Patellar Flexion Angle Research Articles

Sagittal patellar flexion angle measurement determines greater incidence of patella alta in patellar tendinopathy patients.

The objective of this study was to compare patellar height and patella alta between a control cohort and patients with patellar tendinopathy by the sagittal patellar flexion angle (SPFA) measurement. Magnetic resonance imaging (MRI) scans of the knee were obtained from a sports imaging facility and screened to select patients with anterior knee pain. This symptomatic group was divided into two patient cohorts: those with and without MRI features of patellar tendinopathy. Lateral knee radiographs were reviewed and SPFA, knee flexion angle and Insall-Salvati ratio (IS) were measured from the radiographs by two independent reviewers. A total of 99 patients consisting of 48 patellar tendinopathy patients and 51 control patients were included. There was a significantly higher mean patellar height (p = 0.002, d = 0.639) and a greater patella alta incidence in the patellar tendinopathy cohort (25.0%) compared to the controls (3.9%) (p = 0.022, d = 0.312). Insall-Salvati ratio measurements showed no difference in patella alta incidence between tendinopathy and control cohorts. There was excellent inter- and intra-observer reliability of SPFA measurements (ICC 0.99). This is the first study to demonstrate a greater incidence of patella alta in patellar tendinopathy patients compared to controls. A greater patella alta incidence amongst patellar tendinopathy patients as defined by SPFA was found to be clinically relevant, as it suggests these patients may comprise the recalcitrant patient subgroup who do not improve with current surgical intervention and may therefore benefit from a biomechanical surgical solution. III.

A PHOTOELASTIC MODEL OF THE PATELLOFEMORAL JOINT TO STUDY PATELLAR HEIGHT

Background: Patellar height has been related to anterior knee pain and Osgood–Schlatter disease. To study the influence of patellar height on knee biomechanics, a bidimensional photoelastic prototype of the patellofemoral joint was developed. Methods: Nine tests were performed at different knee flexion angles and patellar heights. A free body diagram was constructed for each test. The following parameters were calculated: lengths (patella, patella thickness and ligamentum patellae); patellar height index; angles (knee flexion, patellar flexion, quadriceps and ligamentum patellae force and reaction force at the ankle); moment arms (extensor, quadriceps and ligamentum patellae in relation to both the tibiofemoral and patellofemoral contact points), effective moment arm and forces around the extensor mechanism relative to the applied force. Results: Femoropatellar and femorotibial reaction forces were greater with increased knee flexion and a fixed patellar height. With fixed knee flexion and different patellar heights, these forces were greater if the patella was elevated. A decrease in the angle between the tibial axis and ligamentum patellae was observed when patellar height increased. Patellar flexion angle increased when patellar height increased. This was accompanied by an increase in the angle of action of the quadriceps force. Extensor moment arm decreased with increased patellar height when knee flexion and the tibiofemoral contact point were fixed. Conclusion: A new application of photoelasticity is presented. The preliminary findings obtained confirm the influence of patellar height on patellar biomechanics, and specifically on forces around the extensor mechanism of the knee.

The effect of tibial plateau leveling osteotomy on patellofemoral kinematics in dogs: An in vivo study.

To quantitatively evaluate patellofemoral (PF) kinematics during walking in dogs with cranial cruciate ligament (CrCL) deficiency treated by tibial plateau leveling osteotomy (TPLO). Longitudinal observational study. Dogs with unilateral CrCL deficiency treated by TPLO (n = 10). Horizontal beam fluoroscopic images of the stifles during treadmill walking were acquired 6 months after TPLO. Computed tomography was performed, and digitized bone models of both femurs and patellae were created. These digital models were superimposed over the fluoroscopic images with shape-matching software, and sagittal plane PF kinematics for TPLO-treated and normal contralateral stifles were calculated. Patellofemoral kinematics were described according to phase of gait cycle as well as relative to femorotibial flexion angle. In TPLO-treated stifles, there was an approximately 1-mm increase in cranial displacement of the patella (P < .05) compared with the normal stifle at equivalent femorotibial flexion angles between 120° and 140° and predominately during the stance phase. Proximal-distal translation and patellar flexion angle were mostly unaffected by TPLO when they were assessed according to either equivalent phase of gait cycle or femorotibial flexion angles. In vivo PF kinematics in TPLO-treated stifles were subtly different from normal, characterized by slight cranial shifting of the patella relative to the trochlear groove. The clinical significance of these results remains unknown. These results may provide further understanding into extensor mechanism abnormalities associated with TPLO.

Sagittal patellar flexion angle: a novel clinically validated patellar height measurement reflecting patellofemoral kinematics useful throughout knee flexion.

Patellar height measurements on lateral radiographs are dependent on knee flexion which makes standardisation of measurements difficult. This study described a plain radiographic measurement of patellar sagittal height which reflects patellofemoral joint kinematics and can be used at all degrees of flexion. The study had two parts. Part one involved 44 normal subjects to define equations for expected patellar position based on the knee flexion angles for three new patellar height measurements. A mixed model regression with random effect for individual was used to define linear and polynomial equations for expected patellar position relating to three novel measurements of patella height: (1) patellar progression angle (trochlea), (2) patellar progression angle (condyle) and (3) sagittal patellar flexion. Part two was retrospective and involved applying these measurements to a surgical cohort to identify differences between expected and measured patellar position pre- and post-operatively. All three measurements provided insight into patellofemoral kinematics. Sagittal patellar flexion was the most useful with the least residual error, was the most reliable, and demonstrated the greatest detection clinically. Clinically applied radiographic measurements have been described for patellar height which reflect the sagittal motion of the patella and can be used regardless of the degree of flexion in which the radiograph was taken. The expected sagittal patellar flexion linear equation should be used to calculate expected patellar height. IV.

Kinematically aligned TKA restores physiological patellofemoral biomechanics in the sagittal plane during a deep knee bend.

Although patellofemoral complications after kinematically aligned (KA) TKA are infrequent, the patellar flexion angle and proximal-distal patellar contact location through flexion, and incidence of patellar loss of contact at full extension are unknown. The present study determined whether the patellar flexion angle and proximal-distal patellar contact location of a KA TKA performed with anatomic, fixed-bearing, posterior cruciate-retaining (PCR) components differed from those of the native contralateral knee during a deep knee bend, and determined the incidence of patellar loss of contact at full extension for KA TKA only. During a deep knee bend from full extension to maximum flexion, both knees were imaged in a lateral view using single-plane fluoroscopy for 25 patients with a caliperedKA TKA and a healthy native knee in the contralateral limb. The patellar flexion angle and proximal-distal patellar contact location were measured on images from full extension to maximum flexion in 30° increments. Paired t tests at each flexion angle determined the significance of the difference between the KA TKAknees and the native contralateralknees. In the KA TKAknees, the incidence of patellar loss of contact at full extension was determined. Patient-reported outcome scores also were recorded including the Oxford Knee Score. Mean patellar flexion angles were not different between the KA TKAknees and the nativecontralateral knees throughout the motion arc. The largest statistically significant difference in the mean proximal-distal patellar contact locations was 4mm. The incidence of patellar loss of contact in the KA TKAknees at full extension was 8% (2 of 25 patients). The median Oxford Knee Score was 46 out of 48. CaliperedKA TKA performed withanatomic, fixed-bearing, PCR components restored patellar flexion angles to native and largely restored the proximal-distal patellar contact locations, which at most differed from thenativecontralateral knee by approximately 10% of the mean proximal-distal patellar length. In the KA TKAknees, the incidence of patellar loss of contact was infrequent. These objective biomechanical results are consistent with the relatively high subjective patient-reported outcome scores herein and support the low incidence of patellofemoral complications following KA TKA previously reported. Therapeutic, level III.

Research Methods and Progress of Patellofemoral Joint Kinematics: A Review.

Patellofemoral pain syndrome has a high morbidity, and its pathology is closely associated with patellofemoral joint kinematics. A series of in vivo and in vitro studies have been conducted to explore patellofemoral kinematics, and the findings are relevant to the diagnosis, classification, and management of patellofemoral diseases and even the whole knee joint. However, no definite conclusion on normal patellofemoral kinematics has been established. In this study, the measurement methodologies of patellofemoral kinematics (including data collection methods, loading conditions, and coordinate system) as well as their advantages and limitations were reviewed. Motion characteristics of the patella were analyzed. During knee flexion, the patellar flexion angle lagged by 30–40% compared to the tibiofemoral joint flexion. The patella tilts, rotates, and shifts medially in the initial stage of knee flexion and subsequently tilts, rotates, and shifts laterally. The finite patellar helical axis fluctuates near the femoral transepicondylar axis or posterior condylar axis. Moreover, factors affecting kinematics, such as morphology of the trochlear groove, soft tissue balance, and tibiofemoral motion, were analyzed. At the initial period of flexion, soft tissues play a vital role in adjusting patellar tracking, and during further flexion, the status of the patella is determined by the morphology of the trochlear groove and patellar facet. Our findings could increase our understanding of patellofemoral kinematics and can help to guide the operation plan for patients with patellofemoral pain syndrome.

Patellofemoral kinematic characteristics in anterior cruciate ligament deficiency and reconstruction

BackgroundIt is very important to dynamically evaluate the functional outcome in the knee after anterior cruciate ligament (ACL) reconstruction under physiological weight bearing. The objective of the current study is that we would like to compare the patellofemoral joint kinematics in three ACL status: ACL intact, ACL deficiency, ACL reconstruction.MethodsTwenty patients with unilateral ACL deficient knees were recruited as preoperative group. Six months after ACL reconstruction, these ten subjects were included as postoperative subjects. Ten normal subjects with healthy knees as the control group. Each subject was asked to walk up a custom set of stairs and a single-plane fluoroscopic imaging system was used to determine the 6DOF kinematics of the injured knees, ACL reconstructed knees, and intact knees.ResultsACL deficient knees showed reduced patellar flexion angle and reduced distal patellar translation during knee flexion. ACL reconstructed knees showed abnormal patellofemoral joint kinematics compared to ACL intact and ACL deficient knees, exhibiting increased patellar external rotation, lateral tilt, lateral translation during knee flexion.ConclusionThese findings imply that some alterations persist after ACL deficiency and ACL reconstruction. These abnormal changes will be the onset of degeneration in patellofemoral joint even if the ACL is reconstructed in a way that restores the clinical anteroposterior stability of the knee. Some biomechanical changes should be made to improve the outcome of intervention especially in surgical treatment like ACL reconstruction.

The role of the patellar tendon angle and patellar flexion angle in the interpretation of sagittal plane kinematics of the knee after knee arthroplasty: A modelling analysis

BackgroundMany different measures have been used to describe knee kinematics. This study investigated the changes of two measures, the patellar tendon angle and the patellar flexion angle, in response to variations in the geometry of the knee due to surgical technique or implant design. MethodsA mathematical model was developed to calculate the equilibrium position of the extensor mechanism for a particular tibiofemoral position. Calculating the position of the extensor mechanism allowed for the determination of the patellar tendon angle and patellar flexion angle relationships to the knee flexion angle. The model was used to investigate the effect of anterior–posterior position of the femur, change in joint line, patellar thickness (overstuffing, understuffing), and patellar tendon length; these parameters were varied to determine the effect on the patellar tendon angle/knee flexion angle and patellar flexion angle/knee flexion angle relationships. ResultsThe patellar tendon angle was a good indicator of anterior–posterior femoral position and change in patellar thickness, and the patellar flexion angle a good indicator of change in joint line, and patellar tendon length. ConclusionsThe patellar tendon angle/knee flexion angle relationship was found to be an effective means of identifying abnormal kinematics post-knee arthroplasty. However, the use of both the patellar tendon angle and patellar flexion angle together provided a more informative overview of the sagittal plane kinematics of the knee.

Relationship between inferior patellar mobility and knee flexion angle in community dwelling elderly female

Relationship between inferior patellar mobility and knee flexion angle in community dwelling elderly female

Relationship between patellar tendon shortening and in vitro kinematics in the ovine stifle joint

Post-operative patellar tendon shortening induces a distal positioning of the patella in the femoral trochlear groove, which has been associated with pain and impeded mobility. An idealized in vitro model was used to examine the effects of shortening on patellar kinematics. The PT length was progressively reduced by up to 5 mm (1-mm instalments) using a device secured onto the tendon in n = 9 ovine stifles. In vitro 6 degrees-of-freedom motion data for the patellofemoral and tibiofemoral joints under conditions of passively induced flexion-extension was acquired electromagnetically. Patellar motion was analysed as a function of both tibial and patellar flexion angles relative to the femoral co-ordinate frame. Linear regression with contrasts was used to compare kinematic changes for each shortening level, with significance set at P<0.01. A mean maximum percentage length reduction of 8.2% was achieved. Patellar flexion was linearly correlated with tibial flexion angle in the intact joint, and this correlation persisted after tendon shortening (R = 0.977, P < 0.01). Patellar kinematics expressed as a function of tibial flexion angle were significantly altered by a mean length decrease of 8.2%, while flexion and proximo-distal shift patterns were significantly affected at lesser shortening levels of 3.1% and 4.7%, respectively. Patellar kinematics expressed as a function of patellar flexion angle remained unchanged. These results suggest that patellar motion within the trochlear groove in the ovine stifle joint follows a repeatable three-dimensional path and that patellar tendon shortening advances the position of the patella along this path, without significantly altering it.

In vivo patellar tracking and patellofemoral cartilage contacts during dynamic stair ascending

The knowledge of normal patellar tracking is essential for understanding the knee joint function and for diagnosis of patellar instabilities. This paper investigated the patellar tracking and patellofemoral joint contact locations during a stair ascending activity using a validated dual-fluoroscopic imaging system. The results showed that the patellar flexion angle decreased from 41.9° to 7.5° with knee extension during stair ascending. During first 80% of the activity, the patella shifted medially about 3.9mm and then slightly shifted laterally during the last 20% of the ascending activity. Anterior translation of 13mm of the patella was measured at the early 80% of the activity and the patella slightly moved posteriorly by about 2mm at the last 20% of the activity. The path of cartilage contact points was slightly lateral on the cartilage surfaces of patella and femur. On the patellar cartilage surface, the cartilage contact locations were about 2mm laterally from heel strike to 60% of the stair ascending activity and moved laterally and reached 5.3mm at full extension. However, the cartilage contact locations were relatively constant on the femoral cartilage surface (∼5mm lateral). The patellar tracking pattern was consistent with the patellofemoral cartilage contact location pattern. These data could provide baseline knowledge for understanding of normal physiology of the patellofemoral joint and can be used as a reference for clinical evaluation of patellofemoral disorders.

Simulation of patella alta and the implications for in vitro patellar tracking in the ovine stifle joint

Patella alta is associated with adverse cartilage adaptations, patellofemoral pain, and instability. It is defined by a relatively long patellar tendon and patella positioned in a more proximal location within the patellar groove of the femur. This study used the ovine stifle joint model to investigate the effect of patellar tendon lengthening on the 3D passive kinematics of the patellofemoral and tibiofemoral joints. Eight patellar tendons were lengthened in 2 mm increments up to a maximum of 12 mm (20%) using a device placed in series with the transected patellar tendon. Three-dimensional kinematics were measured in the intact joint and at each increment of patellar tendon length (L(T)) during passively induced tibiofemoral flexion. Patellar flexion angle was linearly correlated with tibial flexion angle in the intact joint, and this correlation persisted after tendon lengthening (R = 0.897-0.965, p < 0.01). Patellofemoral kinematics expressed as a function of tibial flexion angle were significantly altered by L(T) increases >9%. In contrast, when patellofemoral kinematics were expressed as a function of patellar flexion angle they were not significantly altered by increases in L(T). Tibiofemoral kinematics were not affected by the L(T) increases. These results demonstrate that for a given tibial flexion angle, patellar tendon lengthening alters the patellar flexion angle. However, for a given patellar flexion angle, the orientation of the patella in the remaining five degrees of freedom is unchanged, implying a repeatable path of patellar motion.

A low-riding patella in posterior stabilised total knee replacements alters quadriceps' mechanical advantage, resulting in reduced knee flexion moments

Abnormal in vivo Total Knee Replacement (TKR) kinetics is influenced by a range of factors, particularly by changes to the knee's geometric parameters such as the patellar tendon moment arm (PTMA). In this study, ground reaction force (GRF) measurements were combined with simultaneous fluoroscopic image measurements to investigate the relationship between abnormal TKR kinetics and geometric parameters. Nine Scorpio Cruciate Retaining (CR) TKR (Stryker, Newbury, UK), nine Scorpio Posterior Stabilized (PS) TKR and seven normal subjects performed a step-up activity on a forceplate in view of a fluoroscope. The TKR subjects were part of a larger ongoing randomised controlled trial. The maximum external knee flexion moment was 22.0% lower in the Scorpio PS group compared to the Scorpio CR group. No significant differences in PTMA were found between the groups. The Scorpio PS had a low-riding patella, with a 30.7% reduction in patellar height compared to the Scorpio CR. This was probably due to using a thick tibial insert after PCL release in the PS, and led to an 8° increase in patellar flexion angle which altered the patellar mechanism and reduced quadriceps' mechanical advantage. Consequently, PS subjects stepped-up more cautiously with a reduced knee flexion moment.

Improved quadriceps' mechanical advantage in single radius TKRs is not due to an increased patellar tendon moment arm

Single femoral radius TKRs have been reported to improve quadriceps' mechanical advantage, leading to enhanced patient function. An increased patellar tendon moment arm (PTMA) has been cited as the main feature leading to improved quadriceps' mechanical advantage. However, these designs often incorporate a recessed trochlea which alters the patellar mechanism and may contribute to improved quadriceps' mechanical advantage. This study simultaneously measured the PTMA using two and three dimensional methods, as well as quadriceps forces (QF), patellofemoral kinematics and tibiofemoral kinematics in a motion analysis laboratory during an open chain leg extension activity. Six cadaveric knees were tested in the normal state and after implantation of three different single femoral radius TKR designs: cruciate retaining, posterior stabilised and rotating platform posterior stabilised (Stryker, Newbury, UK). QFs in the TKRs were between 15% and 20% lower than normal between 60° and 70° flexion. The increase in PTMA was insufficient to explain the reduced QF in the TKRs. The patellar flexion angle (PFA) of the TKRs was lower than normal at knee flexion angles greater than 50°, probably as a result of the recessed trochlea. A simple patellar model demonstrated that the reduced PFA may explain a large proportion of the reduction in QF after single radius TKR.

Dual Fluoroscopic Analysis of the Posterior Cruciate Ligament-Deficient Patellofemoral Joint during Lunge

To investigate the effect of posterior cruciate ligament (PCL) deficiency on the kinematics and the cartilage contact characteristics of the patellofemoral joint during an in vivo single-leg lunge. Ten patients with an isolated PCL injury in one knee and the contralateral side intact participated in the study. Magnetic resonance and dual fluoroscopic imaging techniques were used to analyze the patellofemoral kinematics and cartilage contact of the intact and the PCL-deficient knee during a quasi-static single-leg lunge from 0 degrees to 120 degrees of flexion. PCL deficiency significantly changed the patellofemoral kinematics between 90 degrees and 120 degrees of knee flexion (P < 0.007): an increased patellar flexion angle by 10.7 degrees on average and a decreased lateral shift (on average -1.9 mm), patellar tilt (approximately -2.7 degrees ), and valgus rotation (approximately -1.8 degrees ) were observed in the PCL-deficient knee compared with the intact contralateral joint. The changes in patellofemoral kinematics resulted in significant changes in patellofemoral cartilage contact (P < 0.007). PCL deficiency caused a distal (approximately -3.3 mm) and medial (approximately + 2.7 mm) shift of cartilage contact from 75 degrees to 120 degrees of flexion. The altered tibiofemoral kinematics that were previously described in PCL deficiency resulted in changes in patellofemoral joint function at flexion angles greater than 75 degrees. This abnormal loading of the patellofemoral joint might predispose the patellofemoral cartilage to degenerative changes. Because we did not detect differences in the patellofemoral joint behavior of the intact and the PCL-deficient knee between 0 degrees and 60 degrees of flexion, rehabilitation exercises might be safely performed in this range of flexion. On the other hand, repetitive deep knee squats should be avoided in PCL-deficient patients, so as not to excessively disturb the patellofemoral cartilage contact kinematics.

In-vitro measurement of the human knee joint motion during quadriceps leg raising

This paper represents a three-dimensional motion analysis of the human knee joint under given conditions of loading and constraint. As the knee is extended by a known force applied to the quadriceps tendon, relative displacements of the femur, tibia, and patella are measured using a video motion analysis system. The most prominent motion of the tibia is external rotation and anterior displacement relative to the femur during knee extension. The patellar flexion angle decreases from 70° to 0°. The moment arm of the knee extensor mechanism exhibits a characteristic bell shape which peaks somewhere in the 40°–60° region of flexion. In general, the quadriceps force results primarily from an increase in the torque exerted by the weight of the lower leg. In the range of 20°–60°, the quardricep force needed to extend the leg remains relatively constant. As the knee approaches full extension, the moment arm decreases due to the fact that the posterior capsule and the ACL begin to tighten in this region. Consequently, the quadriceps force increases rapidly.