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Infrapatellar Fat Pad Syndrome : a Review of Anatomy, Function, Treatment and Dynamics

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Infrapatellar Fat Pad Syndrome : a Review of Anatomy, Function, Treatment and Dynamics Acta Orthop. Belg., 2016, 82, 94-101 ORIGINAL STUDY Infrapatellar fat pad syndrome : a review of anatomy, function, treatment and dynamics Mr James MACE, Prof Waqar BHATTI, Mr Sanjay ANAND From the Department of Trauma and Orthopaedics, Stepping Hill hospital NHS Foundation Trust, Cheshire, UK The infrapatellar (Hoffa’s) fatpad is an important small case series (3,14,15,17,19-21,26,29,35,38,39,43,46, structure within the knee, whose function and role 47). We present an overview of information pertain- are both poorly understood. This review explores the ing to the Infrapatellar fat pad and the role it may anatomy, neural innervation, vascularity, role in bio- play in pathology and pain around the knee. mechanics, pathology, imaging (stressing the impor- tance of dynamic ultrasound assessment) and treat- Anatomy ment of disorders presenting within this structure. Keywords : infrapatellar fatpad ; Hoffa’s fatpad ; ultra- The infrapatellar fat pad is one of three fat pads sound ; fatpad impingement. located in the anterior aspect of the knee (24). Its macroscopic, arthroscopic and radiographic ana- tomic boundaries are all well described (7,11,21,24,32, INTRODUCTION 37,43,49,50). Gallagher et al detail cadaveric anato- my, finding it to be a constant structure bounded In 1904, Albert Hoffa first attributed impinge- superiorly by the inferior pole of the patella, inferi- ment of the Infrapatellar fat pad to symptoms of orly by the anterior tibia, intermeniscal ligament, knee pain. He described inflammatory fibrous hy- meniscal horns and infrapatellar bursa, anteriorly by perplasia of the infrapatellar fat pad at excision, a the patellar tendon and posteriorly by the femoral procedure resulting in symptomatic relief in his se- ries of 21 patients (29). In the last 109 years there still remains an apparent paucity of understanding in the role of the Infrapatellar fat pad in health and n Mr James Mace. n Mr. Sanjay Anand. disease (10,11,21,24). Hoffa disease has been defined Department of Trauma and Orthopaedics, Stepping Hill as, “an impingement of the hypertrophic fat pad be- hospital NHS Foundation Trust, Poplar Grove, Hazel tween the articular surfaces of the knee (femeropa- Grove, Stockport, Cheshire, UK. tellar and femerotibial)” it has also been differenti- n Prof. Waqar Bhatti. ated from Hoffa syndrome, the former being fat fad Department of Radiology, University Hospital of South oedema and fibrosis in a normal joint, with the latter Manchester, Southmoor road, Wythenshawe, Manchester, M23 9LT, UK. occurring in conjunction with concomitant pathol- Correspondence : Mr James Mace, 27 Vaudrey Drive, ogy (43). Reviewing current literature yields at best Cheadle Hulme, Cheadle Cheshire SK8 5LR, UK. subjective clinical observations and somewhat E-mail : [email protected] © 2016, Acta Orthopædica Belgica. Conflicts of interests : Mr S. Anand holds an educational Acta Orthopædica Belgica, Vol. 82 - 1 - 2016 contract with Smith and Nephew. mace-.indd 94 10/03/16 11:22 INFRAPATELLAR FAT PAD SYNDROME 95 condyles and intercondylar notch. Its attachments cular supply to surrounding structures. Hughes et al are not only to the intercondylar notch via the liga- demonstrated a reduction in patellar blood flow of mentum mucosum, but also into the anterior horns 10% following resection of the inftapatellar fat of the menisci, the proximal end of the patella ten- pad (31). Nicholls et al did not resect the fat pad in don and the inferior pole of the patella (24). Lying their study, believing it to be an important contribu- intra-articular but extra synovial and occupying the tor to vascularity of the patellar tendon (45), they whole anterior part of the knee joint in all joint posi- found no significant difference in decline in flow to tions (10) it consists of a central body with medial the patellar from a medial or lateral arthrotomy, and lateral extensions, along with a superior tag, the supporting the notion of a rich functional anastamo- latter of which is not always an anatomical con- sis. Hempfing et al found an increase in patellar stant (24). There are 2 clefts identified macroscopi- blood flow after excision of the fatpad, with the cally and, especially in the presence of an effusion, knee in extension (27), they postulated the excision via MR imaging ; one vertical cleft in the superior of the fatpad decompressed the patellar in extension aspect of the fat pad and horizontal cleft in the allowing for an increased blood flow. The varying postroinferior aspect of the fat pad (1,12,24,32,50,53). techniques and differing equipment used through- During knee trauma the fatpad may fragment mim- out these 3 studies makes direct comparisons im- icking loose bodies on MRI imaging, or hide true possible, but do suggest the infrapatellar fatpad loose bodies within its clefts at arthroscopy (2). makes some contribution to patellar blood flow. Vascularity Neural innervation For a structure to share morphological similari- The nerve supply to the knee has been histori- ties with subcutaneous fat (50), yet only be metabo- cally well documented firstly by Garder and latterly lised in severe malnutrition, and not expand with Kennedy et al (25,34), with the knee taking innerva- increasing BMI (16,24,29,50), implies a degree of bio- tions from the femoral, obturator and sciatic nerves. logical significance (10). It possesses an abundant The predominant nerve supply to the fatpad is the peripheral anastamotic blood supply, the suprome- posterior tibial nerve (34), which provides the ma- dial and suprolateral geniculate arteries provide 2 jority of fibres to the popliteal plexus ; fibres course vertical arteries and are linked horizontally with 2-3 from this innervating the posterior capsule, cruci- arteries running distally (37). In addition, there are ates and anteriorly up to the fatpad. rich local anastamotic links to the menisci anterior- A superfluity of Type VIa free nerve endings has ly, the tibial periostium inferiroly and to the patellar been identified within the fatpad (6,10,24,50) ; these tendon anteriorly. Anatomic studies by Pang et Type VIa free nerve endings can be activated by al (48) revealed a large, mostly transversely orien- mechanical deformation or specific immunoreac- tated, contribution of vessels to the posterior aspect tive chemical agents. They initiate afferent signals and central third of the patellar tendon. The central of pain, pressure and thermal changes to the central area is relatively avascular (37), having connotations nervous system and are active via both fast sharp for central arthroscopy portals and in the harvest of pain pathways and slow chronic pain pathways (6). the fatpad for reconstructive measures. Dye et al (22) describe the conscious neuorsensory Three in vivo studies using Laser Doppler Flow- perception of pain on arthroscopically probing metry (LDF) have sought to monitor blood flow to structures of the knee without anaesthetic ; finding the patellar during surgical approach for total knee the infrapatellar fat pad capable of triggering both arthroplasty. Although recently no significant cor- severe and localising pain. relation between LDF and post operative anterior Substance-P has been implicated in the genesis of knee pain has been found (36), these studies still re- both pain and the induction of a pro-inflammatory veal useful information pertaining to the shared vas- response ; several authors have found substance-P cular supply of the infrapatellar fat pad in clinical nerve fibres in abundance within the fat pad (9,40,55). practice and the contribution of the anastamotic vas- Furthermore in patients experiencing anterior knee Acta Orthopædica Belgica, Vol. 82 - 1 - 2016 mace-.indd 95 10/03/16 11:22 96 J. MACE, W. BHATTI, S. ANAND pain the number of substance –P nerve fibres within flatable fluid cell implanted within the fat pad. An the fatpad increases significantly (40,54). The pres- increase in simulated oedema again decreased patel- ence and number of nociceptive afferent immunore- lofemoral contact area and pressure, whilst increas- active nerve fibres and ability to release pro-inflam- ing measured pressure within the fatpad. However, matory cytokines has led to some question of the fat although these cadaveric studies confer a role of the pad being a potential causative structure in patellar fatpad in biomechanics of the knee, they may not tendinopathy (6,16). There are suggestions it per- represent true in vivo findings. forms a modulatory role in the inflammatory path- Two studies have sought to link the presence of ways active in osteoarthritis (13) and in an in vitro oedema within the fat pad to patellofemoral mal- bovine cartilage model the infrapatellar fat pad tis- tracking (33,52), both support the view that oedema sue has been demonstrated to reduce catabolic me- within the suprolateral portion of the infrapatellar diators (3). fat pad is linked with radiological features sugges- tive of patella maltracking, especially an increase in The role of infrapatellar fat pad in biomechanics the prevalence of patella alta, the exact cause of this remains unclear. In 1950 MacConail surmised the role of fat pads in joints is in occupying anatomical dead space to Diagnosis (inc. prevalence) of fat pad pathology allow synovial fluid to both circulate around a joint and provide efficient lubrication (41), the rich neuro- The diagnosis of infrapatellar fat pad impinge- vascular supply of the infrapatellar fatpad suggests ment is often considered a rare diagnosis of exclu- this may
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