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Skeletal Malalignment and Anterior Knee Pain: Rationale, Diagnosis, and Management

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Skeletal Malalignment and Anterior Knee Pain: Rationale, Diagnosis, and Management Ch11.qxd 10/07/05 7:20 PM Page 185 11 Skeletal Malalignment and Anterior Knee Pain: Rationale, Diagnosis, and Management Robert A. Teitge and Roger Torga-Spak Introduction Association of Skeletal Any variation from optimal skeletal alignment Malalignment and Patellofemoral may increase the vector forces acting on the patellofemoral joint causing either ligament fail- Joint Pathology ure with subsequent subluxation or cartilage Abnormal skeletal alignment of the lower failure as in chondromalacia or arthrosis or both extremity has been associated with various ligament and cartilage failure (Figure 11.1). patellofemoral syndromes and biomechanical Anterior knee pain may result from these abnor- abnormalities. Our understanding of these asso- mal forces or their consequences. ciations continues to develop as many refer- The mechanical disadvantage provided by a ences consider only one aspect of the analysis. skeleton with a geometrical or architectural flaw In the frontal plane, malalignment has been distributes abnormal stresses to both the liga- shown to influence the progression of patello- ments and the joints of the misaligned limb. femoral joint arthritis.4,12 Varus alignment Ligament overload and subsequently failure increases the likelihood of medial patello- (insufficiency) may occur with a single traumatic femoral osteoarthrosis progression while valgus episode as well as repetitive episodes of minor alignment increases the likelihood of lateral trauma or chronic overload. Skeletal malalign- patellofemoral osteoarthrosis progression. ment may cause chondromalacia patella and Fujikawa13 in a cadaveric study found a marked subsequently osteoarthritis by creating an alteration of patellar and femoral contact areas increased mechanical leverage on the with the introduction of increased varus align- patellofemoral joint that can exceed the load ment produced by a varus osteotomy. capacity of the articular cartilage. A reduction in Lerat et al.30 noted a statistically significant contact surface area such as a small patella or a correlation between increased femoral internal high patella or a subluxed patella may also torsion and both patellar chondropathy and increase the unit area loading beyond the load instability. Janssen23 also found patellar disloca- capacity of the articular cartilage, leading to car- tion was most commonly combined with tilage failure (osteoarthritis). increased medial torsion of the femur and spec- Anterior knee pain in association with bony ulated that this medial torsion was responsible malalignment may be the result of the abnormal for the development of dysplasia of the trochlea tension or compression placed on the capsule, and of the patella. Takai et al.41 measured ligaments, synovium, or subchondral bone. femoral and tibial torsion in patients with 185 Ch11.qxd 10/07/05 7:20 PM Page 186 186 Etiopathogenic Bases and Therapeutic Implications Skeletal Malalignment Increased Forces (Overload) Ligament Cartilage (Overloaded) (Overloaded) Subluxation Chondromalacia Dislocation Arthrosis PAIN Figure 11.1. Pathogenesis of anterior knee pain. patellofemoral medial and lateral unicompart- be emphasized that the Q-angle is a normal mental osteoarthrosis and noted that the corre- and necessary anatomic fact responsible for lation of patellofemoral osteoarthritis with balancing the tibiofemoral force transmission. increased femoral torsion (23° vs. 9° in controls) Hvid et al.19 demonstrated a significant rela- was statistically their most significant observa- tion between the Q-angle measurement and tion and suggested that excessive femoral tor- increased hip internal rotation, thus supporting sion is one of the contributory causes of the existence of a torsional malalignment syn- patellofemoral wear. drome of the patellofemoral joint. Insall20 called Turner43 studied the association of tibial tor- an increased Q-angle “patellar malalignment” sion and knee joint pathology and observed that and noted that it was usually associated with patients with patellofemoral instability had increased femoral anteversion and external tib- greater than normal external tibial torsion (25° ial torsion so that the motion of the knee vs. 19°). Eckhoff et al.11 found the tibia in the occurred about an axis that is rotated medially extended knee to be 6° more externally rotated compared with the axes of the hip and ankle than normal controls in a group of patients with joints, producing “squinting” patella. This type anterior knee pain. This was termed knee ver- of knee he stated is prone to chondromalacia sion. Whether this represents an abnormal (clinically “a diffuse aching pain on the antero- skeletal torsion or an abnormal rotation of the medial aspect of the knee”). It should be noted, tibia on the femur due to knee joint soft tissue however, that an increased Q-angle was present laxity or abnormal muscle pull is unknown. in only 40 of 83 (48%) knees in which surgical These studies and many others clearly show realignment for chondromalacia was per- the importance of abnormal skeletal alignment formed. Thus, the problem is not the value of of the lower extremity in the pathogenesis of the Q-angle; the problem is that the Q-angle various disorders of the patellofemoral joint. rotates around the coronal plane of the lower extremity. Q-Angle and Skeletal Malalignment Finally, it should be perhaps mentioned that The Q-angle has been implicated as a major Greene et al.15 showed the reliability of the Q-angle source of patellofemoral pathology, but it must measurement to be poor. Ch11.qxd 10/07/05 7:20 PM Page 187 Skeletal Malalignment and Anterior Knee Pain 187 Definitions: Patellofemoral (Table 11.2). In the frontal plane one can meas- ure varus or valgus and patellar height. In the Alignment sagittal plane one can measure the patellar There are two common uses for the term align- height, distance from the knee joint axis to the ment: (1) malposition of the patella on the patella, depth of the trochlea, and height of the femur, and (2) malposition of the knee joint tibial tubercle. In the horizontal plane one can between the body and the foot with the subse- measure the torsion of the acetabulum, femur, quent effect on the patellofemoral mechanics. tibia and foot, the version of the knee, the posi- While it is more common to consider the posi- tion of the tibial tubercle relative to the trochlear tion of the patella in the trochlea (i.e., subluxa- groove, and the depth of the groove as well as tion), this view inhibits the more important the “patellofemoral alignment.” consideration of what the position of the knee in space relative to the center of gravity of the body Diagnosis of Skeletal Alignment has in developing the force that the patello- Malalignment refers to a variation from the nor- femoral joint will experience. Tracking is the mal anatomy; normal is that which is biome- change in position of patella relative to the chanically optimal. In order to detect and femur during knee flexion and extension, and understand deformities of the lower extremity, while it is obviously important no clinically use- it is important to establish the limits and param- ful tracking measurement systems exist and the eters of normal alignment based on average val- loading characteristics of the patellofemoral ues for the general population. joint are largely unrelated to tracking. The relationship of the patella to the femur Frontal Plane Alignment (patellar malalignment) must be viewed in all Frontal plane alignment is best determined three planes (Table 11.1). In the coronal plane, using longstanding AP radiographs including one can measure Q-angle and patellar spin. In hip, knee, and ankle joint. To determine the the sagittal plane one can measure patellar flex- mechanical axis a line is drawn from the center ion and height; in the horizontal plane one can of the femoral head to the center of the ankle measure patellar tilt or shift. Lauren26 noted that joint (Figure 11.2). Typically, normal alignment shift and mini-tilt may both be manifestations of is defined as the mechanical axis passing just decreased lateral facet cartilage. medial to the center of the knee.34 Valgus align- It is a common mistake to consider alignment ment refers to the mechanical axis passing lat- as referring only to the position of the patella on eral to the center of the knee while varus refers the femoral trochlea. Alignment refers to the to the mechanical axis passing medial to the changing relationship of all the bones of the center of the knee. lower extremity and might best be considered as Two commonly measured angles are the the relationship of the patellofemoral joint to mechanical tibiofemoral angle (center of the body. Mechanical alignment is the sum total femoral head to center of knee to center of talus) of the bony architecture of the entire lower and the anatomical tibiofemoral angle (line extremity from sacrum (center of gravity) to the down center of femoral shaft and line down cen- foot (ground). The position and orientation of ter of tibial shaft). The mechanical tibiofemoral patellofemoral joint to the weight-bearing line angle is the angle between the mechanical axis of determines the direction and magnitude of the femur and the tibia. An angle of 1.2° ±2° is forces that will cross the patellofemoral joint. considered normal (i.e., the limb mechanical The relationship of the patellofemoral joint to axis falls just medial to the center of the knee the body must be defined in all three planes joint).6,7,18,34 The anatomical tibiofemoral
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