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Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purposes of this study are to, firstly, develop techniques to accurately identify extensor mechanism malalignment by measuring the alignment of the quadriceps tendon (QTA) with computerized tomography (CT) scans. Secondly, to investigate correlations between QTA and lower limb bony anatomical variations within a representative normal population. Lastly, to evaluate the clinical significance of QTA by establishing its potential connection with lateral facet patellofemoral joint osteoarthritis (LFPFJOA).

Method

CT scans were orientated to a mechanical axis reference frame and three techniques developed to measure the alignment of the quadriceps tendon. Multiple measurement of bony alignment from the hip to the ankle were performed on each scan. A series of 110 cadaveric CT scans were measured to determine normal values, reproducibility, and correlations with bony anatomy. Secondly, a comparison between 2 groups of 25 patients, 1 group with LFPFJOA and 1 group with isolated medial OA and no LFPFJOA.

Results

From the cadaveric study, it was determined that the alignment of the quadriceps tendon is on average 4.3° (SD 3.9) varus and the apex of the tendon is 9.1 mm (SD 7.7 mm) lateral to the trochlear groove and externally rotated 1.9° (SD 12.4°) from the centre of the femoral shaft. There was no association between the quadriceps tendon alignment and any other bony measurements including tibial tubercle trochlear groove distance (TTTG), coronal alignment, trochlear groove alignment and femoral neck anteversion. A lateralized QTA was significantly associated with LFPFJOA. QTA in the LFPFJOA group was 9.6° varus (SD 2.8°), 21.3 mm (SD 6.6) lateralised and 17.3° ER (SD 11°) compared to 5.5° (SD 2.3°), 10.7 mm (SD 4.9) and 3.3° (SD 7.2°), respectively, in the control group (p < 0.001). A significant association with LFPFJOA was also found for TTTG (17.2 mm (SD 5.7) vs 12.1 mm (SD 4.3), p < 0.01). Logistic regression analysis confirmed the QTA as having the stronger association with LFPFJOA than TTTG (AUC 0.87 to 0.92 for QTA vs 0.79 for TTTG).

Conclusion

These studies have confirmed the ability to accurately determine QTA on CT scans. The normal values indicate that the QTA is highly variable and unrelated to bony anatomy. The comparative study has determined that QTA is clinically relevant and a lateralised QTA is the dominant predictor of severe LFPFJOA. This deformity should be considered when assessing patella maltracking associated with patella osteoarthritis, patella instability and arthroplasty.

Level of evidence

III (retrospective cohort study).

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Western Health, 160 Gordon Street, Footscray, 3011, Australia

    Simon Talbot, Kyle Bennett, Francesca Sasanelli & Andrew Griffith

  2. Medicine, Dentistry and Health Sciences, University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia

    Rachel Zordan

  3. St Vincent’s Hospital, Melbourne, Education and Learning, Victoria Parade, Fitzroy, VIC, 3065, Australia

    Rachel Zordan

  4. Victorian Institute of Forensic Medicine, 65 Kavanagh St, Southbank, 3006, Australia

    Noel Woodford

  5. Department of Forensic Medicine, Monash University, Melbourne, Australia

    Noel Woodford

  6. Department of Orthopaedics and Traumatic Surgery, The University of Sydney, Sydney, Australia

    William L. Walter

  7. Northern Local Area Health District (Royal North Shore Hospital), Sydney, Australia

    William L. Walter

  8. 1/210 Burgundy St, Heidelberg, 3084, Australia

    Simon Talbot

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Contributions

ST designed the study, collected data and wrote the manuscript. RZ analysed data and wrote the manuscript. KB collected data and wrote the manuscript. FS collected data and wrote the manuscript. AG collected data and wrote the manuscript. NW designed the study and wrote the manuscript. BW designed the study and wrote the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Simon Talbot.

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Ethical approval

Ethics approval was sought and gained from the Victorian Institute of Forensic Medicine (VIFM) (EC10-2019) and by St Vincent’s Health Network (HREC/18/SVH/250).

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Informed consent was obtained from all participants in in the cohort study.

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Talbot, S., Zordan, R., Bennett, K. et al. Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis. Knee Surg Sports Traumatol Arthrosc 31, 5950–5961 (2023). https://doi.org/10.1007/s00167-023-07661-z

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  • DOI: https://doi.org/10.1007/s00167-023-07661-z

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