Professional Documents
Culture Documents
Radiology
allowing
niscus.
Its value
chondromalacia
INDEX
TERMS:
4[5].125)
137:57-61,
HE patellofemoral
lenge
suspected
Knee, injuries
(Knee, arthrography,
(PF)
radiography
4[5].122)
October
joint
of numerous
is also discussed,
pateliar
subluxation.
#{149}
Knee,
#{149}
RadIology
differentiation
in arthrography
and recurrent
of the patellofemoral
(PF)
joint, axial
radiographs
obtained,
with positive
studies in 19. The examinaof the Ficat views are discussed.
in selected
patients,
information
not obtainable
by other methods
about the
PF articulation,
Views1
900
H. Newberg,
In 70 patients evaluated
for abnormality
at 300, 600, and 9O (Ficat views) were
tion technique
the examination
600, and
#{149}
Semilunar
patellar
abnormalities
as well
as its usefulness
cartilages
#{149}
(Knee,
special
non-routine
projection,
1980
continues
to be a chal-
for orthopedists
and radiologists.
Patients with
meniscal
lesions may be referred for knee ar-
thrography
when
the patella
and parapatellar
the source
of their
area.
symptoms
is actually
Various
radiographic
techniques
for evaluating
the PF joint have been described,
each with full support and documentation
by the authors
and each with its own limitations
(1-3).
Dynamic
radiography with axial projections
at 30#{176},
60#{176}
and 90#{176}
(Ficat
ANATOMY
inthe
the
femoral
sulcus
are
important
in determining
the
retinaculum.
while the cassette
is held on the distal portion
of the patients thighs, perpendicular
to the beam. With progressive
knee flexion,
the tube must remain
perpendicular
to the
TECHNIQUE
The Ficat
sitting
patella
on a chair
a lead apron
tabletop,
control
views
atop
are obtained
the radiographic
should
with
table,
the patient
PF joint.
shielded
moved
more proximally
on the thigh. The patient
should
try to relax the quadriceps;
tightening
of the extensor
mechanism
can cause a subluxing
patella
to assume
a
normal
position
in the femoral
intercondylar
sulcus (1).
be parallel
by
to the
of Vermont,
Burlington,
of Radiology
VT. Received
On the 30#{176}
view,
the cassette
may need to be
The technique
is more difficult
in very obese patients
and those with a prominent
tibial tubercie.
The 30#{176}
view
may be impossible
to obtain,
and thus the nearest
angle
(D.S.), University
Jan. 9, 1980.
57
of Vermont
College
of Medicine,
Medical
Center
Hospital
jr
58
ARTHUR
H. NEWBERG
AND DAVID
October
SELIGSON
1980
2a
4j
Fig. 2.
should
pression
the PF
difficult
perfectly
patella
beam.
proper
gential
The
Normal
Ficat views
at (a) 30#{176},
(b) 60#{176},
and
be achieved.
It would be incorrect
to give the imthat it is easy to obtain diagnostic
Ficat views of
joint. Some trial and error is inevitable.
It may be
initially
for the technologist
to center
the beam
tangential
to the patella borders.
Palpation
of the
may help determine
the optimum
inclination
of the
The exact angle of flexion
is not as important
as
positioning
in order to obtain the central
ray tanto the patella.
radiographs
are viewed
in the same direction
that
Interpretation
includes
comparison
of both PF joints, functional
relationships,
and
subchondral
bone density.
In addition,
various
quantitative
measurements
can be made from the radiographs.
In the
normal
individual
(Fig. 2), the patella
is well seated
in the
sulcus of the femur in the 30#{176}
projection.
This view is most
likely to show any tendency
toward
subluxation.
The 60#{176}
view
shows
the morphology
of the patella
(C)
90#{176}.
demonstrating
the central
centered
when the apex
vertical
over the sulcus.
contact
of the
CLINICAL
EVALUATION
Patients
were initially
evaluated
by a staff orthopaedist.
If there was suspicion
of PF joint disease
or equivocal
findings
of internal
derangement
of the knee, routine
radiographs
of the knee plus the axial patella
views at 30#{176},
60#{176},
and 90#{176}
were obtained.
All radiographs
were obtained
by the same technologist.
Seventy
patients
were evaluated, including
38 males and 32 females.
The age range
was
13-81
years,
age being
28 years;
however,
30 patients
were younger
than 20 years.
The
initial clinical
presentation
or diagnosis
in the 70 patients
was: chondromalacia
(1 2 patients),
knee
(1 7 patients),
pain
(1 7 patients),
subluxation-dislocation
trauma
(1 1 patients),
THE PATELLOFEMORAL
Vol. 137
JOINT
59
Diagnostic
Radiology
R6o#{176}
Fig. 3a and b.
arising
osteoarthritis
The 60#{176}
view demonstrates
(4 patients),
patellar
lateral subluxation
of the left patella (b). There is an osteochondral
fragment
facet (b, open arrow) and a fragment adjacent to the lateral femoral condyle (b, closed arrow).
prior
tibial
tubercle
to patellar subluxation.
transplant
(3 patients),
osteochondritis
dissecans
(2 patients), loose
body (2 patients),
torn meniscus
(1 patient), and a normal
knee examination
(1 patient [control]).
RESULTS
Initially,
the Ficat views
added
mation,
due to technical
difficulties.
Fig. 4.
(a) 60#{176}
and (b) 90#{176}
views. Abnormal
lateral patellofemoral
contact
90#{176}
there is less contact, which may explain why some patients with advanced
flexed.
little
diagnostic
inforHowever,
after the
is demonstrated
in osteoarthritis.
Note that at
degenerative
disease prefer to keep their knee
60
ARTHUR
H. NEWBERG
AND DAVID
SELIGSON
October
1980
5a
5b
Fig. 5. Positive
or Hughston views
technique
was
mastered,
they
were
useful.
The study
was
abnormal
in 19/70 patients.
in six, there was evidence
of
prior dislocation
with osteochondral
fragments
(Fig. 3).
Four patients
showed
patellar
subluxation,
three
posttraumatic
changes,
two excessive
lateral pressure
(ELPS),
and four advanced
PF arthritis
(Fig. 4).
Seven of the 70 patients
underwent
knee arthrography,
and two of these had a torn meniscus.
One of the seven
patients
had a positive
Ficat study demonstrating
patellar
subluxation
which had not been suspected
clinically
(Fig.
5).
DISCUSSION
skyline
not helpful
in studying
patellar
disorders,
especially
chondromalacia.
At our institution,
the Hughston
view (2)
of both knees
is routine
for evaluating
the PF joint. The
popular
skyline
view obtained
with the knee in marked
flexion
is of no value in studying
PF joint,
because
it draws
as well as cause
the functional
the patelia
condylar
sulcus.
Disorders
of the PF joint
cause
can
locking,
deep
the knee
pain, clicking,
state of the
into the interto give way,
line, mimicking
especially
The radiologic
evaluation
of the PF joint has been the
subject
of numerous
publications,
predominantly
by orthopedists
(1 -8). These authors
have described
different
techniques,
depending
upon their views on the etiology
of
PF disorders.
Arthrography,
according
to most experts,
is
at 60#{176}
(b). Routine
common
internal
derangement
(5). Subluxation
of the knee,
of the patella
and frequently
missed cause
has shown that in patellar
subluxation
of the
condyles
height
the
morphology
may be altered
of the lateral
patella
and
femoral
femoral
condyle
acts
as a buttress
the
to
Diagnostic
THE PATELLOFEMORAL
Vol. 137
lateral pressure
syndrome
narrowing
(arrowhead)
spontaneously
after
dislocation,
Syndrome
entity
of the patella
as viewed
pateliar
subluxation
result in osteoarthritis
show narrowing
increase
(ELPS)
(4). This
characterized
by knee
is a clinical-radio-
pain
and lateral
on axial images,
of the lateral
bone
but without
and dynamics
of the
of the PF joint.
2.
3.
4.
5.
6.
7.
lateral
may be an
lateral
facet
1.
tilting
in subchondral
REFERENCES
be unaware
that a dislocation
even occurred
(2).
to Hughston,
the
orthopaedist
who has not
a recurrent
subluxation
of the patella
for a torn
has had a limited and fortunate
experience
with
knees and meniscectomies
(2).
Ficat has evolved
the concept
of the Excessive
Lateral
logical
It is known
8.
9.
10.
1 1.
that
the patelia
may contain
fairly severe
cartilaginous
changes
which do not give rise to demonstrable
bony changes on
12.
the radiographs
most
common
chondromalacia
13.
be helpful
(13). Since
subluxation
and most
frequently
(5), the dynamic
views
in diagnosing
ACKNOWLEDGMENT:
and technical
assistance.
Radiology
(ELPS).
tient may
According
mistaken
meniscus
Pressure
61
lateral
migration
of the patella
(7). Clinical
diagnosis
of
subluxation
is entirely
compatible
with a normal
radiographic
appearance,
and many normal menisci
have been
unnecessarily
removed
as a result of patellar
subluxation
and the associated
locking
of the
knee secondary
to
hamstring
spasm
(5). The McMurray
test may be falsely
positive
in these patients.
It has been shown that the patella
may reduce
JOINT
this problem
We thank Carol
is probably
the
missed
cause
of
of the PF joint can
in selected
Holcomb,
Jan 1978
Ficat AP, Hungerford DS:
cases.
Joint.
Baltimore,
Williams
and Wilkins,
1977, pp 22-50,
85-100,
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RE, Dunlop JA:
The problem
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1941
Stoug&rd J: Chondromalacia
of the patella. Incidence,
macroscopical
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Nov 1975
Department
of Radiology
Medical Center Hospital
Burlington,
VT 05401
of Vermont