Combined lateral retinacular release with drilling chondroplasty for treatment of patellofemoral osteoarthritis associated with patellar malalignment in elderly patients

Patellar malalignment: A common disorder associated with knee pain

Pain-associated knee joint disorders are common in daily life. Practically, knee pain should be divided into the origin from the isolated tibiofemoral (TF), isolated patellofemoral (PF) joint, or a combination thereof. The TF joint controls the actions of level walking, while the PF joint controls knee flexion-extension. Owing to its sufficient inherent stability, non-traumatic disorders of the isolated TF joint in young individuals are uncommon. In contrast, because of its insufficient inherent stability, non-traumatic disorders of the isolated PF joint are common in young individuals. Patellar malalignment (PM) associated with knee pain is common in all age groups, and the most common predisposing factor is imbalanced peripatellar soft-tissue tension. The outward forces acting on the patella are caused by pulling from the quadriceps femoris during knee flexion to extension (manifested by the quadriceps angle [Q-angle]), and sliding backward of the iliotibial band (ITB) during knee extension to flexion. Once the muscle power of the vastus medialis (especially the vastus medialis obliquus [VMO]) decreases, which lowers the counteracting effect against outward forces, the patella displaces or rotates laterally. The reduced contact surface between the patella and the femoral condyle significantly increases the compressive pressure and injures the articular cartilage. Subsequently, progressive PF degeneration occurs. Although other factors may also cause PM, they are relatively uncommon. In principle, nonsurgical treatment of PM should be considered first, while surgical treatment should follow established indications. Some nonsurgical techniques are currently widely used that feature high satisfaction rates. Surgical techniques are continuously being developed, and their success rates have gradually improved. This study aimed to review the current literature for relevant studies and report related publications of the author's institution to emphasize the universality and importance of PM management. Conceptually, simply focusing on problems of the TF joint cannot treat all knee disorders.

Modified Partial Lateral Facetectomy of the Patella for Stage III Patellofemoral Osteoarthritis with 5-Year Follow-Up

The main aim of this article was to examine the therapeutic evaluation of our modified partial lateral facetectomy of the patella for stage III lateral patellofemoral osteoarthritis (PFOA), which includes (1) partial lateral patella articular facet that was resected; (2) coronal Z-shaped incision to lengthen lateral retinaculum; (3) patellar perimeter electrocoagulation to denervate. Between December 2008 and January 2013, 36 knees of 32 patients with severe patellofemoral (PF) osteoarthritis (OA) were treated with our modified partial patellar lateral facetectomy. All patients were stage III according to the Iwano scale, and their patellas were all Wiberg type III or Baumgartl type IV in shape. The study group included 6 males and 26 females with an average age of 54.03 years and an average disease course of 8.67 years. The modified Kujala scores were used to evaluate PF function, and the congruence angle was used to evaluate the patellar position. Knee Society Scores (KSS) were used to evaluate overall knee function. Six knees of five cases were lost to follow-up. Thirty knees of 27 cases were followed up for 5 years, with an average follow-up time of 60 ± 3.2 months. The average preoperative modified Kujala score was 15.93, and the average score at last follow-up was 32.03; The satisfactory PF function was achieved in 28 knees (93.33%). The congruence angle improved from preoperative +23. 07 degrees to 11. 91 degrees at the last follow-up. The average preoperative KSS were 110.40 points, which increased to 156.77 points at the last postoperative follow-up. Pain was significantly relieved, and the ability to climb stairs was significantly improved. All scores showed statistically significant improvements after surgery (p < 0.05). No complications were reported. Our modified partial lateral facetectomy of the patella for stage III lateral PFOA can relieve pain and partially improve function. This modified procedure is relatively simple, safe, and an effective treatment method for middle-aged and elderly patients with PFOA. Furthermore, this surgery can be used as an alternative or prephase to total knee arthroplasty. This is a Level IV, therapeutic study.

[Expert consensus on surgical treatment of patellofemoral osteoarthritis]

Patellofemoral osteoarthritis (PFOA) is one of the most common causes of anterior knee pain in middle-aged and elderly population. In general, elementary therapy and drug therapy are the preferred choices for PFOA management. However, for those who cannot achieve satisfactory effectiveness with standard non-surgical treatment, surgical therapy stands as an alternative treatment. The surgical therapy includes repair surgery and reconstruction surgery. The choice of surgical plans for PFOA management mainly depends on the etiology, pathogenesis, location, and severity of the lesions. To aid clinical decision-making, the National Clinical Research Center for Geriatric Disorders (Xiangya Hospital) and the Joint Surgery Branch of the Chinese Orthopedic Association arranged nationwide orthopedic specialists to set up a work panel. After reviewing the research progress of surgical therapy and the latest guidelines and consensus for PFOA management, the work panel discussed repeatedly to reach this consensus. The present consensus aims to provide valid evidences for clinical practices of the surgical therapy of PFOA, so as to avoid inappropriate and irregular treatment behaviors, reduce surgical trauma, improve surgical efficacy and the quality of life, and to ease the burden of PFOA.

Patellofemoral Cartilage Restoration: A Systematic Review and Meta-analysis of Clinical Outcomes

BACKGROUND

Many surgical options for treating patellofemoral (PF) cartilage lesions are available but with limited evidence comparing their results.

PURPOSE

To determine and compare outcomes of PF cartilage restoration techniques.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, and Cochrane Library databases. Inclusion criteria were clinical studies in the English language, patient-reported outcomes after PF cartilage restoration surgery, and >12 months' follow-up. Quality assessment was performed with the Coleman Methodology Score. Techniques were grouped as osteochondral allograft transplantation (OCA), osteochondral autograft transfer (OAT), chondrocyte cell-based therapy, bone marrow-based therapy, and scaffolds.

RESULTS

A total of 59 articles were included. The mean Coleman Methodology Score was 71.8. There were 1937 lesions (1077 patellar, 390 trochlear, and 172 bipolar; 298 unspecified). The frequency of the procedures was as follows, in descending order: chondrocyte cell-based therapy (65.7%), bone marrow-based therapy (17.2%), OAT (8%), OCA (6.6%), and scaffolds (2.2%). When compared with the overall pooled lesion size (3.9 cm²; 95% CI, 3.5-4.3 cm²), scaffold (2.2 cm²; 95% CI, 1.8-2.5 cm²) and OAT (1.5 cm²; 95% CI, 1.1-1.9 cm²) lesions were smaller (P < .001), while chondrocyte cell-based therapy lesions were larger (4.7 cm²; 95% CI, 4.1-5.3 cm²; P = .039). Overall, the instability pool was 11.9%, and the anatomic risk factors pool was 32.1%. Statistically significant improvement was observed on at least 1 patient-reported outcome in chondrocyte cell-based therapy (83%), OAT (78%), OCA (71%), bone marrow-based therapy (64%), and scaffolds (50%). There were no significant differences between any group and the overall pooled change in International Knee Documentation Committee score (30.2; 95% CI, 27.4-32.9) and Lysholm score (25.2; 95% CI, 16.9-33.5). There were no significant differences between any group and the overall pooled rate in minor complication rate (7.6%; 95% CI, 4.7%-11.9%) and major complication rate (8.3%; 95% CI, 5.7%-12.0%); however, OCA had a significantly greater failure rate (22.7%; 95% CI, 14.6%-33.4%) as compared with the overall rate (6.8%; 95% CI, 4.7%-9.5%).

CONCLUSION

PF cartilage restoration leads to improved clinical outcomes, with low rates of minor and major complications. There was no difference among techniques; however, failures were higher with OCA.

Hybrid closed wedge high tibial osteotomy improves patellofemoral joint congruity compared with open wedge high tibial osteotomy

PURPOSE

To evaluate clinical outcomes and radiographic changes in patellofemoral (PF) joint congruity between open wedge high tibial osteotomy (OWHTO) and hybrid closed wedge HTO (HCWHTO).

METHODS

From 2011 to 2013, 36 knees in 31 patients who underwent OWHTO and 21 knees in 17 patients who underwent HCWHTO were evaluated in this retrospective study with a minimum 5-year follow-up. Radiological outcomes including hip-knee-ankle angle (HKA), femoral patellar height index (FPHI), preoperative PF osteoarthritis (OA) grade, medial and lateral joint spaces of the PF joint, and congruence angle were measured. Clinical parameters including the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Oxford Knee Score (OKS) were also evaluated. Preoperative and final follow-up values for each procedure were compared in outcome analyses.

RESULTS

Mean preoperative HKA and the degree of PF-OA were significantly more severe for patients treated with HCWHTO compared with those treated with OWHTO (p = 0.001, p = 0.0001). Mean postoperative FPHI was significantly decreased with proximalization of the patella in HCWHTO (p = 0.01) but showed no significant change in OWHTO (n.s.). Regarding PF joint congruity after HCWHTO, lateral joint space and congruence angle were significantly improved (p = 0.0001, p = 0.005), while medial joint space was not significantly changed (n.s.). After OWHTO, congruence angle showed no significant difference (n.s.), but medial and lateral joint spaces were significantly decreased (p = 0.0001, p = 0.018). There were no significant differences in KOOS and OKS between the groups (n.s., n.s.).

CONCLUSIONS

Although degrees of varus knee and PF-OA were more severe in HCWHTO than those in OWHTO, HCWHTO led to improved PF joint congruity, and its mid-term clinical outcomes were equivalent to those of OWHTO. Therefore, in patients with varus knee combined with PF-OA preoperatively, HCWHTO is a more effective treatment than OWHTO.

LEVEL OF EVIDENCE

Therapeutic level III.

Changing trends in the use of cartilage restoration techniques for the patellofemoral joint: a systematic review

PURPOSE

The patellofemoral (PF) joint contains the thickest articular cartilage in the human body. Chondral lesions to this area are often misdiagnosed and can predispose to secondary osteoarthritis if left untreated. Treatment options range from arthroscopic debridement to cartilage restoration techniques such as microfracture (MFx), autologous chondrocyte implantation (ACI), and osteochondral autograft transplantation. The purpose of this study was to systematically assess the trends in surgical techniques, outcomes, and complications of cartilage restoration of the PF joint.

METHODS

This review has been conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The electronic databases PubMed, MEDLINE, and EMBASE were searched from January 1, 2007 to April 30, 2018. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. A two-proportion z test was used to determine whether the differences between the proportions of cartilage restoration techniques used from 2007 to 2012 and 2013-2018 were statistically significant.

RESULTS

Overall, 28 studies were identified, including 708 patients (824 knees) with a mean age of 39.5 ± 10.5 years and a mean follow-up of 39.1 ± 16.0 months. Majority of patients were treated with ACI (45.5%) and MFx (29.6%). A significant increase in the use of the third generation ACI occurred with a simultaneous decreased usage of the conventional MFx over the last 5 years (p < 0.001). All techniques had significant (p < 0.05) improvements in clinical outcomes. The overall complication rate was 9.2%, of which graft hypertrophy (2.7%) was the most prevalent.

CONCLUSIONS

ACI was the most common restoration technique. The use of third generation ACI has increased with a concurrent decline in the use of conventional MFx over the latter half of the past decade (p < 0.001). Overall, the various cartilage restoration techniques reported improvements in patient reported outcomes with low complication rates. Definitive conclusions on the optimal treatment remain elusive due to a lack of high-quality comparative studies.

LEVEL OF EVIDENCE

Level IV, Systematic Review of Level-II-IV studies.

Triple positioning of tibial tubercle osteotomy for patellofemoral disorders

BACKGROUND AND PURPOSE

Patellofemoral disorders are often associated with patellofemoral malalignment. Tibial tubercle transfer is an effective method to correct the patellofemoral malalignment. This study evaluated the long-term results of triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders with 10-year follow-up.

PATIENTS AND METHODS

Fifty-six patients with 62 knees underwent triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders. All patients received standard rehabilitation protocol postoperatively. The average length of follow-up was 128.5±9.8 months (range 116 to 149). The evaluations included pain score, Kujala patellofemoral score, Lysholm score and radiograph of the knee.

RESULTS

The overall clinical results were excellent in 41.9%, good in 37%, fair in 12.9% and poor in 5% at 1 year; and 29% excellent, 41% good, 18.3% fair and 9.3% poor at 10 years. Satisfactory results were 78.9% and 70.9%, and unsatisfactory results 21.1% and 29.1% at 1 year and 10 years respectively. There was no correlation of clinical outcomes with age, sex, body weight and height and preoperative pain score. However, there was a positive correlation of clinical outcomes with the improvement of the congruence angle on postoperative X-rays of the knee, and a negative correlation of clinical outcome with the severity of articular cartilage damage assessed in arthroscopy. The complications included 1 non-union and 1 infection with non-union.

CONCLUSION

Triple positioning of tibial tubercle osteotomy is effective and long lasting in patients with patellofemoral disorders with 70.9% satisfactory results at 10-year follow-up.

LEVEL OF EVIDENCE

IV (refer to instructions for detailed description on the level of evidence).

The operative management of patella malalignment

Management of patellofemoral joint pathology is challenging as a result of the unique and complex organization of static forces and dynamic factors contributing to its functional capacity. Anterior knee pain is a common musculoskeletal complaint seen daily in the practices of primary care physicians, rheumatologists, and orthopedic surgeons. The key to successful treatment lies not only in the correct diagnosis of a chondral defect, but more importantly, in the accurate identification of associated pathomechanical factors. Appreciating the pathoanatomic basis of the disease and addressing imbalances and anatomical abnormalities should guide treatment.Despite the complexity of the interplay of various components it is essential to attempt to describe patellar malalignement as a clinical entity in order to proceed with appropriate surgical management and successful outcomes. The goals of patellofemoral re- alignment surgery should be to create both a stable environment for optimal extensor mechanism performance and an appropriate load transmission for optimal cartilage wear and joint loading. In the context of this article we will review the operative management of patellofemoral malalignment; the indications for surgery, the different techniques available and the evidence regarding their effectiveness.A large number of procedures have been employed and they have all undergone various modifications over the course of the years. The majority of publications are retrospective series in poorly defined population groups. There are significant methodological inconsistencies and as a result there is lack of strong evidence base for the majority of these procedures.