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Diagnostic

Radiology

The Patellofemoral Joint: 300,


Arthur

allowing

niscus.
Its value
chondromalacia
INDEX

TERMS:

4[5].125)

137:57-61,

HE patellofemoral

lenge
suspected

Knee, injuries
(Knee, arthrography,

(PF)

radiography
4[5].122)

October

joint

of numerous

is also discussed,
pateliar
subluxation.

#{149}
Knee,

#{149}

RadIology

differentiation

in arthrography
and recurrent

of the patellofemoral

(PF)

joint, axial

radiographs

obtained,
with positive
studies in 19. The examinaof the Ficat views are discussed.
in selected
patients,
information
not obtainable
by other methods
about the

and the interpretation


can yield valuable

PF articulation,

Views1

900

M.D., and David Seligson, M.D.

H. Newberg,

In 70 patients evaluated
for abnormality
at 300, 600, and 9O (Ficat views) were
tion technique
the examination

600, and

#{149}
Semilunar

patellar

abnormalities

as well

as its usefulness

cartilages

#{149}
(Knee,

special

from a torn mein evaluating

non-routine

projection,

1980

continues

to be a chal-

for orthopedists
and radiologists.
Patients with
meniscal
lesions may be referred for knee ar-

thrography

when

the patella

and parapatellar

the source

of their

area.

symptoms

is actually

Various

radiographic
techniques
for evaluating
the PF joint have been described,
each with full support and documentation
by the authors
and each with its own limitations
(1-3).
Dynamic
radiography with axial projections
at 30#{176},
60#{176}
and 90#{176}
(Ficat

views) yields diagnostic


information
about the PF joint that
is unobtainable
on a single static radiograph
(4).
FUNCTIONAL

ANATOMY

The patella acts as a fulcrum


for knee extension,
creasing the efficiency
of the quadriceps
by increasing

inthe

lever arm of the extensor


mechanism.
The patella protects
the anterior
aspect
of the knee and provides
a smooth
gliding
surface
over the femur.
It moves
freely
during

flexion and extension


through an excursion
of 5-7 cm in
the femoral sulcus, and the configuration
of both the patella
and

the

femoral

sulcus

are

important

in determining

Fig. 1 . The radiographic


technique and
view are illustrated.
Note the goniometer
measurement
of knee flexion. The patient
the thighs and the radiographic
tube is low
the patellofemoral
joint.

the

course of PF tracking (5-7). The patelia is balanced in the


femoral trochlea by the medial pull of the vastus medialis
and the lateral opposition
of the iliotibial band and lateral

patient position for the 30#{176}


used to assist in accurate
is holding the cassette
on
enough to be tangential
to

retinaculum.
while the cassette
is held on the distal portion
of the patients thighs, perpendicular
to the beam. With progressive
knee flexion,
the tube must remain
perpendicular
to the

TECHNIQUE

The Ficat
sitting

patella

on a chair

a lead apron
tabletop,
control

views

atop

are obtained

the radiographic

(Fig. 1). The femurs

should

with
table,

the patient

PF joint.

shielded

moved
more proximally
on the thigh. The patient
should
try to relax the quadriceps;
tightening
of the extensor
mechanism
can cause a subluxing
patella
to assume
a
normal
position
in the femoral
intercondylar
sulcus (1).

be parallel

by

to the

and both knees and feet are pressed


together
to
rotation
and to offer comparison
of the right and

left joints. A long goniometer


is used to accurately
measure
the angle of knee flexion. The central beam is directed
from the feet and is inclined about 10#{176}
toward the tibia,
1

From the Departments

of Vermont,

Burlington,

of Radiology

VT. Received

(A.H.N.) and Orthopaedics

Nov. 13, 1979, and accepted

On the 30#{176}
view,

the cassette

may need to be

The technique
is more difficult
in very obese patients
and those with a prominent
tibial tubercie.
The 30#{176}
view
may be impossible
to obtain,
and thus the nearest
angle
(D.S.), University
Jan. 9, 1980.

57

of Vermont

College

of Medicine,

Medical

Center

Hospital
jr

58

ARTHUR

H. NEWBERG

AND DAVID

October

SELIGSON

1980

2a

4j

Fig. 2.

should
pression
the PF
difficult
perfectly
patella
beam.
proper
gential
The

Normal

Ficat views

at (a) 30#{176},
(b) 60#{176},
and

be achieved.
It would be incorrect
to give the imthat it is easy to obtain diagnostic
Ficat views of
joint. Some trial and error is inevitable.
It may be
initially
for the technologist
to center
the beam
tangential
to the patella borders.
Palpation
of the
may help determine
the optimum
inclination
of the
The exact angle of flexion
is not as important
as
positioning
in order to obtain the central
ray tanto the patella.
radiographs
are viewed
in the same direction
that

the beam passes.

Interpretation

of the Ficat views

includes

comparison
of both PF joints, functional
relationships,
and
subchondral
bone density.
In addition,
various
quantitative
measurements
can be made from the radiographs.
In the
normal
individual
(Fig. 2), the patella
is well seated
in the
sulcus of the femur in the 30#{176}
projection.
This view is most
likely to show any tendency
toward
subluxation.
The 60#{176}

view

shows

the morphology

of the patella

and is best for

(C)

90#{176}.

demonstrating
the central
centered
when the apex
vertical
over the sulcus.

contact
of the

CLINICAL

area. The patella is well


median
ridge is directly

EVALUATION

Patients
were initially
evaluated
by a staff orthopaedist.
If there was suspicion
of PF joint disease
or equivocal
findings
of internal
derangement
of the knee, routine
radiographs
of the knee plus the axial patella
views at 30#{176},
60#{176},
and 90#{176}
were obtained.
All radiographs
were obtained
by the same technologist.
Seventy
patients
were evaluated, including
38 males and 32 females.
The age range

was

13-81

years,

with the average

age being

28 years;

however,
30 patients
were younger
than 20 years.
The
initial clinical
presentation
or diagnosis
in the 70 patients

was: chondromalacia
(1 2 patients),

knee

(1 7 patients),
pain

(1 7 patients),

subluxation-dislocation
trauma

(1 1 patients),

THE PATELLOFEMORAL

Vol. 137

JOINT

59

Diagnostic
Radiology

R6o#{176}

Fig. 3a and b.
arising

The shallow femoral

osteoarthritis

The 60#{176}
view demonstrates

from the medial

(4 patients),

patellar

lateral subluxation
of the left patella (b). There is an osteochondral
fragment
facet (b, open arrow) and a fragment adjacent to the lateral femoral condyle (b, closed arrow).

sulcus may predispose

prior

tibial

tubercle

to patellar subluxation.

transplant

(3 patients),
osteochondritis
dissecans
(2 patients), loose
body (2 patients),
torn meniscus
(1 patient), and a normal
knee examination
(1 patient [control]).

RESULTS
Initially,
the Ficat views
added
mation,
due to technical
difficulties.

Fig. 4.
(a) 60#{176}
and (b) 90#{176}
views. Abnormal
lateral patellofemoral
contact
90#{176}
there is less contact, which may explain why some patients with advanced
flexed.

little

diagnostic
inforHowever,
after the

is demonstrated
in osteoarthritis.
Note that at
degenerative
disease prefer to keep their knee

60

ARTHUR

H. NEWBERG

AND DAVID

SELIGSON

October

1980

5a

5b

Fig. 5. Positive
or Hughston views

technique

was

mastered,

Ficat arthrogram demonstrates


patellar subluxation at 30#{176}
(a) and return to normal
would not have revealed this abnormality.
The patients menisci were normal.

they

were

useful.

The study

was

abnormal
in 19/70 patients.
in six, there was evidence
of
prior dislocation
with osteochondral
fragments
(Fig. 3).
Four patients
showed
patellar
subluxation,
three
posttraumatic
changes,
two excessive
lateral pressure
(ELPS),
and four advanced
PF arthritis
(Fig. 4).
Seven of the 70 patients
underwent
knee arthrography,
and two of these had a torn meniscus.
One of the seven
patients
had a positive
Ficat study demonstrating
patellar
subluxation
which had not been suspected
clinically
(Fig.
5).
DISCUSSION

skyline

not helpful
in studying
patellar
disorders,
especially
chondromalacia.
At our institution,
the Hughston
view (2)
of both knees
is routine
for evaluating
the PF joint. The
popular
skyline
view obtained
with the knee in marked

flexion

is of no value in studying

PF joint,

because

it draws

as well as cause

the functional

the patelia

condylar
sulcus.
Disorders
of the PF joint

cause

can

locking,

deep
the knee

pain, clicking,

state of the
into the interto give way,

and joint effusion

(9-1 1). In chondromalacia,


the pain is probably
related to
abnormal
stress
caused
by malalignment
(9), and these
patients
may have localized
tenderness
in the medial joint

line, mimicking
especially

The radiologic
evaluation
of the PF joint has been the
subject
of numerous
publications,
predominantly
by orthopedists
(1 -8). These authors
have described
different
techniques,
depending
upon their views on the etiology
of
PF disorders.
Arthrography,
according
to most experts,
is

at 60#{176}
(b). Routine

common

internal

the torn meniscus

derangement

(5). Subluxation

of the knee,
of the patella

is probably the most common


of chondromalacia;
Wiberg

and frequently
missed cause
has shown that in patellar

subluxation

of the

condyles

height

the

morphology

may be altered
of the lateral

patella

and

femoral

(12). When the knee is flexed,

femoral

condyle

acts

as a buttress

the
to

Diagnostic

THE PATELLOFEMORAL

Vol. 137

Fig. 6. Ficat view at 30#{176}


demonstrates
is a slight increase in subchonaI
sclerosis

lateral pressure

syndrome

narrowing
(arrowhead)

spontaneously

after

dislocation,

Syndrome
entity

of the patella

as viewed

pateliar
subluxation
result in osteoarthritis

show narrowing
increase

(ELPS)

(4). This

characterized

by knee

is a clinical-radio-

pain

and lateral

on axial images,

of the lateral
bone

but without

PF joint and there


density

and dynamics

of the

of the PF joint.

2.
3.

4.

5.
6.
7.

lateral

may be an
lateral

facet

of the patella when compared


with the opposite
knee.
The 30#{176},
60#{176},
and 90#{176}
views are helpful in studying the
morphology

1.

tilting

(Fig. 6). Ficat believes


that ELPS may
of the PF joint. The axial views will

in subchondral

REFERENCES

and the pa-

be unaware
that a dislocation
even occurred
(2).
to Hughston,
the
orthopaedist
who has not
a recurrent
subluxation
of the patella
for a torn
has had a limited and fortunate
experience
with
knees and meniscectomies
(2).
Ficat has evolved
the concept
of the Excessive
Lateral
logical

It is known

8.

9.
10.
1 1.

that

the patelia
may contain
fairly severe
cartilaginous
changes
which do not give rise to demonstrable
bony changes on

12.

the radiographs
most
common
chondromalacia

13.

be helpful

(13). Since
subluxation
and most
frequently
(5), the dynamic
views

in diagnosing

ACKNOWLEDGMENT:

and technical

assistance.

Radiology

(ELPS).

tient may
According
mistaken
meniscus

Pressure

61

of the left lateral patellofemoral


joint as compared
to the right. There
on the lateral patellar facet. These findings are characteristic
of excessive

lateral
migration
of the patella
(7). Clinical
diagnosis
of
subluxation
is entirely
compatible
with a normal
radiographic
appearance,
and many normal menisci
have been
unnecessarily
removed
as a result of patellar
subluxation
and the associated
locking
of the
knee secondary
to
hamstring
spasm
(5). The McMurray
test may be falsely
positive
in these patients.
It has been shown that the patella

may reduce

JOINT

this problem

We thank Carol

is probably
the
missed
cause
of
of the PF joint can

in selected

Holcomb,

Merchant AC, Mercer AL, Jacobsen RH, et al:


Aoentgenographic
analysis of patellofemoral
congruence.
J Bone Joint Surg [Am]
56:1391-1396,
Oct 1974
Hughston JO:
Subluxation of the patella. J Bone Joint Sug [Am]
50:1003-1026,
Jul 1968
Laurin CA, L#{233}vesque
HP, Dussault A, et al:
The abnormal lateral
patellofemoral
angle: a diagnostic
roentgenographic
sign of recurrent patellar subluxation.
J Bone Joint Surg [Am] 60:55-60,

Jan 1978
Ficat AP, Hungerford DS:

Disorders of the Patello-Femoral

cases.

R.T., for her advice

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Baltimore,
Williams
and Wilkins,
1977, pp 22-50,
85-100,
123-148
Outerbridge
RE, Dunlop JA:
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of chondromalacia
patellae. Clin Orthop 110:177-196,
Jul-Aug
1975
Kaufer H: Mechanical
function of the patella. J Bone Joint Surg
[Am] 53:1551-1560,
Dec 1971
Larson AL, Cabaud HE, Slocum DB, et al:
The patellar cornpression syndrome:
surgical treatment
by lateral retinacular
release. Clin Orthop 134:158-167,
Jul-Aug.
1978
KoIbel A, Bergrnann
G, Aohlmann
A:
A technique
for reproducible roentgenograms
of the intercondylar
sulcus for the study
of the femoropatellar
joint. Z Orthop 117:60-66,
Feb 1979
InsalI J:
Chondromalacia
patellae:
patellar
malalignment
syndrome.
Orthop CIin North Am 10:1 17-127,
Jan 1979
Gruber MA:
The conservative
treatment
of chondromalacia
patellae. Orthop Clin North Am 10:105-1
15, Jan 1979
Bentley G: Chondromalacia
patellae. J Bone Joint Surg [Am]
52:221-232,
Mar 1970
Wiberg G: Aoentgenographic
and anatomic
studies on the
femoropatellar
joint, with special reference
to chrondromalacia
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Acta Orthop Scand 12:319-410,
1941
Stoug&rd J: Chondromalacia
of the patella. Incidence,
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Scand 46:809-822,
Nov 1975

Department
of Radiology
Medical Center Hospital
Burlington,
VT 05401

of Vermont