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Dynamic Q-angle is increased in patients with chronic patellofemoral instability and correlates positively with femoral torsion

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of the study was to evaluate the frontal gait patterns in patients with chronic patellofemoral instability compared to healthy controls. The hypothesis was that internal-rotation–adduction moment of the knee as altered dynamic Q-angle is evident in patients and correlates positively with increased femoral torsion.

Methods

Thirty-five patients with symptomatic recurrent patellofemoral instability requiring surgical treatment were matched for average age, sex, and body mass index with 15 healthy controls (30 knees). Several clinical and radiographic measurements were taken from each participant: internal and external rotation (hipIR, hipER), Q-angle, tubercle sulcus angle (TS-angle), femoral antetorsion (femAT), tibial tubercle–trochlear groove (TT-TG) distance, and frontal leg axis. Additionally, three frontal gait patterns were defined and recorded: (1) internal-rotation–adduction moment of the knee during normal walking, (2) dynamic valgus of the knee, and (3) Trendelenburg’s sign in a single-leg squat. Randomized videography was evaluated by three independent blinded observers. Statistical analysis was performed using regression models and comparisons of gait patterns and clinical and radiological measurements. Furthermore, observer reliability was correlated to gradings of radiological parameters.

Results

Patients showed altered dynamic Q-angle gait pattern during normal walking (p < 0.001) compared to healthy controls (interrater kappa = 0.61), whereas highest observer agreement was reported if femAT was greater than 20° (kappa = 0.85). Logistic regression model revealed higher femAT (18.2° ± 12.5 versus 11.9° ± 7.0 (p = 0.004) as a significant variable, as well as lower TT–TG distance (23.6 mm ± 2.8 vs. 16.6 mm ± 4.9, p = 0.004) on evident dynamic Q-angle gait pattern. Dynamic valgus in a single-leg squat was observed significantly more often in patients (p < 0.001) compared to controls (interrater kappa = 0.7). However, besides the static measured Q-angle as the only significant variable on evident dynamic valgus pattern (13.6° ± 4.6 vs. 10.3° ± 5.2, p = 0.003), no radiological parameter was detected to correlate significantly with dynamic valgus and Trendelenburg's sign (n.s.).

Conclusions

Clinical detection of pathologic torsion and bony alignment may be difficult in patients with patellofemoral instability. The present study demonstrated that dynamic Q-angle gait pattern is significantly altered in patients with chronic patellofemoral instability compared to healthy controls. Moreover, dynamic Q-angle correlates positively with higher femoral torsion and negatively with higher TT–TG distance. Therefore, clinical and radiological assessment of maltorsion should be added to the standard diagnostic workup in cases of patellofemoral instability.

Level of evidence

Level II.

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Available from first author if asked.

References

  1. Brattström H (1964) Shape of the intercondylar groove normally and in recurrent dislocation of patella: a clinical and X-Ray anatomical investigation. Acta Orthop Scand 35:1–148

    Article  Google Scholar 

  2. Bruderer-Hofstetter M, Fenner V, Payne E, Zdenek K, Klima H, Wegener R (2015) Gait deviations and compensations in pediatric patients with increased femoral torsion. J Orthop Res 33:155–162

    Article  Google Scholar 

  3. Claiborne TL, Armstrong CW, Gandhi V, Pincivero DM (2006) Relationship between hip and knee strength and knee valgus during a single leg squat. J Appl Biomech 22:41–50

    Article  Google Scholar 

  4. Dickschas J, Harrer J, Pfefferkorn R, Strecker W (2012) Operative treatment of patellofemoral maltracking with torsional osteotomy. Arch Orthop Trauma Surg 132:289–298

    Article  Google Scholar 

  5. Diederichs G, Kohlitz T, Kornaropoulos E, Heller MO, Vollnberg B, Scheffler S (2013) Magnetic resonance imaging analysis of rotational alignment in patients with patellar dislocations. Am J Sports Med 41:51–57

    Article  Google Scholar 

  6. Feller JA, Amis AA, Andrish JT, Arendt EA, Erasmus PJ, Powers CM (2007) Surgical biomechanics of the patellofemoral joint. Arthroscopy 23:542–553

    Article  Google Scholar 

  7. Franciozi CE, Ambra LF, Albertoni LJ, Debieux P, Rezende FC, Oliveira MA et al (2017) Increased femoral anteversion influence over surgically treated recurrent patellar instability patients. Arthroscopy 33:633–640

    Article  Google Scholar 

  8. Graf KH, Tompkins MA, Agel J, Arendt EA (2018) Q-vector measurements: physical examination versus magnetic resonance imaging measurements and their relationship with tibial tubercle-trochlear groove distance. Knee Surg Sports Traumatol Arthrosc 26:697–704

    Article  Google Scholar 

  9. Greene CC, Edwards TB, Wade MR, Carson EW (2001) Reliability of the quadriceps angle measurement. Am J Knee Surg 14:97–103

    CAS  PubMed  Google Scholar 

  10. Gwynne CR, Curran SA (2018) Two-dimensional frontal plane projection angle can identify subgroups of patellofemoral pain patients who demonstrate dynamic knee valgus. Clin Biomech (Bristol, Avon) 58:44–48

    Article  Google Scholar 

  11. Hinman RS, May RL, Crossley KM (2006) Is there an alternative to the full-leg radiograph for determining knee joint alignment in osteoarthritis? Arthritis Rheum 55:306–313

    Article  Google Scholar 

  12. Imhoff FB, Cotic M, Liska F, Dyrna FGE, Beitzel K, Imhoff AB et al (2019) Derotational osteotomy at the distal femur is effective to treat patients with patellar instability. Knee Surg Sports Traumatol Arthrosc 27:652–658

    Article  Google Scholar 

  13. Imhoff FB, Funke V, Muench LN, Sauter A, Englmaier M, Woertler K et al (2020) 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(3):897–904

    Article  Google Scholar 

  14. Irger M, Achtnich A, Imhoff AB, Schmitt A (2020) Diagnosis and therapy of chronic patellofemoral instability. Orthopade 49:73–84

    Article  CAS  Google Scholar 

  15. Kaiser P, Schmoelz W, Schoettle P, Zwierzina M, Heinrichs C, Attal R (2017) Increased internal femoral torsion can be regarded as a risk factor for patellar instability—A biomechanical study. Clin Biomech (Bristol, Avon) 47:103–109

    Article  Google Scholar 

  16. Kibler WB, Press J, Sciascia A (2006) The role of core stability in athletic function. Sports Med 36:189–198

    Article  Google Scholar 

  17. Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S (1990) Lateral release of the patella: indications and contraindications. Am J Sports Med 18:359–365

    Article  CAS  Google Scholar 

  18. Liebensteiner MC, Ressler J, Seitlinger G, Djurdjevic T, El Attal R, Ferlic PW (2016) High femoral anteversion is related to femoral trochlea dysplasia. Arthroscopy 32:2295–2299

    Article  Google Scholar 

  19. Livingston LA (2002) The accuracy of Q angle values. Clin Biomech (Bristol, Avon) 17:322–323 (author reply 323-324)

    Article  Google Scholar 

  20. Nelitz M, Dreyhaupt J, Williams SR, Dornacher D (2015) Combined supracondylar femoral derotation osteotomy and patellofemoral ligament reconstruction for recurrent patellar dislocation and severe femoral anteversion syndrome: surgical technique and clinical outcome. Int Orthop 39:2355–2362

    Article  Google Scholar 

  21. Paulos L, Swanson SC, Stoddard GJ, Barber-Westin S (2009) Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med 37:1288–1300

    Article  Google Scholar 

  22. Post WR, Teitge R, Amis A (2002) Patellofemoral malalignment: looking beyond the viewbox. Clin Sports Med 21:521–546

    Article  Google Scholar 

  23. Powers CM (2003) The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther 33:639–646

    Article  Google Scholar 

  24. Radler C, Kranzl A, Manner HM, Hoglinger M, Ganger R, Grill F (2010) Torsional profile versus gait analysis: consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity. Gait Posture 32:405–410

    Article  Google Scholar 

  25. Schmidt E, Harris-Hayes M, Salsich GB (2019) Dynamic knee valgus kinematics and their relationship to pain in women with patellofemoral pain compared to women with chronic hip joint pain. J Sport Health Sci 8:486–493

    Article  Google Scholar 

  26. Schneider B, Laubenberger J, Jemlich S, Groene K, Weber HM, Langer M (1997) Measurement of femoral antetorsion and tibial torsion by magnetic resonance imaging. Br J Radiol 70:575–579

    Article  CAS  Google Scholar 

  27. Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J (2006) The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee 13:26–31

    Article  Google Scholar 

  28. Seitlinger G, Moroder P, Scheurecker G, Hofmann S, Grelsamer RP (2016) The contribution of different femur segments to overall femoral torsion. Am J Sports Med 44:1796–1800

    Article  Google Scholar 

  29. Smith TO, Hunt NJ, Donell ST (2008) The reliability and validity of the Q-angle: a systematic review. Knee Surg Sports Traumatol Arthrosc 16:1068–1079

    Article  Google Scholar 

  30. Staheli LT, Corbett M, Wyss C, King H (1985) Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am 67:39–47

    Article  CAS  Google Scholar 

  31. Strecker W (2006) Planning analysis of knee-adjacent deformities. I. Frontal plane deformities. Oper Orthop Traumatol 18:259–272

    Article  Google Scholar 

  32. Wallace DA, Salem GJ, Salinas R, Powers CM (2002) Patellofemoral joint kinetics while squatting with and without an external load. J Orthop Sports Phys Ther 32:141–148

    Article  Google Scholar 

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Funding

Grant (FG-PRJ-418) from Deutsche Arthrose-Hilfe, 2018.

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Authors and Affiliations

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

    Florian B. Imhoff, Matthias Cotic, Felix G. E. Dyrna, Theresa Diermeier, Andrea Achtnich, Andreas B. Imhoff & Knut Beitzel

  2. Department of Orthopedics, Balgrist Hospital, University of Zurich, Zurich, Switzerland

    Florian B. Imhoff

  3. Department of Trauma, Hand and Reconstructive, Surgery University Hospital, Münster, Germany

    Felix G. E. Dyrna

  4. Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA

    Mark Cote

  5. ATOS Clinic, Cologne, Germany

    Knut Beitzel

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  1. Florian B. Imhoff
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Corresponding author

Correspondence to Florian B. Imhoff.

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Conflict of interest

Imhoff FB received fees from mediCAD, Fa. Hectec, Germany, not related to this work. Cotic M: no conflict to report. Achtnich A: no conflict to report. Dyrna F: no conflict to report. Cote M receives personal fees from Arthroscopy Association of North America (AANA), outside the submitted work. Imhoff A is consultant for Arthrex Germany and medi Bayreuth, not related to this work. Beitzel K is consultant for Arthrex Germany.

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17/18S Technical University of Munich.

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Investigation performed at Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany.

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Imhoff, F.B., Cotic, M., Dyrna, F.G.E. et al. Dynamic Q-angle is increased in patients with chronic patellofemoral instability and correlates positively with femoral torsion. Knee Surg Sports Traumatol Arthrosc 29, 1224–1231 (2021). https://doi.org/10.1007/s00167-020-06163-6

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  • DOI: https://doi.org/10.1007/s00167-020-06163-6

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