Even though the vascular supply of the human patella has been object of numerous studies until now, none of them has described in detail the rich arterial supply provided via the infrapatellar fat pad (of Hoffa). Therefore, we aimed to complete the knowledge about this interesting and clinically relevant topic. Five human patellae taken from voluntary body donators were studied at the Department of Applied Anatomy of the Medical University of Vienna. One was dissected under the operation microscope, a second was made translucent by Sihlers-solution, and three underwent angiography using a 3D X-ray unit. The results revealed that the patella to a considerable amount is supplied by arteries coursing through the surrounding parts of the infrapatellar fat pad. The latter were found to branch off from the medial and lateral superior and inferior genicular arteries. Within the infrapatellar fat pad, these arteries formed a dense network of anastomoses which are all contributing to the viability of the patellar bone. Due to the rich arterial supply reaching the patella via the infrapatellar fat pad, it seems advisable to preserve the fat pad during surgery of the knee in order to reduce the risk of vascular impairment of the patella. 1. Introduction The infrapatellar fat pad (of Hoffa) is located in the anterior compartment of the knee joint and is bordered by the inferior pole of the patella, the patellar retinacula, the patellar tendon, the anterior part of the tibia, the anterior horns of the menisci, and the femoral condyles. Further, it is attached to the intercondylar notch of the femur by the infrapatellar synovial plica also referred to as ligamentum mucosum [1]. Because of its high amount of nerve endings, the infrapatellar fat pad may become source of anterior knee pain. As reported by Bennell et al., the application of hypertonic saline into the fat pad led to pain experience in healthy volunteers [2]. In rare cases, tumour-like lesions of the infrapatellar fat pad such as osteochondroma, pigmented villonodular synovitis, synovial cysts [3], and vascular malformation [4] may lead to anterior knee pain. Furthermore, the infrapatellar fat pad may be affected by postarthroscopic alterations, postsurgery fibrosis, and shear injuries [5]. As reported by Bohnsack et al., the fat pad plays a role in stabilizing the knee joint in the extremes of motion, especially during flexion angles of less than 20° and greater than 100° [6]. Due to surgical demand, it is often removed or at least partially resected during surgery in order to improve visibility to the
References
[1]
J. Gallagher, P. Tierney, P. Murray, and M. O'Brien, “The infrapatellar fat pad: anatomy and clinical correlations,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 13, no. 4, pp. 268–272, 2005.
[2]
K. Bennell, P. Hodges, R. Mellor, C. Bexander, and T. Souvlis, “The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad,” Journal of Orthopaedic Research, vol. 22, no. 1, pp. 116–121, 2004.
[3]
H. Nouri, F. Ben Hamida, M. Ouertatani et al., “Tumour-like lesions of the infrapatellar fat pad,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 18, pp. 1391–1394, 2010.
[4]
R. B. Comert, U. Aydingoz, O. A. Atay, G. Gedikoglu, and M. N. Doral, “Vascular malformation in the infrapatellar (Hoffa's) fat pad,” Knee, vol. 11, no. 2, pp. 137–140, 2004.
[5]
J. A. Jacobson, L. Lenchik, M. K. Ruhoy, M. E. Schweitzer, and D. Resnick, “MR imaging of the infrapatellar fat pad of hoffa,” Radiographics, vol. 17, no. 3, pp. 675–691, 1997.
[6]
M. Bohnsack, C. Hurschler, T. Demirtas, O. Rühmann, C. Stukenborg-Colsman, and C. J. Wirth, “Infrapatellar fat pad pressure and volume changes of the anterior compartment during knee motion: possible clinical consequences to the anterior knee pain syndrome,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 13, no. 2, pp. 135–141, 2005.
[7]
D. E. Kayler and D. Lyttle, “Surgical interruption of patellar blood supply by total knee arthroplasty,” Clinical Orthopaedics and Related Research, no. 229, pp. 221–227, 1988.
[8]
D. Kohn, S. Deiler, and M. Rudert, “Arterial blood supply of the infrapatellar fat pad. Anatomy and clinical consequences,” Archives of Orthopaedic and Trauma Surgery, vol. 114, no. 2, pp. 72–75, 1995.
[9]
S. S. Shim and G. Leung, “Blood supply of the knee joint: a microangiographic study in children and adults,” Clinical Orthopaedics and Related Research, vol. 208, pp. 119–125, 1986.
[10]
M. H. Kirschner, J. Menck, A. Nerlich, R. Walser, V. Bühren, and G. O. Hofmann, “The arterial blood supply of the human patella: its clinical importance for the operating technique in vascularized knee joint transplantations,” Surgical and Radiologic Anatomy, vol. 19, no. 6, pp. 345–351, 1997.
[11]
R. Scapinelli, “Blood supply of the human patella. Its relation to ischaemic necrosis after fracture.,” Journal of Bone and Joint Surgery B, vol. 49, no. 3, pp. 563–570, 1967.
[12]
R. Scapinelli, “Studies on the vasculature of the human knee joint.,” Acta Anatomica, vol. 70, no. 3, pp. 305–331, 1968.
[13]
S. Bj？rkstr？m and I. Goldie, “A Study of the arterial supply of the patella in the normal state, in chondromalacia patellae and in osteoarthritis,” Acta Orthopaedica Scandinavica, vol. 51, pp. 63–70, 1980.
[14]
P. E. Howard, J. W. Wilson, T. A. Robbins, and G. A. Ribble, “Normal blood supply of the canine patella.,” American Journal of Veterinary Research, vol. 47, no. 2, pp. 401–403, 1986.
[15]
C. Sihler, “Ueber Muskelspindeln und intramuskul？re Nervenendigungen bei Schlangen und Fr？schen,” Archiv für Mikroskopische Anatomie, vol. 46, no. 1, pp. 709–723, 1895.
[16]
J. Liu, P. V. Kumar, Y. Shen, H. K. Lau, B. P. Pereira, and R. W. H Pho, “Modified Sihler’s technique for studying the distribution of intramuscular nerve branches in mammalian skeletal muscle,” The Anatomical Record, vol. 247, pp. 137–144, 1997.
[17]
R. N. S. Slater, J. D. Spencer, M. A. Churchill, G. P. Bridgeman, and M. Brookes, “Observations on the intrinsic blood supply to the human patella: disruption correlated with articular surface degeneration,” Journal of the Royal Society of Medicine, vol. 84, no. 10, pp. 606–607, 1991.
[18]
R. M. Holtby and P. Grosso, “Osteonecrosis and resorption of the patella after total knee replacement: a case report,” Clinical Orthopaedics and Related Research, no. 328, pp. 155–158, 1996.
[19]
M. A. Ritter, S. A. Herbst, E. M. Keating, P. M. Faris, and J. B. Meding, “Patellofemoral complications following total knee arthroplasty: effect of a lateral release and sacrifice of the superior lateral geniculate artery,” Journal of Arthroplasty, vol. 11, no. 4, pp. 368–372, 1996.
[20]
D. A. Dennis, “Periprosthetic fractures following total knee arthroplasty,” Journal of Bone and Joint Surgery A, vol. 83, no. 1, pp. 120–130, 2001.
[21]
G. W. Brick and R. D. Scott, “Blood supply to the patella. Significance in total knee arthroplasty,” Journal of Arthroplasty, vol. 4, pp. S75–S79, 1989.
[22]
R. Vialle, J. Y. Tanguy, P. Cronier, H. D. Fournier, X. Papon, and P. Mercier, “Anatomic and radioanatomic study of the lateral genicular arteries: application to prevention of postoperative hemarthrosis after arthroscopic lateral retinacular release,” Surgical and Radiologic Anatomy, vol. 21, no. 1, pp. 49–53, 1999.
[23]
R. L. Nicholls, D. Green, and M. S. Kuster, “Patella intraosseous blood flow disturbance during a medial or lateral arthrotomy in total knee arthroplasty: a laser Doppler flowmetry study,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 14, no. 5, pp. 411–416, 2006.
[24]
N. Tanaka, H. Sakahashi, E. Sato, K. Hirose, and T. Isima, “Influence of the infrapatellar fat pad resection in a synovectomy during total knee arthroplasty in patients with rheumatoid arthritis,” Journal of Arthroplasty, vol. 18, no. 7, pp. 897–902, 2003.
[25]
M. Lemon, I. Packham, K. Narang, and D. M. Craig, “Patellar tendon length after knee arthroplasty with and without preservation of the infrapatellar fat pad,” Journal of Arthroplasty, vol. 22, no. 4, pp. 574–580, 2007.
[26]
K. Takatoku, H. Sekiya, M. Hayashi, Y. Hoshino, and Y. Kariya, “Influence of fat pad removal on patellar tendon length during growth,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 13, no. 8, pp. 706–713, 2005.
[27]
V. Sanchis-Alfonso, A. Subías-López, C. Monteagudo-Castro, and E. Roselló-Sastre, “Healing of the patellar tendon donor defect created after central-third patellar tendon autograft harvest: a long-term histological evaluation in the lamb model,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 7, no. 6, pp. 340–348, 1999.
[28]
K. Ogata, R. A. Shively, P. L. Shoenecker, and Shih-Lieh Chang, “Effects of standard surgical procedures on the patellar blood flow in monkeys,” Clinical Orthopaedics and Related Research, vol. 215, pp. 254–259, 1987.
[29]
Y. Fu, G. Wang, and Q. Fu, “Patellar resurfacing in total knee arthroplasty for osteoarthritis: a meta-analysis,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 19, no. 9, pp. 1460–1466, 2011.
[30]
M. Ogon, F. Hartig, C. Bach, M. Nogler, I. Steingruber, and R. Biedermann, “Patella resurfacing: no benefit for the long-term outcome of total knee arthroplasty. A 10 to 16.3 follow-up,” Archives of Orthopaedic and Trauma Surgery, vol. 122, no. 4, pp. 229–234, 2002.
[31]
M. Hasegawa, G. Kawamura, H. Wakabayashi, A. Sudo, and A. Uchida, “Changes to patellar blood flow after minimally invasive total knee arthroplasty,” Knee Surgery, Sports Traumatology, Arthroscopy, vol. 17, no. 10, pp. 1195–1198, 2009.
[32]
S. Gupta, A. Augustine, L. Horey, R. M. D. Meek, M. G. Hullin, and A. Mohammed, “Electrocautery of the patellar rim in primary total knee replacement: beneficial or unnecessary?” Journal of Bone and Joint Surgery B, vol. 92, no. 9, pp. 1259–1261, 2010.
[33]
M. Bohnsack, A. Wilharm, C. Hurschler, O. Rühmann, C. Stukenborg-Colsman, and C. J. Wirth, “Biomechanical and kinematic influences of a total infrapatellar fat pad resection on the knee,” American Journal of Sports Medicine, vol. 32, no. 8, pp. 1873–1880, 2004.
[34]
J. Pang, S. Shen, W. R. Pan, I. R. Jones, W. M. Rozen, and G. I. Taylor, “The arterial supply of the patellar tendon: anatomical study with clinical implications for knee surgery,” Clinical Anatomy, vol. 22, no. 3, pp. 371–376, 2009.
