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The complexity of bony malalignment in patellofemoral disorders: femoral and tibial torsion, trochlear dysplasia, TT–TG distance, and frontal mechanical axis correlate with each other

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

A Correction to this article was published on 21 June 2019

This article has been updated

Abstract

Purpose

Several anatomic risk factors associated with patellofemoral disorders have been described. The purpose of this study was to analyze the relationship between bony parameters commonly used to analyze and define patellofemoral malalignment.

Methods

Patients with patellofemoral disorders presenting between 2016 and 2018 who underwent a standardized radiographic workup including conventional radiographs, weight bearing full-leg radiographs, magnetic resonance imaging (MRI) of the knee, and torsional analysis using hip–knee–ankle MRI were initially included. Patients with a history of lower extremity fracture and a history of surgical procedures affecting bony alignment or partial/total arthroplasty were subsequently excluded. Radiographs and MRI of all included patients were analyzed by four independent observers. Parameters of interest were: femoral torsion, tibial torsion, trochlear dysplasia, tibial tuberosity–trochlear groove (TT–TG) distance, and frontal mechanical axis. All parameters were compared between patients with low grade and high grade trochlear dysplasia as well as between female and male patients. Correlation of continuous variables was assessed with the Pearson correlation coefficient. A binary logistic regression model was used for the calculation of odds ratio between different parameters. Interclass correlation coefficients (ICC) were calculated to determine the interobserver reproducibility.

Results

A total of 151 patients could be included for detailed analysis. Group comparison revealed that patients with high grade trochlear dysplasia showed significantly higher values for femoral torsion (low grade: 9.8° ± 11.0°, high grade: 16.8° ± 11.5°; p < 0.001) and significantly higher values for TT–TG distance (low grade: 19.0 mm ± 5.0 mm, high grade: 21.9 mm ± 5.4 mm; p = 0.002). No significant difference was found for age, tibial torsion, and frontal mechanical axis. With regard to gender, female patients had higher values for femoral torsion (female: 15.6° ± 11.3°, male: 11.0° ± 12.7°; p = 0.044). The correlation analysis found significant correlation between femoral torsion and tibial torsion (r = 0.244, p = 0.003), femoral torsion and TT–TG distance (r = 0.328, p < 0.001), femoral torsion and frontal mechanical axis (r = 0.291, p < 0.001), and tibial torsion and TT–TG distance (r = 0.182, p = 0.026).

Conclusion

Bony malalignment in patients with patellofemoral disorder is a complex problem given the significant correlation between femoral and tibial torsion, trochlear dysplasia, TT–TG distance, and frontal mechanical axis. Advanced imaging to analyze rotational and frontal plane alignment is recommended in patients with trochlear dysplasia and/or increased TT–TG on standard radiographs and knee MRI. Understanding of the bony pathology in patellofemoral disorders is key to improve the therapeutic and surgical decision.

Level of evidence

III, retrospective cohort study.

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Change history

  • 21 June 2019

    The original article can be found online.

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Acknowledgements

Bernhard Haller (Technical University of Munich) for statistical analysis support.

Funding

There was no financial conflict of interest with regards to this study.

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Authors and Affiliations

  1. Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany

    Florian B. Imhoff, Victor Funke, Lukas N. Muench, Andreas B. Imhoff & Matthias J. Feucht

  2. Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaningerstr 22, Munich, 81675, Germany

    Andreas Sauter, Maximilian Englmaier & Klaus Woertler

Authors
  1. Florian B. Imhoff
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  2. Victor Funke
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  3. Lukas N. Muench
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  4. Andreas Sauter
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  5. Maximilian Englmaier
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  6. Klaus Woertler
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  7. Andreas B. Imhoff
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  8. Matthias J. Feucht
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Contributions

FI had the initial study idea, defined study setup and methods, and made substantial contribution to the manuscript. VF served as an investigator and made substantial contribution to the manuscript. ML served as an investigator and internal reviewer of the manuscript. AS is a special trained musculoskeletal radiologist and made substantial contribution to the study setup and served as an investigator. ME was an investigator of the radiological measurements and served as an internal reviewer with contribution to the manuscript. KW was responsible for radiologic parameters obtained retrospectively and made substantial contribution to the methods and served as an internal reviewer of the manuscript. AI made substantial contribution to the study setup and methods section and served as an internal reviewer of the manuscript. MF accomplished the statistics, contributed to the methods and the manuscript.

Corresponding author

Correspondence to Andreas B. Imhoff.

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Conflict of interest

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

Informed consent

Informed consent was obtained at the time of clinical and radiological assessment from all individual participants included in this retrospective study.

Ethical approval

Ethical approval was obtained from the Ethics Committee of the Technical University of Munich (398/18 S).

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The original version of this article was revised: The given\family names of authors were incorrectly published in original publication.

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Imhoff, F.B., Funke, V., Muench, L.N. et al. The complexity of bony malalignment in patellofemoral disorders: femoral and tibial torsion, trochlear dysplasia, TT–TG distance, and frontal mechanical axis correlate with each other. Knee Surg Sports Traumatol Arthrosc 28, 897–904 (2020). https://doi.org/10.1007/s00167-019-05542-y

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