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The Role of Skeletal Malalignment In Patellofemoral Disorders
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The Role of Skeletal Malalignment In Patellofemoral Disorders

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (31 May 2021) | Viewed by 22703

Special Issue Editors

Dr. Vicente Sanchis-Alfonso

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Guest Editor
Staff Orthopaedic Surgeon, Department of Orthopaedic Surgery, Hospital Arnau de Vilanova, Valencia, Spain
Interests: patellofemoral joint; anterior knee pain; patellar instability; knee osteotomy
Dr. Robert A. Teitge

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Co-Guest Editor
Senior Staff Physician Detroit Medical Center, Detroit, Professor (retired) Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, MI, USA
Interests: patellofemoral joint; anterior knee pain; patellar instability; knee osteotomy

Special Issue Information

Dear Colleagues,

Clearly, skeletal malalignment, especially abnormal femoral and/or tibial torsion, is the most ignored factor not only in the diagnosis but even more so in the treatment of patients with patellofemoral disorders (anterior knee pain and/or patellar instability). Skeletal malalignment is not an abnormal Q-angle or an increased TT-TG distance. Skeletal malalignment is also not the position of the patella on the trochlea nor its increased shift (subluxation) or increased tilt. In this Special Issue, we are going to analyze skeletal alignment, that is, the alignment of the limb measured in all three planes—coronal, sagittal, and transverse. We are going to focus especially on torsional abnormalities (transverse plane). Currently, there is little interest among knee surgeons in rotational osteotomies, and there are two reasons for this: (1) there is no consensus on how to measure torsion, and the values the radiologist gives us often do not match the clinical findings, which generates doubt and uncertainty; (2) there are patients with clear torsional anomalies who are asymptomatic, which increases our uncertainty and discourages surgeons when indicating rotational osteotomy. On the other hand, the “collective consciousness”, that is to say the beliefs shared by the majority of orthopedic surgeons, conveys the idea that rotational osteotomy is a complex surgery with a high risk of severe complications. It seems very aggressive to cut the femur or the tibia of a young and healthy person who “only complains of pain”. However, this could not be further from the truth. Rotational osteotomy is actually a very well-tolerated surgery, with a low complication rate and in many cases, with immediate results in eliminating pain.

Dr. Vicente Sanchis-Alfonso
Dr. Robert A. Teitge
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Anterior knee pain
  • Femoral anteversion
  • External tibial rotation
  • Femoral torsion
  • Tibial torsion
  • Rotational osteotomy
  • Genu valgum
  • Genu recurvatum

Published Papers (7 papers)

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Editorial

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4 pages, 199 KiB  
Editorial
Torsional Abnormality: The Forgotten Issue in the Diagnosis and Treatment of the Anterior Knee Pain Patient
by Vicente Sanchis-Alfonso and Robert A. Teitge
J. Clin. Med. 2022, 11(12), 3530; https://doi.org/10.3390/jcm11123530 - 20 Jun 2022
Cited by 2 | Viewed by 1304
Abstract
Currently, no one doubts that the vast majority of anterior knee pain (AKP) cases do not need surgery [...] Full article
(This article belongs to the Special Issue The Role of Skeletal Malalignment In Patellofemoral Disorders)

Research

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19 pages, 3627 KiB  
Article
Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability
by Robert C. Palmer, David A. Podeszwa, Philip L. Wilson and Henry B. Ellis
J. Clin. Med. 2021, 10(14), 3035; https://doi.org/10.3390/jcm10143035 - 8 Jul 2021
Cited by 16 | Viewed by 6235
Abstract
Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Previous studies have estimated the incidence of acute patellar dislocation at 43 per 100,000 children younger than age 16 years. The medial patellofemoral ligament (MPFL) complex is a static soft tissue [...] Read more.
Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Previous studies have estimated the incidence of acute patellar dislocation at 43 per 100,000 children younger than age 16 years. The medial patellofemoral ligament (MPFL) complex is a static soft tissue constraint that stabilizes the patellofemoral joint serving as a checkrein to prevent lateral displacement. The causes of PFI are multifactorial and not attributed solely to anatomic features within the knee joint proper. Specific anatomic features to consider include patella alta, increased tibial tubercle–trochlear groove distance, genu valgum, external tibial torsion, femoral anteversion, and ligamentous laxity. The purpose of this paper is to provide a review of the evaluation of PFI in the pediatric and adolescent patient with a specific focus on the contributions of coronal and transverse plane deformities. Moreover, a framework will be provided for the incorporation of bony procedures to address these issues. Full article
(This article belongs to the Special Issue The Role of Skeletal Malalignment In Patellofemoral Disorders)
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9 pages, 1234 KiB  
Article
Proximal Tibiofibular Dislocation in Closing-Wedge High Tibial Osteotomy Increases the Risk of Medium and Long-Term Total Knee Replacement
by Juan Sánchez-Soler, Alex Coelho, Raúl Torres-Claramunt, Berta Gasol, Albert Fontanellas, Simone Perelli, Pedro Hinarejos and Joan Carles Monllau
J. Clin. Med. 2021, 10(13), 2743; https://doi.org/10.3390/jcm10132743 - 22 Jun 2021
Cited by 1 | Viewed by 1688
Abstract
Proximal tibiofibular dislocation in closing-wedge high tibial osteotomy increases the risk of medium and long-term total knee replacement. Background: High tibial osteotomy is an effective treatment for medial osteoarthritis in young patients with varus knee. The lateral closing-wedge high tibial osteotomy (CWHTO) [...] Read more.
Proximal tibiofibular dislocation in closing-wedge high tibial osteotomy increases the risk of medium and long-term total knee replacement. Background: High tibial osteotomy is an effective treatment for medial osteoarthritis in young patients with varus knee. The lateral closing-wedge high tibial osteotomy (CWHTO) may be managed with tibiofibular dislocation (TFJD) or a fibular head osteotomy (FHO). TFJD may lead to lateral knee instability and thereby affect mid- and long-term outcomes. It also brings the osteotomy survival rate down. Objective: To compare the CWHTO survival rate in function of tibiofibular joint management with TFJD or FHO, and to determine whether medium and long-term clinical outcomes are different between the two procedures. Material & Methods: A retrospective cohort study was carried out that included CWHTO performed between January 2005 to December 2018. Those patients were placed in either group 1 (FHO) or Group 2 (TFJD). Full-leg weight-bearing radiographs were studied preoperatively, one year after surgery and at final follow-up to assess the femorotibial angle (FTA). The Rosenberg view was used to assess the Ahlbäck grade. The Knee Society Score (KSS) was used to assess clinical outcomes and a Likert scale for patient satisfaction. The total knee replacement (TKR) was considered the end of the follow-up and the point was to analyze the CWHTO survival rate. A sub-analysis of both cohorts was performed in patients who had not been FTA overcorrected after surgery (postoperative FTA ≤ 180°, continuous loading in varus). Results: A total of 230 knees were analyzed. The follow-up period ranged from 24–180 months. Group 1 (FHO) consisted of 105 knees and group 2 (TFJD) had 125. No preoperative differences were observed in terms of age, gender, the KSS, FTA or the Ahlbäck scale; neither were there any differences relative to postop complications. The final follow-up FTA was 178.7° (SD 4.9) in group 1 and 179.5° (SD 4.2) in group 2 (p = 0.11). The Ahlbäck was 2.21 (SD 0.5) in group 1 and 2.55 (SD 0.5) in group 2 (p = 0.02) at the final follow-up. The final KSS knee values were similar for group 1 (86.5 ± 15.9) and group 2 (84.3 ± 15.8). Although a non-significant trend of decreased HTO survival in the TFJD group was found (p = 0.06) in the sub-analysis of non-overcorrected knees, which consisted of 52 patients from group 1 (FHO) and 58 from group 2 (TFJD), 12.8% of the patients required TKR with a mean of 88.8 months in group 1 compared to 26.8% with a mean of 54.9 months in the case of group 2 (p = 0.005). However, there were no differences in clinical and radiological outcomes. Conclusion: TFJD associated with CWHTO shows an increase in the conversion to TKR at medium and long-term follow-up with lower osteotomy survival than the CWHTO associated with FHO, especially in patients with a postoperative FTA ≤ 180° (non-overcorrected). There were no differences in clinical, radiological or satisfaction results in patients who did not require TKR. Level of evidence III. Retrospective cohort study. Full article
(This article belongs to the Special Issue The Role of Skeletal Malalignment In Patellofemoral Disorders)
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8 pages, 2256 KiB  
Article
Locating the Origin of Femoral Maltorsion Using 3D Volumetric Technology—The Hockey Stick Theory
by Joan Ferràs-Tarragó, Vicente Sanchis-Alfonso, Cristina Ramírez-Fuentes, Alejandro Roselló-Añón and Francisco Baixauli-García
J. Clin. Med. 2020, 9(12), 3835; https://doi.org/10.3390/jcm9123835 - 26 Nov 2020
Cited by 8 | Viewed by 6528
Abstract
Background: The origin of femoral maltorsion is often unknown. However, defining the origin of the rotation of the femoral maltorsion can be useful for establishing the most suitable point to do an external derotational osteotomy. Previous studies have not considered the femoral diaphysis [...] Read more.
Background: The origin of femoral maltorsion is often unknown. However, defining the origin of the rotation of the femoral maltorsion can be useful for establishing the most suitable point to do an external derotational osteotomy. Previous studies have not considered the femoral diaphysis in their investigations of the origin of the deformity. The study of the whole morphology of the femur with 3D volumetric tools, including the femoral diaphysis can contribute to a better understanding of the behavior of femoral maltorsion. Methods: An atypical case of unilateral femoral anteversion was selected. Both femurs were used to obtain 3D bio-models. The mirror image of the asymptomatic side was obtained and overlapped with the symptomatic femur. The Hausdorff–Besicovitch method was used to evaluate the morphologic discrepancies (in mm) between the two femurs in three zones: (1) the femoral neck, (2) the proximal diaphysis, and (3) the distal diaphysis. The differences between the two femurs were analyzed and its correlation was statistically defined using a lineal regression model. Results: The deformity in the distal diaphysis increased from the supracondylar area until the apex of the antecurvatum angle (R2 = 0.91) and then decreased until the base of the femoral neck (R2 = (−0.83)), to finally increase significantly in the femoral neck area (R2 = 0.87). All of the correlations were statistically significant (p-value ˂ 0.001). Conclusion: The femoral maltorsion originates in the supracondylar area and its rotational axis is the longitudinal axis of the femoral diaphysis. Even though the deformity affects the femoral diaphysis, its clinical relevance is much higher in the femoral neck since the rotational axis passes through its base. Thus, the osteotomy can be conducted along all of the femoral diaphysis as long as it is done perpendicular to it. Full article
(This article belongs to the Special Issue The Role of Skeletal Malalignment In Patellofemoral Disorders)
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10 pages, 14497 KiB  
Article
A 3D-CT Analysis of Femoral Symmetry—Surgical Implications
by Joan Ferràs-Tarragó, Vicente Sanchis-Alfonso, Cristina Ramírez-Fuentes, Alejandro Roselló-Añón and Francisco Baixauli-García
J. Clin. Med. 2020, 9(11), 3546; https://doi.org/10.3390/jcm9113546 - 3 Nov 2020
Cited by 8 | Viewed by 1888
Abstract
Background: Mirroring the image of the affected side is a widely used technique for surgical planning in orthopedic surgery, especially for fractures and custom-made prostheses. Our objective is to evaluate the three-dimensional symmetry of the femurs using finite element analysis and manual alignment. [...] Read more.
Background: Mirroring the image of the affected side is a widely used technique for surgical planning in orthopedic surgery, especially for fractures and custom-made prostheses. Our objective is to evaluate the three-dimensional symmetry of the femurs using finite element analysis and manual alignment. Methods: Using the computed tomography of 15 patients without lower limb pathology, 30 3D biomodels of their femurs were obtained. The error obtained through image manipulation was calculated and broken down into a rendering error and a manual overlay error. The Hausdorff–Besicovitch method was applied to obtain the total asymmetry. The manipulation error was theb subtracted from it to obtain the intrapersonal asymmetry. Results: The mean intrapersonal asymmetry was 0.93 mm. It was obtained by subtracting the error derived from rendering and alignment of 0.59 mm (SD 0.17 mm) from the overall mean error of 1.52 mm (SD 1.45). Conclusions: Intrapersonal femoral asymmetry is low enough to use the mirror image of the healthy side as a reference for three-dimensional surgical planning. This type of planning is especially useful in deformity surgery when the objective of the surgery is not to restore only one specific parameter but to obtain a general functional morphology when a healthy contralateral femur is available. Full article
(This article belongs to the Special Issue The Role of Skeletal Malalignment In Patellofemoral Disorders)
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7 pages, 1134 KiB  
Article
Proximal Tibiofibular Dislocation in a Closing-Wedge High Tibial Osteotomy Causes Lateral Radiological Gapping of the Knee: A Prospective Randomized Study
by Raúl Torres-Claramunt, Juan Francisco Sánchez-Soler, Pedro Hinarejos, Aleix Sala-Pujals, Joan Leal-Blanquet and Joan Carles Monllau
J. Clin. Med. 2020, 9(6), 1622; https://doi.org/10.3390/jcm9061622 - 27 May 2020
Cited by 3 | Viewed by 1830
Abstract
Background: To determine whether a proximal tibiofibular joint dislocation (TFJD) increases lateral compartment gapping more than a fibular head osteotomy (FHO) during a closing-wedge high tibial osteotomy (CWHTO). The second objective was to determine whether lateral compartment gapping affects clinical outcomes. Methods: A [...] Read more.
Background: To determine whether a proximal tibiofibular joint dislocation (TFJD) increases lateral compartment gapping more than a fibular head osteotomy (FHO) during a closing-wedge high tibial osteotomy (CWHTO). The second objective was to determine whether lateral compartment gapping affects clinical outcomes. Methods: A prospective randomized clinical study was carried out that included 18 patients in Group 1 (FHO) and 18 in Group 2 (TFJD). Varus-stress radiographs of all the patients with both knees at full extension and at 30° of flexion were studied pre-operatively and 12 months post-operatively. Lateral compartment gapping was measured in millimeters. The Knee Society Score (KSS) was used to assess clinical stability. Results: The difference between the pre- and post-operative measurements relative to gapping in the lateral knee compartment at 0° of knee flexion was 1.3 mm (SD 1.8) in Group 1 and 4.5 mm (SD 2.4) in Group 2 (p = 0.006). At 30° of knee flexion, this difference was 1.9 mm (SD 1.2) in Group 1 and 5.2 mm (SD 3.1) in Group 2 (p = 0.01). No differences were observed in the pre- and post-operative period relative to gapping in healthy knees. Pre-operatively, both groups presented similar KSS knee values: Group 1 with 54.7 (SD 11.7), Group 2 with 54.8 (SD 11.1) (n.s.). Post-operatively, these values were also similar: Group 1 with 93.2 (SD 7.4), Group 2 with 93.5 (SD 5.5) (n.s.). Conclusions: In patients who have undergone a CWHTO, TFJ dislocation increases knee lateral compartment gapping when compared to an FHO at 0° and 30° of knee flexion. However, this fact seems to have no repercussion on the functional status of the knees as measured with the KSS at the one-year follow-up. Full article
(This article belongs to the Special Issue The Role of Skeletal Malalignment In Patellofemoral Disorders)
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Other

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9 pages, 831 KiB  
Opinion
Reflections on Rotational Osteotomies around the Patellofemoral Joint
by Roland M. Biedert
J. Clin. Med. 2021, 10(3), 474; https://doi.org/10.3390/jcm10030474 - 27 Jan 2021
Cited by 5 | Viewed by 1864
Abstract
Torsional abnormalities of the femur represent a significant risk factor for patellar instability or patellofemoral complaints. Although their clinical implication has been demonstrated, there is still a debate going on about different aspects. These include, especially, the various methods of measurements with a [...] Read more.
Torsional abnormalities of the femur represent a significant risk factor for patellar instability or patellofemoral complaints. Although their clinical implication has been demonstrated, there is still a debate going on about different aspects. These include, especially, the various methods of measurements with a wide range of physiologic values, the indication or clear recommendation for surgical correction, and the site of the rotational osteotomy. Nevertheless, good subjective and objective functional results were reported after femoral rotational osteotomies. This is mostly not a review of the literature, but a collection of personal thoughts and observations. Full article
(This article belongs to the Special Issue The Role of Skeletal Malalignment In Patellofemoral Disorders)
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