Advanced Chondromalacia Research Articles

Poster 239: Advanced Patellofemoral Chondromalacia Does Not Affect Outcomes After Meniscal Root Repair

Objectives: Meniscal root tears have been shown to accelerate cartilage breakdown and increase the risk of total knee arthroplasty (TKA) if left unaddressed. Unfortunately, many patients with meniscal root tears already have associated chondromalacia which can impact surgical outcomes. The presence of advanced chondromalacia in the medial or lateral compartmentsof the knee is a known contraindication to performing meniscal root repair; however, the effect of advanced patellofemoral chondromalacia on meniscal root outcomes is not known. The purpose of this study was to compare the outcomes of meniscal root repair in patients with and without advanced patellofemoral chondromalacia (PFC). Methods: A retrospective review of prospectively collected data of patients undergoing meniscal root repair by a single surgeon was conducted between January 2016 and December 2019. Patients were included if they had undergone an isolated posterior medial or lateral meniscal root repair. The meniscal root repair was performed using a transtibial suture technique. Patients were placed into one of two groups depending on the amount of patellofemoral chondromalacia present at the time of surgery. Patients with Outerbridge grade 0-2 were placed in the Minimal Patellofemoral Chondromalacia (MPFC) Group. Patients with Outerbridge 3-4 changes found the time of surgery were placed in the Patellofemoral Chondromalacia (PFC) Group. Patients with Outerbridge 3-4 changes found in the medial or lateral compartment were excluded from the study. Lysholm Knee Scoring Scale and the International Knee Documentation (IKDC) Subjective Knee Form were collected preoperatively, 6,12 and 24 months after surgery. Clinical outcomes followed included recurrent meniscal tear, conversion to total knee arthroplasty, knee arthrofibrosis requiring manipulation under anesthesia/lysis of adhesions and infection. PASS and MCID were determined using data on meniscal repairs in other literature. Continuous data was compared using two-tailed student-T test while categorical data was compared utilizing chi-square testing. Results: A total of 27 patients made up the PFC group and 54 in the MPFC group. There was no difference between the groups with regards to age, sex, BMI or laterality of the procedure. The PFC group had 26 medial and 1 lateral meniscal root repairs. The MPFC group had 51 medial and 3 lateral repairs. The average Outerbridge score of the patella for the PFC group was 3.2 compared to 1.8 in the MPFC group (p<.001). The Outerbridge score for the trochlea in each group was 3.4 vs. 1.6 for the PFC and MPFC groups respectively (p<.001). No difference was identified between the Outerbridge score for the medial compartment for the PFC and MPFC groups (1.48 vs 1.46 respectively) or the lateral compartments (0.48 vs. 0.61 respectively). Lysholm and IKDC scores rose significantly over the pre- operative value at all time points in the study for both groups. No difference was seen between the two groups for the Lysholm or IKDC scores at any timepoint during study. PASS rates for IKDC between the two groups were similar with 6,12 and 24-month PASS rates being 66.7%, 87.5% and 81.4% respectively for the PFC group and 62.9%, 77.8% and 85.2% for the MPFC group. There was also no difference between the groups with regards to the percentage of patients reaching MCID for IKDC. The PFC group showed the percentage of patients reaching MCID to be 81.5%, 100% and 92.6% at the 6,12, and 24 month time points respectively while the MPFC group showed the percentage of patients reaching MCID to be 75.9%, 88.9% and 94.4% at the 6,12 and 24 month postoperative time points respectively. There was 1 (3.7%) recurrent tear in the PFC group and 3 (5.6%) in the MPFC group (p=.72). One patient (3.7%) in the PFC and none of the MPFC group were converted to TKA by the 2-year follow up (p=.15). Each group had 1 patient develop arthrofibrosis requiring MUA/LOA. There were no infections in the PFC group and one in the MPFC group which was a superficial wound infection that resolved after a course of oral antibiotics. Conclusions: In our series, the presence of advanced patellofemoral chondromalacia did not lead to inferior short-term outcomes in patients undergoing meniscal root repair compared to patients without patellofemoral chondromalacia. IKDC and Lysholm scores were similar between the PFC and MPFC group at all time points while scores for both groups were significantly higher than preoperative levels at all time points. The ability to reach MCID and PASS for IKDC was not significantly different between the two groups. In addition, there was not a significant difference between the two groups in the number of recurrent tears, conversion to total knee arthroplasty or complications identified. Our results show meniscal root repair can be performed in patients with severe patellofemoral chondromalacia with similar results as patients undergoing root repair without severe patellofemoral chondromalacia. Patellofemoral chondromalacia should not be considered a contraindication to meniscal root repair.

The relationship between early-onset chondromalacia and the position of the patella.

Background There are many underlying accelerator factors for chondromalacia and one of the well-known factors is patellar malalignment. Purpose To evaluate the relationship between early-onset chondromalacia and patellar position; and, second, to evaluate the value of patellar malalignment criteria. Material and Methods Patients aged 18–40 years with advanced chondromalacia were included. For comparison, a control group was defined with the same number of individuals of the same mean age. The magnetic resonance imaging (MRI) sagittal view with the greatest patellar length was used to obtain the patellar height measurement with the Insall-Salvati index. For the remaining three indices—modified Insall-Salvati, Caton-Deschamps, and Blackburne-Pell—a sagittal view with the greatest patellar articular surface was used. Discordance was defined as contradiction with the measured index and the other three indices. Results Both patella alta and baja were found to be predisposing factors for chondromalacia. Modified Insall-Salvati index was the most concordant measurement to define patella alta. Conclusion Both patella alta and patella baja were found to predispose to chondromalacia. Patella baja is rare, which may explain why it is not often mentioned as a predisposing factor. The modified Insall-Salvati index ratio was the best patella alta indicator that showed chondral status, more than patellar placement, and was more concordant with the other indices. Blackburne-Pell had the second highest number and ratio of discordance. BP cannot be optimally calculated because deciding the location of the tibial plateau seems to be problematic since it is a three-dimensional and complicated structure.

The relationship between patellofemoral arthritis and fat tissue volume, body mass index and popliteal artery intima-media thickness through 3T knee MRI

Background/aimEvaluating the relationship of patellar chondromalacia with obesity, infrapatellar fat pad (IFP) volume and popliteal artery intima-media thickness (IMT).Materials and methodsA total of 203 patients with different degree of patellar chondromalacia (103 male, 100 female) and 52 control subjects (19 male, 33 female) were included and grouped according to sex, age, body surface area (BSA), body mass index (BMI) and patellar chondromalacia classification. All measurements were completed with 3T magnetic resonance imaging (MRI). Articular cartilage and IFP volume were measured in saggital plane using double echo steady state (DESS) and DIXON sequences, respectively. Patellar cartilage damage was graded using modified outerbridge classification, and the relations among cartilage volume and BMI, BSA, IFP, IMT were statistically assessed.ResultsPopliteal artery IMT showed an independent association with the prevalence of cartilage defects and IFP volumes (P ˂ 0.001). There was an association between BMI and IFP volumes (P ˂ 0.001). However, no differences were observed between IFP volume and different chondromalacia groups. When IFP measurements were corrected using individual BMI and BSA values, a positive correlation was found between control and advanced chondromalacia groups (P ˂ 0.001).ConclusionThis study demonstrates the relationship among obesity, IMT and chondromalacia and highlights this potential circle to develop effective treatments and inhibit the progression of chondromalacia.

Treatment of patellofemoral chondropathy with the Bandi tibial tubercle osteotomy: More than 10 years follow-up

Isolated degenerative patellofemoral chondropathy is a prevalent disease. There is still controversy regarding its ideal type of management. A retrospective study was performed to assess the outcomes of 28 patients with a minimum of 10-year follow-up, in whom the Bandi tibial tubercle osteotomy was performed. The Bentley score was applied pre and postoperatively to evaluate the clinical results. Preoperatively, 21 (67%) patients were rated as fair and seven (33%) as poor according to the Bentley functional scale for patellofemoral osteoarthritis. At 5 years of follow-up, one case was rated as excellent, 23 (81%) cases as good, three as fair and one as poor. At 10 years of follow-up no cases were rated as excellent, 17 (61%) cases as good, four (14%) as fair and seven (25%) as poor. The difference in terms of poor results evaluated at five and 10 years after the surgery was statistically significant ( p < 0.05). We concluded that excellent and good short-term results can be expected with the use of the Bandi tibial tubercle osteotomy in patients with isolated degenerative patellofemoral chondropathy; however, such outcomes tend to deteriorate over the time, especially in patients with advanced chondromalacia, making its indication controversial.

THE CLASSIC: Tibial Plateau Prosthesis

THE CLASSIC: Tibial Plateau Prosthesis

Patellectomy: an overview with reconstructive procedures.

Patellectomy is a relatively old procedure and its effect on knee function has been a matter of controversy. Although indications for a patellectomy have been narrowed, patellectomy still is indicated as the last choice of treatment in certain situations including comminuted fractures, advanced chondromalacia or osteoarthritis, dislocations, infections, and tumoral conditions. Excision of the patella results in a decrease in the moment arm of the extensor mechanism, alteration of the forces acting on the tibiofemoral joint and instant center of motion, limitation of range of motion, anterior instability, loss of protection of the trochlea from injury, and poor cosmesis. A good technique of patellectomy should overcome all or at least some of these problems. Although comparison of various techniques of patellectomy is impossible because of the lack of prospective randomized trials, reinforcement techniques seem more logical than simple repair procedures.

Arthroscopic management of temporomandibular joint disc perforations and associated advanced chondromalacia by discoplasty and abrasion arthroplasty: A supplemental report

Purpose: This article describes the results of treating temporomandibular joint (TMJ) articular disc perforation and advanced chondromalacia arthroscopically by the use of discoplasty and abrasion arthroplasty. Patients and Methods: Forty-four joints were treated in 25 patients (23 females and 2 males). Twenty-nine disc perforations were present, 24 joints had grade III chondromalacia (fibrillated cartilage), and 14 joints had grade IV chondromalacia (exposed bone). Surgical procedures included 14 abrasion arthroplasties and 24 motorized shavings or holmium laser vaporizations. Holmium laser discoplasty with mobilization was used in 29 joints. Patients were followed-up for an average of 40.8 months (11 to 74 months). Results: Preoperative pain on the visual analog scale (VAS) (1 to 10 cm) ranged from 5 to 10 cm, with an average of 7.4 cm. Postoperatively, nine patients had no pain and 16 patients had an average VAS of 2.7 cm (range, 1 to 5 cm). Preoperatively, 30 joints had clicking, and 14 joints had crepitation. Postoperatively, 25 joints had no noise, 12 joints had slight intermittent clicking, and seven joints had crepitation. The preoperative range of motion averaged 29.7 mm. Postoperatively, the range of motion averaged 37.7 mm (range, 33 to 42 mm). All patients could masticate a regular diet except hard food after an average of 40.8 months (11 to 74 months). Conclusions: These findings seem to justify the arthroscopic surgical procedures of discoplasty for disc perforations, motorized shaving, or holmium laser vaporization of grade III chondromalacia, and abrasion arthroplasty for bone exposure. The results also question the need for discectomy in the treatment of disc perforation.

Arthroscopic management of temporomandibular joint disc perforations and associated advanced chondromalacia by discoplasty and abrasion arthroplasty: A supplemental report

Arthroscopic management of temporomandibular joint disc perforations and associated advanced chondromalacia by discoplasty and abrasion arthroplasty: A supplemental report

Chondromalacia patellae: fat-suppressed MR imaging.

To evaluate the accuracy of fat-suppressed magnetic resonance (MR) imaging in diagnosing chondromalacia patellae. Seventy-one patients underwent fat-suppressed MR imaging and arthroscopy of the patellofemoral compartment. Findings were classified as early or advanced chondromalacia or as normal and were correlated with arthroscopic findings. Early and advanced stages of chondromalacia patellae were reliably detected, with positive predictive values of 85% and 92%, respectively. Specificity in early stages was 94% and in late stages was 98%. However, the overall accuracies did not differ substantially from those reported in studies that did not use fat-suppressed imaging. Axial, fat-suppressed MR imaging accurately depicts changes caused by chondromalacia patellae. Early stages can be seen as intrasubstance changes of increased signal intensity. Results of this study suggest a high degree of specificity in excluding both early and advanced changes.

Arthroscopic management of temporomandibular joint disc perforations and associated advanced chondromalacia by discoplasty and abrasion arthroplasty: preliminary results.

This article describes the arthroscopic surgical treatment of disc perforations by discoplasty to mobilize the disc and reduce joint friction. Grade IV chondromalacia with exposed bone was treated by abrasion arthroplasty with the goal of resurfacing the bone with fibrocartilage. Preliminary data on the results of these procedures are presented.

Pathobiology of articular cartilage in trapeziometacarpal osteoarthritis. II. Surface ultrastructure by scanning electron microscopy

Regional variation in the surface ultrastructure of hyaline cartilage in the osteoarthritic trapeziometacarpal joint was studied by means of scanning electron microscopy. Articular surface degeneration on intact osteochondral specimens was analyzed and correlated with known patterns of gross, histologic, and biochemical disease. The earliest changes were observed in the tangential surface lamina and occurred in areas of chondromalacia in the palmar contact area of the joint. Progressive disruption of this superficial fibrillar layer of the articular cartilage was followed by disorganization of the underlying chondrocytes and matrix. In palmar regions with more advanced chondromalacia and loss of eosinophilic staining, free cellular elements and craters 20–30 μm in diameter, resembling empty chondrocyte lacunae, appeared in conjunction with the absence of any tangential surface meshwork. Eburnated areas demonstrated no fibrillar or cellular elements. Disruption of the protective surface lamina of trapeziometacarpal articular cartilage occurs in a geographic pattern corresponding to joint contact areas and regions of selective biochemical decomposition of proteoglycan matrix. These observations support an interdependent relationship between mechanically induced abrasive surface wear and biochemical matrix degradation in the production of the cartilage lesion of trapeziometacarpal osteoarthritis.

Insall Proximal Realignment for Disorders of the Patella

Proximal realignment with standard lateral retinacular release (Insall operation) was performed on 35 knees with a follow-up time of two to 11 years. The results for chondromalacia patellae were satisfactory to excellent results in 20 of 23 knees (87%) at two years and in eight of 15 knees (55%) at five to 11 years. Satisfactory to excellent results in 11 of 12 knees (92%) were noted for recurrent patellar dislocation. This procedure should be reserved for advanced chondromalacia patellae (Grades III and IV) and recurrent patellar dislocation. Anatomic studies suggest that the pain relief was most likely due to a combination of patellar denervation and restoration of patellar congruence.

Total patellectomy: Report of twenty-eight cases

The ensemble of results reported definitely establishes that total patellectomy has a place in the treatment of fractures. A simple intervention, it ensures rapid functional recuperation complete and definitive, in severely comminuted fractures and in long-standing unreduced, ununited or malunited fractures of either the transverse or comminuted type. The method has not been generally accepted as the routine treatment of fresh transverse fractures, and it is the writer's opinion that in the majority of transverse fractures good results are obtainable by operative reduction and screw fixation. Total patellectomy is giving encouraging results in osteoarthritis of the knee joint, particularly when the process is confined to the patellofemoral segment. The method is also proving of value in the treatment of advanced chondromalacia and recurrent dislocation of the patella. The writer's experience includes twenty-eight cases of total patellectomy. Late observations were made in twenty-one of the cases, in nineteen, after a postoperative time lapse varying from five to fourteen years. Sixteen of the cases were fresh comminuted fractures, two were old fractres, one was an osteoarthritic process of the knee joint and two cases were recurrent dislocations. Fifteen of the twenty-one patients obtained completely satisfactory results, the mobility and strength of the knee being normal. Two other patients mentioned having a sensation of insecurity at times. One patient complained of buckling of the joint and three patients had limited motion, but in none of these four cases could the result be charged directly to the operation. In the case of buckling there was evidence of a cartilage derangement, in two cases there were arthritic complications which had been present prior to the operation, and in the fourth case the patient had fallen and torn the new attachment of the patellar and quadriceps tendons. With the exception of two cases in which arthritic changes were already present in the knee joint at the time of the operation, no evidence of erosion was observed on the condylar surfaces in any of the twenty-one cases.