Patellofemoral Chondromalacia Research Articles

Tibial Tubercle Osteotomies Performed in an Outpatient Setting Have a Low Rate of Early Complications

PurposeThe purpose of this study was to characterize the early postoperative complications following outpatient Tibial Tubercle Osteotomy (TTO) to determine its safety in this setting. MethodsPatients undergoing TTO by a single surgeon between July 2017 and August 2022 for patellar instability or patellofemoral chondromalacia and achieving minimum 3 months of clinical and radiographic follow-up were evaluated for inclusion. Although an inclusion criterion was minimum follow-up of 3 months, if evidence of a healed osteotomy was observed sooner, final follow up was accepted at 2 months. Patient demographics, perioperative risk factors, and incidence of complications were collected retrospectively. Categorical data was analyzed using chi-squared and Fisher exact tests. Continuous data was analyzed using two-tailed t-tests and Mann-Whitney U data for parametric and nonparametric data, respectively. ResultsA total of 195 knees in 167 patients met inclusion criteria, with a mean age of 24.7 ± 9.2 years and mean follow-up time of 10.9 months (range: 2 - 69 months).51 early postoperative complications occurred in 47 (24.1%) knees in 42 (25.1%) patients. 10 major and 41 minor complications occurred. Major complications were associated with older age (p = 0.015), smoking (p = 0.038), and smaller preoperative patellar tendon-lateral trochlear ridge distance (p = 0.012). 44 reoperations occurred in 42 (21.5%) knees in 37 (22.2%) patients. The most common reasons for reoperation included removal of symptomatic hardware (31 knees; 15.9%) and arthrofibrosis requiring lysis of adhesions and manipulation under anesthesia (8 knees; 4.1%). The mean time to reoperation was 13.0 months (range: 1 – 42 months). Smaller body mass index was associated with increased risk of reoperation (p = 0.002). ConclusionOutpatient TTO is safe when performed with the described technique, however the later development of minor complications is not infrequent following surgery. Patients should be counseled regarding a relatively high incidence of hardware irritation, arthrofibrosis, and eventual reoperation.

Outcomes After Meniscal Root Repair in Patients With and Without Advanced Patellofemoral Chondromalacia: Comparison at 2-Year Follow-up.

Meniscal root repair can improve patient outcomes significantly; however, several contraindications exist, including arthritic change to the medial or lateral tibiofemoral compartments. The purpose of this study was to evaluate the outcomes of meniscal root repair in patients with advanced patellofemoral chondromalacia (PFC). It was hypothesized that the presence of advanced PFC would not significantly affect the postoperative outcomes. Cohort study; Level of evidence, 3. A retrospective review was conducted of patients who underwent meniscal root repair with at least 2 years of follow-up data. Patients with chondromalacia as determined by arthroscopic visualization (defined as Outerbridge grade 3 or 4) were placed in the PFC group; patients with Outerbridge grade 0 to 2 chondromalacia were placed in the non-PFC group. Outcomes were measured by the Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) Subjective Knee Form. Clinical outcomes including complications were also recorded. Quantitative data between the groups were analyzed using the 2-tailed independent-samples t test. Overall, this study included 81 patients (35 in the PFC group, 46 in the non-PFC group). The mean follow-up times were 25.1 months in the PFC group and 24.8 months in the non-PFC group. In both groups, Lysholm and IKDC scores improved significantly with 24-month Lysholm scoresaveraging 85.86 in the PFC group and 86.61 in the non-PFC group (P = .62) and 24-month IKDC scores averaging 77.66 for the PFC group and 79.59 for the non-PFC group (P = .45). The cohorts demonstrated similar rates of retear, arthrofibrosis, infection, and progression to total knee arthroplasty. The presence of advanced PFC was not associated with inferior outcomes in patients who underwent posterior meniscal root repair, and rates of recurrent tears, postoperative infection, arthrofibrosis, and conversion to total knee arthroplasty were similar between the study groups. These findings suggest that PFC may not significantly alter the results of meniscal root repair and should not be considered an absolute contraindication for this procedure.

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.

Correlation of Patellofemoral Chondromalacia and Body Mass Index (BMI) in Relation to Sex and Age Analysis of 1.5T and 3.0T Magnetic Resonance (MR) Images Using the Outerbridge Scale.

BACKGROUND Cartilage disease (chondromalacia) is most commonly found in the patellofemoral joint. Non-invasive magnetic resonance imaging methods are used to assess the severity of chondromalacia. The available literature lacks papers describing the predilection of chondromalacia changes to BMI assessed on the basis of geometric data that can be assessed by 1.5T and 3.0T MRI. The aim of this study was to assess the relationship between the severity of chondromalacia of the patellofemoral joint and age, sex, and BMI assessed on the 1.5T and 3.0T MRI scanners. MATERIAL AND METHODS The study involved 324 patients, including 159 (49%) women and 165 (51%) men, aged 8-87 years (mean age: 45.1±20.9). The studied group had a BMI in the range of 14.3-47.3 (M: 27.7±5.02). A 1.5T and 3.0T MRI scanner were used in the study. To assess the cartilage of the patellofemoral joint, Outerbridge scales were used. RESULTS The age of the patients showed a significant correlation (Spearman's rank, P<0.0001) with Outterbridge grade for each surface of patellofemoral joint. Higher correlation between BMI and Outerbridge grade was noted in the patella (rho=0.4139) than in the femur (rho=0.2890). There were no significant differences between women and men in the Outerbridge assessment of the knee joint (P>0.05). Significant more degeneration was found at the 1.5T scanner compared to the 3.0T MRI (P<0.0025). CONCLUSIONS The severity of chondromalacia significantly depends on age and BMI level. There is a stronger correlation between the degree of chondromalacia and BMI in women than in men.

Adaptación transcultural al Español y Validación de la Escala de Lysholm para evaluar la funcionalidad de la rodilla

BackgroundThe Lysholm scale was developed in 1982 and modified in 1985 in order to assess the functionality of patients with knee ligament injuries; since then it has been widely used to subjectively evaluate patients in relation to their functional capacity. The purpose of the study was to carry out its translation and cross-cultural adaptation to Colombian Spanish and to develop psychometric validation through the evaluation of internal consistency and test-retest reliability. MethodsAfter identifying the original scale of interest, translation (English-Spanish), cultural adaptation and re-translation (Spanish-English) were carried out by native linguist experts, who assessed the similarity of the content of both products (original and retranslated). Likewise, this latest version was evaluated by 40 patients with knee disease (meniscal injury, anterior cruciate ligament rupture, chondromalacia and gonarthrosis), who confirmed that they understood the text. Subsequently, the internal consistency was evaluated using Cronbach's alpha test for all items, and the intraclass correlation coefficient – ??total score of the sub-construct through a random sample (n=93), which validated the factorial structure of the scale. ResultsCronbach's alpha was 0.737 and the interclass correlation coefficient was 0.844, associated with a high inter-observer agreement (Gamma=0.752). The Bland-Altman plot did not show systematic differences between the measurements DiscussionThis Spanish (Colombian) version of the Lysholm scale is a valid tool to measure functionality in patients with meniscal lesions of the anterior cruciate ligament, patellofemoral chondromalacia and gonarthrosis in Spanish-speaking countries (preferably in Colombia). Evidence LevelI

Patellofemoral Chondromalacia Does Not Influence Radiographic and Clinical Outcomes following High Tibial Osteotomy.

Effect of patellofemoral (PF) chondromalacia on results of high tibial osteotomy (HTO) has not been identified. Therefore, the objective of the present study was to analyze the effect of PF chondromalacia on relatively short-term radiographic and clinical outcomes of HTO. Patients who underwent open wedge HTO (OWHTO) from February 2010 to January 2015 were enrolled. A total of 101 knees were divided into two groups: 56 knees without PF chondromalacia in group A, while 45 knees with PF chondromalacia extended to subchondral bone in group B. Radiologic outcomes were compared using mechanical tibiofemoral angle, ratio of weight-bearing line (WBL), and minimal joint space width of the lateral compartment. Clinical outcomes were compared using range of motion in affected knee, visual analog scale, modified Lysholm score, and Kujala score. The mean mechanical tibiofemoral angle was 4.6 degree in group A and 4.8 degree in group B. The mean ratio of WBL was 63.8% in group A and 63.6% in group B at final. The mean minimum joint space width of the lateral compartment was 5.8 mm in group A and 5.8 mm in group B on standing AP radiograph. It was 5.3 mm in group A and 5.4 mm in group B on Rosenburg view at final. The mean ROM was 137.2 degree in group A and 137.5 degree in group B. The mean visual analog scale was 2.1 in group A and 2.3 in group B at final. The mean modified Lysholm score was 90.6 in group A and 89.1 in group B at final. The mean Kujala score was 90.2 in group A and 89.1 in group B at final. PF chondromalacia does not influence short-term radiographic and clinical outcomes following OWHTO.

Prospective, Randomized, Double-Blind Evaluation of the Efficacy of a Single-Dose Hyaluronic Acid for the Treatment of Patellofemoral Chondromalacia.

Background:Patellofemoral pain is common in the young and active populations. Nonoperative management is limited and focuses on physical therapy. Hyaluronic acid (HA) is an injectable device that has been used for the treatment of knee osteoarthritis.Hypothesis:A single injection of HA would reduce pain and improve function in patients with patellofemoral pain who had previously failed conservative management.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:A total of 86 patients with patellofemoral pain (65 females, 21 males; mean ± SD age, 27.0 ± 7.7 years; height, 168.6 ± 8.9 cm; weight, 74.6 ± 17.0 kg; body mass index, 26.2 ± 5.2 kg/m2) enrolled in this study after failing conservative management. Patients were randomly allocated to either 6 mL of HA or a sham injection. All patients were prescribed an additional home exercise program, including lower extremity strengthening and flexibility exercises, and were evaluated at 1, 3, and 6 months. Outcome assessments included patellofemoral pain assessment with a visual analog scale during a single-legged squat, KOOS (Knee injury and Osteoarthritis Outcome Score), Kujala score, Tegner activity rating, and normalized isometric knee extension strength. Group assignment was revealed after the 6-month assessment, and crossover treatment was offered to patients in the sham group who were still symptomatic. Linear mixed models were used to compare outcomes between groups and across time.Results:A total of 45 patients were randomized to HA injection and 41 to sham, with 6 patients lost to follow-up (93% follow-up rate). Patients in both groups experienced a significant reduction in visual analog pain ratings and significant improvements in all domains of the KOOS and in Kujala scores at 6 months when compared with baseline measurement (P < .05); however, there was no significant difference between groups. There were no differences observed over time or between groups for normalized knee extension strength or Tegner activity rating (P > .05).Conclusion:HA injection had no clinically meaningful effect on pain or functional outcomes in patients diagnosed with patellofemoral pain. Improvements were observed for both groups in patient-reported pain and function, with no change in quadriceps strength or activity rating.Registration:NCT01771952 (ClinicalTrials.gov identifier).

Prospective, Randomized, Double Blind Evaluation of the Efficacy of a Single Dose Hyaluronic Acid for the Treatment of Patellofemoral Chondromalacia

Objectives:Introduction: Patellofemoral pain is common and is often diagnosed as chondromalacia patella in the absence of radiographic evidence of osteoarthritis. Chondromalacia patella is often painful and debilitating, affecting patients’ function, activity level and quality of life. Non-operative management is limited and focuses on physical therapy and modalities. Hyaluronic acid (HA) is an injectable device that has been used for the treatment of knee osteoarthritis. We hypothesize that a single injection of HA will reduce pain, improve function and improve muscle strength in patients who have previously failed conservative management.Methods:Methods: This was a prospective, randomized, double-blind, sham-controlled, parallel group clinical trial to compare outcomes for 6-months after a single injection of HA (Synvisc One) in the knees of patients with a diagnosis of chondromalacia patella. A total of 86 patients with a clinical diagnosis of chondromalacia (65F/21 M, 27.0±7.7years, 168.6±8.9 cm, 74.6±17.0 kg, BMI 26.0±5.2) including no radiographic evidence of tibiofemoral or patellofemoral osteoarthritis were recruited and enrolled in this study. All patients failed at least 1 month of conservative management including a program of therapeutic quadriceps strengthening exercises under a physical therapist’s direction. Patients were evaluated by blinded observers. Outcome assessments included patellofemoral pain assessment using a visual analog scale during a single leg squat, knee osteoarthritis outcome score (KOOS), Tegner activity rating and normalized isometric knee extension strength. After baseline measurements, patients were randomly allocated to either 6 cc of HA or a sham injection (needle stick) and visually shielded during injection for blinding. All patients were prescribed an additional home exercise program including lower extremity strengthening and flexibility exercises and followed at 1, 3 and 6 months. Group assignment was revealed to the patients after the 6 month outcome assessment and crossover treatment offered to patients receiving the sham injection who were still symptomatic. Repeated measures ANOVA was used to compare outcomes between groups and across time.Results:Results: 45 patients were randomized to HA injection, 41 to sham, and 5 patients were lost to follow up (93% follow up rate). Patients in both groups experienced a significant reduction in visual analog pain ratings and significant increases in all domains of the KOOS at the 6 months compared to baseline measurement (P<0.05); however, there was no significant difference between groups. There were no differences observed over time or between groups for normalized knee extension strength or Tegner activity rating (P<0.05).Conclusion:Conclusion: We observed improvements in patient reported pain and function with no change in quadriceps strength or activity rating. HA injections did not have an effect at 6 months after injection. HA injection had no effect on pain or functional outcomes in patients with a clinical diagnosis of chondromalacia patella.

Magnetic Resonance Imaging for Patellofemoral Chondromalacia: Is There a Role for T2 Mapping?

Background:Patellofemoral pain is common, and treatment is guided by the presence and grade of chondromalacia.Purpose:To evaluate and compare the sensitivity and specificity in detecting and grading chondral abnormalities of the patella between proton density fat suppression (PDFS) and T2 mapping magnetic resonance imaging (MRI).Study Design:Cohort study; Level of evidence, 2.Methods:A total of 25 patients who underwent MRI of the knee with both a PDFS sequence and T2 mapping and subsequently underwent arthroscopic knee surgery were included. The cartilage surface of the patella was graded on both MRI sequences by 2 independent, blinded radiologists. Cartilage was then graded during arthroscopic surgery by a sports medicine fellowship–trained orthopaedic surgeon. Reliability, sensitivity, specificity, and accuracy were determined for both MRI methods. The findings during arthroscopic surgery were considered the gold standard.Results:Intraobserver and interobserver agreement for both PDFS (98.5% and 89.4%, respectively) and T2 mapping (99.4% and 91.3%, respectively) MRI were excellent. For T2 mapping, the sensitivity (61%) and specificity (64%) were comparable, whereas for PDFS there was a lower sensitivity (37%) but higher specificity (81%) in identifying cartilage abnormalities. This resulted in a similar accuracy for PDFS (59%) and T2 mapping (62%).Conclusion:Both PDFS and T2 mapping MRI were reliable but only moderately accurate in predicting patellar chondromalacia found during knee arthroscopic surgery.

Medial maleollus rotational malunion – Case report

Patellofemoral arthroplasty (PFA) is increasingly performed for symptomatic patellofemoral arthritis. The purpose of this study was to evaluate the outcomes of PFA based on preoperative radiographic severity of patellofemoral arthritis.All patients who underwent PFA for isolated patellofemoral arthritis between 2002 and 2013 and had undergone preoperative magnetic resonance imaging were identified. Radiographic severity of patellofemoral arthritis was classified according to the Iwano classification system. Groups were divided between mild (grade 0-I) and moderate to severe (grade II-IV) patellofemoral arthritis. Clinical outcomes were evaluated using the Knee Society scores (KSS), University of California at Los Angeles (UCLA) and Tegner scores.Seventy-five knees in 55 patients met inclusion criteria. Mean age was 51 years (range, 36 to 81), and mean follow-up was 3 years (range, 2 to 10). All patients had grade IV patellofemoral chondromalacia and/or significant subchondral cyst formation and edema on magnetic resonance imaging. On plain radiographs, there were no patients with Iwano grade 0, 21 grade I, 15 grade II, 21 grade III, and 18 grade IV patellofemoral arthritis. There was significantly more improvement in KSS pain (P = .046), KSS function (P = .02), University of California at Los Angeles (UCLA) (P = .046) and Tegner (P = .008) scores in the Iwano grade II-IV group vs the Iwano grade I group. Patient-reported pain quality improved significantly more following PFA in the grade II-IV group (P = .04).Patients with evidence of mild patellofemoral arthritis on plain radiographs demonstrated less improvement in pain and function after PFA than those with more advanced patellofemoral arthritis. Caution should be used when considering PFA for patients with minimal radiographic evidence of patellofemoral arthritis.

Preoperative Patellofemoral Chondromalacia is Not a Contraindication for Fixed-Bearing Medial Unicompartmental Knee Arthroplasty

BackgroundPatellofemoral chondromalacia (PFCM) has historically been considered a contraindication for unicompartmental knee arthroplasty (UKA), but there is limited data assessing PFCM's impact on the results of fixed-bearing UKA. Our objective was to assess the impact of medial patellar and/or medial trochlear PFCM on overall and patellofemoral-specific 2-year outcomes after fixed-bearing medial UKA. MethodsIntraoperative notes defined the presence and location of PFCM during fixed bearing medial UKA. Outcome measures included the New Knee Society Score (NKSS), Kneeling Ability Score (KAS) and Forgotten Joint Score (FJS-12). Thirty-one knees with PFCM (PFCM group), and 52 knees without PFCM (N-PFCM group) were included for analysis. Mann-Whitney U tests assessed the statistical significance of observed differences, and a Bonferroni correction was applied, adjusting threshold for significance to P = .005. ResultsAt minimum follow-up of 2 years, no statistical differences were detected between the N-PFCM and PFCM groups in the postoperative NKSS (159 vs 157, P = .731), preoperative to postoperative NKSS change (P = .447), FJS-12 (70.5 vs 67.6, P = .471), or KAS (71% vs 65%, P = .217). Patients with isolated patellar chondromalacia (n = 13) demonstrated trends toward worse outcomes according to NKSS (147, P = .198), FJS-12 (58, P = .094), and KAS (46%, P = .018), but were statistically insignificant. No failures occurred in either group. ConclusionFunctional outcomes of fixed-bearing medial UKA are not adversely impacted by the presence of PFCM involving the medial patellar facet and/or medial or central trochlea. Further follow-up is needed to determine longer-term implications of fixed-bearing medial UKA in patients with PFCM.

Outcomes of Patellofemoral Arthroplasty Based on Radiographic Severity

BackgroundPatellofemoral arthroplasty (PFA) is increasingly performed for symptomatic patellofemoral arthritis. The purpose of this study was to evaluate the outcomes of PFA based on preoperative radiographic severity of patellofemoral arthritis. MethodsAll patients who underwent PFA for isolated patellofemoral arthritis between 2002 and 2013 and had undergone preoperative magnetic resonance imaging were identified. Radiographic severity of patellofemoral arthritis was classified according to the Iwano classification system. Groups were divided between mild (grade 0-I) and moderate to severe (grade II-IV) patellofemoral arthritis. Clinical outcomes were evaluated using the Knee Society scores (KSS), University of California at Los Angeles (UCLA) and Tegner scores. ResultsSeventy-five knees in 55 patients met inclusion criteria. Mean age was 51 years (range, 36 to 81), and mean follow-up was 3 years (range, 2 to 10). All patients had grade IV patellofemoral chondromalacia and/or significant subchondral cyst formation and edema on magnetic resonance imaging. On plain radiographs, there were no patients with Iwano grade 0, 21 grade I, 15 grade II, 21 grade III, and 18 grade IV patellofemoral arthritis. There was significantly more improvement in KSS pain (P = .046), KSS function (P = .02), University of California at Los Angeles (UCLA) (P = .046) and Tegner (P = .008) scores in the Iwano grade II-IV group vs the Iwano grade I group. Patient-reported pain quality improved significantly more following PFA in the grade II-IV group (P = .04). ConclusionPatients with evidence of mild patellofemoral arthritis on plain radiographs demonstrated less improvement in pain and function after PFA than those with more advanced patellofemoral arthritis. Caution should be used when considering PFA for patients with minimal radiographic evidence of patellofemoral arthritis.

Calcific mediopatellar plica: a case report

A 38-year-old male patient was admitted to our clinic with the complaints of pain and swelling in his right knee for two years. He had mechanical symptoms for nearly six months. Merchant and lateral knee X-ray revealed calcification in the medial patellar retinaculum. Magnetic resonance imaging demonstrated increased ossification and cortical irregularity in the patella's medial and inferior pole. Due to long-term complaints of the patient, arthroscopy was planned with the preliminary diagnoses of patellofemoral chondromalacia, cartilage degeneration and mediopatellar plica (MPP) syndrome. Arthroscopy revealed a calcific MPP, an interesting entity. It should be kept in mind that plica may become calcific in patients with suspected MPP and the complaints of the patient may not disappear within if left untreated.

Prevalence and clinical significance of chondromalacia isolated to the anterior margin of the lateral femoral condyle as a component of patellofemoral disease: observations at MR imaging

To determine the prevalence of chondromalacia isolated to the anterior margin of the lateral femoral condyle as a component of patellofemoral disease in patients with anterior knee pain and to correlate it with patient demographics, patellar shape, and patellofemoral alignment. Retrospective study over a 1-year period reviewing the MR knee examinations of all patients who were referred for assessment of anterior knee pain. Only patients with isolated lateral patellofemoral disease were included. Age, gender, distribution of lateral patellofemoral chondromalacia, and grade of cartilaginous defects were documented for each patient. Correlation between the distribution of lateral patellofemoral chondromalacia and patient demographics, patellar shape, and indices of patellar alignment (femoral sulcus angle and modified Q angle) was then ascertained. There were 50 patients (22 males, 28 females) with anterior knee pain and isolated patellofemoral disease. The majority of the patients (78%) had co-existent disease with grade 1 chondromalacia. No significant correlation was found between patients with chondromalacia isolated to the anterior margin of the lateral femoral condyle and age, gender, patellar shape, or modified Q angle (p > 0.05). However, patients with chondromalacia isolated to the anterior margin of the lateral femoral condyle had a shallower femoral sulcus angle (mean 141.8°) compared to the patients with lateral patellar facet disease (mean 133.8°) (p = 0.002). A small percentage of patients with anterior knee pain have chondromalacia isolated to the anterior margin of the lateral femoral condyle. This was associated with a shallower femoral sulcus angle.

MRI evaluation of anterior knee pain: predicting response to nonoperative treatment

Tibial tubercle lateral deviation and patellofemoral chondromalacia are associated with anterior knee pain (AKP). We hypothesized that increased tibial tubercle lateral deviation and patellofemoral chondromalacia on magnetic resonance imaging correlates with the presence of AKP and with failure of nonoperative management. In this retrospective comparative study, a blinded musculoskeletal radiologist measured tibial tubercle lateral deviation relative to the trochlear groove in 15 controls, 15 physical therapy responders with AKP, and 15 physical therapy nonresponders with AKP. Patellar and trochlear cartilage was assessed for signal abnormality, irregularity, and defects. The mean tibial tubercle lateral deviation in controls, physical therapy responders, and physical therapy nonresponders were 9.32 +/- 0.68, 13.01 +/- 0.82, and 16.07 +/- 1.16 mm, respectively (data are mean +/- standard deviation). The correlation coefficients for tubercle deviation, chondromalacia patellae, and trochlear chondromalacia were 0.51 (P < 0.01), 0.44 (P < 0.01), and 0.28 (P < 0.05), respectively. On analysis of variance, tubercle deviation and chondromalacia patellae contributed significantly to prediction of AKP and response to physical therapy. The presence of chondromalacia patellae and a tubercle deviation greater than 14.6 mm is 100% specific and 67% sensitive with a positive predictive value of 100% and negative predictive value of 75% for failure of nonoperative management. Subjects with AKP have more laterally positioned tibial tubercles and are more likely to have patellar chondromalacia. Patients with AKP, chondromalacia patellae, and a tubercle deviation greater than 14.6 mm are unlikely to respond to nonoperative treatment. Knowledge of tibial tubercle lateralization and presence of chondromalacia patellae may assist clinicians in determining patient prognosis and selecting treatment options.

Combined Proximal and Distal Realignment Procedures to Treat the Habitual Dislocation of the Patella in Adults

Background Habitual dislocation of the patella (HDP) is a rare condition. Many surgical procedures using proximal realignment have been reported to treat HDP in children, with around 80% satisfactory results. However, few articles have addressed the treatment of HDP associated with high-grade patellofemoral chondromalacia in adults. Hypothesis A combination of proximal and distal realignment procedures of the patella will reduce pain and increase function in adult patients with HDP. Study Design Case series; Level of evidence, 4. Methods Twelve patients with 13 symptomatic cases of HDP of the knee underwent surgical treatment that included lateral release, medial retinaculum advancement, and the anteromedial tibial tubercle transfer procedure. The average period between dislocation and surgery was 10.8 years. One patient had an additional procedure, an open-wedge varus corrective osteotomy of the distal femur, because of a 20° valgus deformity of the knee. The patellofemoral morphology study included routine and Merchant views of the knee and a computed tomography scan at full extension and at 30° flexion of the knee, before the operation and at follow-up. Any associated intra-articular pathologic findings during the surgical procedure were addressed. Patellofemoral function was evaluated with the Kujala functional score before surgery and at the time of the final follow-up. Results Chondromalacia of the patella over the medial facet and central ridge was grade III in 8 knees and grade IV in 5 knees. Corresponding chondral erosion of the lateral femoral condyle was noted in every knee. All patients were followed for an average period of 67.3 months (range, 25-103 months). The average preoperative Kujala functional score was 43.9 and the average postoperative score was 88.9 (P < .05). Radiographically, there was a statistically significant improvement in the congruence angle from 62.1° ± 15.0° preoperatively to —2.7° ± 9.8° postoperatively (P < .01) and in the lateral patellofemoral angle from —40.2° ± 9.3° preoperatively to 1.4° ± 7.0° postoperatively (P < .01). No patient has reported an episode of patellar dislocation after the surgical procedures. Conclusion Combined proximal and distal realignments of the patella effectively treat HDP in adults with associated high-grade patellofemoral chondromalacia.

Arthroscopic treatment of symptomatic type D medial plica

We aimed to review the results of subtotal arthroscopic resection of symptomatic type D medial plica. We retrospectively evaluated 23 knees with symptomatic type D medial plica in 22 patients without other intra-articular pathology. All patients complained of chronic knee pain that had not been alleviated by medical treatment or physical therapy. In only three (13%) of the patients studied was the plica diagnosed pre-operatively with magnetic resonance imaging. The type D medial plicae in our series were classified as fenestrated (14 knees), torn (5 knees), or reduplicated (4 knees). Fibrotic changes in the plicae and degenerative changes on the medial femoral condyle were found in 16 knees Patellofemoral chondromalacia was present in three knees Arthroscopic partial resection was performed in all patients. Comparative Lysholm Knee Scale scores before and after surgery revealed a significant clinical improvement (pre-operative status, 67.19 +/- 8.05 vs. post-operative status, 90.57 +/- 9.80; P < 0.001). Type D medial plica should be considered as a possible cause of chronic knee pain. Arthroscopic partial resection of the plicae in symptomatic patients gives satisfactory results.

Indications, Contraindications, and Pitfalls of Patellofemoral Arthroplasty

Recently, there has been renewed interest in patellofemoral arthroplasty, with the development of newer designs that have produced more consistent outcomes; however, historically, the reported results of this procedure have varied widely1. The purpose of this article is to analyze trends in the published results of this procedure, to identify critical factors contributing to the success or failure of these operations, and to relate the initial lessons that we have learned from our six-year clinical experience with the Avon patellofemoral arthroplasty (Stryker Orthopaedics, Mahwah, New Jersey). Indications, contraindications, mid-term follow-up results, and ways to avoid pitfalls are delineated. It is our intent that, with this information, surgeons will have a more critical view when considering patellofemoral arthroplasty for salvage in patients with isolated patellofemoral arthritis or advanced, refractory, symptomatic patellofemoral chondromalacia. In 1955, McKeever described the first successful attempt at prosthetic salvage in patients with symptomatic isolated patellofemoral degenerative disease2. His technique involved only patellar resurfacing with a Vitallium shell (Fig. 1), and it has been abandoned because of concerns about potential trochlear wear. In 1979, the era of patellofemoral arthroplasty began when Blazina et al. reported the results of the use of the Richards I/II prosthesis (Smith-Nephew Richards, Memphis, Tennessee)3. Refinements and development of other prostheses followed. These procedures have achieved variable success, with rates of satisfactory outcomes ranging from 42% to 92%1,4. Some of these prosthetic designs have been associated with problems. For example, as first noted by Blazina et al., medial impingement of the patellar prosthesis in flexion in excess of 90° continues to be a common design-related concern that has been implicated in the etiology of recurrent postoperative effusion3 (Fig. 2). Despite the existing problems, most of these devices continue to have their advocates; however, …

Semitendinosus tenodesis for repair of recurrent dislocation of the patella in children.

Recurrent dislocation of the patella is more common in girls than in boys. Although several predisposing factors may exist, patellar dislocation is most commonly associated with familial ligamentous laxity. Many surgical repairs have been described to stabilize the patella. We have found the semitendinosus transfer to the patella to result in a predictable, stable patellofemoral joint without risk of injury to the proximal tibial physis. Between January 1990 and December 1997, 29 children have been treated at the Children's Hospital of Eastern Ontario with a semitendinosus transfer for recurrent dislocation of the patella. Seven children were excluded from the study because of insufficient follow-up; consequently this series consisted of 22 children. Four children underwent bilateral repairs, hence 26 knees that have been operated on with this procedure were included in this study. There were three boys and 19 girls, with an average age at surgery of 14 years and 4 months, ranging from 8 years and 11 months to 17 years and 10 months. The average length of follow-up was 3 years and 2 months, ranging between 2 years and 7 years and 4 months. All children had experienced greater than three episodes of recurrent dislocation of the patella. Pain consistent with patellofemoral syndrome or chondromalacia was present in 17 of 26 knees. On clinical examination, 10 knees exhibited marked ligamentous laxity. There were nine positive patellar apprehension tests, and eight patellae were hypermobile. All children were treated with a semitendinosus transfer to the patella with concomitant tightening of the medial retinaculum and a lateral retinacular release. On long-term follow-up, 23 of the 26 knees (88%) were asymptomatic, and the child had returned to regular activities. Each child completed the Lysholm and the subjective component of the Zarins-Rowe questionnaire to determine the subjective results of the repair procedure. Three children complained of patellofemoral symptoms. One child experienced recurrence of the patellar dislocation, and one child developed medical patellar subluxation.

Fat-suppressed three-dimensional fast spoiled gradient-recalled echo imaging: A modified fs 3d spgr technique for assessment of patellofemoral joint chondromalacia

Fast fat-suppressed (FS) three-dimensional (3D) spoiled gradient-recalled echo (SPGR) imaging of 64 articular cartilage regions in 16 patellofemoral joints was evaluated to assess its feasibility in diagnosing patellofemoral chondromalacia. It demonstrated good correlation with arthroscopic reports and took about half of the examination time that FS 3D SPGR did. This modified, faster technique has the potential to diagnose patellofemoral chondromalacia with shorter examination time than FS 3D SPGR did.