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The Effects of Articular, Retinacular, or Muscular Deficiencies On Patellofemoral Joint Stability

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80 views6 pages

The Effects of Articular, Retinacular, or Muscular Deficiencies On Patellofemoral Joint Stability

Uploaded by

Suyash Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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The effects of articular, retinacular, or

muscular deficiencies on patellofemoral


joint stability
A BIOMECHANICAL STUDY IN VITRO

W. Senavongse, Normal function of the patellofemoral joint is maintained by a complex interaction between
A. A. Amis soft tissues and articular surfaces. No quantitative data have been found on the relative
contributions of these structures to patellar stability. Eight knees were studied using a
From Imperial materials testing machine to displace the patella 10 mm laterally and medially and measure
College, London, the force required. Patellar stability was tested from 0˚ to 90˚ knee flexion with the
England quadriceps tensed to 175 N. Four conditions were examined: intact, vastus medialis
obliquus relaxed, flat lateral condyle, and ruptured medial retinaculae. Abnormal trochlear
geometry reduced the lateral stability by 70% at 30˚ flexion, while relaxation of vastus
medialis obliquus caused a 30% reduction. Ruptured medial retinaculae had the largest
effect at 0˚ flexion with 49% reduction. There was no effect on medial stability. There is a
complex interaction between these structures, with their contributions to loss of lateral
patellar stability varying with knee flexion.

The function of the patellofemoral joint is nor- been reports of the effects of particular stabilis-
mally maintained by a complex interaction ing mechanisms,13-15 none has studied the rel-
between soft tissues and bony structures. The ative contributions of the different active, pas-
structures responsible for its stability can be sive and static patellar stabilisers.
divided into three groups: the active stabilisers This study examined patellar stability in the
represented by the quadriceps muscles, the pas- objective mechanical sense and was not con-
sive stabilisers particularly the retinaculae and cerned with subjective instability. Its aim was
" W. Senavongse, PhD, Post-
the static stabilisers represented by the articu- to measure the forces required to cause the
doctoral Research Assistant lar surfaces. In normal knees these structures patella to sublux medially and laterally, allow-
Biomechanics Section,
Mechanical Engineering
act in harmony to maintain stability of the ing the effects of various abnormalities associ-
Department, Room 638 joint. However, this complex interaction can ated with patellar instability to be quantified.
Mechanical Engineering
Building, Imperial College
be disrupted by pathology or trauma, which
London, South Kensington may result in patellofemoral instability. Materials and Methods
Campus, London SW7 2AZ,
UK.
Instability such as patellar subluxation or Specimens and specimen preparation. Eight
dislocation is common and may require treat- knees were obtained at post-mortem with eth-
" A. A. Amis, DSc, Professor
Musculoskeletal Surgery ment by conservative or surgical methods. ical approval and the informed consent of rel-
Department, Imperial More than 100 surgical procedures have been atives. They were sealed in polyethylene bags
College London, Charing
Cross Hospital 7E, London described for treating patellofemoral instabil- and frozen at -20˚C prior to use. The mean age
W6 8RF, UK. ity, including a combination of lateral retin- of the donors was 69 years (57 to 87). The
Correspondence should be acular release, medial capsular reefing or patel- specimens included 20 cm each of femur and
sent to Professor A. A. Amis
at Imperial College London,
lar tendon transfer.1-9 Despite these procedures tibia. The specimens were prepared and
South Kensington Campus, the rate of recurrence remains high.10-12 The mounted using methods which have been
London SW7 2AZ, UK;
e-mail:
underlying problem is that patellofemoral described previously.16 The skin, underlying
a.amis@imperial.ac.uk instability can be subtle and multi-factorial. fat and muscles, other than the distal quadri-
©2005 British Editorial
There is a lack of useful information about the ceps were removed. Care was taken to preserve
Society of Bone and relative importance of different pathologies, or the retinaculae and the fascia of the quadriceps
Joint Surgery
doi:10.1302/0301-620X.87B4.
of the mechanical effectiveness of the different muscles intact. The quadriceps were then sepa-
14768 $2.00 surgical techniques. In order to make the cor- rated as accurately as possible into six compo-
J Bone Joint Surg [Br]
rect diagnosis and choose an appropriate treat- nents: rectus femoris (RF), vastus intermedius
2005;87-B:577-82. ment, it would be helpful to understand the rel- (VI), vastus lateralis longus (VLL), vastus later-
Received 8 July 2003;
Accepted after revision
ative contributions of the different patellar alis obliquus (VLO), vastus medialis longus
18 June 2004 stabilising mechanisms. Although there have (VML), and vastus medialis obliquus (VMO).17

VOL. 87-B, No. 4, APRIL 2005 577


578 W. SENAVONGSE, A. A. AMIS

place the patella laterally and medially in a controlled man-


ner while measuring the force required. The knee was
mounted via an intramedullary femoral rod in the mount-
ing device on the base of the Instron machine with the line
joining the posterior femoral condyles describing the
medial-lateral axis, parallel to the displacement axis. The
centre of rotation of the knee was assumed to be at the fem-
oral epicondyle. Subsequently, the quadriceps muscles were
loaded. The knee was orientated with the lateral aspect
uppermost, and with the tibia flexing in a horizontal plane
(Fig. 1). The initial femoral rotation and its alignment were
ensured by the cementing technique of the intramedullary
rod. The quadriceps components were each loaded by
cables routed via pulleys to hanging weights and a total
load of 175 N was applied. The muscle groups were ten-
sioned in their anatomical directions and in proportion to
their physiological cross-sectional areas.17
The patella was connected via the three-degree-of-free-
dom linkage to the load cell on the moving crosshead of the
Instron. At the patella, a ball-bearing inside the patella, cen-
tred 10 mm deep to the anterior surface, allowed natural
tilt and other rotations of the patella (three-degrees-of-free-
dom) when it was displaced laterally and medially (Fig. 1).
This arrangement allowed five-degrees-of-freedom while
controlling the medial-lateral translation.
Patellar force-displacement behaviour was tested at 0,
10, 20, 30, 45, 60, and 90˚ knee flexion. Extension of the
knee was blocked at each angle by a vertical rod, anterior to
the tibial rod, at a radius of 120 mm from the epicondyle.
Fig. 1
The patella was cyclically displaced 10 mm laterally and 10
The experiment set up, but with the displacing mecha- mm medially from its stable position at 100 mm/min. The
nism disconnected to reveal the intra-patellar ball-
bearing (reprinted with permission from the Ortho- fourth load vs displacement cycle was recorded at each
paedic Research Society16). knee flexion angle. The relative stiffness of the Instron load
frame and specimen mounting was very high (1250 Nmm-1)
when compared with the tissues resisting patellar displace-
The distal tendinous fibres of the muscles merged together ment. Therefore, crosshead motion was a sufficiently accu-
and were left intact to ensure that the actions of the muscles rate representation of patellar motion.
were as physiological as possible. Vastus intermedius was Patellar stability measurement protocols. Measurements of
separated from the femur. patellar stability were performed in four testing conditions:
Cloth strips were wrapped and looped over the proximal intact knee, VMO malfunction, lateral trochlear dysplasia,
end of each muscle component and attached by stitching and with the medial patellofemoral ligaments ruptured.
through the whole muscle bulk. Rectus femoris and vastus The tests were performed in that particular order in order
intermedius were looped together to form a central muscle to assess the effects of each condition on its own. The
group. The cloth strips provided a firm attachment for a pathological abnormalities were simulated as follows:
muscle loading cable for each of the five muscle groups VMO malfunction was simulated simply by relaxing the
(RF+VI, VLL, VLO, VML, and VMO). VMO muscle (taking the weights off). The VMO tension
Experiment set-up. A stability testing rig was mounted in was shared out among the other muscle parts maintaining a
an Instron 1122 materials testing machine (Instron Ltd., total tension of 175 N. This was done immediately after the
Buckinghamshire, UK). The stability rig was in two parts, force-displacement behaviour was recorded at each angle
one fixed to the base of the Instron, the other suspended of flexion in the ‘intact’ knee.
from the loadcell in the moving crosshead (Fig. 1). The Lateral trochlear dysplasia was simulated by cutting a sub-
fixed part consisted of a femoral mounting on a steel base- chondral wedge out of the lateral condyle to flatten the lat-
plate with pulleys fixed onto the base of the Instron. The eral facet (Fig. 2). The patellar force-displacement behaviour
moving part was a three-degree-of-freedom mounting was recorded using the same protocol mentioned above.
allowing for patellar translation and rotation in the sagittal Medial retinacular structures ruptured: a double hook
plane. The moving crosshead of the Instron was used to dis- was used to pull the patella laterally until the medial reti-

THE JOURNAL OF BONE AND JOINT SURGERY


THE EFFECTS OF ARTICULAR, RETINACULAR, OR MUSCULAR DEFICIENCIES ON PATELLOFEMORAL JOINT STABILITY 579

Restraining force (N)


160 Intact
140 VMO relaxed
120
100
80
60
40
20
0

0 10 20 30 40 50 60 70 80 90
Flexion angle (°)

Fig. 3

The force required to displace the patella 10 mm laterally for the intact
knee, and after relaxation of the VMO (mean ± 1 SD).

140

Restraining force (N)


Intact
120
100 Flat lateral
80 trochlea
60
40
20
0

0 10 20 30 40 50 60 70 80 90
Flexion angle (°)

Fig. 4

The force required to displace the patella 10 mm laterally for the intact
knee, and after flattening the lateral facet of the trochlea (mean ± 1 SD ).
There were significant differences at all angles.

Fig. 2
Restraining force (N)

140
The procedure for flattening the lateral femoral trochlea by removal Intact
120
of a wedge of bone. Medial retinaculae
100
80 ruptured
60
naculae ruptured. The quadriceps muscles were relaxed 40
(except rectus femoris which had 20 N tension). This was 20
done to protect the patella from excessive force because it 0
fractured under both 175 N quadriceps tension and the lat- 0 10 20 30 40 50 60 70 80 90
eral displacing force. The double hooks were positioned Flexion angle (°)
proximally and distally under the medial border of the
patella and were pulled laterally with a crosshead speed of Fig. 5

10 mm/min until the medial structures ruptured. The lateral The force required to displace the patella 10 mm laterally for the intact
trochlea was reconstructed by repositioning the original knee, and after rupturing the medial retinacular structures (mean ± 1 SD).
The starred points had significant differences.
bone wedge and adding wooden fillers which had the same
thickness as the saw cuts. This assembly was fixed by a
bone screw. The testing protocol was then resumed.
Data analysis. The reduction of the restraining forces from The mean patellar restraining force vs knee flexion angle
the ‘intact’ level for each simulated pathology at different curves at 10 mm lateral displacement are shown in Figure
angles of knee flexion was examined by analysis of variance 3. For the intact knee, 10 mm lateral displacement needed a
with a Tukey post test and an alpha level of 0.05. mean force of 126 N at 0˚ flexion reducing to a minimum of
75 N at 20˚ flexion and rising to 125 N at 90˚ flexion. VMO
Results release had a significant effect on the lateral restraining
The mediolateral stability of the patella for the intact knee force throughout flexion (Fig. 3). Flattening the lateral facet
has been described previously.16 of the femoral trochlea reduced the lateral restraining force

VOL. 87-B, No. 4, APRIL 2005


580 W. SENAVONGSE, A. A. AMIS

The mean patellar restraining force versus knee flexion


Reduction of displacing

80
VMO relaxed
70 angle curves at 10 mm medial displacement are shown in
Flat lateral trochlea
60
Medial retinaculae
Figure 7. For the intact knee, 10 mm medial displacement
force (%)

50 ruptured needed between 144 N and 239 N from 0˚ to 90˚ knee flex-
40
ion. It is clear that these simulated pathologies had no prac-
30
20 tical effect on medial patellar stability.
10
0 Discussion
0 10 20 30 40 50 60 70 80 90
This paper has presented data which we believe to be the
Knee flexion (°)
first attempt to demonstrate the relative effects of various
Fig. 6 abnormalities on patellar stability. Although a loss of ten-
Percentage loss of resistance to 10 mm lateral patellar displacement
sion from the VMO had an effect on lateral stability
caused by each of the three simulated pathologies in isolation. throughout knee flexion, this was overshadowed by the
greater effect caused by flattening the lateral facet of the
trochlea from 0˚ to 60˚ knee flexion. In the extended knee a
rupture of the medial retinacular structures had the largest
effect.
250
Restraining force (N)

Intact In addition to studying lateral displacement of the


200 VMO relaxed
Flat lateral trochlea
patella, which causes most clinical problems, this study also
150 Medial retinaculae displaced the patella medially and this is the first time that
ruptured this has been studied. Medial patellar subluxation may
100
50
occur as a result of surgical overcorrection of lateral mal-
alignment. The retinacular, muscular and articular abnor-
0
0 10 20 30 40 50 60 70 80 90 malities studied have all been related to lateral patellar
Flexion angle (°) instability. It was not surprising to find that they had no sig-
nificant effect on patellar medial stability. There is pub-
Fig. 7
lished data15 showing that division of the lateral retinaculae
Variation of force required to displace the patella 10 mm medially for the reduces lateral patellar stability.
intact knee, and after the three simulated pathologies, vs knee flexion.
If the VMO was relaxed, the force required to displace
the patella 10 mm laterally was reduced approximately
30% between 20˚ and 90˚ knee flexion. In the extended
knee, this loss of stability reduced to 14% which was an
significantly throughout flexion (Fig. 4). Rupture of the unexpected finding. The VMO tension acts both medially
medial retinacular structures reduced the restraining force and posteriorly17 and is known to resist lateral patellar dis-
throughout flexion (Fig. 5) which increased markedly as the placement.18-20 It has been noted that the VMO is the first
knee approached full extension. part of the quadriceps to weaken, and the last to be rehabil-
The effects of the abnormalities on lateral patellar stabil- itated.21,22 Clinical observations linking loss of active full
ity were compared. VMO release reduced the restraining knee extension to VMO atrophy have led to the belief that
force between 18 N and 38 N throughout flexion. Ruptur- VMO has its main role in the last 15˚ of active knee exten-
ing the medial patellofemoral ligaments reduced the sion. Many conservative treatments are based on this
restraining force from 13 N to 62 N throughout flexion. hypothesis. In contrast, the present study found the smallest
The largest reduction caused by rupturing the medial liga- effect of VMO relaxation was in terminal knee extension
ments was at 0˚ knee flexion. The largest pathological effect and a number of electromyographic studies23-25 have failed
on lateral stability was flattening the lateral trochlear facet, to find selective vastus medialis activity in this arc. In sum-
reducing the restraining force by between 50 N and 60 N mary, though, this experiment showed that a quadriceps
throughout flexion. A graph of percentage reduction of lat- imbalance caused by loss of VMO tension caused a signifi-
eral displacing force caused by each of the pathologies vs cant reduction in lateral patellar stability throughout knee
knee flexion angles was plotted in order to compare the flexion. However, without knowing how this effect com-
contributions of each (Fig. 6). The mean reduction caused pared with those of the retinacular or articular geometry,
by VMO release was 27% (14 to 33). The loss of the VMO we cannot conclude that VMO is the most important patel-
tension had the least effect in the extended knee (14%). The lar stabiliser.
mean reduction after flattening the lateral trochlear facet If the lateral facet of the trochlea had its slope reduced to
was 55 ± 17% (26 to 72). This was the largest effect at five zero, the force required to displace the patella laterally fell
of the seven positions tested. The mean reduction after rup- 70% at 20˚ knee flexion. This reduction was the largest sin-
turing the medial retinacular structures was 25 ± 13% (15 gle effect in these experiments in the arc of flexion where
to 49). This was the largest effect in full extension. dislocations occur most often in life. In the normal knee,

THE JOURNAL OF BONE AND JOINT SURGERY


THE EFFECTS OF ARTICULAR, RETINACULAR, OR MUSCULAR DEFICIENCIES ON PATELLOFEMORAL JOINT STABILITY 581

the combined effect of the patellar tendon and quadriceps we knew from prior experience16 that higher tension
tensions is to pull the patella posteriorly and laterally, and caused tearing of the loading cables from the muscle heads.
this is resisted by the slope of the lateral trochlear facet.26,27 Previous work31 has shown that the results will not be
Mechanically, therefore, it is clear that a loss of that slope affected greatly by changes in overall muscle force. In addi-
will lead to lateral patellar displacement occurring more tion, the muscle tension was constant at all angles of knee
readily. In a lateral radiograph of a normal knee the line of flexion, whereas in life the tension increases as we squat
the base of the trochlear groove remains within the outline down. This may have affected the relative VMO contribu-
of the anterior femoral lateral condyle, which is the edge of tion in the flexed knee in this work. The complete relax-
the trochlea. However, if the trochlea is dysplastic and is ation of VMO in this study probably caused its maximum
flat mediolaterally, the base of the groove meets the outline effect, compared to partial weakness in vivo. The modifica-
of the condyle on the radiograph. This is the ‘crossing sign’ tion of the trochlear geometry was a reverse of the Albee
described by Dejour et al28 who saw it in 96% of their cases procedure32 that has normally been used to treat trochlear
with objective patellar instability and in only 2% of their dysplasia. However, there may also be abnormalities of the
controls. As the trochlear groove becomes flatter, so the sul- soft tissues and of limb alignment in such cases in vivo
cus angle seen on a ‘skyline’ radiograph increases. This which could not be simulated in this work. The advantages
angle has been correlated with the severity of other features of working in vitro include the ability to control the
of extensor mechanism dysplasia.29 In this study, the slope mechanics accurately, and then to make paired, within-
of the lateral trochlear facet was 22˚ ± 5˚ (mean ± SD) at the specimen, comparisons of the effects of the simulated
contact zone for 20˚ knee flexion.30 This was reduced to 0˚ pathologies. This study provides information that will help
in all of the knees when testing the effect of trochlear geom- to plan objective studies in vivo.
etry on lateral patellar stability. The quantitative results of these experiments have pro-
If the medial passive restraints were ruptured by displac- vided objective evidence relating to the relative effects of
ing the patella laterally, the force later required to displace simulated abnormalities for the muscles, joint geometry
the patella 10 mm laterally was reduced 49% in the or retinaculae on mediolateral patellar stability. Figure 6
extended knee, and to a decreasing extent as the knee shows clearly that there was a complex interaction between
flexed. Figure 5 shows how the effect of the medial retin- them, with their contributions to loss of lateral patellar sta-
aculae increased rapidly in the last 20˚ of knee extension. bility varying with knee flexion. Although non-surgical
Previous cutting studies have found that the medial patello- treatment is always preferable, the results suggest that the
femoral ligament was the single most important passive role of VMO may be less important than abnormal tro-
restraint to lateral patellar displacement at or close to full chlear articular geometry, and that the medial retinaculae
knee extension.13,15 The role of these structures has not become more important for patellar stability as the knee
been studied previously at other angles of knee flexion. As extends. In addition, Figures 3 to 5 show that the patella
the knee reaches full extension, the patella moves proxi- was least stable at 20˚ knee flexion in the normal knee and
mally out of engagement with the trochlear groove, and that continued to be the case with each of the three simu-
becomes mobile mediolaterally when the muscles are lated pathologies.
relaxed. Tensing the quadriceps normally pulls the patella The Instron material testing machine was donated by the Arthritis Research
proximally and slightly laterally, and patellar mobility is Campaign (ARC). Dr Senavongse was supported by the Thai government and a
project grant from the ARC.
lost. The loss of this stability after rupturing the medial ret- No benefits in any form have been received or will be received from a com-
inaculae suggests that the retinaculae are tensed by the mercial party related directly or indirectly to the subject of this article.
proximal movement of the patella, with a mechanism akin
to pulling up the ridge of a tent until the guy ropes become References
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THE JOURNAL OF BONE AND JOINT SURGERY

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