Lateral Patellar Compression Syndrome

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Topic updated on 08/27/13 5:23pm
Introduction
  • Improper tracking of patella in trochlear groove
  • Caused by tight lateral retinaculum
    • leads to excessive lateral tilt without excessive patellar mobility
  • Miserable Triad
    • is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. They include:
      • femoral anteversion
      • genu valgum
      • external tibial torsion / pronated feet
Presentation
  • Presentation
    • pain with stair climbing
    • theatre sign (pain with sitting for long periods of time)
  • Physical exam
    • pain with compression of patella and moderate lateral facet tenderness
    • inability to evert the lateral edge of the patella
Imaging
  • Radiographs
    • patellar tilt in lateral direction
Treatment
  • Nonoperative
    • NSAIDS, activity modification, and therapy
      • indications
        • mainstay of treatment and should be done for extensive period of time
      • technique
        • therapy should emphasize vastus medialis strengthening and closed chain short arc quadriceps exercises 
  • Operative
    • arthroscopic lateral release 
      • indications
        • objective evidence of lateral tilting (neutral or negative tilt)
        • pain refractory to extensive rehabilitation
        • inability to evert the lateral edge of the patella
        • ideal candidate has no symptoms of instability
        • medial patellar glide of less than one quadrant
        • lateral patellar glide of less than three quadrants
    • patellar realignment surgery 
      • Maquet (tubercle anteriorization)
        • indicated only for distal pole lesions
        • only elevate 1 cm or else risk of skin necrosis
      • Elmslie-Trillat (medialization)
        • indicated only for instability with lateral translation (not isolated lateral tilt)
        • avoid if medial patellar facet arthrosis
      • Fulkerson alignment surgery (tubercle anteriorization and medialization) 
        • indications (controversial)
          • lateral and distal pole lesions 
          • increased Q angle
        • contraindications
          • superior medial arthrosis (scope before you perform the surgery)
          • skeletal immaturity
Techniques
  • Arthroscopic lateral release 
    • technique
      • viewing through superior portal will show medial facet does not articulate with trochlea at 40 degrees of knee flexion
      • be sure adequate hemostasis is obtained
      • postoperatively the patella should be able to be passively tilted 80°
    • complications
      • persistent or worsened pain
      • patellar instability with medial translation

 

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Qbank (3 Questions)

TAG
(OBQ11.34) An 18-year-old female has 9 months of anterior knee pain recalcitrant to physical therapy that includes VMO strengthening, NSAIDS, and lifestyle modification. On physical examination she has no effusion in the knee and her Q angle is measured at 15 degrees. She has less than one quadrant of medial patella translation and less than two quadrants of lateral patella translation. The lateral edge of the patella is unable to be everted. A merchant view radiograph is shown in Figure A. The tibia tubercle-trochlear groove distance is measured as 14mm on a CT scan. Which of the following procedures is MOST appropriate? Topic Review Topic
FIGURES: A          

1. Lateral retinacular release
2. Anterolateral tibial tubercle osteotomy
3. Anterior tibial tubercle osteotomy (Maquet)
4. Medial tibial tubercle osteotomy (Elmslie-Trillat)
5. Medial plica resection

PREFERRED RESPONSE ▶
TAG
(OBQ05.184) A 21-year-old female presents with left knee pain for six months. The symptoms are worse climbing stairs and sitting for long periods of time. On physical exam she has a stable knee with no effusion and pain with compression of the patella. Her Q angle is 21 degrees. What is the first step in management? Topic Review Topic

1. arthroscopic lateral retinacular release
2. tubercle elevation and medialization
3. strict immobilization and non-weight bearing for four weeks
4. open chain exercises and a focus on seated leg extensions
5. closed chain exercises with focus on quadriceps and hamstring strengthening

PREFERRED RESPONSE ▶



Cases

http://upload.orthobullets.com/cases/1322/xray lateral 2.jpg http://upload.orthobullets.com/cases/1322/xray ap.jpg http://upload.orthobullets.com/cases/1322/xray lateral.jpg
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