回复给编辑的信。

IF 5 2区 医学 Q1 ORTHOPEDICS
Simon Talbot
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None of these patients had a history of patella instability. Therefore, their arthritis is likely due to an imbalance in the forces acting on the patella rather that a history of previous injury. Indeed, this was demonstrated, with a strong association between quadricep malalignment and the presence of Lateral Facet PFJOA. In this study, the objective measures of trochlear anatomy (trochlear groove alignment and coronal orientation, trochlear ridge heights and lateralisation of the trochlear sulcus) were not significantly associated with Latera Facet PFJOA. This does not exclude the possibility that trochlear dysplasia may be present in patients with other patterns of PFJOA or in patients with a history of instability.</p><p>The letter further states that ‘papers have highlighted the (sic) trochlear dysplasia is the main aetiology of PFJOA’. While our research did not aim to answer this question, the statement requires examination. Upon reviewing the cited papers [<span>3, 4, 7</span>], it is evident this statement is not supported. None of the papers claim that trochlear dysplasia is the aetiology of PFJOA. Regarding the largest case series [<span>3</span>], it is important to note that the authors do not claim a causative effect of trochlear dysplasia on patella osteoarthritis. Rather, they highlight as a limitation that the research is a cross-sectional study and that ‘a longitudinal study is needed to better characterize the relationship between trochlear dysplasia and OA’. Furthermore, they state that ‘Patellofemoral OA could potentially lead to secondary trochlear remodeling, resulting in abnormal trochlear depth, abnormal facet ratio, and abnormal sulcus angle.’ It is interesting to note that [<span>3</span>] also concluded that there was a strong association between trochlear dysplasia and medial tibiofemoral degeneration, and a negative association with lateral tibiofemoral degeneration.</p><p>Mofidi et al. [<span>4</span>] examined trochlear dysplasia in patients undergoing isolated patellofemoral replacement (<i>n</i> = 18) and found a flatter trochlear angle (149° vs. 132°) at the level of the epicondyles compared to a control group. The authors also reported a high rate of patella alta, suggesting that this study group may have a history of patella instability. Finally, the study by Valoroso et al. 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Putting aside again the difficult concept of causation, we would like to point to the results of our large and comprehensive analysis of quadriceps alignment and bony anatomy in a normal (nonarthritic) population which was reported in the first section of our publication (see Talbot et al. [<span>6</span>]). This looked for any association between quadriceps alignment and trochlear groove shape, including the coronal alignment of the trochlear groove, the rotational alignment of the groove, the degree of lateralisation of the sulcus and the relative heights of the trochlear ridges. There was no association between quadriceps alignment and trochlear groove anatomy identified, so the suggestion that there may be a causative relationship between them is speculative and unfounded. This does not exclude the possibility that two or more independent deformities can occur together. 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引用次数: 0

摘要

再一次抛开因果关系的困难概念,我们想指出我们对正常(无关节炎)人群的股四头肌排列和骨骼解剖进行的大量全面分析的结果(见Talbot et al.[6])。该研究寻找股四头肌排列与滑车沟形状之间的任何关联,包括滑车沟的冠状排列、旋转排列、沟的偏侧程度和滑车脊的相对高度。没有发现股四头肌排列和滑车沟解剖之间的关联,因此认为它们之间可能存在因果关系的建议是推测性的和没有根据的。这并不排除两种或两种以上独立的畸形同时发生的可能性。这通常发生在髌骨不稳定的患者中,其中可能出现多发性畸形,如滑车发育不良,胫骨结节偏侧和股扭转,从而产生临床疾病。我们打算发表一项研究,记录股四头肌错位和髌骨不稳定之间的关系。我们向信的作者保证滑车形态将得到充分的评估。我们鼓励未来任何关于髌骨生物力学或不稳定性的研究,以同样充分地评估股四头肌的排列。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Reply to ‘Comment on “Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis”’

Reply to ‘Comment on “Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis”’

Reply to ‘Comment on “Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis”’

Reply to ‘Comment on “Quadriceps tendon malalignment is an independent anatomical deformity which is the primary abnormality associated with lateral facet patellofemoral joint osteoarthritis”’

We thank the authors of the Letter to the Editor for their commentary regarding our publication and their appreciation of the importance of quadriceps malalignment [1]. The concerns raised in the letter highlight some of the common confusions around the subtle differences between patella instability and patella arthritis. Trochlear dysplasia is a known risk factor for patella instability, and patients with instability and subsequent chondral damage have a high rate of patellofemoral joint osteoarthritis (PFJOA).

Our study identified a biomechanical deformity in the quadriceps mechanism due to an external rotation of the proximal quadriceps muscle around the shaft of the femur. To determine if this was a clinically relevant cause of patella maltracking we assessed it in a group of patients with severe patella maltracking leading to Lateral Facet PFJOA. None of these patients had a history of patella instability. Therefore, their arthritis is likely due to an imbalance in the forces acting on the patella rather that a history of previous injury. Indeed, this was demonstrated, with a strong association between quadricep malalignment and the presence of Lateral Facet PFJOA. In this study, the objective measures of trochlear anatomy (trochlear groove alignment and coronal orientation, trochlear ridge heights and lateralisation of the trochlear sulcus) were not significantly associated with Latera Facet PFJOA. This does not exclude the possibility that trochlear dysplasia may be present in patients with other patterns of PFJOA or in patients with a history of instability.

The letter further states that ‘papers have highlighted the (sic) trochlear dysplasia is the main aetiology of PFJOA’. While our research did not aim to answer this question, the statement requires examination. Upon reviewing the cited papers [3, 4, 7], it is evident this statement is not supported. None of the papers claim that trochlear dysplasia is the aetiology of PFJOA. Regarding the largest case series [3], it is important to note that the authors do not claim a causative effect of trochlear dysplasia on patella osteoarthritis. Rather, they highlight as a limitation that the research is a cross-sectional study and that ‘a longitudinal study is needed to better characterize the relationship between trochlear dysplasia and OA’. Furthermore, they state that ‘Patellofemoral OA could potentially lead to secondary trochlear remodeling, resulting in abnormal trochlear depth, abnormal facet ratio, and abnormal sulcus angle.’ It is interesting to note that [3] also concluded that there was a strong association between trochlear dysplasia and medial tibiofemoral degeneration, and a negative association with lateral tibiofemoral degeneration.

Mofidi et al. [4] examined trochlear dysplasia in patients undergoing isolated patellofemoral replacement (n = 18) and found a flatter trochlear angle (149° vs. 132°) at the level of the epicondyles compared to a control group. The authors also reported a high rate of patella alta, suggesting that this study group may have a history of patella instability. Finally, the study by Valoroso et al. [7] includes only 16 patients undergoing PFJ replacement and does not have a control group.

These papers do not constitute adequate evidence that trochlear dysplasia is the ‘main aetiology of PFJOA’ let alone that it is an important factor in the subgroup of patients with lateral facet PFJOA and no significant history of patella instability (as analysed in Talbot et al. [6]). In order to claim causation, longitudinal studies are required, and the three quoted references are cross-sectional studies.

Importantly Davis-Tuck et al. [2], and more recently Nair et al. [5] have shown an association between a wider (flatter) sulcus angle and a lower rate of development of PFJOA.

In a similar fashion, we have been careful to not claim that quadriceps malalignment causes Lateral Facet PFJOA, rather that there is a strong association between the presence of quadriceps malalignment and Lateral Facet PFJOA. While it is tempting to conclude that the increased pressure on the lateral facet of the patella caused by an externally rotated quadriceps musculature would cause Lateral Facet PFJOA, this can only be confirmed using a well-designed, adequately powered, longitudinal study.

With regard to the concerns raised as to the level at which we measured the trochlear groove, the three cited papers all measured the relative shape of the trochlear groove at the level of the epicondylar axis. This is the same level at which we measured it.

The final statement in the letter also requires examination. The suggestion is made that quadriceps malalignment could potentially be the ‘cause’ of trochlear bone morphology. Putting aside again the difficult concept of causation, we would like to point to the results of our large and comprehensive analysis of quadriceps alignment and bony anatomy in a normal (nonarthritic) population which was reported in the first section of our publication (see Talbot et al. [6]). This looked for any association between quadriceps alignment and trochlear groove shape, including the coronal alignment of the trochlear groove, the rotational alignment of the groove, the degree of lateralisation of the sulcus and the relative heights of the trochlear ridges. There was no association between quadriceps alignment and trochlear groove anatomy identified, so the suggestion that there may be a causative relationship between them is speculative and unfounded. This does not exclude the possibility that two or more independent deformities can occur together. This often happens in patients with patella instability in which multiple deformities, such as trochlear dysplasia, tibial tubercle lateralisation and femoral torsion, may occur to produce the clinical disorder.

We intend to publish a study documenting the association between quadriceps malalignment and patella instability. We reassure the author(s) of the letter that trochlear morphology will be adequately assessed. We encourage any future research into patella biomechanics or instability to similarly adequately assess quadriceps alignment.

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来源期刊
CiteScore
8.10
自引率
18.40%
发文量
418
审稿时长
2 months
期刊介绍: Few other areas of orthopedic surgery and traumatology have undergone such a dramatic evolution in the last 10 years as knee surgery, arthroscopy and sports traumatology. Ranked among the top 33% of journals in both Orthopedics and Sports Sciences, the goal of this European journal is to publish papers about innovative knee surgery, sports trauma surgery and arthroscopy. Each issue features a series of peer-reviewed articles that deal with diagnosis and management and with basic research. Each issue also contains at least one review article about an important clinical problem. Case presentations or short notes about technical innovations are also accepted for publication. The articles cover all aspects of knee surgery and all types of sports trauma; in addition, epidemiology, diagnosis, treatment and prevention, and all types of arthroscopy (not only the knee but also the shoulder, elbow, wrist, hip, ankle, etc.) are addressed. Articles on new diagnostic techniques such as MRI and ultrasound and high-quality articles about the biomechanics of joints, muscles and tendons are included. Although this is largely a clinical journal, it is also open to basic research with clinical relevance. Because the journal is supported by a distinguished European Editorial Board, assisted by an international Advisory Board, you can be assured that the journal maintains the highest standards. Official Clinical Journal of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).
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