Chondromalacia Patellae

 

Patella Chondromalacia Patella cartAMIC

 

Definitions

 

Patellofemoral Pain Syndrome

- anterior knee pain in the absence of cartilage damage

- adolescents

- female > male

- maltracking

- patella tilt / Lateral patella pressure syndrome

 

Chondromalacia patella

- damage to the articular cartilage of the patella / trochlea causing anterior knee pain

- trauma

- acute PFJ dislocation

- chronic maltracking

- patella tilt / Lateral patella pressure syndrome

 

Epidemiology

 

Smith PLoS One 2018

- systematic review of anterior knee pain

- incidence general population 23%

- incidence adolescents 29%

 

International Cartilage Research Society Arthroscopy (ICRS) Classification

 

ICRSICRSICRSICRS

Grade I:   Nearly normal -  soft indentation / superficial fissures and cracks

Grade II:   Abnormal - cartilage lesions < 50% of cartilage depth

Grade III:  Severely abnormal - cartilage lesions > 50% of cartilage depth

Grade IV:  Severely abnormal - cartilage lesion down to subchondral bone

 

Grade I: Softening

 

Grade II: < 50% of cartilage depth

 

Patella Fibrillation ArthroscopyChondromalacia Patella Grade 3Grade 2 patella

 

Grade III: > 50% cartilage depth

 

Patella Grade 3 ArthroscopyPatella Grade 2 Chondromalaciae

 

Grade IV: subchondral bone

 

Patella Grade 4 Arthroscopygrade IV trochlea

 

Symptoms

 

Anterior Knee Pain - often worse with prolong sitting

Swelling

 

Signs

 

PFJ crepitus

Maltracking

Tight lateral retinaculum

 

MRI

 

Patella cartPatella cartilage

 

Patella cartPatella cart

 

Trochlea MRITrochlea MRI

 

Trochlea cartTrochlea MRI

 

Non-operative Management

 

Physiotherapy

 

Quadriceps exercises

 

van der Heijden et al Cochrane Database 2015

- evidence for exercise therapy in reducing anterior knee pain

 

Patellofemoral knee braces

 

PFJ bracePFJ brace

 

Culvenor et al Br J Sports Med 2020

- systematic review

- some evidence that braces can reduce AKP

 

Petersen et al Arch Orthop Trauma Surg 2016

- RCT of brace + exercise program versus exercise program alone

- 156 patients with patellofemoral pain syndrome

- better results with medially directed patella realignment brace

 

Taping

 

Patella taping

 

Luo et al Medicine 2024

- systematic review of kinesio taping for patellofemoral pain syndrome

- evidence for improved pain, but not improved function

 

Neuromuscular stimulation

 

Talbot et al Mil Med 2020

- RCT of 130 members of the military with PFPS

- use of electrical stimulation improved strength compared to strength training along

 

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 for Patellofemoral pain syndrome

 

Tibial tuberosity Osteotomy

 

www.boneschool.com/tibialtuberosityosteotomy

 

Options

 

Medialization / Elmslie-Trillat

Anteromedialization / Fulkerson

Elevation / Maquet

 

TTOMaquet

Fulkerson                                         Maquet

 

Jack et al Bone Joint Res 2012

- 50 knees with normal tracking and CMP

- treated with Fulkerson / anteromedializaiton

- 72% good or excellent results

 

Fisher et al Arthroscopy 2016

- 77 military patients undergoing a TTO for chondromalacia patella

- 63% returned to military duties

 

Rosso et al AJSM 2017

- 69 patients with grade I / II patellofemoral degeneration treated with anteromedialization

- 25% would not undergo the surgery again

 

Operative options for focal chondral defects of the patella

 

Arthroscopy

 

Debridement

 

Grade 2 patellaPatella debridement

Debridement patella chondral flap

 

Trochlea cartTrochlea debridement

Debridement trochlea chondral damage

 

Federico et al Am J Sports Med 1997

- arthroscopic shaving in 36 patients with grade 2 or worse

- no malalignment

- only 50% good or excellent result

 

Microfracture

 

Trochlea defectTrochlea microfracture

Microfracture of trochlea chondral defect

 

van Tuijn et al Cartilage 2023

- systematic review of microfracture

- worse outcomes in PFJ than in knee condyles

 

Cartilage restoration procedures

 

www.boneschool.com/chondraldefects

 

PFJ cartilage restoration procedures PFJ

 

Hinckel et al AJSM 2020

- systematic review of PFJ cartilage lesions in 2000 patients

- clinical patient improvement of various restoration procedures

- MACI 83%

- OAT 78%

- OCA 71%

- AMIC 64%

- OCA had highest failure rate

 

AMICAMICAMIC

AMIC procedure of a full thickness patella lesion

 

Tibial tuberosity osteotomy (TTO)

 

Trinh et al Arthroscopy 2013

- systematic review of patients with PFJ chondral lesions

- compare isolated ACI versus combined ACI and TTO

- better outcomes with ACI / TTO

 

TTOTTOTTOTTO