title: Characterization of patellar maltracking using dynamic kinematic CT imaging in patients with patellar instability.
abstract: OBJECTIVE
  Little has been reported on the relationship between patellar maltracking and instability. Patellar maltracking has been subjectively described with the "J sign" but is difficult to assess objectively using traditional imaging. Dynamic kinematic computed tomography (DKCT) allows dynamic assessment of the patellofemoral joint. DKCT was used to visualize and quantify patellar maltracking patterns, and severity of maltracking was correlated with the presence or absence of patellar instability symptoms.
  
  
  METHODS
  Seventy-six knees in 38 patients were analysed using DKCT. Maltracking was defined as deviation of the patella from the trajectory of the trochlear groove and was characterized by patellar bisect offset, which was measured at 10° intervals of knee flexion during active flexion and extension. Bisect offset measurements were grouped by number of quadrants of maximum lateral patellar motion, with one, two, and three quadrants corresponding to 75-99, 100-125, and >125 %, respectively. Patellar instability symptoms were correlated with maltracking severity.
  
  
  RESULTS
  Two knees were excluded because of poor imaging quality. Fifty of 74 knees had patellar instability, and 13 patients had bilateral symptoms. Of these, four (8 %) had normal tracking patterns; 41 (82 %) had increased lateral translation in extension, which we termed the J-sign pattern; 4 (8 %) had persistent lateralization of the patella throughout range of motion; and 1 had increased lateral translation in flexion. In knees with the J-sign pattern, degree of maltracking was graded by severity: J1 (n = 24), J2 (n = 19), and J3 (n = 15). The sensitivities of J-sign grades in predicting patellar instability symptoms were 50 % (J1), 80 % (J2), and 93 % (J3) (p < 0.01). There were significant differences in sensitivity between knees with no J sign or J1 versus J2 or J3 (p = 0.02).
  
  
  CONCLUSIONS
  DKCT showed several patellar maltracking patterns in patients with patellar instability. A J-sign pattern with more than two quadrants of lateral translation correlated with the presence of patellar instability symptoms. Incorporation of this approach of objectively quantifying maltracking patterns is recommended in the evaluation of patellofemoral instability.
  
  
  METHODS
  IV.
authors.affiliation: Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline St. JHOC 5, Baltimore, MD, 21287, USA. Mtanaka4@jhmi.edu.
authors.forename: Miho J
authors.initials: MJ
authors.lastname: Tanaka
authors.affiliation: Department of Research, Cleveland Clinic Akron General, Akron, OH, USA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Elias
authors.affiliation: Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline St. JHOC 5, Baltimore, MD, 21287, USA.
authors.forename: Ariel A
authors.initials: AA
authors.lastname: Williams
authors.affiliation: Department of Radiology, The Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Shadpour
authors.initials: S
authors.lastname: Demehri
authors.affiliation: Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline St. JHOC 5, Baltimore, MD, 21287, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Cosgarea
mesh_terms: D000293:Adolescent; D000328:Adult; D001696:Biomechanical Phenomena; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000000981:diagnostic imaging* / Q000601:surgery; D007719:Knee Joint; D008297:Male; D010329:Patella / Q000000981:diagnostic imaging*; D057071:Patellofemoral Joint / Q000000981:diagnostic imaging* / Q000601:surgery; D010808:Physical Examination; D016059:Range of Motion, Articular; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D055815:Young Adult
keywords: Computed tomography; Dynamic imaging; Maltracking; Patellofemoral instability