The arthroscopic treatment of chondromalacia patellae

Three hundred and nineteen patients who had chondromalacia patellae and persistent patellofemoral pain after six months of conservative management underwent arthroscopy and arthroscopic surgery. The results in four aetiological groups were reviewed at one year and five years after operation. Morbidity was minimal. Lavage produced early remission in all groups. Shaving offered a particular advantage in the post-traumatic group. Lateral release plus shaving and lavage was beneficial in the group with maltracking patellae and in half of the idiopathic group. In the group with unstable patellae, lateral release produced good results in only one in four patients. In conclusion, we consider that arthroscopic surgery has a useful role to play in the management of chondromalacia patellae.     

Arthroscopic treatment of posttraumatic chondromalacia patellae

An arthroscopic procedure of excision of damaged cartilage and drilling the subchondral bone plate for treatment of chondromalacia patellae is described. Satisfactory results and absence of major complications are reported in a preliminary, short-term series of 24 cases of symptomatic posttraumatic chondromalacia patellae, with a mean follow up of 12 months.     

Low level laser treatment of chondromalacia patellae

Summary A randomized, double blind study of low level laser treatment of chondromalacia of the patella in 40 patients has been undertaken. Chondromalacia was established by arthroscopy and was related to subjective symptoms. Eight treatments were given during five weeks by a physiotherapist with the use of a GAAS pulsed laser, real or sham. Assessment of the location, quality and intensity of pain, and the influence on mood, gait, sleep, work, and sports was made before and after treatment including an eight to twelve week evaluation. No statistical difference was found between real and sham use of low level laser for the symptoms of chondromalacia of the patella.

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Résumé On a réalisé chez 10 malades une étude randomisée, à double insu, du traitement de la chondropathie de la rotule par laser de basse intensité. Le diagnostic avait été confirmé par arthroscopie, en présence d'une symptomatologie subjective. Huit séances de traitement ont été effectuées pendant cinq semaines par un physiothérapeute utilisant un laser alternatif GAAS, réel ou simulé. Une évaluation du siège, du type et de l'intensité de la douleur ainsi que de l'influence de l'humeur, de la marche, du sommeil, du travail et de l'activité sportive a été faite avant et après traitement. Aucune différence statistiquement valable n'a pu être mise en évidence entre l'effet d'un laser réel ou simulé vis à vis des symptômes de la chondropathie rotulienne.

     

Operative treatment of chondromalacia patellae (author's transl)

Operative treatment of chondromalacia patella should be indicated especially in adolescents with great care. It can be clearly identified by a narrowing of the cartilage on the X-ray (tangential picture of the femoropatellar joint) and the presence of osteophytes on the margin of the joint. The following methods of operative treatment are recommended: Proximal decompressive operation by splitting the lateral retinaculum in light cases and the elevation of the tuberositas tibiae for severe chondromalacia and femoropatellar arthrosis. Follow-up examinations and the results are presented.     

Repair of symptomatic cartilage lesions of the knee: the place of autologous chondrocyte implantation

An increasing number of patients with cartilage defects of the knee are being treated with autologous chondrocyte implantation (ACI). To date, no clear guidelines exist for the use and indications of this technique. The BVOT and SOBCOT have established a working group to review the clinical results and the cost-effectiveness of the various treatment modalities and particularly of ACI. This group has formulated recommendations and presents a treatment algorithm based on an in-depth review of recent European and American literature, on peer-reviewed opinions of leading investigators in the field and on a comparative analysis of the clinical results and health-economic aspects of current cartilage repair techniques.     

The influence of subchondral vascularisation on chondromalacia patellae

An experiment was carried out on 40 rabbits in which the blood supply to the patella was interrupted for periods from 2 weeks to 6 months. With prolonged ischaemia, there were clear changes in the articular cartilage which were comparable with those seen in chondromalacia patellae.     

Articular cartilage changes in chondromalacia patellae

Full thickness samples of articular cartilage were removed from areas of chondromalacia on the medial and "odd" facets of the patellae of 21 adults and examined by histology, autoradiography and electron microscopy. Surface fibrillation, loss of superficial matrix staining and reduced 35SO4 labelling was seen, with little change in the deep zone. Ten cases showed "fibrous metaplasia" of the superficial cartilage with definite evidence of cell division and apparent smoothing of the surface. Scattered chondrocyte replication appeared to occur in the surrounding intact cartilage. The findings suggest that early lesions in chondromalacia patellae may heal either by cartilage or fibrous metaplasia and that this may account for the resolution of clinical symptoms.     

The importance of the mediopatellar synovial plica for chondromalacia patellae

Summary In 60 autopsy knee joints findings on morphology and topography of medio- and suprapatellar plicae and level of insertion of the medial vastus muscle in relation to localization and degree of severity of chondromalacia were determined. The middle fields were affected most frequently and severely with 70% (chondromalacia class II and III). Thirty specimen with mediopatellar plica could be identified out of which 29 (97%) had class II or III chondromalacia; out of 30 specimen without a plica 18 (60%) showed chondromalacia. Accordingly a significant correlation could be detected between the incidence of chondromalacia and that of a mediopatellar synovial plica. When measuring the level of insertion of the medial vastus muscle class III chondromalacia showed an average level of insertion of 11%, class II of 22%, and class 0 or I of 30%. These differences are statistically significant. Patellar index, patellar facet angle, and patellar depth angle did not show any direct correlation to chondromalacia. The question arises whether the involution anomaly of the genicular septa and the muscular changes are not a manifestation of the same developmental disorder, thus creating the basis for an imbalance of the dynamic functional structure.

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Zusammenfassung An 60 Leichenkniegelenken wurden Befunde über Morphologie und Topographie der Plica medio- und suprapatellaris sowie der Ansatzhöhe des M. vastus medialis im Vergleich zur Lokalisation und Schweregrad der Chondromalazie erhoben. Am häufigsten und schwersten betroffen waren die mittleren Felder mit 70% (Chondromalazie II. und III. Grades). Es fanden sich 30 Präparate mit einer mediopatellaren Plica, davon hatten 29 (97%) eine Chondromalazie II. oder III. Grades; 30 Präparate hatten keine Plica, von ihnen wiesen 18 (60%) eine Chondromalazie auf. Es ließ sich demnach eine signifikante Abhängigkeit zwischen dem Vorkommen einer Chondromalazie and dem Auftreten einer Plica synovialis mediopatellaris feststellen. Bei der Vermessung der Ansatzhöhe des M. vastus medialis ergab sich für die Chondromalazie 111. Grades eine durchschnittliche Ansatzhöhe von 11%, beim Grad II von 22% and bei Grad 0 oder I von 30%. Diese Unterschiede sind ebenfalls signifikant. Der Patellaindex, der Patellafacettenwinkel und der Patellatiefenindex ließen keine direkte Beziehung zur Chondromalazie erkennen. Es wird die Frage aufgeworfen, ob die Rückbildungsanomalien der Kniesepten und die muskulären Veränderungen nicht Ausdruck derselben Entwicklungsstörung sind, womit Voraussetzungen für eine Störung des dynamischen Leistungsgefüges geschaffen werden.

     

Historical perspectives of chondromalacia patellae.

Widespread misuse of the term chondromalacia has led to confusion regarding its true meaning. This term should not be used to diagnose patellofemoral pain, but to describe lesions of articular cartilage. Recent advances using stereophotogrammetry to evaluate the patellofemoral joint and its articular cartilage may lead to new insight into the etiology of these lesions.     

First successful autologous chondrocyte implantation in Pakistan

Osteochondritis dissecans entails a hyaline cartilage defect of the articular surface causing pain and functional restriction in young adults, sometimes resulting in early degenerative arthritis. Conventional treatment methods such as abrasion chondroplasty and mosaicplasty have limitations in terms of quality of the resultant cartilage and donor site morbidity. A more recent technique, autologous chondrocyte implantation (ACI) results in hyaline cartilage formation and gives good long-term outcome, but requires a high-level cell culture facility and two surgical procedures. The patient was a young female with knee pain, intermittent locking and feeling of "joint mouse". MRI scan and arthroscopy showed a 2 x 2 cm full thickness osteochondral defect in the medial femoral condyle. A free fragment of articular cartilage was found, which was extracted arthroscopically, and chondrocytes were cultured from it in the Juma laboratory. Subsequently, patient underwent surgery whereby the chondrocytes were injected under a periosteal patch sewn over the defect. Over six months, patient's symptoms completely resolved and she returned to full function. A repeat arthroscopy after one year revealed complete filling of the previous defect with normal appearing cartilage indicating success of the procedure. This technology can be utilized for treating patients with a variety of conditions affecting hyaline cartilage of joints.     

The effect of lateral retinacular release in idiopathic chondromalacia patellae

Summary The results of lateral retinacular release were evaluated in 28 patients with idiopathic chondromalacia patellae. Follow-up was performed 3–5 years after the operation. At follow-up 13 patients were improved, while the symptoms were equal or intensified in 15 patients. However, compared with the situation before the operation, the levels of activity were increased in only two patients, while the levels of activity were unchanged or reduced in the remaining 26 patients. From this study it is concluded that the results of lateral retinacular release for idiopathic chondromalacia patellae are poor with regard to relief of symptoms, and especially with regard to improvement in ability to perform physical activities.     

Molecular markers in the evaluation of autologous chondrocyte implantation

Purpose: With the help of molecular markers, it has become possible to quantify cartilage repair and degradation in joints. In this study, we attempt to determine whether or not molecular markers in synovial fluid can be helpful in defining the repair process following autologous chondrocyte implantation (ACI). Type of Study: As part of a prospective clinical pilot study, 17 patients were evaluated before, as well as 6 weeks, 3, 6, and 12 months after the ACI. A synovial analysis was performed and molecular markers for bone and cartilage metabolism were determined. Methods: A number of parameters, including pyridinium crosslink (PY), deoxypyridinolin (DPD), n-telopeptide (NTX) from type I collagen, MMP-1, MMP-3; TIMP-1, PICP, proteoglycan, and YKL-40 were analyzed. The levels were referenced to the total protein concentration of the synovial fluid. The synovial analyses were compared with clinical parameters (Larson score) and magnetic resonance imaging (MRI) examinations. Results: The analysis of the data revealed differing trends for the various synovial markers over time. The most remarkable marker was found to be DPD, which increased continuously between surgery and week 12, only to disappear after the repair process had ceased 1 year after surgery. All molecular markers for cartilage degradation increased initially after surgery and dropped off below the original levels 3 to 6 months later. Conclusions: The evaluation revealed that the determination of marker levels can provide valuable information regarding the metabolism of bone and cartilage in a joint. They seem to provide a method for monitoring the repair process associated with the various treatment forms for chondral lesions.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: pp 397–403     

Early results of autologous chondrocyte implantation in the talus

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was 'pleased' or 'extremely pleased', which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site.     

The effect of lateral retinacular release in idiopathic chondromalacia patellae

The results of lateral retinacular release were evaluated in 28 patients with idiopathic chondromalacia patellae. Follow-up was performed 3-5 years after the operation. At follow-up 13 patients were improved, while the symptoms were equal or intensified in 15 patients. However, compared with the situation before the operation, the levels of activity were increased in only two patients, while the levels of activity were unchanged or reduced in the remaining 26 patients. From this study it is concluded that the results of lateral retinacular release for idiopathic chondromalacia patellae are poor with regard to relief of symptoms, and especially with regard to improvement in ability to perform physical activities.     

Radiographic assessment in patellar instability and chondromalacia patellae

Minor degrees of malalignment of the patella and anatomical abnormalities including a flattened sulcus angle and an increased ratio between patellar tendon length and patellar length (PT:P) have been suggested as predisposing factors in the causation of chondromalacia patellae, as well as patellar instability. In order to confirm or refute this hypothesis a prospective study has been performed comparing the congruence and sulcus angles and the PT:P ratio in a group of 35 patients with chondromalacia confirmed by arthroscopy and a group of 33 patients with instability, with those of a group of 50 knees in normal volunteers. While there was a statistically significant correlation between an increased sulcus and congruence angle and a high-riding patella in patients with instability, no correlation could be identified in patients with idiopathic chondromalacia.