Effect of Q-angle on patellar positioning and thickness of knee articular cartilages

Comparing the Effect of Mechanical Loading on Deep and Superficial Cartilage Using Quantitative UTE MRI

BACKGROUND

The biomechanical properties of deep and superficial cartilage may be different, yet in vivo MRI validation is required.

PURPOSE

To compare the effect of mechanical loading on deep and superficial cartilage in young healthy adults using ultrashort echo time (UTE)-T2* mapping.

STUDY TYPE

Prospective, intervention.

SUBJECTS

Thirty-one healthy adults (54.8% females, median age = 23 years).

FIELD STRENGTH/SEQUENCE

3-T, PD-FS, and UTE sequences with four echo times (TEs = 0.1, 0.5, 2.8, and 4.0 msec; 0.6 mm isotropic spatial resolution) of the left knee, acquired before and after loading exercise.

ASSESSMENT

Quantitative UTE-T2* maps of the entire knee were generated using UTE images of four TEs. In deep and superficial cartilage of patella, medial and lateral femur, medial and lateral tibia cartilage (PC, MFC, LFC, MTC, and LTC), which were segmented manually, cartilage thickness and T2* values before and after loading were measured, extracted, taken averages of, and compared. Scan-rescan repeatability was evaluated. Body weight and body mass index (BMI) data were collected. Physical activity levels were evaluated using International Physical Activity Questionnaire.

STATISTICAL TESTS

Paired sample t-tests, paired Wilcoxon Mann-Whitney tests, Pearson and Spearman correlation analyses, Kruskal-Wallis tests with post-hoc Bonferroni correction. A P-value <0.05 was considered statistically significant.

RESULTS

The scan-rescan repeatability was good (RMSA-CV < 10%). After exercise, deep cartilage exhibited no significant differences in cartilage thickness (PPC = 0.576, PMTC = 0.991, PMFC = 0.899, PLTC = 0.861, PLFC = 0.290) and T2* values (PPC = 0.914, PMTC = 0.780, PMFC = 0.754, PLTC = 0.327, PLFC = 0.811), which both significantly decreased in superficial PC, MFC, LFC, and MTC. The T2* values of superficial MTC and deep MFC were moderately correlated with higher body weight (ρ = 0.431) and lower BMI (ρ = -0.499), respectively.

DATA CONCLUSION

Deep and superficial cartilage may respond differently to mechanical loading as assessed by UTE-T2*.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 3.

The effect of quadriceps anatomical factors on patellar stability: A systematic review

PURPOSE

The aim of this systematic review was to analyse the effect of quadriceps anatomical factors on patellar stability.

METHODS

The protocol for this review was registered on PROSPERO with registration number CRD42022334265. A systematic PRISMA compliant database search was conducted. Electronic databases (MEDLINE, Global Health, MIDIRS, Embase, PsycARTICLES and APA PsycInfo), currently registered studies, conference proceedings and the reference lists of included studies were searched. A narrative synthesis provided a summary of current evidence pertaining to the effect of quadriceps anatomical factors on patellar stability.

RESULTS

A total of 9168 records were screened in the initial search. Of these, 20 articles satisfied the inclusion criteria, assessing 754 knees of 689 patients, and 69 cadaveric knees. Vastus medialis obliquus strength (VMO) affected patellar stability up to 15° of knee flexion, whereas medial retinaculum integrity did so up to 30° of knee flexion. Studies disagreed as to whether this applied to the rest of knee flexion. There is conflicting evidence regarding the effect of VMO elevation, cross-sectional area and angulation on patellar stability. The lateral retinaculum contributed to patellar stability throughout the entirety of knee flexion. Quadriceps angle altered patellar orientation during knee flexion, but not extension.

CONCLUSION

Whilst vastus medialis obliquus strength was found to be a determinant of patellar stability, there is conflicting evidence regarding the effect of VMO morphological parameters on patellar stability. The lateral retinaculum provided stability throughout the entirety of knee flexion, and the medial retinaculum did so up to 30° of flexion.

Anatomical Variation in Quadriceps Angle With Regard to Different Anthropometric Parameters in a Tertiary Care Center in Northern India: A Descriptive Study

BACKGROUND

The quadriceps angle, commonly known as the Q-angle, is the angle formed between the vectors of the pull of the quadriceps muscle and the patellar tendon. The literature varies in terms of the values of Q angles measured by various researchers. It is well appreciated that the normal Q-angle should fall between 12° and 20°, with males being at the lower end of this range and females having higher measurements. An increase in Q-angle beyond the normal range has been associated with knee extensor dysfunction leading to patellar instability. Keeping in mind the clinical and biomechanical importance of the Q-angle, the aim of this study was to compare and establish the range of the Q-angle in healthy individuals and evaluate its variations with respect to age, weight, height, gender, dominant side, and femoral bicondylar distance. These observations will be helpful for sports therapists in understanding the evaluation of Q-angle in athletes as a prognostic value for probable knee pathologies that may appear in the future.

METHODS

The current study was conducted at a tertiary care center, and a total of 100 healthy adults between the ages of 18 and 35 were enrolled in the study (50 males and 50 females), following which their Q-angles, bicondylar distances, and femur lengths were measured. Individuals with any lower limb injury that resulted in a ligamentous, muscular, or bony defect; any spinal or neurological injury; any diagnosed knee disorder, such as a fracture, acute or chronic knee pain, patellar dislocation, or prior orthopaedic surgery in the lower extremities, were excluded from the study. Data were analyzed using paired t-tests, independent sample t-tests, ANOVA, and Pearson correlation coefficients.

RESULT AND CONCLUSION

The mean Q-angle in males was found to be 11.14° ± 1.9° on the right side and 10.84° ± 1.86° on the left side. In females, it was found to be 13.68° ± 1.87° on the right side and 13.61° ± 2.04° on the left side. Among males, right and left Q-angles showed significant positive correlations with height, weight, BMI, right femur length, left femur length, right bicondylar distance, and left bicondylar distance (p<0.05). The highest correlation was found between weight and BMI. Among females, the right Q-angle showed significant positive correlations with weight and BMI (p<0.05). The highest correlation was found with weight.

Quadriceps muscle volume has no effect on patellofemoral cartilage lesions in patients with end-stage knee osteoarthritis

PURPOSE

The quadriceps muscle has a positive effect on anterior knee pain. However, its effect on the patellofemoral (PF) cartilage in patients with end-stage knee osteoarthritis is unknown. The present study aimed to evaluate whether the quadriceps muscle area had a positive effect on the PF cartilage and whether this muscle had a positive effect on the clinical scores.

MATERIALS AND METHODS

Patients with confirmed cartilage status and clinical scores who underwent total knee arthroplasty (TKA) were included. The PF cartilage status was evaluated during TKA. The thickness and the area of the quadriceps muscle were measured using a knee computed tomography scan obtained before the surgery. The Q-angle, hip-knee-ankle angle, alignment, and Insall-Salvati ratio were measured by radiography.

RESULTS

Altogether, 204 patients were included in the study. Logistic regression was performed including factors associated with PF cartilage lesions. The regression model was found to be statistically significant (Hosmer-Lemeshow test, χ² = 0.493). A smaller hip-knee-ankle (HKA) angle was associated with a higher incidence of PF cartilage lesions (p = 0.033) and only the alignment had an effect on the PF cartilage lesions. PF cartilage lesions did not correlate with the clinical scores. A thicker medial portion of the quadriceps muscle was associated with a significantly higher Knee Society Knee Score (KSKS) (p = 0.028).

CONCLUSIONS

Quadriceps muscle thickness and area, Q-angle, and patellar height were not associated with PF cartilage lesions, while a smaller HKA angle was associated with PF cartilage lesions. The presence of PF cartilage lesions did not affect the clinical symptoms. However, a thicker medial portion of the quadriceps muscle was associated with a higher KSKS.

Effect of static knee joint flexion on vastus medialis obliquus fiber angle in patellofemoral pain syndrome: An ultrasonographic study

INTRODUCTION

In patients with patellofemoral pain syndrome, the vastus medialis obliquus muscle fiber angle measured by ultrasound at knee extension was found to be different from that in healthy individuals. An important feature of patellofemoral pain syndrome is the increase in pain severity during activities that require knee flexion.

OBJECTIVE

To investigate whether there was an ultrasonographic change in the vastus medialis obliquus fiber angle by flexing the knee joint in patients with patellofemoral pain syndrome compared to healthy pain-free individuals.

DESIGN

A cross-sectional clinical study.

SETTING

An outpatient clinic of a tertiary care hospital.

PARTICIPANTS

Forty-seven patients with patellofemoral pain syndrome (median age of 40 years) and 43 healthy volunteers (median age of 39 years) were included in the study.

INTERVENTIONS

No intervention.

MAIN OUTCOME MEASURES

Vastus medialis obliquus fiber angle measured by ultrasonography at three different positions of knee joint including extension, 30° of flexion, and 45° of flexion.

RESULTS

There was no significant change in the vastus medialis obliquus fiber angle with knee flexion in both groups (p > .05 for each group). However, the median vastus medialis obliquus fiber angle values in the group with patellofemoral pain syndrome were significantly lower at all knee joint angles than those in the comparison group (p < .05 at all knee joint angles).

CONCLUSIONS

Although the vastus medialis obliquus fiber angle does not change with static knee flexion, the lower angle of the vastus medialis obliquus fiber in those with patellofemoral pain syndrome implicitly suggests that vastus medialis obliquus dysfunction may exist.

Clinical Significance of Combined Weight-Bearing and Non-Weight-Bearing Positions and MRI Examination in Evaluating Genu Varus

Objective

To siscuss the clinical significance of the early diagnosis of knee varus and knee osteoarthritis with the combination of negative position and non‐negative position and radiography.

Methods

One hundred and eighty patients whose femorotibial angles <182° (genu varus positive) measured by X‐ray at the weight‐bearing position and femorotibial angles ≥182° (genu varus negative) measured by X‐ray at the non‐weight‐bearing position were selected as the sample group from those patients who received knee joint Magnetic resonance imaging (MRI) examination from July 2015 to July 2017. One hundred and eighty patients whose femorotibial angles ≥182° (genu varus negative) measured at both the weight‐bearing position and the non‐weight‐bearing position were selected as the control group. Femorotibial angles of both groups were respectively measured, to respectively compare and analyze the effect of non‐weight‐bearing false‐negative genu varus on the occurrence and severity of injury of medial meniscus and femorotibial articular cartilage. The two groups of patients had no previous history of knee surgery, and no lower limb fracture, inflammation, tumor, metabolic bone disease, or congenital disease.

Results

The weight‐bearing tibiofemoral angles of the non‐weight‐bearing false‐negative genu varus group and the negative genu varus group (180.998° ± 0.589°) were lower than the non‐weight‐bearing tibiofemoral angles (182.501° ± 0.290°), and they were positively correlated (t = −15.048, P < 0.01). The non‐weight‐bearing knee varus medial meniscus incidence of false‐ negative group. Medial meniscus injury that occurred in the sample group were 86.7% (156/180) in the anterior horn, 91.7% (165/180) in the body, 88.3% (159/180) in the posterior horn. Medial meniscus injury that occurred in the control group were 46.7% (84 /180) in the anterior horn, 40.6.3% (73/180) in the body, 43.3% (78/180) in the posterior horn. The incidence of degenerative groups, the differences were statistically significant. The incidence and severity of injury were as follows: medial meniscus anterior horn (χ² = 41.966, P = 0.000), body (χ² = 104.94, P = 0.000), posterior horn (χ² = 81.025, P = 0.000). The incidence and severity of medial meniscus injury in the non‐weight‐bearing knee varus false negative group was higher than in the control group. The non‐weight‐bearing knee varus false‐negative group medial tibiofemoral articular cartilage degeneration rate was 95.0% (171/180); in the control group, medial tibiofemoral articular cartilage degeneration was 65.1% (117/180). Two medial tibiofemoral articular cartilage degeneration incidence were statistically significant. The incidence and severity of injury were as follows: medial tibiofemoral articular cartilage (χ² = 50.625, P = 0.000). The incidence and severity of medial tibiofemoral articular cartilage injury in the non‐weight‐bearing knee varus false negative group was higher than in the control group.

Conclusion

The combined weight‐bearing position and non‐weight‐bearing position imaging examination for diagnosing the non‐weight‐bearing false‐negative genu varus patients at an early date is of significant importance to the early diagnosis and treatment of knee osteoarthritis.

Healthy knees have a highly variable patellofemoral alignment: a systematic review

PURPOSE

There is still lack of knowledge regarding the variability of patellofemoral alignment in healthy, non-osteoarthritic knees, without patellofemoral instability. Therefore, a systematic review of the existing literature was performed to evaluate the variability of patellofemoral alignment.

METHODS

Patellofemoral alignment of the knee was defined by the following parameters: sulcus angle (SA), femoral trochlear depth (FTD), patellar tilt angle (PTA), lateral patellofemoral angle (LPFA), lateral femoral trochlear inclination (LFTI) and tibial tubercle-trochlear groove distance (TT-TG). The electronic databases MEDLINE and EMBASE were searched from database inception to search date (January 11, 2019) and screened for relevant studies. The PRISMA guidelines were followed. Articles reporting PF alignment measurements of healthy knees in patients between 15 years and 47 years were included.

RESULTS

A total of 15 studies met the inclusion criteria. The studies reported mean values and standard deviations for the SA between 118.7° ± 7 and 168°; for the FTD between 3.4 mm ± 1.1 and 7.1 mm ± 1.8; for the PTA between 0.7° ± 4.99 and 17.05° ± 4.3; for the LPFA between 6.26° ± 4.1 and 11.1° ± 4.0; for the LFTI between 16.3° ± 2.8 and 22.1° ± 1.9; and for the TT-TG between 9.8 mm ± 4.6 and 17.3 mm ± 5.3.

CONCLUSION

Patellofemoral alignment in the healthy knee is extremely variable. A more precise knowledge of the complex relationship between the patella and the trochlea may help to better diagnose PF disorders and eventually help in selecting the correct therapy. Furthermore, standardised imaging protocols and measurement techniques for patellofemoral parameters are needed.

LEVEL OF EVIDENCE

III.

Measurement of the quadriceps (Q) angle with respect to various body parameters in young Arab population

The quadriceps angle (Q angle), formed between the quadriceps muscles and the patella tendon, is considered clinically as a very important parameter which displays the biomechanical effect of the quadriceps muscle on the knee, and it is also regarded a crucial factor for the proper posture and movement of the knee patella. The Q angle is routinely and regularly used as an assessment parameter during the diagnosis of many knee-related problems, including the anterior knee pain, osteoarthritis, and degenerative knee disorders. This study had been conducted so as to measure the normal Q angle values range in the Arab nationalities and determine the correlation between Q angle values and several body parameters, including gender, height, weight, dominant side, and the condylar distance of the femur. The study includes 500 healthy young Arab students from the Yarmouk University and Jordan University of Science and Technology. The Q angle of those volunteers was measured using a universal manual Goniometer with the subjects in the upright weight-bearing position. It was found that Q angle was greater in young women than young men. Also, the analysis of the data revealed an insignificant increase in the dominant side of the Q angle. In addition, the Q angle was significantly higher in the taller people of both sexes. However, the Q angle did not present any considerable correlation with weight in the study population; conversely, it was clearly observed that there was a link with the condylar distance of the femur in both sexes. It was also noticed that the Q angle increased remarkably when there was an increase in the condylar distance. Consequently, it turned out that the gender, height, and the condylar distance were momentous factors that had impact on the Q angle in our study samples. However, weight and dominancy factors did not show to have any influence on the values in our study.

Relationship Between Q-Angle and Articular Cartilage in Female Patients With Symptomatic Knee Osteoarthritis: Ultrasonographic and Radiologic Evaluation

OBJECTIVES

This study aims to examine the association between Q-angle and clinical, radiological, and ultrasonographic findings in patients with knee osteoarthritis (OA).

PATIENTS AND METHODS

Sixty-eight female patients (mean age 59.8±6.8 years; range 39 to 78 years) diagnosed with knee OA were included in this study and classified into two groups according to Q-angle of symptomatic knees: low Q-angle group (LQ) (n=40) and high Q-angle group (HQ) (n=28) (LQ-angle <15° and HQ-angle ≥15°, respectively). Patients were clinically assessed for pain and functional status by using a visual analog scale and the Western Ontario and McMaster Universities Arthritis Index. X-rays of knees were scored using the Kellgren-Lawrence OA grading system. Symptomatic knees were also evaluated using ultrasonography for distal femoral cartilage thickness/grading.

RESULTS

No significant difference was observed in clinical and imaging findings between the groups (p>0.05). HQ-angle measurements were positively correlated with cartilage grading by ultrasonography (r=0.435, p=0.033) and Kellgren-Lawrence grading system (r=0.435, p=0.021), and negatively correlated with cartilage thickness measurements of the medial femoral condyle (r=-0.399, p=0.036).

CONCLUSION

We found that HQ-angle was associated with cartilage thickness measurements of the medial femoral condyle and cartilage grading by ultrasonography and the Kellgren-Lawrence grading system in patients with knee OA.

Effects of eccentric overload training on patellar tendon and vastus lateralis in three days of consecutive running

BACKGROUND

The analysis of structural changes in patellar tendon and muscle of healthy subjects in response to mechanical loads provides useful insight into the mechanism underlying overuse injuries.

METHODS

Changes produced in tendon and muscles structures after eccentric overload training and three consecutive running days were examined. Twenty healthy subjects were recruited and divided into two groups. One group (ECC) performed eccentric overload squat training (six weeks). After such training, the ECC group performed three running sessions on consecutive days, as did the control group (CONT). The structure of their patellar tendons and vastus lateralis muscles was quantified using ultrasound and Doppler imaging. Images were obtained before and after eccentric training for the ECC group and on every day of running performance for both groups.

RESULTS

After eccentric training, the ECC group experienced an increase in cross-sectional area (CSA) of patellar tendon (P=0.012). After every day of running, the ECC group experienced a decrease in CSA (P=0.027). In the CONT group, after one day of running a significant increase was observed in anteroposterior width of their patellar tendon (P=0.028), as well as a decrease in pennation angle of vastus lateralis muscle (P=0.028) within three days of running sessions.

CONCLUSIONS

Eccentric overload training brought about changes in the patellar tendon consistent with an improvement in the quality of the tissue. The ECC group in our study showed a more normalised pattern than the CONT group in the running performance, in agreement with previous research.

LEVEL OF EVIDENCE

Level 3, controlled trial.

Sagittal patellar tilt and concomitant quadriceps hypotrophy after tibial nailing

PURPOSE

The aim of the study was to analyse the patellofemoral alignment in the sagittal plane following tibial fracture surgery with intramedullary nailing and its relationship to parapatellar muscle status.

METHODS

The patellofemoral MRI results of 27 patients (15 males and 12 females) treated with locked intramedullary nailing following tibia shaft fracture were reviewed. The mean age of the patients was 41.8 (±15) years. The patella-patellar tendon angle (P-PT) and the distance between the inferior patellar pole and the tibial tubercle (DP-TT) were evaluated for both the operated extremity and the contralateral normal side. MRI assessment of the infrapatellar fat pad, quadriceps, sartorius, gracilis, semi-membranosus muscles and biceps muscles was also carried out. The correlation between the changes in skeletal muscle mass, the volume of the infrapatellar fat pad and the alterations in the DP-TT distances and P-PT angles were analysed.

RESULTS

The quadriceps muscle cross-sectional diameter had a mean of 157.2 mm(2) (115.6/319.5) in the operated extremity, and it was 193 mm(2) (77.6/282.2) in the non-operated normal side (p = 0.001). For the Gracilis muscle, the mean was 84.4 mm(2) (19.7/171) at the operated extremity and 75.7 mm(2) (26.9/238.2) on the normal side (p = 0.05). The cross-sectional areas of the semi-membranosus, sartorius and biceps muscles in the operated and non-operated extremity were not noticeably different (n.s). The P-PT angle was 153° (129.7/156.4) in the operated extremity and 145.7° (137.6/163.4) in the non-operated normal extremity (p < 0.05). While DP-TT distance was 11.4 mm (9.4/20.4) in the operated extremity, it was 14.1 mm (7.3/17.1) in the non-operated extremity (p = 0.001). The correlation analyses revealed that the quadriceps hypotrophy negatively correlated (r = -0.4, p = 0.02) with the P-PT angle but positively correlated with the increase in gracilis muscle volume (r = 0.4, p = 0.03).

CONCLUSION

This study revealed that patellofemoral joint kinematics in the operated extremity was diminished in the sagittal plane correlating with the quadriceps muscle volume loss and gracilis muscle hypertrophy. The modalities focused on both preventing and treating the hypotrophy of the quadriceps muscle following the surgical treatment of tibial fracture, which may help to overcome this quite common pathology.

Consistency of Lower-Body Dimensions Using Surface Landmarks and Simple Measurement Tools

Caia, J, Weiss, LW, Chiu, LZF, Schilling, BK, and Paquette, MR. Consistency of lower-body dimensions using surface landmarks and simple measurement tools. J Strength Cond Res 30(9): 2600-2608, 2016-Body dimensions may influence various types of physical performance. This study was designed to establish the reliability and precision of bilateral lower-body dimensions using surface anatomic landmarks and either sliding calipers or goniometry. Fifty university students (25 men and 25 women) were measured on 2 separate occasions separated by 48 or 72 hours. A small digital caliper was used to acquire longitudinal dimensions of the feet, whereas a larger broad-blade caliper was used to measure lower-limb, hip, and pelvic dimensions. Quadriceps angle (Q-angle) was determined through surface goniometry. Data for all foot and lower-limb dimensions were both reliable and precise (intraclass correlation coefficient (ICC) ≥0.72, SEM 0.1-0.5 cm). Measures of Q-angle were also reliable and precise (ICC ≥0.85, SEM 0.2-0.4°). Findings from this investigation demonstrate that lower-body dimensions may be reliably and precisely measured through simple practical tests, when surface anatomic landmarks and standardized procedures are used. Although intertester reliability remains to be established, meticulous adherence to specific measurement protocols is likely to yield viable output for lower-body dimensions when more sophisticated methods are unavailable or inappropriate.

Lateral patellar translation effects after arthroscopic partial meniscectomy of torn discoid lateral meniscus

OBJECTIVE

To investigate the effects of arthroscopic partial meniscectomy of torn discoid lateral meniscus on patellar tracking.

METHODS

In all, 112 patients (112 knees) who underwent arthroscopic partial meniscectomy participated in the study. All subjects were examined with standing weight-bearing magnetic resonance imaging (MRI) preoperatively and one month postoperation. Axial-plane images through the maximum width of the patella and the maximum dorsal area of the femoral condyles were superimposed and the bisect offset index used to quantify patellar translation. Differences between pre- and postoperation in the bisect offset indexes were calculated and compared by Student's paired t-test. P < 0.05 was considered statistically significant.

RESULTS

Before surgery, the mean bisect offset index was 0.574 (0.437-0.692). One month postoperation, the mean bisect offset index was 0.622 (0.510-0.801). The postoperation bisect offset index increased by an average of 0.048 (-0.018 to 0.129) compared with the preoperation value; this difference is statistically significant result (t = 18.33, P < 0.01).

CONCLUSION

After arthroscopic partial meniscectomy, the patella translates more lateral to the femoral trochlear groove. These results suggest that arthroscopic partial meniscectomy may result in patellar maltracking.