0:00

I wanna emphasize that we should look at the ret inoculum

0:04

when we're looking at the quadriceps,

0:06

because extension into the medial

0:08

and reac, lateral ret inoculum is common.

0:11

You don't have to have a massive tear for it to happen,

0:14

but it changes the reconstruction for the surgeon.

0:18

It makes it more complicated.

0:19

So in this case, we have a tear. It's full thickness.

0:24

It was limited to the medial side of the knee,

0:28

but on our axial images, the reticulum is abnormal

0:32

and thickened, the patient has some lateral patellar,

0:35

uh, subluxation.

0:37

So just watch out for this.

0:39

And, uh, always look like in anything

0:42

that we see in M mss K that's torn.

0:44

You wanna look at all of the fibers that are, all

0:47

of the tissues that are continuous with it,

0:49

uh, for extension.

0:50

And, uh, therefore look at the reticulum in the

0:53

quadriceps tears.

0:55

So with that, let's look at the peri patella reac.

0:58

We have the medial and the lateral reticulum.

1:02

These are multi-layered, so it's okay again for you

1:06

to see multiple layers.

1:08

The outermost layer is going to be the superficial fascia.

1:11

The ret inoculum itself, uh, has a number of layers.

1:15

Generally two are clearly, uh, visible on both the medial

1:19

and lateral side, especially on T one weighted images.

1:22

And I really like having T one weighted images.

1:26

Uh, when we do our, uh, knee or proton density, non-fat sat,

1:30

because can tell you on fat sat, you'll see the edema,

1:34

but the anatomy of these structures is not as well shown.

1:38

And if you have chronic pathology, it's easy to overlook.

1:41

Uh, on the non-fat sat, uh, this is taken from an article

1:46

by Maran, uh, just pointing out the various contributions,

1:50

uh, to the lateral RET reticulum.

1:53

It has, uh, components coming from the IT band.

1:56

It has components coming from the quadriceps.

1:59

There are components of the fascia that blend

2:02

with it more posteriorly.

2:04

So these are multi-layered

2:06

and we don't need to remember all of this,

2:07

but we need to remember that it's okay for it

2:10

to look like it's got multiple bands, uh, to it.

2:13

And same thing again, on the medial side.

2:16

Multiple bands are really, really, uh, normal finding, uh,

2:20

in these reac.

2:22

I don't see much injury wise in terms

2:24

of the lateral ret ulu.

2:26

The main thing that I'm going to see

2:28

with it is this excessive lateral pressure syndromes

2:33

where the, uh, RET macula may look thickened.

2:36

Um, and this has been associated, uh,

2:40

by Fcat many years ago with the development

2:43

of a bipartite, uh, patella.

2:45

But it's not a structure that we see a lot of tears in.

2:49

This is a related, uh, lesion to the bipartite,

2:52

just so you're aware of it.

2:54

This is the so-called dorsal defect

2:56

of the patella located in a similar

2:59

position at the upper outer patella.

3:01

But this one does not have a separate bone fragment.

3:04

The cartilage may or may not be intact,

3:07

and some of these can be asy, uh, can be symptomatic,

3:11

especially those that have chondral abnormalities

3:14

and associated, uh, bone marrow edema.

3:17

Most of them, however, are just an incidental finding.

3:21

Now, The medial ret inoculum we do need to look at,

3:24

especially in patients with patellar dislocation.

3:27

So here we can see the medial RET inoculum, uh,

3:31

has multiple layers.

3:33

The most important of which is the one at the top,

3:36

which is the medial patello femoral ligament that, uh,

3:40

Brady already, uh, mentioned in his, uh, presentation.

3:44

So that's the only one our surgeons reconstruct,

3:47

and it's located up high.

3:49

Here we see one that's stretched out

3:50

and partially torn in a patient that's still dislocated.

3:55

This is unusual. Most of the time, uh,

3:57

the patients have already, uh, been, been reduced.

4:01

And the clues, Uh, to the presence

4:03

of this injury are characteristic

4:05

Osteochondral Regions of edema, cartilage damage and

4:10

Injury To that medial, uh, ulu.

4:15

So this is often what we'll see.

4:17

This is a really severe injury.

4:18

This patient sustained the lateral patella dislocation,

4:22

and we're seeing soft tissue disruption involving the

4:26

vastus medias.

4:27

This little inferior portion

4:29

of the vastus medias is sometimes referred to

4:32

as the Vastus medias oblique.

4:34

Um, it, it has some separation for the rest of the vastus,

4:38

and we have a tear going through there.

4:40

And the entire ret aum is a BOLs, uh, from the patella.

4:45

And in this patient we have very minimal, uh,

4:48

osteochondral injury,

4:49

but we have an extensive soft tissue injury here.

4:54

From the literature, we can see the intimate relationship

4:57

of the medial reticulum,

5:01

specifically the medial patello femoral ligament

5:03

with the terminal fibers of the vasts medias labeled here.

5:07

Vasts medias oblique for that inferior portion,

5:11

and you can see that they are intimate

5:13

and run posteriorly from that, uh, towards its insertion,

5:18

which is in the area of the medial, uh,

5:21

collateral ligament insertion at the knee joint.

5:25

So I use this as my landmark when I'm looking

5:28

and I look in the, find the vast medias

5:33

and I work my way down.

5:35

And then as I go down to the area of the adductor tubercle

5:39

that I know I should be in the area of the MPFL,

5:43

and I can look at it, it's been written in the literature

5:46

that it's always injured to varying degree in patients

5:49

with patellar dislocations.

5:52

Um, and you know, unfortunately,

5:54

we don't always image people acutely.

5:57

And, uh, if you go chronic, some

5:59

of the more mild injuries heal

6:01

and are quite difficult to, to recognize in the acute phase.

6:05

Uh, it's much more easy.