoral joint osteoarthritis: an important subgroup of knee osteoarthritis. Rheumatology 46(7):1057–1062CrossRefPubMed

Maine S, O’Gorman P, Barzan M, Stockton CA, Lloyd D, Carty CP (2019) Rotational malalignment of the knee extensor mechanism. Defining rotation of the quadriceps and its role in the spectrum of patellofemoral joint instability. JBJS Open Access 4(4):1–7CrossRef

Mizuno Y, Kumagai M, Mattessich SM, Elias JJ, Ramrattan N, Cosgarea AJ et al (2001) Q-angle influences tibiofemoral and patellofemoral kinematics. J Orthop Res 19(5):834–840CrossRefPubMed

Momoli A, Modena M, Giaretta S (2013) Extensor mechanism realignment procedures in the treatment of patellofemoral instability. Joints 1(2):21–26PubMedPubMedCentral

Skouras AZ, Kanellopoulos AK, Stasi S, Triantafyllou A, Koulouvaris P, Papagiannis G et al (2022) Clinical significance of the static and dynamic Q-angle. Cureus. https://doi.org/10.7759/cureus.24911CrossRefPubMedPubMedCentral

Nisar S, Palan J, Rivière C, Emerton M, Pandit H (2020) Kinematic alignment in total knee arthroplasty. EFORT Open Rev 5(7):380–390CrossRefPubMedPubMedCentral

Shatrov J, Battelier C, Sappey-Marinier E, Gunst S, Servien E, Lustig S (2022) Functional alignment philosophy in total knee arthroplasty - rationale and technique for the varus morphotype using a CT based robotic platform and individualized planning. SICOT J. https://doi.org/10.1051/sicotj/2022010CrossRefPubMedPubMedCentral

Fulkerson JP (1983) Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop Relat Res 177:176–181CrossRef

10.

Wilkens OE, Hannink G, van de Groes SAW (2020) Recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques. Knee Surg Sports Traumatol Arthrosc 28(6):1919–1931CrossRefPubMed

11.

Marquez-Lara A, Andersen J, Lenchik L, Ferguson CM, Gupta P (2017) Variability in patellofemoral alignment measurements on MRI: influence of knee position. AJR Am J Roentgenol 208(5):1097–1102CrossRefPubMed

12.

Ormeci T, Turkten I, Sakul BU (2022) Radiological evaluation of patellofemoral instability and possible causes of assessment errors. World J Methodol 12(2):64–82CrossRefPubMedPubMedCentral

13.

Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502CrossRefPubMedPubMedCentral

14.

Hochreiter B, Hirschmann MT, Amsler F, Behrend H (2019) Highly variable tibial tubercle-trochlear groove distance (TT-TG) in osteoarthritic knees should be considered when performing TKA. Knee Surg Sports Traumatol Arthrosc 27(5):1403–1409CrossRefPubMed

15.

Hosmer DW, Lemeshow S (2000) Applied logistic regression, 2nd edn. John Wiley and Sons, New York, NY, pp 160–164CrossRef

16.

Balcarek P, Jung K, Frosch KH, Stürmer KM (2011) Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete. Am J Sports Med 39(8):1756–1761CrossRefPubMed

17.

Berruto M, Ferrua P, Carimati G, Uboldi F, Gala L (2013) Patellofemoral instability: classification and imaging. Joints 1(2):7–14PubMedPubMedCentral

18.

Haj-Mirzaian A, Guermazi A, Hakky M, Sereni C, Zikria B, Roemer FW et al (2018) Tibial tuberosity to trochlear groove distance and its association with patellofemoral osteoarthritis-related structural damage worsening: data from the osteoarthritis initiative. Eur Radiol 28(11):4669–4680CrossRefPubMed

19.

Tsavalas N, Katonis P, Karantanas AH (2012) Knee joint anterior malalignment and patellofemoral osteoarthritis: an MRI study. Eur Radiol 22(2):418–428CrossRefPubMed

20.

Camathias C, Rutz E, Brunner R, Vavken P, Gaston M (2014) Poor outcome at 7.5 years after Stanisavljevic quadriceps transposition for patello-femoral instability. Arch Orthop Trauma Surg 134(4):473–478CrossRefPubMed

21.

Eckhoff D, Hogan C, DiMatteo L, Robinson M, Bach J (2007) Difference between the epicondylar and cylindrical axis of the knee. Clin Orthop Relat Res 461:238–244CrossRefPubMed

22.

Iranpour F, Merican AM, Baena FR, Cobb JP, Amis AA (2010) Patellofemoral joint kinematics: the circular path of the patella around the trochlear axis. J Orthop Res 28(5):589–594CrossRefPubMed

23.

Iranpour F, Merican AM, Dandachli W, Amis AA, Cobb JP (2010) The geometry of the trochlear groove. Clin Orthop Relat Res 468(3):782–788CrossRefPubMed

24.

Talbot S, Dimitriou P, Radic R, Zordan R, Bartlett J (2015) The sulcus line of the trochlear groove is more accurate than Whiteside’s line in determining femoral component rotation. Knee Surg Sports Traumatol Arthrosc 23(11):3306–3316CrossRefPubMed

Title: Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis
Authors: Simon Talbot
Rachel Zordan
Kyle Bennett
Francesca Sasanelli
Andrew Griffith
Noel Woodford
William L. Walter
Publication date: 21-11-2023
Publisher: Springer Berlin Heidelberg
Keywords: Osteoarthrosis
Osteoarthrosis
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 12/2023
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-023-07661-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis

Abstract

Purpose

Method

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Method

Results

Conclusion

Level of evidence

Please log in to get access to this content

Other articles of this Issue 12/2023

Changes in ankle and hip joints following medial opening-wedge high tibial osteotomy affect knee joint line obliquity

Meniscectomy is associated with a higher rate of osteoarthritis compared to meniscal repair following acute tears: a meta-analysis

Intra-operative laxity and balance impact 2-year pain outcomes in TKA: a prospective cohort study

Mesenchymal stem cell implantation provides short-term clinical improvement and satisfactory cartilage restoration in patients with knee osteoarthritis but the evidence is limited: a systematic review performed by the early-osteoarthritis group of ESSKA-European knee associates section

Anterior cruciate ligament femoral footprint is oblong-ovate, triangular, or two-tears shaped in healthy young adults: three-dimensional MRI analysis

Arthroscopic Latarjet yields better union and prevention of instability compared to arthroscopic bony Bankart repair in shoulders with recurrent anterior instability: a systematic review