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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Injury patterns of medial patellofemoral ligament and correlation

analysis with articular cartilage lesions of the lateral femoral condyle
after acute lateral patellar dislocation in adults: An MRI evaluation
Guang-ying Zhang a, Lei Zheng b, Yan Feng c, Hao Shi d, Wei Liu a, Bing-jun Ji b,
Bai-sheng Sun b, Hong-yu Ding a,*
a
Department of Ultrasonography, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan 250014, China
b
Department of Radiology, Shandong Provincial Corps Hospital of Chinese People’s Armed Police Force, Jinan 250014, China
c
Department of Radiology, Affiliated Hospital of Binzhou Medical College, Binzhou 256603, China
d
Department of Radiology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan 250014, China

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: The purpose of this study was to investigate the injury characteristics of medial
Accepted 28 September 2015 patellofemoral ligament (MPFL), and to analyse the correlations between the injury patterns of MPFL
and articular cartilage lesions of the lateral femoral condyle in adults with acute lateral patellar
Keywords: dislocation (LPD).
Lateral patellar dislocation Methods: Magnetic resonance (MR) images were prospectively obtained in 121 consecutive adults with
Knee acute LPD. Images were acquired using standardised protocols and these were independently evaluated
Medial patellofemoral ligament
by two radiologists.
Articular cartilage
Magnetic resonance imaging
Results: Forty-eight cases of partial MPFL tear and 71 cases of complete MPFL tear were identified.
Injuries occurred at an isolated femoral attachment (FEM) in 48 cases, an isolated patellar insertion (PAT)
in 36 cases and an isolated mid-substance (MID) in five cases. More than one site of injury to the MPFL
(COM) was identified in 30 cases.
The prevalence rate of chondral and osteochondral lesions of the lateral femoral condyle were 4.2%
(2/48) and 6.3% (3/48) in the FEM subgroup, 19.4% (7/36) and 22.2% (8/36) in the PAT subgroup and 6.7%
(2/30) and 13.3% (4/30) in the COM subgroup, respectively. The PAT subgroup showed significantly
higher prevalence rate of chondral and osteochondral lesions in the lateral femoral condyle when
compared with the FEM subgroup.
The prevalence rate of chondral and osteochondral lesions of the lateral femoral condyle were 8.5%
(6/71) and 19.7% (14/71) in the complete MPFL tear subgroup and 10.4% (5/48) and 4.2% (2/58) in the
partial MPFL tear subgroup, respectively. The subgroup of the complete MPFL tear showed significantly
higher prevalence rate of osteochondral lesions in the lateral femoral condyle when compared with the
subgroup of the partial MPFL tear.
Conclusions: Firstly, the MPFL is most easily injured at the FEM, and secondly at the PAT in adults after
acute LPD. The complete MPFL tear is more often concomitant with osteochondral lesions of the lateral
femoral condyle than the partial MPFL tear. The isolated patellar-sided MPFL tear is more easily
concomitant with chondral lesions and osteochondral lesions of the lateral femoral condyle than the
isolated femoral-sided MPFL tear.
ß 2015 Elsevier Ltd. All rights reserved.

Introduction

Acute lateral patellar dislocation (LPD) is a common injury that

* Corresponding author at: Department of Ultrasonography, Shandong Provincial
Qianfoshan Hospital of Shandong University, 16766 Jingshi Rd, Li-Xia District,
250014 Jinan, China. Tel.: +86 18663733771; fax: +86 0531 8296 3647.
E-mail address: qydinghy@163.com (H.-y. Ding).
typically occurs in young, active patients as a result of a variety of
activities, which accounts for approximately 2–3% of all knee
injuries [1]. This injury may result in numerous lesions, including

http://dx.doi.org/10.1016/j.injury.2015.09.025
0020–1383/ß 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025
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articular cartilage lesions of the lateral femoral condyle and medial
patella, medial patellofemoral ligament (MPFL) tears and so on
[2–12]. Although the evaluation of MPFL tears after LPD in adults
has been described in a few papers, there still remains some
conflicts about the main rupture location of the MPFL [6–10]. Since
many authors advocate the treatment methods should be changed
based on the different injury locations of the MPFL, the
identification of MPFL injury locations appears to be of essential
clinical value [7,13–16]. Although there were some studies about
articular cartilage lesions of the inferomedial patella and lateral
femoral condyle [2,4,5,7,8,10,12,17], there were no studies concen-
trating on the correlations between the injury patterns of the MPFL
and articular cartilage lesions of lateral femoral condyle in adults.
Articular cartilage lesions and MPFL injury patterns (including
injury types and locations) are important factors to be considered for
treatment strategies [7,8,11,13–17]. Therefore, we undertook this
prospective magnetic resonance imaging (MRI) study to investigate
the injury characteristics of the MPFL, as well as the correlations
between the injury patterns of the MPFL and articular cartilage
lesions of the lateral femoral condyle after acute LPD in adults.
Materials and methods
Patients
This study was approved by our institutional ethics committee,
and informed consent was obtained from all patients.
Patients were eligible for inclusion if they were 18 years of age
and had suffered an acute, first-time LPD regardless of injury
mechanism.
We used the following inclusive selection criteria:
1. The presence of locked acute dislocation or history of reduced
dislocation within 15 days of the injury.
2. Typical clinical findings: haemarthrosis, medial parapatellar
structures and femoral epicondyle painful on palpation, and
apprehension sign (except in locked dislocation).
3. Bone contusion involving both the lateral femoral condyle and
the medial patella demonstrated on MRI.
Exclusion criteria included previous surgery on the injured
knee, conditions associated with serious neuromuscular or
congenital diseases, patellar dislocation or symptoms of patellar
instability in the affected knee prior to the acute lesion and
nontraumatic patellar dislocation (e.g., dislocation during gait or
squatting with moderate stress on the knee, resulting in
dislocation without acute pain in the knee). Patients over
45 years of age were excluded in order to avoid factors of
osteoarthritis in the patellofemoral joint. In addition, when no
distinct fibres or remnants were identified at the expected MPFL
course on MR images, and there was no appreciable surrounding
oedema, the ligament was designated as absent and excluded
from the study.
By the criteria mentioned above, there were 121 knees of
121 consecutive patients (69 women and 52 men; mean age,
25 years; range, 18–44 years) who were enrolled in the study.
MRI technique
The MRI was performed using the Magnetom Symphony Syngo
MR A30 (Siemens, Erlangen, Germany), and all the patients
underwent the imaging with their knees positioned in full
extension. The following sequences were obtained: a transverse
fat-saturated proton-density weighted fast spin-echo imaging
sequence (repetition time/echo time, 4500 ms/33 ms; flipangle,
1508; field of view, 160 mm  160 mm; section thickness, 3.0 mm)
Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025
was followed by a coronal fat-saturated proton density (2000/15;
field of view, 150 mm; matrix, 320  224 pixels; slice thickness,
3.0 mm; skip, 0.3 mm), a sagittal proton density (1950–2766/14;
field of view, 140–150 mm; matrix range, 320–384  192–224
pixels; slice thickness, 3.0 mm; skip, 0.3 mm), a sagittal fat-saturated
proton density (2650–4366/13–16; field of view, 140–150 mm;
matrix range, 256–384  224–256; slice thickness, 3.0 mm; skip,
0.3 mm), and a sagittal T2 (3700–4766/80–87; field-of-view
range, 140–150 mm; matrix range, 320–384  224; slice thickness,
3.0 mm; skip, 0.3 mm).
MRI evaluation
The MR images were analysed independently by two experi-
enced radiologists who had 12 and 15 years of clinical experience
each in musculoskeletal radiology, and who were both unaware of
the results of previous imaging interpretations. All of the images
were read in a non-selected order, and the readers were blinded to
patient information. The conclusions of each radiologist were
initially recorded. In the event of disagreement, the images were
then reviewed to reach consensus.
Using diagnostic classification criteria from Elias and Zhang [2–
5], the MPFL injuries were divided into partial and complete tears.
The manifestations of the partial MPFL tear were defined as
thickening and irregularity of the contour, including discontinuity
of normal fibres, and intra-ligamentous or extensive periligamen-
tous oedema. The manifestations of the complete MPFL tear were
defined as fibres in the expected region of the MPFL being
completely discontinuous or appearing absent, with extensive
surrounding oedema.
The partial or complete disruption of the MPFL was evaluated in
three locations: at its patellar insertion (PAT), its mid-substance
(MID) and its femoral attachment (FEM), including avulsion-type
fracture at PAT or FEM. Injuries occurred simultaneously in more
than one location of the MPFL were classified as combined injury
[2,3,5–7,9].
Articular cartilage lesion was divided into chondral lesion and
osteochondral lesion [18]. The chondral lesion was defined as a
partial-thickness defect with a depth of <100% of the thickness of
articular cartilage without the exposure of the subchondral bone
or a full-thickness defect with exposed but otherwise intact
subchondral bone. An osteochondral lesion was defined as
full-thickness chondral abnormalities with underlying cortical
defect.
Trochlear dysplasia, dysplasia of the femoral trochlea, was
categorised to type A (fairly shallow trochlea), type B (flat or
convex trochlea), type C (asymmetry of the trochlea facets: lateral
trochlea convex and medial facet hypoplastic) and type D
(asymmetry of the trochlea facets, vertical joint and cliff pattern)
in conformity with Dejour [19].
Statistical analysis
Data analysis was performed using Statistical Package for the
Social Sciences (SPSS) software (SPSS Inc., Chicago, IL, USA). A
kappa statistic was used to assess inter-observer agreement for
MRI studies to depict the MPFL lesions and the articular cartilage
lesions of the lateral femoral condyle. The kappa value was
interpreted as follows: poor agreement, <0.2; fair agreement,
0.2–0.4; moderate agreement, 0.4–0.6; good agreement, 0.6–0.8
and very good agreement, 0.8–1.
A statistical analysis was performed utilising the Chi-squared
test to define the relationship between the injury patterns of the
MPFL and articular cartilage lesions of the lateral femoral condyle
in adults after acute LPD. A P-value of <0.05 was considered
statistically significant.
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Results
MPFL injury
Injury to the MPFL was found in 98.3% of the patients (119 of 121)
after acute LPD, including 48 cases of partial MPFL tear (Figs. 1
and 2A) and 71 cases of complete MPFL tear (Figs. 3A, 4A and 5A).
For the remaining two patients, no obvious MPFL injury was
identified.
Injury to the MPFL occurred at an isolated FEM in 48 patients
(39.7%) (Figs. 1 and 3A), an isolated PAT in 36 patients (29.8%)
(Figs. 2A and 4A) and an isolated MID in five patients (4.1%). In
24.8% (30 of 121) of cases, more than one site of injury to the MPFL
was identified (COM), including 16 cases of combined MPFL injury
at the FEM and the PAT (Fig. 5A); eight cases of injury at the FEM
and the MID; four cases of injury at the PAT and the MID; two cases
of injury at the FEM, the MID and the PAT.
According to the injury patterns of the MPFL (injury locations
and injury types), the study group was divided into two subgroups
for further analyses: subgroup of injury locations: FEM, PAT and
COM, and subgroup of injury types: partial tear and complete tear.
The patients with an isolated lesion at the MID of the MPFL (five
patients) were excluded from the statistical analysis of the
subgroup of injury locations.
The subgroups were considered parametric in relation to age
and sex, showing that there are no differences in terms of the
statistical analysis.
Trochlear dysplasia
Normal patellofemoral anatomy was observed in 78 patients
(65.5%) in the MPFL tear group. In the remaining patients, the
distribution was as follows: type A, 16% (n = 19); type B, 10.9%
(n = 13); type C, 5.9% (n = 7); and type D, 1.7% (n = 2).
In the partial MPFL tear subgroup, there were eight cases of type
A trochlear dysplasia, seven cases of type B trochlear dysplasia,
four cases of type C trochlear dysplasia and one case of type D
trochlear dysplasia. In the complete MPFL tear subgroup, there
were 11 cases of type A trochlear dysplasia, six cases of type B
trochlear dysplasia, three cases of type C trochlear dysplasia and
one case of type D trochlear dysplasia.
In the FEM subgroup, there were eight cases of type A trochlear
dysplasia, five cases of type B trochlear dysplasia, three cases of
type C trochlear dysplasia and one case of type D trochlear
Fig. 1. A 22-year-old man was diagnosed with partial MPFL tear at its femoral
attachment. The axial MR image shows the partial MPFL tear at its femoral
attachment (white arrow).
Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025
3
dysplasia. There were six cases of type A trochlear dysplasia, four
cases of type B trochlear dysplasia and three cases of type C
trochlear dysplasia in the PAT subgroup. There were five cases of
type A trochlear dysplasia, three cases of type B trochlear dysplasia
and one case of type C trochlear dysplasia in the COM subgroup;
and one case of type B trochlear dysplasia and one case of type D
trochlear dysplasia in the MID subgroup.
There were no significant differences between the injury
patterns of the MPFL (injury types and injury locations) regarding
the distributions of trochlear dysplasia (x2 = 1.853, P = 0.173;
x2 = 0.325, P = 0.85).
The statistical analyses between the injury patterns of the MPFL
(injury types and injury locations) and trochlear dysplasia are
shown in Tables 1 and 2.
Correlation analyses between the MPFL injury patterns and articular
cartilage lesions of the lateral femoral condyle
Twenty-seven cases of articular cartilage lesions of the lateral
femoral condyle were identified by MRI, including 11 cases of
chondral lesions (Fig. 2 and Fig. 3) and 16 cases of osteochondral
lesions (Fig. 4 and Fig. 5). The prevalence rate of articular cartilage
lesions of the lateral femoral condyle was 22.3%, and the
prevalence rate of chondral lesions and osteochondral lesions
were 9.1% and 13.2%, respectively.
The statistical analyses between the injury patterns of the MPFL
and articular cartilage lesions of the lateral femoral condyle are
shown in Tables 3 and 4. The difference in the prevalence rate of
osteochondral lesions of the lateral femoral condyle was found to
be statistically significant between the partial and complete MPFL
tear subgroups (Table 3). The differences in the prevalence rate of
chondral lesions and osteochondral lesions of the lateral femoral
condyle were found to be statistically significant between the FEM
and PAT subgroups (Table 4).
Kappa analysis of MRI determinations between two blinded
observers yielded values of 0.743 for the MPFL injury types,
0.841 for the MPFL injury locations and 0.702 for articular cartilage
lesions of the lateral femoral condyle, indicating good, very good
and good concordance, respectively.
Discussion
The most important passive restraint against LPD is the MPFL,
which accounts for 50–60% of the total restraining force against
LPD [20–24]. The MPFL injury occurred in up to 96–100% in adults
after acute LPD [6–9]. Injury to the MPFL may reduce passive
stability and predict subsequent instability with non-operative
treatment, and these have led to an increase in initial management
by operative repair or reconstruction of the MPFL [7,16,25–
28]. However, the main rupture location of the MPFL in the case of
LPD in adults remains debatable. Balcarek studied 21 adults after
acute LPD, and he found that the prevalence rate of the MPFL injury
was 100%, including 62% of the MPFL disruption occurred at its
FEM, 19% occurred at the PAT, 14% occurred at the MID, 5%
occurred at multiple sites [6]. The findings of the MPFL will more
likely rupture at the FEM after an acute LPD in adults was also
supported by several studies [7–9]. However, Paakkala evaluated a
series of 23 adults after acute LPD and found that the MPFL injury
located at the PAT in 16 cases (69.6%), occurred at the MID in
11 cases (47.8%) and occurred at the FEM in 15 cases (65.2%)
[10]. But Paakkala did not mention the incidence rate of the
combined MPFL injury and its injury locations in detail. Our study
result was consistent with previous studies that the MPFL was
more easily to be injured at the FEM in adults, followed by the PAT,
which was not consistent with previous research results in
children and adolescents [5,29–32]. The distribution of the MPFL
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Fig. 2. A 20-year-old man was diagnosed with partial MPFL tear at its patellar insertion and chondral lesion at the lateral femoral condyle. (A) The axial MR image shows
the partial MPFL tear at its patellar insertion (white arrow). (B) The sagittal MR image shows a full-thickness chondral defect (white arrow) located anterior to the anterior
margin of the anterior horn of the lateral meniscus. (C) The coronal MR image shows a full-thickness chondral defect (white arrow) located in the anterior aspect of the
lateral femoral condyle.

injury location may be relevant to the anatomy of the MPFL in
adults. When traced from the adductor tubercle to the super-
omedial border of the patella, the MPFL widens near the patellar
attachment and blends anteriorly with the vastus medialis
obliquus (VMO) before inserting on the superomedial border of
the patella and is reinforced by the tendon of the VMO muscle
[33,34]; hence, the femoral attachment is the weakest part of the
MPFL and most likely to be injured in adults. In addition, although
the patellar insertion of the MPFL is reinforced by the tendon of the
VMO muscle, but we supposed that the MPFL injury at the isolated
PAT is caused by the combined force of the distraction force and
shearing force, whereas the MPFL injury at the isolated MID or FEM is
caused by the distraction force only [5]. It is likely therefore that the
shearing force applied to the PAT is greater than that of the MID and
the FEM, so the MPFL is also easily to be injured at its PAT in adults.
During the dislocation and reduction stages, the medial patella
strikes against the lateral femoral condyle, thus giving rise to the
high incidence and typical locations of cartilaginous defects [5–
7,35,36]. Sillanpää evaluated a series of 53 adults after acute LPD,
and he found that the prevalence rate of chondral lesions of the
femoral condyle was 19%. But Sillanpää did not report the
incidence rate of the osteochondral lesions of the lateral femoral
condyle, and he reported that the total incidence rate of
osteochondral lesions of the patellofemoral joint was 28%
[7]. Balcarek reported a 4.8% incidence of osteochondral lesion
involving the lateral femoral condyle following an acute LPD in
adults. But Balcarek did not report the chondral lesions of the
lateral femoral condyle, and he reported that the total incidence
rate of the chondral lesions of the patellofemoral joint was 19%
[6]. Sanders evaluated a series of 25 patients after acute LPD, and
he found 6 cases of articular cartilage lesions of the lateral femoral
condyle in adults [36]. Our study showed that the prevalence rate
of articular cartilage lesion in the lateral femoral condyle was
22.3% and the prevalence rate of osteochondral lesion was 13.2%,
which was slightly lower than Sanders’s study but higher than
Balcarek’s study. This might be related to the selections of the
patients in the studies. All patients in Sanders’s study underwent
surgical treatment, so the injury degree might be more serious
[36]. Therefore, the incidence rate of articular cartilage lesions of
the lateral femoral condyle was also higher than that of our study.
The injury degree in Balcarek’s study was perhaps relatively lighter
than that in our study group, such as the incidence rates of the
complete MPFL tear and the combined MPFL injury were all lower
than that of our study [6].
To our knowledge, studies concerning the relationships
between the injury patterns of the MPFL and articular cartilage
lesions of the lateral femoral condyle in adults have not been
reported up to now. There was only one study reported that the
occurrence of the initial chondral lesions of the femur and the
occurrence of the initial osteochondral lesions of the patellofe-
moral joint were all not related to any MPFL injury locations in
adults [7]. But 53 cases were all complete MPFL tears in Sillanpää’s
study, including 24 cases of combined MPFL injury. In addition,
most of the MPFL injuries occurred at its femoral attachment, while
rarely occurred at the isolated PAT or MID in that study. So we
believe that the differences mentioned above may lead to different
results. Our study results showed that the prevalence rates of the
chondral and osteochondral lesions of the lateral femoral condyle

Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025
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G.-y. Zhang et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx 5

Fig. 3. A 25-year-old man was diagnosed with complete MPFL tear at its femoral attachment and chondral lesion at the lateral femoral condyle. (A) The axial MR image shows
the complete MPFL tear at its femoral attachment (white arrow). Note the articular cartilage lesions of the patella (black arrow). (B) The sagittal MR image shows a cleft-like
chondral lesion (white arrow) of the lateral femoral condyle. Note the thinning of the articular cartilage around the cleft. (C) The coronal MR image shows a cleft-like chondral
lesion (white arrow) in the corresponding area of the lateral femoral condyle.

between two locational subgroups of the MPFL injury (PAT
subgroup and FEM subgroup) were statistically different. We
supposed that the MPFL injury at the isolated PAT is caused by the
combined force of the distraction force and shearing force, whereas
the MPFL injury at the isolated FEM is caused by the distraction
force only. It is likely therefore that the shearing force applied to
the PAT is greater than that of the FEM. Although the articular
cartilage lesions of the lateral femoral condyle are mostly caused
by the shearing force, the MPFL injury at the PAT is more easily
concomitant with articular cartilage lesions of the lateral femoral
condyle, including chondral and osteochondral lesions [5]. How-
ever, the anatomy of the patellofemoral joint and the injury
mechanisms of LPD are not yet fully understood. Hence, further
studies are needed to confirm our hypotheses.
Our study results showed that there was no significant
difference between the partial and complete MPFL injuries with
respect to the prevalence rate of chondral lesions of the lateral
femoral condyle after acute LPD, but the prevalence rate of
osteochondral lesions between the two types of the MPFL injuries
discussed above was statistically significant. The reason might be
consistent with the injury mechanism of Zhang and Zheng’s study
discussed previously [3,5]. The more powerful shift force and
distraction force applied to the MPFL was, the more severe damage
might occur to the MPFL; and the more powerful shearing force
and impaction force applied to the lateral femoral condyle, the
more severe injuries (e.g., osteochondral lesions) to the articular
cartilage of the lateral femoral condyle. The finding suggests that
the radiologist should carefully evaluate the articular cartilage of
the lateral femoral condyle with the complete MPFL injury in MR
examination because osteochondral lesion might occur more
frequently in this case, compared with the partial MPFL injury.
There are various kinds of effective methods aiming at
osteochondral lesions or full-thickness chondral lesions of the
articular cartilage, including fixation techniques, bone-marrow
stimulation techniques, osteochondral grafting (autograft and
allograft) and autologous chondrocyte implantation (ACI), whereas
there is a lack of effective methods for partial-thickness chondral
defects [37–47]. Hence, the identification of osteochondral lesions
may be of more significant value in clinical treatment selection.
When the complete MPFL tear or patellar-sided MPFL tear is
identified in MRI, the radiologists should be more careful to
observe the articular cartilage of the lateral femoral condyle to
confirm whether there is an osteochondral fracture or a full-
thickness chondral fracture, and vice versa. When a complete MPFL
rupture or patellar-sided MPFL tear is identified on MRI scan, it
might be worthwhile for orthopaedic surgeons to apply arthros-
copy or arthrotomy to make a more accurate assessment of the
degree of damage of the MPFL and the articular cartilage of the
lateral femoral condyle. If an osteochondral or a full-thickness
chondral lesion occurs, not only MPFL repair or reconstruction but
also cartilage repair may be needed at the same time. When the
patellar-sided MPFL injury was identified on MRI, the radiologists
or orthopaedic surgeons should also be more careful to observe
whether there are chondral lesions of the lateral femoral condyle
even though no osteochondral lesions were identified. Previous
studies showed that abnormal loading of the cartilage may lead to
chondropathy and degenerative disease over time [48,49], so more
effective and long-term treatment was needed for the patients

Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025
G Model
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6 G.-y. Zhang et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx

Fig. 4. A 20-year-old woman was diagnosed with complete MPFL tear at its patellar insertion and osteochondral lesion at the lateral femoral condyle. (A) The axial MR image
shows the complete MPFL tear at its patellar insertion (white arrow). (B) The sagittal MR image shows a full-thickness defect of the cartilage with underlying cortical defect
(white arrow) located anterior to the anterior margin of the anterior horn of the lateral meniscus. (C) The coronal MR image shows a full-thickness defect of the cartilage with
underlying cortical defect (white arrow) located anterior to the anterior margin of the anterior horn of the lateral meniscus. Note the loose body of the osteochondral lesion of
the lateral femoral condyle (black arrow).

with chondral lesions at the lateral femoral condyle, especially at
the weight-bearing region.
The study did have some limitations. Firstly, the injury patterns
of the MPFL and articular cartilage lesions were not evaluated
surgically but based on the MRIs only; therefore, we were unable to
determine the accuracy of these MRI findings. Nonetheless,
previous studies have shown that MRI is an accurate method for
the diagnosis of injury patterns of the MPFL and articular cartilage
lesions of the patellofemoral joint after acute LPD [3,35]. Our study
results also showed that the inter-observer agreement was good
for the evaluation of injury types of the MPFL, very good for the
evaluation of injury locations of the MPFL and good for the
evaluation of the articular cartilage lesions of the lateral femoral
condyle. Therefore, we believe that our study can be carried out
based on the MR images. Secondly, we did not make a quantitative
analysis between the injury patterns of the MPFL and the size of the
articular cartilage lesion of the lateral femoral condyle, which
might be more useful in clinical applications. Thus, a further study
is to be carried out by focusing on this point in the next stage.
Thirdly, it was hard to distinguish osteochondral fracture from the
lesion of the osteochondritis dissecans. Nonetheless, previous
studies have shown that osteochondritis dissecans most common-
ly involves the medial femoral condyle and rarely involves the
lateral femoral condyle [50]. In addition, osteochondritis dissecans
of the patellofemoral joint characteristically occurs where the
lateral femoral condyle contacts the lateral facet of the patella [51],
which is different from the lateral patellar dislocation. And all the
cases in our study had bone contusion involving both the lateral
femoral condyle and the medial patella, but no one had bone
contusion involving the lateral patella on MRI. Moreover, all of the
inclusive patients with articular cartilage lesion of the lateral
femoral condyle also had articular cartilage lesion in the
inferomedial patella. And all selected were burst knee injury
rather than long-term chronic knee pain. Therefore, although it
was hard to distinguish osteochondral fracture from the lesion of
the osteochondritis dissecans, we still believe that the MRI
diagnosis of osteochondral fracture of the lateral femoral condyle
can be carried out based on the factors mentioned above. A study
with more rigorous inclusion criteria is needed to confirm our
results. Fourthly, there is no consideration of mechanism of MPFL
injury in our study. Different injury mechanisms maybe the
important reason why the injury patterns of MPFL differ from
one study to another. Lateral patellar dislocation typically occurs in
teenagers and young adults involved in athletic activities and results
from a twisting motion of the knee while the knee is in a state of
flexion. But patella dislocation and reduction are instantaneous, it is
hard for the patients to describe the injury actions in detail. Thus, a
further study is to be carried out by focusing on this point in the next
stage. Lastly, the cartilage-specific sequences were not applied in the
MR examinations, such as spoiled gradient-recalled echo and fast
low-angle shot sequences, which provide a high spatial resolution
and have therefore been described as being useful in segmenting
techniques for quantitative cartilage studies. However, the dis-
advantages of these sequences are a high sensitivity to susceptibility
artefacts and a limited visualisation of the subchondral bone,
menisci and ligaments [35,52,53]. Previous reports also showed that
1.5 T MRI with fat-suppressed fast spin-echo proton-density-
weighted sequences can be used to evaluate the cartilage of the

Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025
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G.-y. Zhang et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx 7

Fig. 5. A 35-year-old woman was diagnosed with combined MPFL injury and osteochondral lesion at the lateral femoral condyle. (A) The axial MR image shows the combined
injury of the MPFL with complete tear at its patellar insertion (white arrow) and femoral attachment (black arrow). (B) The sagittal MR image shows a small osteochondral
defect (white arrow) located anterior to the anterior margin of the anterior horn of the lateral meniscus. (C) The coronal MR image shows a small osteochondral defect (white
arrow) located in the anterior aspect of lateral femoral condyle.

knee with accuracy comparable to that of other cartilage-specific articular cartilage lesions in our study. Of course, a further study
sequence protocols [35,54,55]. In the current study, we used fat- based on the surgical results is needed to confirm our study results.
saturated proton-density-weighted fast spin-echo sequences with a In summary, our results suggest the following:
3-mm slice thickness in transverse, sagittal and coronal planes. Our
study result also showed that the inter-observer agreement was 1. The MPFL injuries and articular cartilage lesions of the lateral
good for the evaluation of articular cartilage lesions of the lateral femoral condyle are common sequelae in adults after acute LPD.
femoral condyle. So we believed that it was feasible to assess
Table 3
Statistical analysis between subgroup of MPFL injury types and articular cartilage
Table 1 lesions of the lateral femoral condyle.
Statistical analysis between MPFL injury types and trochlear dysplasia.
MPFL injury type Chondral lesion (%) Osteochondral lesion (%)
MPFL injury type Trochlear dysplasia
Partial MPFL tear 10.4 (5/48) 4.2 (2/48)
No Yes Complete MPFL tear 8.5 (6/71) 19.7 (14/71)
Chi-square test x2 = 0.132, P = 0.716 x2 = 5.952, P = 0.015
Partial 28 20
Complete 50 21

Chi-square test x2 = 1.853, P = 0.173 Table 4

Statistical analysis between subgroup of MPFL injury locations and distributions of
articular cartilage lesions of the lateral femoral condyle.

MPFL injury location Articular cartilage

Table 2
Statistical analysis between MPFL injury locations and trochlear dysplasia. Normal (%) Chondral Osteochondral
lesions (%) lesions (%)
MPFL injury location Trochlear dysplasia
PAT 58.3 (21/36) 19.4 (7/36)a 22.2 (8/36)a
No Yes FEM 89.6 (43/48) 4.2 (2/48) 6.3 (3/48)
PAT 23 13 Combined 80 (24/30) 6.7 (2/30) 13.3 (4/30)
FEM 31 17
Chi-square test x2 = 12.7, P = 0.019
Combined 21 9
Note: The patients with an isolated lesion at the mid-substance (five patients) were
Chi-square test x2 = 0.325, P = 0.85 excluded from the statistical analysis.
a
Note: The patients with an isolated lesion at the mid-substance (five patients) were Significant difference compared with the isolated femoral attachment injury
excluded from the statistical analysis. subgroup.

Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025
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JINJ-6392; No. of Pages 9
8 G.-y. Zhang et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Firstly, the MPFL is most easily injured at the FEM, and secondly
at the PAT.
2. The complete MPFL tear is more easily concomitant with
osteochondral lesions of the lateral femoral condyle than the
partial MPFL tear after acute LPD in adults.
3. The isolated patellar-sided MPFL tear is more easily concomitant
with chondral lesions and osteochondral lesions of the lateral
femoral condyle than the isolated femoral-sided MPFL tear after
acute LPD in adults.
Conflict of interest
The authors declared no conflict of interest. No external funding
was received in the study.
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Please cite this article in press as: Zhang G-y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with
articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: An MRI evaluation. Injury
(2015), http://dx.doi.org/10.1016/j.injury.2015.09.025