0:01

Right along to case number two then. So again here, uh,

0:06

on this one, uh, I don't remember seeing any localizers,

0:09

but obviously Localizer would be, uh, first look at and as a side too,

0:14

uh, uh,

0:15

and to mention along with the localizers and looking at the initial images,

0:20

I look for any signs of surgery, okay?

0:23

And one of the main places I look for surgery, okay? Besides obviously this one,

0:28

this person had a presumed tibial tubercle transfer. Okay?

0:32

But what I want you to pay attention to is hopa fat pad,

0:35

particularly medial and laterally, okay? Um,

0:37

what you'll see is some subtle scarring,

0:40

and this has been actually written up by, uh, my mentor, Dr.

0:43

Resnick and Rad a few years back along with our former fellows, Mohamed. Uh,

0:48

but basically you're just gonna look for some fibrosis and scarring. Typically,

0:52

it's gonna be linear, directed towards the joint, okay?

0:55

And that is important because then when I see that,

0:58

I'm gonna ask for op notes and prior imaging,

1:01

and that's gonna change how I read the study,

1:03

particularly if they're worried about re repairs of menisci and or cartilage

1:08

loss, what have you. Okay? Especially if they've been, you know,

1:11

dabbling around in their mucking around trying to incite some healing for the

1:15

patient's knee, obviously. Okay? But in this case, obviously we have, uh,

1:20

metallic susceptibility artifact obviously would be better evaluated by, uh,

1:24

a radiograph correlation. But we see that it's centered within, at the, uh,

1:29

tibial tubercle. So presumably this patient had a prior, uh,

1:33

tibial osteotomy, okay? And, or, sorry, tib,

1:38

tibial tubercle transfer. And what is that done for?

1:41

That's basically done to offload, okay?

1:44

The pool of the quadriceps upon the patella to

1:49

maintain the patella, which, uh, maintain its, uh,

1:52

proper position during flexion and extension,

1:55

or normal gait within the trochlea. Okay?

1:59

So this person had the patellar alignment addressed.

2:04

Now, if you study patellar instability or patella femoral syndrome,

2:08

broad syndrome, okay? Lot of problems, but classically,

2:11

obviously presents with anterior knee pain. And if,

2:14

for those that are interested, I would highly recommend the authors out of, uh,

2:18

Leon France. Okay? They, they are, uh, they,

2:23

they have, um, really over the years and, and,

2:26

and surgical history really worked with, uh,

2:30

patello femoral instability, that realm. And they've actually, uh,

2:34

you can think of patella, uh, instability, uh,

2:38

as being caused by a few things, okay?

2:40

But the main things that we're gonna look for,

2:42

the three or four things are gonna be the qua, the Q angle, okay?

2:46

Or that is the quadriceps pooling that patella and a normal Q angle,

2:51

uh, I argue, and many, uh, some authors will argue is better identified or,

2:56

or, um, measured with a nice normal, uh, bone length study.

3:01

And what you wanna do is measure the,

3:04

the angle between two lines, okay? The,

3:07

the lines sub tended by the, uh, ASIS to the central patella,

3:12

and the central patella to the tibial tubercle. And normal,

3:15

depending on who you read, is gonna be about 15 degrees or so. Okay?

3:19

So the higher the degree,

3:21

the more you can imagine that quadriceps pooling or trying to yank out that

3:26

patella from its trochlea group. The other thing along those lines,

3:30

the next segue to look at is gonna be the trochlea. Okay? Now,

3:34

depending on who you read fearman at all, and others in radiology,

3:38

you wanna go to the p the, the level of the PCL footprint, okay?

3:43

Measure up about three centimeters, okay?

3:47

And so here, uh, let's just say, I don't know, three centimeters.

3:53

For some reason the measurement is not working. But usually,

3:56

let's say three centimeters, oh, here we go. Let's say three centimeters,

4:00

right about there. So I would correlate with my axials,

4:03

go up on my axials, okay? And usually it's gonna be around here,

4:08

but obviously I would have two windows open, I would correlate, but what I,

4:12

I kind of eyeball it. I use my supercomputer, that is my brain, okay?

4:17

And I just kind of look at the morphology of the, uh, the trochlea,

4:21

not only the bone, but also the, the cartilage. And we, we can see here,

4:27

it's pretty flat, okay? Now, there's a whole bunch of classification systems.

4:32

The more common one you probably en encounters the de jour classification.

4:36

And as a side de jour was also a, not, I,

4:40

I believe a trainee or maybe even faculty at LE in Leone, France,

4:44

and dealing with a lot of these patellofemoral, uh, syn syndrome problems. Okay?

4:49

So one, so things to look for along with the, the morphology,

4:54

uh, of the, along with the Q angle,

4:57

you wanna look at the morphology of the trochlea,

4:59

which is the du jour classification. And I always have to look it up,

5:03

but I think there's usually about one or four.

5:05

But basically it goes from slightly, uh, little bit of, uh,

5:10

contour deformity or loss to flat to basically, uh, uh,

5:15

loss. And it basically looks like, uh, what's been likened to a, um, uh,

5:20

various different hats and what have you.

5:21

And you can look that up in the literature, okay? On the opposite side,

5:26

the patella can have abnormal morphology, okay?

5:28

The lateral facet can be elongated, okay? It could be truncated,

5:33

and it can even look like sort of like this, where it's sort of comma shaped,

5:37

where the medial facet is sort of truncated.

5:40

And you have this sort of elongated, um, uh, Patel lateral patella facet.

5:44

And I believe the classification, and mind you, I always have to look it up too,

5:48

I think it's the YR classification, and there's usually a one through three.

5:52

And I believe recent, uh, as of the last I checked, there was an upgrade. Uh,

5:56

someone added a type four,

5:58

but basically the more elongated okay? And truncate elongated,

6:03

the lateral facet is, and the truncated,

6:06

the medial facet is the more abnormal contact you're gonna have at this joint

6:11

leading to early choral and chondral loss of the patella femoral compartment.

6:16

And that's what we're trying to prevent, okay? And then more distally,

6:20

arguably the, the fourth thing that you wanna mention, okay,

6:22

is the tibial tuberosity hyphen troia groove distance. Okay?

6:27

And the way I do this is no, nothing magical, okay?

6:30

I kind of look for where the, uh, the, uh, the tro groove is shallows,

6:36

and I just hover my arrow there,

6:39

and then I will draw a line to what I think is the central of the TBO

6:43

tubercle, okay? I'm sure if you guys wanna be precise, um,

6:48

you can look up in the radiology literature,

6:50

in the methodology section of various articles and get a better, uh,

6:53

idea of how they do it. But, uh, this is the quick and dirty of how I do it.

6:58

And depending on how sensitive or specific you wanna be, uh,

7:02

what I've read in the literature is anywhere from, I don't know,

7:05

15 to 20 millimeters is gonna be the cutoff where you're gonna worry about, uh,

7:09

uh, um, fixing that, uh, or doing a patella transfer. So,

7:14

as you can imagine, okay,

7:17

with each of these abnormalities that can contribute to patello femoral

7:22

instability, what the surgeons from France, from Leon France, and others,

7:27

okay? You can actually, um,

7:30

curate and design a surgery for each patient with patella

7:35

femoral problems.

7:36

So you can imagine if someone that has maybe a tr prominent tr beak here,

7:42

or a flat trochlear surface where they're not accepting the patellas,

7:46

particularly within that, uh, flexion, early flexion and extension,

7:50

some surgeons will do a trop plasty tr trop plasty,

7:54

where they cut out part of the tral here and they actually push the trochlear

7:59

down. But not many surgeons are able to do this. It's a quite complex surgery,

8:04

okay? Other things that people will do is they'll tighten up the ret macula,

8:09

okay? Or loosen it up, what have you, medial laterally, respectively. Okay?

8:14

And then the other thing, more commonly thing that I see here in,

8:17

in the United States is they'll do this. So-called focus and procedure,

8:21

or this tibial tubercle transfer by moving the patellar tendon, okay?

8:26

Uh, letting up and easing up that pool on the patella so it doesn't dislocate or

8:31

subluxate as readily. Other things that you can also see, okay?

8:36

Some people will actually filet or cut the quadriceps tendon and bring a limb

8:41

over here again, to sort of limit that pool, that vector pool,

8:46

uh, of the patella, maintain the patella within its trochlear group, okay?

8:52

But in this case, I would say how I would read this, okay,

8:56

that this is a shallow or flat trochlear groove, probably a,

9:01

I don't know, a de jore two or three if pressed. Um, this, uh,

9:06

lateral facet is arguably remodeled, but probably was, um, uh,

9:11

elongated before. So probably maybe a weiberg three or four.

9:15

And the la medial facet is truncated. And then I would also mention,

9:19

obviously the high grade conal loss of the median ridge of the patella,

9:23

as well as the lateral patella facet. And then finally mention in the same,

9:27

in one breath,

9:28

the distance of that trochlear groove distance in case they wanna go there and,

9:33

uh, provide, uh, address the,

9:36

the position of the patella tendon and that pool on the patella. Okay,

9:41

so that's, uh, this case. Any questions on Pat Teller? Instability

9:48

In terms of couple of the structures that I get confused with is the petal

9:52

femoral ligament and the reac. I can see that there's some, um, uh,

9:57

waviness to it. So how do you distinguish between the two and pathology?

10:01

So really the more I'm reading,

10:03

the more I think every joint we're all covered by one big fascia and we're

10:08

continuous. Um, but if some authors will say,

10:13

when you see muscle, they consider that ligament.

10:16

So they'll call this medial Patel femoral ligament.

10:19

When you stop seeing the vast medias oblique muscle, okay?

10:23

That's when they'll call it retin ulu. So this here, I, you know,

10:27

if press yes, I would call this the medial patella femoral reticulum,

10:32

and then more distally, okay? There is also a medial patella,

10:37

tibial ligament, and if there's a medial side, there's gonna be a lateral side.

10:41

So the corollary on the lateral side is gonna be the lateral patella tibial

10:45

ligament coming back up more. Uh, cran,

10:48

you had the lateral patel femoral reticulum,

10:51

and then even more cranial where you had the AVAs lateral.

10:54

Some people argue that's what you call the, the, the lateral Patel femoral, uh,

11:00

ligament. Good questions.

11:05

And there's ness, the lateral component.

11:08

And that's purely because the patella is subluxed, isn't it?

11:11

Yeah. Yeah. That, that can be subluxed. It could be positional,

11:15

but mind you too, as we all age, okay,

11:18

and that can be a pitfall as we age and get older tendons and our body parts

11:23

degenerate. So, uh, be careful over calling,

11:26

especially in older patients, when things look redundant or wavy,

11:31

what have you, it can just be within the realm of normal,

11:35

in which case I may dictate in, you know, uh, you know,

11:38

lax appearance or undulating appearance of whatever ligament or tendon

11:43

correlate for possible instability or laxity at imaging

11:48

or, or at clinically. Any other questions on this one? Great questions,

11:51

by the way.

11:53

And, and actually, what,

11:54

what sequence do you use to look at the ligaments to identify a tear within

11:58

these, uh, reac ligaments?

12:00

Uh, I, I, I mostly use axials for these reac ligaments.

12:05

Yeah. And, and we would just do a fluid sensitive

12:08

Oh yeah, yes. A nice,

12:10

a nice fluid sensitive side by side with usually a, like AT one or, you know,

12:15

depending on, you know, some people will get PDs, what have you. Yeah. Yeah.

12:20

And then also too, along those lines, uh, um, too sir, that, you know,

12:24

when there's a transient lateral patella dislocation, you often, we often,

12:27

as some of you know, we see that ro you know,

12:30

sometimes a robust edema within the deep aspect and deep and medial aspect

12:35

of the VAs medias obliques muscle to accompany all that.