RE: doubled crossed patellar tendon

Hi,

 

Here is the summary of my inquiry about the crossed-doubled patellar tendon.

 

5x confident about prior tendon translocation surgery (Roux-Goldthwait procedure)

 

2x favouring an anatomical variant, citing the below reference from Loizides A et al., 2017

 

 

Coincidentally, today I have received new clinical information that my patient was treated surgically in the 90s for repeated patellar dislocation. Bingo, case solved!

 

In fact, I now have serious doubts about the existence of a doubled crossed patellar tendon anatomic variant and I would like to open for discussion based on the following:

 

 

While I think there is consensus about patellar tendon variants, like the one published here:

 

The uncrossed-doubled patellar tendon: A novel imaging finding

Syed Mohammed Ali Haydar, Jonathan Miles, Rikin Hargunani

Radiol Case Rep. 2019 Dec; 14(12): 1509–1512. Published online 2019 Oct 18. doi: 10.1016/j.radcr.2019.09.029

 

I do have serious concerns that the crossed-doubled patellar tendon, as it is performed by the Roux-Goldthwait procedure, actually exists as a variant because there is only 1 (one!) publication on this finding and it is referenced over and over again. The patient in this case report actually had 2x knee surgery for 'hemangioma', when the patient was 15 y/o! I find that suspicious and I have serious concerns about some missing information.     

 

A case of crossed-doubled patellar tendon: an atavistic variant, simple mutation or pathologic finding?

Alexander Loizides, Carmelo Messina, Bernhard Glodny, Leonhard Gruber, Erich Brenner, Hannes Gruber, Benjamin Henninger

Surg Radiol Anat. 2017; 39(1): 111–114. Published online 2016 Jun 15. doi: 10.1007/s00276-016-1706-x

 

 

So with all of that said, I am really wondering, if we in this wonderful community of MSK experts, could find a consensus if a crossed-doubled patellar tendon actually exists as a variant or not? I am not aware of this variant being described in any anatomical textbook and I have not seen any cases published or posted cases in children which I find very suspicious. Please correct me if I am wrong.

 I am neither bored, nor looking for trouble but if we agree this specific anatomic variant does not exist, I question if this case report can or should stand any longer because it confuses people who search for this and always come up with the same paper!

 

BTW, this topic had been brought up previously on OCAD on Feb. 27^th 2019 by Avneesh and others, also posting at least two other cases of doubled patellar tendon without known prior surgery. At least one case also had patellar malalignment! The colleagues are cc'd.

 

Modified Roux-Goldthwait Procedure for Management of Patellar Dislocation in Skeletally Immature Patients with Down Syndrome

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394190/

 

 

 

Enjoy RSNA!

 

 

Björn

 

 

 

From: ocad-msk@googlegroups.com <ocad-msk@googlegroups.com> On Behalf Of Björn Jobke
Sent: 25 November 2019 15:52
To: OCAD <ocad-msk@googlegroups.com>
Subject: doubled crossed patellar tendon

 

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Hello OCAD,

 

My mystery case of the year.

 

52 y/o pat.

 

Relevant Clinical History: Recurrent patellar dislocation, since giving way whilst standing. Had injection for her pain few years back. Her pain has come back and bothering her too much. Diffuse tenderness present

No other history available.

No X-ray.

 

http://www.claripacs.com/a.php?a=125&mode=simple

 

 

What's going on? Variant or unknown prior surgical procedure?

 

Björn

 

 

 

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Happy Thanksgiving!

I hope you appreciate the absurdity of the clinical request.  This is an endstage retracted plantar plate tear with button hole protrusion of the MT head through the defect and dorsal dislocation of the 2nd toe.  

The blue arrow indicates the retracted, torn plantar plate.  Notice the lateral dislocation of the Flexor tendons at the level of the MT/neck; typically the tendons are centered in a midline plantar groove in the plantar plate and stabilized by a flexor pulley.  White arrow indicates flexor tenosynovitis, due to pathologic communication between the MTPJ and the tendon sheath as a result of the plantar plate tear.

Here's my question, what is the Red Arrow pointing to?

That's the terminal plantar fascia. In the forefoot, deep distal fibers insert onto the plantar plate, but superficial fibers insert onto the dermis.  That's interesting, isn't it?

No history of trauma, acute onset of pain, reported as subhcondral fracture. 

Reported as normal

Reported as normal

There is new subtle smooth articular flattening visible in the Dunn view only

Is there real mixed lucency and sclerosis, or is this shine through of the acetabulum? Do you think there might be evolving AVN, or just subtle articular collapse related to prior fracture without AVN?  Would you recommend follow up MRI? Would you recommend DEXA?

Hypermobile discoid Lateral Meniscus in 9yo M with 2 mos posterior knee pain

There is posterocentral subluxation of the complete discoid LM with bright intrasubstance signal and expansion of the posterior horn region, but no visible surface defect.  Wrisberg (which doesn't look thick) inserts onto the PH region.          

   I cannot see popliteomeniscal fascicles, which I presume are developmentally absent. 

42 yo Skydiver took a "fall" last month...be careful Andrei!!!

There is extensive BME of the talar body and posterior superior calcaneus, with displaced osteochondral fracture of the calcaneus at the posterior subtalar joint margin (red arrow)

The talar body (black arrow) and lateral talar process fracture (white arrow) are much better seen on T1w
Lateral talar process fracture (aka snowboarder fracture); I have seen this in someone running away from the police who jumped off an elevated subway track....now in a Skydiver.  Not many snowboarders in my neighborhood. 

SLAP 3 tear and medial biceps pulley injury

SLAP 3 tear and medial biceps pulley injury (Habermeyer type 1)

29-year-old handball player with anterior shoulder pain, locking and snapping.

MR arthrography study shows thickening and irregularity of the medial aspect of the biceps pulley (coracohumeral and superior glenohumeral ligaments). Note also a longitudinal tear of the superior labrum ("bucket-handle" tear) best seen on coronal images.

Arthroscopic examination confirms the bucket-handle tear of the superior labrum associated with medial biceps pulley injury.

Treatment consisted of removal of the 'bucket-handle' segment,  biceps tenotomy, and tenodesis by arthroscopic transfer of the long head of the biceps tendon to the anterior aspect of the lateral conjoint tendon.