PFJ osteoarthritis

 

PFJ OA

 

Definition

 

Full thickness loss of the articular cartilage lining the patella and the trochlea

 

Epidemiology

 

Hart et al Br J Sports Medicine 2017

- systematic review on prevalence of PFJ OA on xray / MRI knees with pain

- 50% incidence of OA affecting the PFJ

 

Kobayashi et al Osteoarthritis Cartilage

- systematic review of patients with knee pain

- overall prevalence PFJ OA 39%

- PFJ OA females 41%, males 23%

- isolated PFJ OA 8%

 

Etiology

 

Obesity

Repetitive deep flexion

Malalignment / patella maltracking / trochlea dysplasia

Lateral patella tightness

Blunt trauma

 

Symptoms

 

Anterior knee pain - sitting / rising from chair / stairs

 

Signs

 

Tender patella - especially lateral facet

Pain with movement PFJ

 

X-ray

 

Narrowing / osteophytes / sclerosis

Tilt / subluxation

 

Patella OA TiltPatella OA SubluxationPatella OA Lateral

Tilt                                                            Subluxation / osteophytes                              

 

MRI

 

PFJ OA mildMild PFJ OA

Moderate lateral facet PJF OA with tilt

 

PFJ OAPFJ OA MRI

Severe lateral PFJ OA in the setting of maltracking / subluxation / tilt

 

Arthroscopy

 

PFJ OA ArthroscopyPFJ OA Arthroscopy

 

Patella Grade 4 ArthroscopyPatella Trochela Grade 4 Damage

 

Patterns

 

Lateral facet - patella maltracking / trochlea dysplasia

Medial facet - patella dislocation and cartilage damage

Global - primary OA, patella fracture, obesity

Central trochlea - repetitive deep flexion

 

Patella OALateral PFJ OA

Medial facet OA                                       Lateral facet OA

 

Management

 

Non Operative

 

Quadriceps exercises

 

van der Heijden et al Cochrane Database 2015

- evidence for exercise therapy in reducing anterior knee pain

 

Bracing / Taping

 

Callaghan et al Syst Rev 2021

- systematic review of bracing and taping for PFJ OA

- good evidence for short term reduction in pain

 

Injections

 

Hyaluronic acid

 

Hart et al Orthop J Sports Med 2019

- RCT of 86 patients with patellofemoral pain syndrome

- no efficacy of HA versus sham injections at 6 months

 

PRP

 

Dai et al Arthroscopy 2017

- meta-analysis of RCTs of injections for knee OA

- 10 RCTs and 1000 patients

- PRP superior to HA and saline at 12 months

 

Belk et al AJSM 2021

- systematic review of PRP versus HA for knee osteoarthritis

- improved outcomes with PRP versus HA

 

Operative

 

Options

 

Lateral retinacular release

Tibial tuberosity osteotomy

Facetectomy

Patellectomy

Patellofemoral joint replacement

Total knee replacement

 

Lateral retinacular release

 

Indications

 

Lateral facet OA in setting of lateral tilt and tight lateral retinaculum

Lateral patella compression syndrome

 

Complications

 

Medial patella instability - don't over release

Hemarthrosis - superior lateral geniculate artery

 

Patella Tilt Moderate OAPatella Tilt Moderate OA MRILateral release

 

Technique

 

Vumedi arthroscopic lateral release technique

 

Results

 

Arthroscopic lateral release

 

Aderinto et al Arthroscopy 2002

- retrospective study of 53 knees

- 80% patients felt some reduction in pain

- 41% unsatisfied

 

Open versus arthroscopic

 

Hamawandi et al Arch Orthop Trauma Surg 2022

- RCT of open v arthroscopic release in 80 patients

- better functional outcomes at 2 years with arthroscopic release

- 4 cases medial patellar instability in the open release group

 

Lateral retinacular lengthening

 

O'Neill et al JBJS Am 1997

- RCT of arthroscopic release versus open retinacular lengthening

- 86 patients

- better outcomes with open retinacular lengthening

 

Tibial tuberosity osteotomy

 

Types

 

Maquet - elevation

Elmslie-Trillat - medialization

Fulkerson - anteromedialization

 

Maquet procedure

 

Maquet APMaquet Lateral

 

Technique

 

Perform TTO then elevate with insertion bone graft

- originally described elevating by 2.5 cm

- problems with skin necrosis / prominence

- reduced to only 1 cm and recommended via an anterolateral incision

 

Results

 

Jenny et al KSSTA 1996

- 100 knees treated with Maquet for grade IV OA

- 62% success rate

 

Atkinson et al Arch Orthop Trauma Surg 2012

- 50 knees with PFJ OA treated with 10 - 15 mm elevation using femoral head allograft

- 77% good or excellent results

- 3 tibial tuberosity fractures

- 8% superficial wound infections

 

Fulkerson

 

Technique

 

Arthroscopy techniques PDF

 

Vumedi surgical technique video

 

Oblique osteotomy 45˚

- enables antero-medial transfer of tibial tuberosity

- unloads the lateral facet simultaneously

 

Fulkerson Osteotomy APFulkerson Osteotomy Lateral

 

TTO 1TTO 2

 

Results

 

Fulkerson et al Am J Sports Med 2019

- anteromedialization osteotomy in 17 knees with distal or lateral OA

- 15 year follow up

- 94% would repeat the procedure

 

Yang et al J Orthop Surg 2021

- Fulkerson osteotomy in 40 patients mean age 50

- 20% went on to have TKA

 

Berk et al Orthop J Sports Med 2023

- review of 344 TTO

- stiffness 16%

- superficial infection 8%

- hemarthrosis 6%

 

Facetectomy

 

Indication

 

Isolated OA of one facet

 

Techniques

 

Open procedure

 

Vumedi surgical technique

 

Arthroscopic lateral facetectomy

 

Surgical technique PDF

 

Youtube surgical technique video

 

Results

 

Wetzels et al Knee 2012

- lateral facectomy in 168 knees with average 11 year follow up

- 37% failure

 

Douiri et al Arthroscopy 2022

- arthroscopic lateral facetectomy and release in 56 knees

- 86% survival at 7 years

 

Paulos et al Arthroscopy 2008

- arthroscopic lateral release and partial lateral facetectomy in 66 knees

- 88% very satisfied or satisfied

 

Patellectomy

 

Patellectomy LateralPatellectomy Skyline

 

Technique

 

Concept

 

Excise patella in full close retinaculum tightly with VMO advancement

 

Concerns

- extensor lag and weakness

- continued pain if trochlea lesions

- issues with later TKA

 

AO Surgery Reference Technique



Surgical technique PDF

 

Results

 

Outcomes

 

Baker et al JBJS 1988

- patellectomy for OA in 20 knees

- 19/20 satisfied

 

Cavaignac et al KSSTA 2014

- systematic review of 31 articles and 1400 patellectomies

- 85% good or excellent if extensor mechanism reinforcement is performed

 

Complications

 

Ziran et al CORR 1994

- 12 patellectomies

- good function, but extensor weakness and ROM differences



Asopa et al J Orthop Surg Res 2015

- better results with disease confined to the patella

 

TKA and patellectomy

 

Asadollahi et al Knee 2017

- systematic review of TKA after previous patellectomy

- reduced flexion and increased risk complications in patients with patellectomy

 

Patellofemoral joint replacement

 

PFJRPFJRPFJR

 

Technique

 

Vumedi surgical technique video

 

JBJS Essential Surgical technique PDF

 

Contra-indications

 

Inflammatory conditions

Patella maltracking / malalignment

Tibiofemoral arthritis / medial or lateral joint pain / instability

 

PJF OA

 

Results

 

Outcomes

 

Sava et al KSSTA 2023

- systematic review of inlay versus only PFJR

- no difference in functional outcome

- higher progression of OA with only trochlea implants

 

Australian Joint Registry 2023

- 15 year revision rate of 3326 PJF arthroplasty: 35.6

- increased risk with males and < 65

  PFJ Arthroplasty TKA
1 year 1.4 1.0
3 year 6.5 2.4
5 year 10.6 3.1
7 year 15.3 4.6
10 year 22.4 6.2
15 year 35.6 7.7

 

Complications

 

PFJAPFJR