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Knee Surgery, Sports Traumatology, Arthroscopy
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 10/2017

01-10-2017 | Knee

Sagittal plane tilting deformity of the patellofemoral joint: a new concept in patients with chondromalacia patella

Authors: Ertugrul Aksahin, Cem Nuri Aktekin, Onur Kocadal, Semra Duran, Cüneyd Gunay, Defne Kaya, Onur Hapa, Murad Pepe

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 10/2017

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Abstract

Purpose

The aims of this study were to evaluate sagittal plane alignment in patients with chondromalacia patella via magnetic resonance imaging (MRI), analyse the relationships between the location of the patellar cartilaginous lesions and sagittal alignment and finally investigate the relationships between the sagittal plane malalignment and patellofemoral loadings using by finite element analysis.

Methods

Fifty-one patients who were diagnosed with isolated modified Outerbridge grade 3–4 patellar chondromalacia based on MRI evaluation and 51 control subjects were evaluated. Chondromalacia patella patients were divided into three subgroups according to the chondral lesion location as superior, middle and inferior. The patella–patellar tendon angle (P–PT) was used for evaluation of sagittal alignment of patellofemoral joint. Each subgroup was compared with control group by using P–PT angle. To investigate the biomechanical effects of sagittal plane malpositioning on patellofemoral joint, bone models were created at 30°, 60° and 90° knee flexion by using mean P–PT angles, which obtained from patients with chondromalacia patellae and control subjects. The total loading and contact area values of the patellofemoral joints were investigated by finite element analysis.

Results

The mean age of all participants was 52.9 ± 8.2 years. The mean P–PT angle was significantly lower in chondromalacia group (142.1° ± 3.6°) compared to control group (144.5° ± 5.3°) (p = 0.008). Chondral lesions were located in superior, middle and inferior zones in 16, 20 and 15 patients, respectively. The mean P–PT angles in patients with superior (141.8 ± 2.7) and inferior subgroups (139.2 ± 2.3) were significantly lower than the values in the control group (p < 0.05). The contact area values were detected higher in models with chondromalacia than in the control models at the same flexion degrees. There were increased loadings at 30° and 90° flexions in the sagittal patellar tilt models.

Conclusion

This study revealed that sagittal plain malpositioning of the patellofemoral joint might be related to chondromalacia, especially in the presence of lesions in the upper and lower part of the patella. This condition leads to supraphysiological loadings on the patellofemoral joint. Sagittal patellar tilt should be considered in the evaluation and management of patellar cartilage defects. Taking sagittal plane malalignment into consideration in patellofemoral joint evaluation will enable us to design new physical and surgical modalities.

Level of evidence

IV.
Literature
1.
Aksahin E, Kocadal O, Aktekin CN, Kaya D, Pepe M, Yılmaz S, Yuksel HY, Bicimoglu A (2016) The effects of the sagittal plane malpositioning of the patella and concomitant quadriceps hypotrophy on the patellofemoral joint: a finite element analysis. Knee Surg Sports Traumatol Arthrosc 24:903–908CrossRefPubMed
2.
Aksahin E, Yilmaz S, Karasoy I, Duran S, Yuksel HY, Dogan O, Yildirim AO, Bicimoglu A (2015) Sagittal patellar tilt and concomitant quadriceps hypotrophy after tibial nailing. Knee Surg Sports Traumatol Arthrosc. doi:10.​1007/​s00167-015-3533-8 PubMed
3.
Baldwin MA, Clary CW, Fitzpatrick CK, Deacy JS, Maletsky LP, Rullkoetter PJ (2012) Dynamic finite element knee simulation for evaluation of knee replacement mechanics. J Biomech 45:474–483CrossRefPubMed
4.
Belvedere C, Ensini A, Leardini A, Dedda V, Feliciangeli A, Cenni F, Timoncini A, Barbadoro P, Giannini S (2014) Tibio-femoral and patello-femoral joint kinematics during navigated total knee arthroplasty with patellar resurfacing. Knee Surg Sports Traumatol Arthrosc 22:1719–1727CrossRefPubMed
5.
Besier TF, Gold GE, Beaupre GS, Delp SL (2005) A modeling framework to estimate patellofemoral joint cartilage stress in vivo. Med Sci Sports Exerc 37:1924–1930CrossRefPubMed
6.
Bland JM, Altman D (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 327:307–310CrossRef
7.
Borotikar B, Sheehan F (2013) In vivo patellofemoral contact mechanics during active extension using a novel dynamic MRI-based methodology. Osteoarthr Cartil 21:1886–1894CrossRefPubMedPubMedCentral
8.
Caton J, Deschamps G, Chambat P, Lerat J, Dejour H (1981) Patella infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot 68:317–325
9.
Chan VO, Moran DE, Mwangi I, Eustace SJ (2013) Prevalence and clinical significance of chondromalacia isolated to the anterior margin of the lateral femoral condyle as a component of patellofemoral disease: observations at MR imaging. Skeletal Radiol 42:1127–1133CrossRefPubMed
10.
Dejour D, Ferrua P, Ntagiopoulos P, Radier C, Hulet C, Rémy F, Chouteau J, Chotel F, Boisrenoult P, Sebilo A (2013) The introduction of a new MRI index to evaluate sagittal patellofemoral engagement. Orthop Traumatol Surg Res 99:S391–S398CrossRefPubMed
11.
Draper C, Besier T, Gold G, Fredericson M, Fiene A, Beaupre G, Delp S (2006) Is cartilage thickness different in young subjects with and without patellofemoral pain? Osteoarthr Cartil 14:931–937CrossRefPubMed
12.
Endo Y, Schweitzer ME, Bordalo-Rodrigues M, Rokito AS, Babb JS (2007) MRI quantitative morphologic analysis of patellofemoral region: lack of correlation with chondromalacia patellae at surgery. AJR Am J Roentgenol 189:1165–1168CrossRefPubMed
13.
Farrokhi S, Keyak J, Powers C (2011) Individuals with patellofemoral pain exhibit greater patellofemoral joint stress: a finite element analysis study. Osteoarthr Cartil 19:287–294CrossRefPubMed
14.
Fitzpatrick CK, Baldwin MA, Laz PJ, FitzPatrick DP, Lerner AL, Rullkoetter PJ (2011) Development of a statistical shape model of the patellofemoral joint for investigating relationships between shape and function. J Biomech 44:2446–2452CrossRefPubMed
15.
Grelsamer RP, Dejour D, Gould J (2008) The pathophysiology of patellofemoral arthritis. Orthop Clin North Am 39:269–274CrossRefPubMed
16.
Grelsamer RP, Weinstein CH, Gould J, Dubey A (2008) Patellar tilt: the physical examination correlates with MR imaging. Knee 15:3–8CrossRefPubMed
17.
Hambly K, Bobic V, Wondrasch B, Van Assche D, Marlovits S (2006) Autologous chondrocyte implantation postoperative care and rehabilitation: science and practice. Am J Sports Med 34:1020–1038CrossRefPubMed
18.
Ho KY, Keyak JH, Powers CM (2014) Comparison of patella bone strain between females with and without patellofemoral pain: a finite element analysis study. J Biomech 47:230–236CrossRefPubMed
19.
Huang C-H, Hsu L-I, Chang T-K, Chuang T-Y, Shih S-L, Lu Y-C, Chen C-S, Huang C-H (2014) Stress distribution of the patellofemoral joint in the anatomic V-shape and curved dome-shape femoral component: a comparison of resurfaced and unresurfaced patellae. Knee Surg Sports Traumatol Arthrosc. doi:10.​1007/​s00167-014-3485-4
20.
Kalichman L, Zhang Y, Niu J, Goggins J, Gale D, Felson DT, Hunter D (2007) The association between patellar alignment and patellofemoral joint osteoarthritis features—an MRI study. Rheumatology (Oxford) 46:1303–1308CrossRef
21.
Lavagnino M, Arnoczky SP, Dodds J, Elvin N (2011) Infrapatellar straps decrease patellar tendon strain at the site of the jumper’s knee lesion: a computational analysis based on radiographic measurements. Sports Health 3:296–302CrossRefPubMedPubMedCentral
22.
Lee C-H, Wu C-C, Pan R-Y, Lu H-T, Shen H-C (2014) Medial retinacular flap advancement and arthroscopic lateral release for symptomatic chronic patellar lateral subluxation with tilting. Knee Surg Sports Traumatol Arthrosc 22:2499–2504CrossRefPubMed
23.
Li L, Patil S, Steklov N, Bae W, Temple-Wong M, D’Lima DD, Sah RL, Fregly BJ (2011) Computational wear simulation of patellofemoral articular cartilage during in vitro testing. J Biomech 44:1507–1513CrossRefPubMedPubMedCentral
24.
Luyckx T, Didden K, Vandenneucker H, Labey L, Innocenti B, Bellemans J (2009) Is there a biomechanical explanation for anterior knee pain in patients with patella alta? Influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg Br 91:344–350CrossRefPubMed
25.
Macmull S, Jaiswal PK, Bentley G, Skinner JA, Carrington RW, Briggs TW (2012) The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae. Int Orthop 36:1371–1377CrossRefPubMedPubMedCentral
26.
Merchant AC, Mercer RL, Jacobsen RH, Cool CR (1974) Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am 56:1391–1396CrossRefPubMed
27.
Mesfar W, Shirazi-Adl A (2005) Biomechanics of the knee joint in flexion under various quadriceps forces. Knee 12:424–434CrossRefPubMed
28.
Mouzopoulos G, Borbon C, Siebold R (2011) Patellar chondral defects: a review of a challenging entity. Knee Surg Sports Traumatol Arthrosc 19:1990–2001CrossRefPubMed
29.
Potter HG, Jain SK, Ma Y, Black BR, Fung S, Lyman S (2012) Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/MRI follow-up. Am J Sports Med 40:276–285CrossRefPubMed
30.
Potter HG, Linklater JM, Allen AA, Hannafin JA, Haas SB (1998) Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am 80:1276–1284CrossRefPubMed
31.
Reikeras O, Hoiseth A (1990) Patellofemoral relationships in normal subjects determined by computed tomography. Skeletal Radiol 19:591–592CrossRefPubMed
32.
Schmid MR, Hodler J, Cathrein P, Duewell S, Jacob HA, Romero J (2002) Is impingement the cause of jumper’s knee? Dynamic and static magnetic resonance imaging of patellar tendinitis in an open-configuration system. Am J Sports Med 30:388–395CrossRefPubMed
33.
Shalhoub S, Maletsky LP (2014) Variation in patellofemoral kinematics due to changes in quadriceps loading configuration during in vitro testing. J Biomech 47:130–136CrossRefPubMed
34.
Tanamas SK, Teichtahl AJ, Wluka AE, Wang Y, Davies-Tuck M, Urquhart DM, Jones G, Cicuttini FM (2010) The associations between indices of patellofemoral geometry and knee pain and patella cartilage volume: a cross-sectional study. BMC Musculoskelet Disord 11:87CrossRefPubMedPubMedCentral
35.
Tecklenburg K, Dejour D, Hoser C, Fink C (2006) Bony and cartilaginous anatomy of the patellofemoral joint. Knee Surg Sports Traumatol Arthrosc 14:235–240CrossRefPubMed
36.
Vasiliadis HS, Lindahl A, Georgoulis AD, Peterson L (2011) Malalignment and cartilage lesions in the patellofemoral joint treated with autologous chondrocyte implantation. Knee Surg Sports Traumatol Arthrosc 19:452–457CrossRefPubMed
37.
von Eisenhart-Rothe R, Siebert M, Bringmann C, Vogl T, Englmeier KH, Graichen H (2004) A new in vivo technique for determination of 3D kinematics and contact areas of the patello-femoral and tibio-femoral joint. J Biomech 37:927–934CrossRef
38.
Ward SR, Terk MR, Powers CM (2007) Patella alta: association with patellofemoral alignment and changes in contact area during weight-bearing. J Bone Joint Surg Am 89:1749–1755PubMed
39.
Wilson NA, Press JM, Koh JL, Hendrix RW, Zhang LQ (2009) In vivo noninvasive evaluation of abnormal patellar tracking during squatting in patients with patellofemoral pain. J Bone Joint Surg Am 91:558–566CrossRefPubMedPubMedCentral
Metadata
Title
Sagittal plane tilting deformity of the patellofemoral joint: a new concept in patients with chondromalacia patella
Authors
Ertugrul Aksahin
Cem Nuri Aktekin
Onur Kocadal
Semra Duran
Cüneyd Gunay
Defne Kaya
Onur Hapa
Murad Pepe
Publication date
01-10-2017
Publisher
Springer Berlin Heidelberg
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 10/2017
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-016-4083-4

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