Orthopaedics & Traumatology: Surgery & Research (2011) 97, 776—778

CASE REPORT

Posttraumatic dislodgement of the infrapatellar fat

pad: An unusual type of superolateral impingement
L. Mathieu ∗, M. Chetouani , D. Janku , E. Vandenbussche , B. Augereau

Georges-Pompidou European Hospital, Department of Orthopaedic Surgery, 20/40, rue Leblanc, 75908 Paris cedex 15, France

Accepted: 23 May 2011

KEYWORDS Summary The authors report a rare case of dislodgement of the infrapatellar fat pad induced
Infrapatellar fat pad; by traumatic hyperflexion. Because of the unusual clinical presentation, open excision was
Impingement performed to exclude a possible tumoral etiology. This entity seems to be an acute form of
syndromes; superolateral fat pad impingement.
Hoffa’s disease; © 2011 Elsevier Masson SAS. All rights reserved.
Anterior knee pain

Introduction Case report

Impingement of the infrapatellar fat pad is a rare entity A 50-year-old patient who was an amateur weight-lifter, con-
which is often diagnosed by elimination in the presence of sulted for left knee pain which had persisted for 15 days
persistent anterior knee pain [1]. These are traumatic or following traumatic hyperflexion from a fall. There was no
microtraumatic syndromes, with two main entities: poste- prior history of trauma or pain in this knee. He presented
rior impingement in the femorotibial joint space in Hoffa’s with mechanical anterolateral pain which had begun after
disease and superior impingement with the lateral femoral the fall, had continued since when walking and which was
condyle which is less well known but which seems to be worse when going up or down stairs. The patient did not
more frequent [2]. The authors describe an atypical presen- report any fluid accumulation, locking or instability. On clin-
tation of superolateral impingement whose diagnosis could ical examination, knee alignment was normal, the knee was
only be made postoperatively. The clinical, therapeutic and dry and range of motion was normal. There was no liga-
etiopathogenic signs of this unusual form are discussed with ment laxity. There was palpable swelling above the lateral
a review of the literature. femorotibial joint space which corresponded to the source
of pain. This was a solid mass that was painful when touched.
Extension of the knee did not increase pain, but there was
acute pain at 20◦ of flexion and the mass disappeared under
the lateral condyle. There was no patellar instability. X-rays
of the knee were normal, with no patella alta or patellar
subluxation. Proton density MRI with fat suppression (PD fat
∗ Corresponding author. sat) revealed an abnormal image of the superior infrapatel-
E-mail address: laurent tom2@yahoo.fr (L. Mathieu). lar fat pad with a heterogeneous oval mass near the lateral

1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2011.05.009
Traumatic dislodgement of the infrapatellar fat pad 777

Figure 1 Axial (a) and coronal (b) PD fat sat MRI showing a heterogeneous mass of the infrapatellar fat pad.

joint capsule. On axial and coronal slices with the knee in after surgery, he reported occasional infrapatellar pain, with
extension, the mass came in contact with the iliotibial band no patellofemoral pain syndrome. The knee was dry with
with a peripheral high intensity signal (Fig. 1). normal range of motion and there was no amyotrophy of the
The results suggested a traumatic infrapatellar fat pad quadriceps.
injury, but the unusual features of the mass posed a
problem of differential diagnosis with a tumoral or pseu-
dotumoral lesion. Open surgical excision was decided to Discussion
release impingement and for histology. Surgery was per-
formed by lateral parapatellar approach. The swelling rose Traumatic infrapatellar fat pad lesions are a rare entity
from under the joint capsule in front of the iliotibial band. which may occur following an anterior cruciate ligament
Arthrotomy revealed dislocation of the superior infrapatel- tear, patellar instability or arthroscopy; or they may be part
lar fat pad in the anterolateral joint space with an area of of a fat pad impingement syndrome [2]. Hoffa’s disease
compression across from the lateral condyle and an edema described in 1904 [3] is the most well-known form of this
in the area corresponding to the oval lesion seen on MRI entity and includes posterior impingement in the femorotib-
(Fig. 2). The dislocated part of the fat pad was excised ial joint space due to infrapatellar fat pad hypertrophy
and an aspiration drain was placed in the joint before clos- following acute trauma or microtraumas [4]. The mecha-
ing. The histolopathological analysis of the resected tissue nism is repeated hyperextension or rotational strains [5]. In
(measuring 1 × 3 cm) confirmed the absence of tumoral pro- the acute stage, hypertrophy is associated with an edema
liferation and showed inflammation and contusion of the from hemmorhage and inflammation. In the chronic stage,
adipose tissue. The postoperative course was uneventful. fibroblast proliferation transforms the inflammatory adipose
The patient went back to work 2 months after surgery and tissue into fibrous scar tissue [3,4]. Features of superolat-
began biking and swimming after 3 months. Seven months eral impingement were recently been described on MRI [6]
as a result of damage to the superior infrapatellar fat pad
from chronic impingement between the patellar ligament
and the lateral femoral condyle. Patella alta and/or patel-
lar tracking anomalies are predisposing factors. Although it
is not well known and has rarely been reported in the lit-
erature, superolateral impingement may be more frequent
than Hoffa’s disease [2].
In the present case, an acute form of Hoffa’s disease was
first suspected, but several elements did not support this.
First, the Hoffa test was negative. This is performed with
the knee in flexion by applying pressure to the infrapatellar
fat pad on the border of the patellar ligament, then the
knee is extended. The test is positive if pain is worse when
the knee is extended [3]. Also, the palpable mass extended
well beyond the patellar ligament and was accompanied by
unusual acute pain.
MRI confirmed the damage to the infrapatellar fat pad,
but did not provide a definite diagnosis. The increased sig-
Figure 2 Anterolateral arthrotomy revealing the dislocated nal intensity of the superior infrapatellar fat pad did not
part of the infrapatellar fat pad. correspond to features of Hoffa’s disease, but was more
778 L. Mathieu et al.

suggestive of chronic superolateral impingement character- Conclusion

ized by disappearance of the superior fat pad between the
patellar ligament and the lateral femoral condyle [2]. The The presentation of traumatic dislocation of the infrapatel-
anterolateral oval mass was also characteristic of the for- lar fat pad in this patient seems to be an acute form of
mation of nodules found in superolateral impingement [6]. superolateral fat pad impingement which has not yet been
However, the clinical history did not correspond to chronic described. Because of the atypical clinical signs and MRI fea-
impingement and the patient did not have predisposing fac- tures, the diagnosis could only be made after surgery and
tors. Moreover, the volume and heterogeneous feature of histological evaluation of the excised tissue.
the mass could also suggest a tumoral lesion of the infrap-
atellar fat pad which was revealed by trauma. A chondroma
or lipoma was improbable because there were no visible cal- Disclosure of interest
cifications which are characteristic of the former, or low
intensity signal on fat saturation sequences for the latter. On
The authors declare that they have no conflicts of interest
the other hand, it might have been a synovial hemangioma
concerning this article.
or a sarcomatous malignant tumor whose characteristics are
non specific on MRI [7]. Histological evaluation of the mass
was therefore necessary to avoid missing the diagnosis of a
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