Skip to main content
SpringerLink
Log in

Assessment of in vivo loading history of the patellofemoral joint: a study combining patellar position, tilt, alignment and bone SPECT/CT

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The current study investigates whether patella height and tilt or leg alignment influence the intensity values as well as the distribution pattern of single photon emission computerized tomography/computerized tomography (SPECT/CT) tracer uptake in the patellofemoral joint.

Methods

99mTc-HDP-SPECT/CT and radiographs of consecutive 84 knees were prospectively obtained. Lateral radiographs were analyzed in terms of patellar height, Insall-Salvati index and modified Insall-Salvati index. Skyline views were analyzed for Laurin’s lateral patellofemoral angle. On long-leg radiographs, the mechanical leg alignment was classified as varus, valgus or neutral. SPECT/CT was analyzed for each anatomical region using a previously validated SPECT/CT localization and grading algorithm. Mean, standard deviation, minimum and maximum of grading for each area of the localization scheme were recorded. Nonparametric Spearman’s correlations were used to correlate patellar height, lateral patellar angle and leg alignment with the tracer uptake intensity. Chi-square statistics were used for categorical data (p < 0.05).

Results

A patella baja correlated significantly with higher SPECT/CT tracer uptake in all patellar and lateral femoral regions (p < 0.001). A higher lateral patellar tilt correlated significantly with higher tracer uptake in the superior lateral femoral parts and the tibial tubercle. In mechanically varus aligned knees, there was significantly higher SPECT/CT tracer uptake on the medial and in valgus knees on the lateral part of the patellofemoral joint (p < 0.05).

Conclusions

As the intensity and distribution of the SPECT/CT significantly correlated with patella baja and patellar tilt, SPECT/CT might be considered as imaging modality for evaluating patients with patellofemoral disorders and for follow-up of patients after patellofemoral realignment procedures.

Level of evidence

Diagnostic study, Level II.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. AL-Sayyad M, Cameron JC (2002) Functional outcome after tibial tubercle transfer for the painful patella alta. Clin Orthop Relat Res 396:152–162

    Article  PubMed  Google Scholar 

  2. Amis AA, Farahmand F (1996) Biomechanics masterclass: extensor mechanism of the knee. Curr Orthop 10(2):102–109

    Article  Google Scholar 

  3. Amis AA, Oguz C, Bull AM, Senavongse W, Dejour D (2008) The effect of trochleoplasty on patellar stability and kinematics: a biomechanical study in vitro. J Bone Joint Surg Br 90(7):864–869

    Article  CAS  PubMed  Google Scholar 

  4. Buck FM, Hoffmann A, Hofer B, Pfirrmann CW, Allgayer B (2009) Chronic medial knee pain without history of prior trauma: correlation of pain at rest and during exercise using bone scintigraphy and MR imaging. Skelet Radiol 38(4):339–347

    Article  Google Scholar 

  5. Caton J (1989) Method of measuring the height of the patella. Acta Orthop Belg 55(3):385–386

    CAS  PubMed  Google Scholar 

  6. Dejour D, Saggin P (2010) The sulcus deepening trochleoplasty-the Lyon’s procedure. Int Orthop 34(2):311–316

    Article  PubMed Central  PubMed  Google Scholar 

  7. Fulkerson JP, Schutzer SF, Ramsby GR, Bernstein RA (1987) Computerized tomography of the patellofemoral joint before and after lateral release or realignment. Arthroscopy 3(1):19–24

    Article  CAS  PubMed  Google Scholar 

  8. Grelsamer RP, Bazos AN, Proctor CS (1993) Radiographic analysis of patellar tilt. J Bone Joint Surg Br 75(5):822–824

    CAS  PubMed  Google Scholar 

  9. Grelsamer RP, Meadows S (1992) The modified Insall-Salvati ratio for assessment of patellar height. Clin Orthop Relat Res 282:170–176

    PubMed  Google Scholar 

  10. Hirschmann MT, Adler T, Rasch H, Hugli RW, Friederich NF, Arnold MP (2010) Painful knee joint after ACL reconstruction using biodegradable interference screws-SPECT/CT a valuable diagnostic tool? A case report. Sports Med Arthrosc Rehabil Ther Technol 2:24

    Article  PubMed Central  PubMed  Google Scholar 

  11. Hirschmann MT, Davda K, Iranpour F, Rasch H, Friederich NF (2011) Combined single photon emission computerised tomography and conventional computerised tomography (SPECT/CT) in patellofemoral disorders: a clinical review. Int Orthop 35(5):675–680

    Article  PubMed Central  PubMed  Google Scholar 

  12. Hirschmann MT, Davda K, Rasch H, Arnold MP, Friederich NF (2011) Clinical value of combined single photon emission computerized tomography and conventional computer tomography (SPECT/CT) in sports medicine. Sports Med Arthrosc 19(2):174–181

    Article  PubMed  Google Scholar 

  13. Hirschmann MT, Iranpour F, Davda K, Rasch H, Hugli R, Friederich NF (2010) Combined single-photon emission computerized tomography and conventional computerized tomography (SPECT/CT): clinical value for the knee surgeons? Knee Surg Sports Traumatol Arthrosc 18(3):341–345

    Article  PubMed  Google Scholar 

  14. Hirschmann MT, Iranpour F, Konala P, Kerner A, Rasch H, Cobb JP, Friederich NF (2010) A novel standardized algorithm for evaluating patients with painful total knee arthroplasty using combined single photon emission tomography and conventional computerized tomography. Knee Surg Sports Traumatol Arthrosc 18(7):939–944

    Article  PubMed  Google Scholar 

  15. Hirschmann MT, Konala P, Iranpour F, Kerner A, Rasch H, Friederich NF (2011) Clinical value of SPECT/CT for evaluation of patients with painful knees after total knee arthroplasty-a new dimension of diagnostics? BMC Musculoskelet Disord 12(1):36

    Article  PubMed Central  PubMed  Google Scholar 

  16. Hirschmann MT, Mathis D, Afifi FK, Rasch H, Henckel J, Amsler F, Wagner CR, Friederich NF, Arnold MP (2013) Single photon emission computerized tomography and conventional computerized tomography (SPECT/CT) for evaluation of patients after anterior cruciate ligament reconstruction: a novel standardized algorithm combining mechanical and metabolic information. Knee Surg Sports Traumatol Arthrosc 21(4):965–974

    Article  PubMed  Google Scholar 

  17. Hirschmann MT, Mathis D, Rasch H, Amsler F, Friederich NF, Arnold MP (2013) SPECT/CT tracer uptake is influenced by tunnel orientation and position of the femoral and tibial ACL graft insertion site. Int Orthop 37(2):301–309

    Article  PubMed Central  PubMed  Google Scholar 

  18. Hirschmann MT, Schon S, Afifi FK, Amsler F, Rasch H, Friederich NF, Arnold MP (2013) Assessment of loading history of compartments in the knee using bone SPECT/CT: a study combining alignment and 99mTc-HDP tracer uptake/distribution patterns. J Orthop Res 31(2):268–274

    Article  CAS  PubMed  Google Scholar 

  19. Hirschmann MT, Wagner CR, Rasch H, Henckel J (2012) Standardized volumetric 3D-analysis of SPECT/CT imaging in orthopaedics: overcoming the limitations of qualitative 2D analysis. BMC Med Imaging 12(1):5

    Article  PubMed Central  PubMed  Google Scholar 

  20. Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101(1):101–104

    Article  CAS  PubMed  Google Scholar 

  21. Kalichman L, Zhang Y, Niu J, Goggins J, Gale D, Felson DT, Hunter D (2007) The association between patellar alignment and patellofemoral joint osteoarthritis features–an MRI study. Rheumatology (Oxford) 46(8):1303–1308

    Article  CAS  Google Scholar 

  22. Kalichman L, Zhang Y, Niu J, Goggins J, Gale D, Zhu Y, Felson DT, Hunter DJ (2007) The association between patellar alignment on magnetic resonance imaging and radiographic manifestations of knee osteoarthritis. Arthritis Res Ther 9(2):R26

    Article  PubMed Central  PubMed  Google Scholar 

  23. Kalichman L, Zhu Y, Zhang Y, Niu J, Gale D, Felson DT, Hunter D (2007) The association between patella alignment and knee pain and function: an MRI study in persons with symptomatic knee osteoarthritis. Osteoarthritis Cartilage 15(11):1235–1240

    Article  CAS  PubMed  Google Scholar 

  24. Karlsson J, Bunketorp O, Lansinger O, Romanus B, Sward L (1986) Lowering of the patella secondary to anterior advancement of the tibial tubercle for the patellofemoral pain syndrome. Arch Orthop Trauma Surg 105(1):40–45

    Article  CAS  PubMed  Google Scholar 

  25. Kraus VB, McDaniel G, Worrell TW, Feng S, Vail TP, Varju G, Coleman RE (2009) Association of bone scintigraphic abnormalities with knee malalignment and pain. Ann Rheum Dis 68(11):1673–1679

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  26. Lancourt JE, Cristini JA (1975) Patella alta and patella infera. Their etiological role in patellar dislocation, chondromalacia, and apophysitis of the tibial tubercle. J Bone Joint Surg Am 57(8):1112–1115

    CAS  PubMed  Google Scholar 

  27. Laprade J, Culham E (2003) Radiographic measures in subjects who are asymptomatic and subjects with patellofemoral pain syndrome. Clin Orthop Relat Res 414:172–182

    Article  PubMed  Google Scholar 

  28. Laurin CA, Levesque HP, Dussault R, Labelle H, Peides JP (1978) The abnormal lateral patellofemoral angle: a diagnostic roentgenographic sign of recurrent patellar subluxation. J Bone Joint Surg Am 60(1):55–60

    CAS  PubMed  Google Scholar 

  29. Lo GH, Hunter DJ, Zhang Y, McLennan CE, Lavalley MP, Kiel DP, McLean RR, Genant HK, Guermazi A, Felson DT (2005) Bone marrow lesions in the knee are associated with increased local bone density. Arthritis Rheum 52(9):2814–2821

    Article  PubMed  Google Scholar 

  30. Lorberboym M, Ami DB, Zin D, Nikolov G, Adar E (2003) Incremental diagnostic value of 99mTc methylene diphosphonate bone SPECT in patients with patellofemoral pain disorders. Nucl Med Commun 24(4):403–410

    Article  CAS  PubMed  Google Scholar 

  31. Meyer SA, Brown TD, Pedersen DR, Albright JP (1997) Retropatellar contact stress in simulated patella infera. Am J Knee Surg 10(3):129–138

    CAS  PubMed  Google Scholar 

  32. Rasch H, Falkowski AL, Forrer F, Henckel J, Hirschmann MT (2013) 4D-SPECT/CT in orthopaedics: a new method of combined quantitative volumetric 3D analysis of SPECT/CT tracer uptake and component position measurements in patients after total knee arthroplasty. Skeletal Radiol 42(9):1215–1223

    Article  PubMed  Google Scholar 

  33. Sasaki T, Yagi T (1986) Subluxation of the patella Investigation by computerized tomography. Int Orthop 10(2):115–120

    Article  CAS  PubMed  Google Scholar 

  34. Singerman R, Davy DT, Goldberg VM (1994) Effects of patella alta and patella infera on patellofemoral contact forces. J Biomech 27(8):1059–1065

    Article  CAS  PubMed  Google Scholar 

  35. Specogna AV, Birmingham TB, Hunt MA, Jones IC, Jenkyn TR, Fowler PJ, Giffin JR (2007) Radiographic measures of knee alignment in patients with varus gonarthrosis: effect of weightbearing status and associations with dynamic joint load. Am J Sports Med 35(1):65–70

    Article  PubMed  Google Scholar 

  36. Stefanik JJ, Zhu Y, Zumwalt AC, Gross KD, Clancy M, Lynch JA, Frey Law LA, Lewis CE, Roemer FW, Powers CM, Guermazi A, Felson DT (2010) Association between patella alta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis: the multicenter osteoarthritis study. Arthritis Care Res (Hoboken) 62(9):1258–1265

    Article  CAS  Google Scholar 

  37. Wirth CJ, Zichner L, Kohn D (2005) Knie. In: Kohn D (ed) Orthopädie und Orthopädische Chirurgie. Thieme, Stuttgart, pp 332–343

    Google Scholar 

Download references

Acknowledgments

We greatly thank the Deutsche Arthrose-Hilfe e.V., Frankfurt am Main, Germany, the Gottfried und Julia Bangerter-Rhyner-Stiftung, Berne, Switzerland for their support to our research.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland-Bruderholz, 4101, Bruderholz, Switzerland

    Stephan N. Schön, Faik K. Afifi, Niklaus F. Friederich, Markus P. Arnold & Michael T. Hirschmann

  2. Institute for Radiology and Nuclear Medicine, Kantonsspital Baselland-Bruderholz, 4101, Bruderholz, Switzerland

    Helmut Rasch

  3. Amsler Consulting, Basel, Switzerland

    Felix Amsler

Authors
  1. Stephan N. Schön
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Faik K. Afifi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Helmut Rasch
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Felix Amsler
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Niklaus F. Friederich
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Markus P. Arnold
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Michael T. Hirschmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael T. Hirschmann.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schön, S.N., Afifi, F.K., Rasch, H. et al. Assessment of in vivo loading history of the patellofemoral joint: a study combining patellar position, tilt, alignment and bone SPECT/CT. Knee Surg Sports Traumatol Arthrosc 22, 3039–3046 (2014). https://doi.org/10.1007/s00167-013-2698-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-013-2698-2

Keywords

Search

Navigation