The majority of patellar avulsion fractures in first-time acute patellar dislocations included the inferomedial patellar border that was different from the medial patellofemoral ligament attachment

Abstract

Purpose

Accurate assessment of the locations of patellar avulsion fractures in acute patellar dislocations is clinically relevant for decision making for treatment. The study aim was to classify the locations of patellar avulsion fractures with a focus on the ligament attachments of medial stabilizing structures.

Methods

Out of 131 first-time acute traumatic patellar dislocations, 61 patients had patellar fractures. Subsequently, 10 patients with isolated osteochondral fractures of the articular surface in the patella were excluded. Finally, 51 patients (34 females and 17 males, average age: 18.5 years, 95% CI 16.1–20.9) were included in the study cohort. Based on the locations of the patellar attachment, the patients were divided into three groups: the superior group [medial patellofemoral ligament (MPFL) attachment], inferior group [medial patellotibial ligament (MPTL)/medial patellomeniscal ligament (MPML) attachment], and mixed group.

Results

In the patellar avulsion group (51 patients), the superior group, mixed group, and inferior group contained 8/51 (16%), 12/51 (24%), and 31/51 (61%) patients, respectively.

Conclusions

This study showed that 84% of the patellar avulsion fractures were located in the inferomedial patellar border, which consisted of MPTL/MPML attachments that were clearly different from the true “MPFL” attachment at the superomedial patellar border. In terms of the clinical relevance, the acute surgical repair of MPTL/MPML attachments in the inferomedial patellar border may not sufficiently control the patella if optimal management of the MPFL is not performed.

Level of evidence

IV.

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References

  1. 1.

    Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220

    Article  CAS  Google Scholar 

  2. 2.

    Balcarek P, Ammon J, Frosch S, Walde TA, Schuttrumpf JP, Ferlemann KG, Lill H, Sturmer KM, Frosch KH (2010) Magnetic resonance imaging characteristics of the medial patellofemoral ligament lesion in acute lateral patellar dislocations considering trochlear dysplasia, patella alta, and tibial tuberosity-trochlear groove distance. Arthroscopy 26:926–935

    Article  Google Scholar 

  3. 3.

    Conlan T, Garth WP Jr, Lemons JE (1993) Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 75:682–693

    Article  CAS  Google Scholar 

  4. 4.

    Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26

    Article  CAS  Google Scholar 

  5. 5.

    Dietrich TJ, Betz M, Pfirrmann CW, Koch PP, Fucentese SF (2014) End stage extension of the knee and its influence on tibial tuberosity trochlear groove distance (TTTG) in asymptomatic volunteers. Knee Surg Sports Traumatol Arthrosc 22:214–218

    Article  Google Scholar 

  6. 6.

    Dietrich TJ, Fucentese SF, Pfirrmann CW (2016) Imaging of individual anatomical risk factors for patella instability. Semin Musculoskelet Radiol 20:65–73

    Article  Google Scholar 

  7. 7.

    Duthon VB (2015) Acute traumatic patellar dislocation. Orthop Traumatol Surg Res 101:S59–67

    Article  CAS  Google Scholar 

  8. 8.

    Elias DA, White LM, Fithian DC (2002) Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 225:736–743

    Article  Google Scholar 

  9. 9.

    Guerrero P, Li X, Patel K, Brown M, Busconi B (2009) Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study. Sports Med Arthrosc Rehabil Ther Technol 1:17

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Hinckel BB, Gobbi RG, Kaleka CC, Camanho GL, Arendt EA (2018) Medial patellotibial ligament and medial patellomeniscal ligament: anatomy, imaging, biomechanics, and clinical review. Knee Surg Sports Traumatol Arthrosc 26:685–696

    Article  Google Scholar 

  11. 11.

    Kaleka CC, Aihara LJ, Rodrigues A, de Medeiros SF, de Oliveira VM, de Paula Leite Cury R (2017) Cadaveric study of the secondary medial patellar restraints: patellotibial and patellomeniscal ligaments. Knee Surg Sports Traumatol Arthrosc 25:144–151

    Article  Google Scholar 

  12. 12.

    Kepler CK, Bogner EA, Hammoud S, Malcolmson G, Potter HG, Green DW (2011) Zone of injury of the medial patellofemoral ligament after acute patellar dislocation in children and adolescents. Am J Sports Med 39:1444–1449

    Article  Google Scholar 

  13. 13.

    Kruckeberg BM, Chahla J, Moatshe G, Cinque ME, Muckenhirn KJ, Godin JA, Ridley TJ, Brady AW, Arendt EA, LaPrade RF (2018) Quantitative and qualitative analysis of the medial patellar ligaments an anatomic and radiographic study. Am J Sports Med 46:153–162

    Article  Google Scholar 

  14. 14.

    LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L (2007) The anatomy of the medial part of the knee. J Bone Joint Surg Am 89:2000–2010

    Article  Google Scholar 

  15. 15.

    Longo UG, Ciuffreda M, Locher J, Berton A, Salvatore G, Denaro V (2017) Treatment of primary acute patellar dislocation: systematic review and quantitative synthesis of the literature. Clin J Sport Med 27:511–523

    Article  Google Scholar 

  16. 16.

    Marcacci M, Zaffagnini S, Bruni D, Muccioli G, Giordano G, Alvarez P (2010) MPTL (medial patellotibial ligament) reconstruction. In: Zaffagnini S, Dejour D, Arendt E (eds) Patellofemoral pain, instability, and arthritis. Springer, Berlin, pp 185–192

    Google Scholar 

  17. 17.

    Matic GT, Magnussen RA, Kolovich GP, Flanigan DC (2014) Return to activity after medial patellofemoral ligament repair or reconstruction. Arthroscopy 30:1018–1025

    Article  Google Scholar 

  18. 18.

    Merchant AC, Mercer RL, Jacobsen RH, Cool CR (1974) Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am 56:1391–1396

    Article  CAS  Google Scholar 

  19. 19.

    Mochizuki T, Tanifuji O, Sato T, Watanabe S, Omori G, Endo N (2019) Scoring system for optimal management of acute traumatic patellar dislocation: a multicenter study. J Orthop Sci. https://doi.org/10.1016/j.jos.2019.03.009

    Article  PubMed  Google Scholar 

  20. 20.

    Nomura E, Inoue M, Osada N (2005) Anatomical analysis of the medial patellofemoral ligament of the knee, especially the femoral attachment. Knee Surg Sport Traumatol Arthrosc 13:510–515

    Article  Google Scholar 

  21. 21.

    Philippot R, Boyer B, Testa R, Farizon F, Moyen B (2012) The role of the medial ligamentous structures on patellar tracking during knee flexion. Knee Surg Sports Traumatol Arthrosc 20:331–336

    Article  CAS  Google Scholar 

  22. 22.

    Sillanpaa PJ, Peltola E, Mattila VM, Kiuru M, Visuri T, Pihlajamaki H (2009) Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow- up study. Am J Sports Med 37:1513–1521

    Article  Google Scholar 

  23. 23.

    Sillanpää PJ, Salonen E, Pihlajamäki H, Mäenpää HM (2014) Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome. Knee Surg Sports Traumatol Arthrosc 22:2414–2418

    Article  Google Scholar 

  24. 24.

    Smirk C, Morris H (2003) The anatomy and reconstruction of the medial patellofemoral ligament. Knee 10:221–227

    Article  Google Scholar 

  25. 25.

    Sobhy MH, Mahran MA, Kamel EM (2013) Midterm results of combined patellofemoral and patellotibial ligaments reconstruction in recurrent patellar dislocation. Eur J Orthop Surg Traumatol 23:465–470

    Article  Google Scholar 

  26. 26.

    Takagi S, Sato T, Watanabe S, Tanifuji O, Mochizuki T, Omori G, Endo N (2018) Alignment in the transverse plane, but not sagittal or coronal plane, affects the risk of recurrent patella dislocation. Knee Surg Sports Traumatol Arthrosc 26:2891–2898

    Article  Google Scholar 

  27. 27.

    Vetrano M, Oliva F, Bisicchia S, Bossa M, De Carli A, Di Lorenzo L, Erroi D, Forte A, Foti C, Frizziero A, Gasparre G, Via AG, Innocenti B, Longo UG, Mahmoud A, Masiero S, Mazza D, Natali S, Notarangelo C, Osti L, Padulo J, Pellicciari L, Perroni F, Piccirilli E, Ramponi C, Salvatore G, Panni AS, Suarez T, Tarantino U, Vittadini F, Vulpiani MC, Ferretti A, Maffulli N (2017) I.S.Mu.L.T. firtst-time patellar dislocation guidelines. Muscles Ligaments Tendons J 7:1–10

    Article  Google Scholar 

  28. 28.

    Zaidi A, Babyn P, Astori I, White L, Doria A, Cole W (2006) MRI of traumatic patellar dislocation in children. Pediatr Radiol 36:1163–1170

    Article  Google Scholar 

Download references

Acknowledgements

The authors would like to thank all doctors in Niigata University and the affiliated hospitals: Drs. Watanabe K, Yamamoto N, Omori G, Shiozaki H, Segawa H, Matsueda M, Yamagiwa H, Higano Y, Ariumi A, Mera H, Murayama T, Fujii T, Koga H, Takagi S, Muraoka O, Yamanaka K, Hokari S, Hosono Y, Otani K, Soeno T, Hijikata H, Sasage Y, Maeda K, Someya K, Fujita Y, Takagi Y, Shima T, and Koga Y.

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Correspondence to Tomoharu Mochizuki.

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Mochizuki, T., Tanifuji, O., Watanabe, S. et al. The majority of patellar avulsion fractures in first-time acute patellar dislocations included the inferomedial patellar border that was different from the medial patellofemoral ligament attachment. Knee Surg Sports Traumatol Arthrosc 28, 3942–3948 (2020). https://doi.org/10.1007/s00167-020-05853-5

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Keywords

  • Acute patellar dislocation
  • Patellar avulsion facture
  • Medial patellofemoral ligament
  • Medial patellotibial ligament
  • Medial patellomeniscal ligament