Personal use only. MRI of the extensor mechanism of the knee. 5 th Musculoskeletal MRI meeting. Falkowski, MD, MHBA
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1 MRI of the extensor mechanism of the knee 5 th Musculoskeletal MRI meeting Falkowski, MD, MHBA
2 Outline extensor mechanism - anatomy - pathology - controversies anterior knee pain biomechanics
3 Extensor mechanism Pe rso na lu se 3 on ly
4 layers / laminations: Quadriceps tendon vastus med. VM+VL RF VI layers conjoined tendons frequency four none 6 % three vastus med. + lat. (mid portion) 56 % two mid portion + superficial or deep 30 % one all 8 % Zeiss J, AJR 1992
5 Vascular supply of tendon: Quadriceps tendon - angiogram of 33 cadaveric quadriceps tendons 3 vessels (Medial, Lateral and Peripatellar arcades) zonal supply (each 1 cm size): hypovascular zone 2 (1-2 cm above upper patellar pole) Yepes H, J Bone Joint Surg 2008
6 Vascular supply of tendon: Quadriceps tendon - angiogram of 33 cadaveric quadriceps tendons 3 vessels (Medial, Lateral and Peripatellar arcades) zonal vascular supply: rectus femoris > deeper portions (all vastus) RF VI P Yepes H, J Bone Joint Surg 2008
7 Quadriceps tendon Inconsistency regarding localization of tendon ruptures: Pe - distance to patella: rso 1-2 cm above vs. directly at upper pole of patella superficial (RF) vs. deep portions (vastus) na lu se on ly Scuderi C, Am J Surg 1958; Nance EP, Radiology 1982; Evans EJ, J Anat 1991; Zeiss J, AJR 1992; Raatikainen T, Acta Orthop Scand 1994; Yablon CM, MRI Clin N Am 2014; Foley R, J Ultrasound Med 2015
8 Quadriceps tendon Inconsistency regarding localization of tendon ruptures: Zeiss J, AJR 1992 * cited for: superficial (RF) ruptures Rectus femoris Vastus med. Vastus lat. Vastus intermed. Inaccuracy regarding citation
9 Quadriceps tendon Rupture association with other joint injuries - retrospective 10 year period with surgical repair of knee extensor mechanism - 64 cases (31 quadriceps tendon ruptures: 3 other injuries) average age of patients: 51 years no direct impact high energy trauma, all indirect low energy trauma McKinney B, KSSTA 2008
10 Important findings after patellar dislocation 3rd Educational SSSR Meeting The Knee Joint Perspectives of Anatomist, Physicist, Radiologists and Referring Physicians - Mechanism - Findings - Predisposing factors - Measurements
11 Anatomy: MPFL and medial Retinaculum Diederichs G, Radiographics 2010 Panagiotopoulos E, KSSTA 2006 Placella G, KSSTA 2014
12 Anatomy: MPFL and medial Retinaculum MPFL VMO
13 Anatomy: MPFL and medial Retinaculum MPFL VMO
14 Anatomy: MPFL and medial Retinaculum MR MPFL MCL
15 Anatomy: MPFL and medial Retinaculum MR MCL
16 Findings on MRI: Frequency of injuries after lat. patellar dislocation Injury Number of patients MPFL (patellar attachment) 47 % 93/195 MPFL (femoral attachment) 26 % 50/195 MPFL (both attachments) 13 % 26/195 osteochondral lesion 49 % 96/195 loose bodies 13 % 23/195 patellar avulsion / fracture 7 % 14/195 medial collateral lig. injury 19 % 37/195 meniscus tear 21 % 41/195 Guerrero P, Sports Med Arthrosc Rehabil Ther Technol
17 Patellar Height Pe rso na lu se on ly Indicex Patella alta on X-Ray Insall-Salvati > 1.2 modified Insall-Salvati > 2.0 Caton-Deschamps Blackburne-Peel Patella alta on MR > > 2.07 > > 1.48 > > 1.08 Yue RA, J Knee Surg 2017
18 Patellar Height - no gender differences (transient patellar dislocation and control group) - differences between mature and immature patients (both groups): higher ratios in immature patients - immature patients: Insall-Salvati-I. and Blackburne- Peel-I. overdiagnose Patella alta in 50-60% of knee studies (patellar instability cases not included) Yue RA, J Knee Surg 2017 Shin AY, J Pediatric Orthop BB 1998
19 Signs for Patellar Maltracking Cartilage edema at lateral patellar facet: before trochleoplasty after trochleoplasty Falkowski AL, Am J Sports Med 2017
20 Signs for Patellar Maltracking Patellar tendon-lateral femoral condyle friction syndrome Superolateral Hoffa s fad = pad edema associated with anterior / anterolateral knee pain in edema group measurements of Insall-Salvati-Ratio higher (p<0.001) Chung CB, Skeletal Radiol 2001 Subhawong TK, AJR 2010
21 Signs for Patellar Maltracking Patellar tendon-lateral femoral condyle friction syndrome Superolateral Hoffa s fad = pad edema Subhawong TK, AJR 2010 Matcuk GR, AJR 2014
22 Signs for Patellar Maltracking Pe rso na lu se 22 on ly
23 Patellar tendon Rupture association with other joint injuries - retrospective 10 year period with surgical repair of knee extensor mechanism - 64 cases (33 patellar tendon ruptures: 10 other injuries) average age of patients: 36 years McKinney B, KSSTA 2008
24 Patellar tendon Pe rso na lu se on ly McKinney B, KSSTA 2008
25 Patellar tendon Rupture association with other joint injuries - retrospective 10 year period with surgical repair of knee extensor mechanism - 64 cases (33 patellar tendon ruptures: 10 other injuries) McKinney B, KSSTA 2008
26 Patellar tendon Jumper s knee = patellar tendinosis misnomer: patellar tendonitis - histopathologic: mucoid degeneration due to overuse - epidemiology: young athletes (soccer, basketball, volleyball, tennis, etc.) stress in flexion Yablon CM, MRI Clin N Am 2014 Khan K, Radiology 1996 Johnson D, J Bone Joint Surg 1996
27 Patellar tendon proximal Traction apophysitis distal in adolescents Sinding-Larsen-Johansson Osgood-Schlatter - inferior patellar pole - tibial tuberosity bone fragmentation, edema (bone / soft tissue), thickening of pat. tendon Yablon CM, MRI Clin N Am 2014
28 Patellar tendon proximal Traction apophysitis distal in adolescents Sinding-Larsen-Johansson Osgood-Schlatter - inferior patellar pole - tibial tuberosity
29 Conclusion Extensor mechanism stabilizer of patellar tracking Measurements of patellar height: on MR Ruptures of quadriceps and patellar tendon mostly in proximity to patella Rupture of patellar > quadriceps tendon associated with other knee joint injuries varies DD for anterior knee pain
30 Thank you Anna L. Falkowski Research Fellow at Musculoskeletal Radiology University of Michigan, Ann Arbor
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