The Knee
Volume 18, Issue 1 , Pages 24-29, January 2011

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

  • Chi-Chuan Wu

      Affiliations

    • Corresponding Author InformationCorresponding author. Department of Orthopedics, Chang Gung Memorial Hospital, 5 Fu-Hsin St., 333, Taoyuan, Taiwan. Tel.: +886 3 3281200x2423; fax: +886 3 3278113.

Received 28 August 2009; received in revised form 27 December 2009; accepted 6 January 2010. published online 19 February 2010.

Article Outline

Abstract 

This paper described a less invasive surgical technique that was performed for treatment of elderly patients with isolated patellofemoral (PF) osteoarthritis (OA) associated with patellar malalignment, although their tibiofemoral joints are minimally osteoarthritic.

Two hundred and thirty-four knees in 126 consecutive elderly patients (average, 72yrs) diagnosed with combined disorders were treated by lateral retinacular release with drilling chondroplasty. The inclusion criteria were patient age ≥ 65yrs, isolated stage 2 or 3 PF-OA (modified Iwano staging by radiology), and a laterally subluxed patella shown on a Merchant's axial radiograph. Outcome was judged by three parameters: clinical PF function (modified Kujala scoring), congruence angle, and PF-OA staging. Two hundred and one knees in 107 patients were followed-up for an average of 4.2yrs (range, 2.1-7.5yrs) and 19 patients were lost to follow-up. No surgical complications occurred through the course of treatment. Clinical PF function improved in knees that showed unsatisfactory performance (modified Kujala scoring < 32) preoperatively, with 78.1% of the knees showing satisfactory performance (modified Kujala scoring ≥ 32) at the latest follow-up. Congruence angle improved in 85.6% of the knees and PF-OA staging improved in 77.1% of the knees. Combined lateral retinacular release with drilling chondroplasty is a feasible alternative for treatment of PF-OA associated with patellar malalignment in elderly patients where knee arthroplasty cannot be performed by various reasons. Advantages of this combined surgical technique include a less invasive procedure, minimal complication rate, and an acceptable success rate (78%, modified Kujala scoring≥32).

Keywords: Lateral retinacular release, Drilling chondroplasty, Patellofemoral osteoarthritis

 

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1. Introduction 

Patellar malalignment is common in patients at orthopedic clinics [1], [2], [3]. The pathomechanism of this disorder has been extensively studied; imbalance of soft tissue tension around the patella and trochlear dysplasia are considered the two most common causes [4], [5]. If patellar malalignment is ignored or if effective treatment fails, progression to patellofemoral (PF) osteoarthritis (OA) is believed to be likely [6], [7].

Clinically, a number of elderly patients (≥ 65yrs) suffer from PF-OA, although their tibiofemoral joints are relatively normal [8], [9]. Even so, isolated PF-OA is considered less common than tibiofemoral OA and 5% of patients is reported among total patients with knee OA [10], [11]. However, in the United Kingdom, 9.2% of knees with isolated PF-OA in patients (≥ 40years) with pain in 206 knees had been reported [12]. Moreover, 18.5% of male patients and 17.1% of female patients were found with isolated PF-OA in patents of more than 60years old [13]. If various methods of conservative treatment fail and the patient is still in pain, the optimal method of surgical treatment is difficult to determine. The reported success rates are around 67% for the microfracture technique, 85% for the transfer of the tibial tubercle, and 96% for PF or total knee arthropasty [10], [11], [14], [15], [16], [17], [18]. However, knee arthroplasty is generally not permitted by our National Health Insurance due to high cost, despite that it is much more effective in treating isolated PF-OA [10], [11]. In our institution, a less invasive surgical technique that combined lateral retinacular release with drilling chondroplasty was therefore used to treat isolated PF-OA associated with patellar malalignment in some elderly patients. Patients with the pathological bone morphology were excluded as suggested by the medical literature [14], [15], [19]. The greatest advantages of this combined technique include a small incision wound, immediate ambulation after the operation without aids, a short hospital stay, and potential efficacy of treatment. The aim of this retrospective study was to report on the clinical and the radiological outcomes of the combined techniques in the treatment of combined disorders.

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2. Patients and methods 

From July 1999 to May 2006, 126 consecutive elderly patients with 234 knees presenting with isolated PF-OA were treated at our institution with the combined surgical techniques. The author performed and followed up all surgeries. No knee arthroplasty was performed during these years of the study. Patients were aged from 65-78yrs (average age, 72yrs) with a male to female ratio of 1:5. One hundred and eight patients had bilateral disorders and 18 patients had unilateral disorders.

All patients complained of varied degrees of aching pain in the knee during climbing stairs, especially downstairs, sitting for a long time (movie sign), and difficulty in squatting. However, their knees were painless while walking on level ground. Physical examination revealed that the knees had normal or minimally abnormal alignment (valgus 0°-10° of anatomic axis in this series). To investigate the alignment of the lower extremity, the axis among the thigh, the knee, and the leg was inspected grossly. Additionally, the knee radiographs of anteroposterior (valgus 6°±5° of anatomic axis in this series) and lateral views with weight bearing and an axial view were routinely checked. Most of the patients could not fully extend their knees. Patellar grinding tenderness was strongly positive in all knees. Anteroposterior and lateral radiographs of the knee showed normal or minimally osteoarthritic pictures (grade 1; Ahlbäck grading) in the tibiofemoral joint [20]; however, both views and a Merchant's axial view showed stage 2 (186 knees) or 3 (48 knees) PF-OA change (modified Iwano staging) with laterally subluxed patella (congruence angle > 0°, Fig. 1) [4], [5], [12], [13], [15], [21], [22], [23]. Cases with patellar tilt (congruence angle < 0°) or dislocation (evaluated by an axial view) or trochlear dysplasia (evaluated by a lateral view with the lateral trochlear line crossing the central trochlear line or an axial view with a flat lateral condyle) were excluded [3], [4], [15]. The exclusion of above situations was for simplifying the comparison or being considered potentially less effective as suggested by the literature [14], [15], [19]. Patients with patellar tilt indicated that the patellofemoral OA was less severe and conservative treatment was normally adequate. Inclusion criteria for this study were patient age ≥ 65yrs, isolated stage 2 or 3 PF-OA, and a laterally subluxed patella on a Merchant's axial radiograph [22]. Exclusion criteria were stage 1 PF-OA, associated with stages 2-5 tibiofemoral OA on a plain radiograph, pathological bone morphologies including trochlear dysplasia or no subluxed patella on a Merchant's axial radiograph. Cases without patellar malalignment on an axial radiograph were excluded for the convenience of radiography on regular follow-up. For patients with bilateral disorders, one-stage correction was done simultaneously.

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  • Fig. 1 

    A congruence angle (CA) is the angle formed between the bisector line of a sulcus angle and the tip-tip line. A sulcus angle is formed between the two tangential lines of the joint surface of the medial and the lateral femoral condyles. A tip-tip line connects the tips of the sulcus angle and the patellar ridge. A positive value of a CA indicates lateral patellar subluxation.

A modified Kujala scoring system with 40 points in total was used to evaluate clinical improvement of PF joints [24]. The scoring system included climbing stairs (10), squatting (5), prolonged sitting with the knee flexed (10), swelling (10), and atrophy of thigh (5). A score of 36-40 points was considered excellent and a score of 32-35 points was considered good. In this study, only excellent or good results were deemed satisfactory (≥ 80% of scoring). This scoring system was selected for its specificity regarding the PF joint.

In this study, modified Iwano staging was used to evaluate radiological improvement in PF-OA: stage 0, normal joint space; stage 1, mild degeneration with osteophytes or sclerosis, and narrow joint space in the lateral patellar facet; stage 2, moderate degeneration with obliterated joint space in part of the lateral patellar facet; and stage 3, severe degeneration with wholly obliterated joint space in the lateral patellar facet [22].

The congruence angle was used to evaluate improvement in patellar location (Fig. 1) [3], [15], [23].

Fisher's exact test, chi-square test or paired Student's t-test was used to compare improvement. A p < 0.05 value was considered statistically significant.

2.1. Surgical technique 

All surgeries were performed with spinal anesthesia. Patients were in the supine position and no pneumatic tourniquets were used.

A 3cm skin incision was made along the superolateral aspect of the patella, 5mm from the lateral patellar edge (Fig. 2). After the lateral retinaculum was incised, the knee joint was exposed. The lateral retinaculum was dissected with tissue scissors longitudinally up- and downwards. Retinacular release was confirmed to be complete by palpation with fingers. The lower margin of the release reached the tibiofemoral joint level with full extension of the knee. Complete hemostasis was performed with retraction of the skin up- and downwards.

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  • Fig. 2 

    The release line for the lateral retinaculum of a patella was performed around the patella with 5mm from the lateral patellar edge. Then, it extended upwards to the muscular site of the vastus lateralis and downwards to the tibiofemoral joint level.

All osteophytes on the lateral femoral condyle and the patella were excised with a rongeur clamp. Using a tower clip, the patella was turned over to let its articular surface face outwards. A 2.4mm Kirschner wire with low-speed power driver was used to penetrate the subchondral bone plate on the lateral patellar facet. In most instances, 20-30 holes were made on the lateral patellar facet and the medial patellar facet was debrided. Finally, the subchondral bone plate in the lateral femoral condyle was drilled and the knee joint was irrigated with massive quantities of normal saline solution. After complete hemostasis was reconfirmed, the wound was closed with absorbable sutures. The capsule was not closed. No drain was inserted. The time taken for a one-side surgery was normally less than 30minutes.

Patients were allowed to ambulate without aids immediately after the operation and were discharged the next morning. Full daily activities and knee range of motion exercises were encouraged whenever the pain was tolerable. Follow-up at the outpatient department was scheduled at one, three, and 12months, and eventually annually. Functional outcomes of the PF joint and a Merchant's axial radiograph were checked during each follow-up. Quadriceps strengthening exercises were encouraged at all opportunities.

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3. Results 

Intra-operatively, on the lateral facet of the patella, erosion to bone (grade 4 in the Outerbridge classification) in the articular cartilage was seen partially in stage 2 PF-OA patients and wholly in stage 3 PF-OA patients [15], [25].

Two hundred and one knees in 107 patients were followed up for an average of 4.2yrs (range, 2.1-7.5yrs). Nineteen patients were lost to follow-up despite best contact efforts. Complete follow-up was achieved in 94 patients with bilaterally operated knees and in 13 patients with unilaterally operated knees. No surgical complications were noted through the course of treatment. No infections or problematic wounds were noted. The situation of the retropatellar cartilage (Outerbridge classification) despite no direct inspection later was represented by the stage of PF-OA.

Modified Kujala scores revealed unsatisfactory preoperative PF function (modified Kujala scoring ≤ 32) in all 201 knees (average, 22; range 18-31). At the latest follow-up, PF function (modified Kujala scoring) in 157 knees was satisfactory (modified Kujala scoring ≥ 32; average, 34, range, 32-38). Thus, the satisfactory PF function rate improved from 0% to 78.1% (p<0.001, Table 1). The rate of satisfactory improvement was statistically different for stage 2 and 3 PF-OA (84.0% versus 52.6%; p<0.001; Table 2). Before surgery, no patients were able to assume a full squatting position. At the latest follow-up, 146 out of the 201 knees (72.6%) could squat with only minor discomfort (p<0.001). Squatting was achieved in 81.0% of the knees with stage 2 and in 36.8% with stage 3 PF-OA (p<0.001; Table 2). The most notable improvement was in ability to climb stairs and squat. Complaints of pain during prolonged sitting, knee swelling or thigh atrophy were rarely noted preoperatively or at the latest follow-up.

Table 1. Surgical outcome using combined lateral retinacular release with drilling chondroplasty for treatment of patellofemoral osteoarthritis associated with lateral patellar subluxation in elderly patients (n=201).
ItemPreoperativelyLatest follow-upp value
Satisfactory PF function
0%78.1%< 0.001
Congruence angle
+11.1°+4.7°< 0.001
(range, +2°∼+56°)(range, -7°∼+40°)
PF-OA staging
(stage 2) 163(stage 1) 135< 0.001
(stage 2) 28
(stage 3) 38(stage 1) 9< 0.001
(stage 2) 11
(stage 3) 18

PF: Patellofemoral, OA: Osteoarthritis.

Table 2. Comparison of surgical outcome between two groups of knees with different stages of PF-OA (n=201).
ItemPre-op stage 2Pre-op stage 3p value
(n=163)(n=38)
Satisfactory clinical function
Pre-op0%0%1.0
Latest follow-up84.0%52.6%< 0.001
Squatting achievement
Pre-op0%0%1.0
Latest follow-up81.0%36.8%< 0.001
Improvement of CA90.8%63.2%< 0.001
(average angle)7.3°2.6°< 0.001
Improvement of PF-OA staging82.8%52.6%< 0.001
Improvement of both clinical function and CA88.334.2%< 0.001

CA: Congruence angle, PF-OA: Patellofemoral osteoarthritis, Pre-op: Preoperatively.

Congruence angle improved in 172 knees (85.6%) and ranged from an average of + 11.1° (range, +2° to +56°) preoperatively to +4.7° (range, -7° to +40°) at the latest follow-up (p<0.001, Table 1). A statistically significant difference was noted for stage 2 and 3 PF-OA with an average improvement of 7.3° compared with 2.6° (p<0.001). There were no cases with deterioration of congruence angle.

Modified Iwano staging on Merchant's axial radiograph revealed that PF-OA staging improved in 155 knees (77.1%) (p<0.001, Table 1). Before surgery, 163 knees were in stage 2 and at the latest follow-up, 0, 135, and 28 knees were in stage 0, 1, and 2, respectively (p<0.001). Improvement was noted in 82.8% of the knees at preoperative stage 2 PF-OA. Before surgery, 38 knees were at stage 3 and at the latest follow-up, 0, 9, 11, and 18 of these knees were in stage 0, 1, 2, and 3, respectively (p<0.001, Fig. 3). Improvement was seen in 52.6% of the knees preoperatively at stage 3 PF-OA. A statistical difference was noted for stage 2 and 3 PF-OA on Merchant's radiograph (p<0.001, Table 2). There were no cases with deterioration of PF-OA staging.

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  • Fig. 3 

    A 73year-old female sustained bilateral stage 3 patellofemoral osteoarthritis (PF-OA) associated with lateral patellar subluxation (top). Bilateral combined disorders were treated with lateral retinacular release and drilling chondroplasty. Improvement to stage 1 PF-OA and satisfactory patellofemoral function were achieved at 7year follow-up (bottom).

A vast majority of patients exhibited an improved PF joint in terms of clinical PF function (78.1%) and congruence angle (85.6%). In 172 knees with improved congruence angle, 153 knees demonstrated improved clinical PF function, while 19 knees did not. In 29 knees without congruence angle improvement, only four knees had improved PF function and 25 knees did not. This difference was statistically significant (p<0.001). This comparison indicated that improved congruence angle might predict improved clinical PF function. However, in 163 knees with stage 2 PF-OA, 144 knees had improved in both clinical PF function and congruence angle, and in 38 knees with stage 3 PF-OA, 13 knees had improved in both clinical PF function and congruence angle (p<0.001). Furthermore, in 38 knees with stage 3 PF-OA, improved congruence angle was not associated with concomitant improved clinical PF function (p=0.12).

Improvement of PF-OA staging in 77.1% of the knees and improvement of clinical PF function in 78.1% of the knees were noted. In 155 knees with improved PF-OA staging, 129 knees had improved clinical PF function and 26 knees did not. In 46 knees without improved PF-OA staging, 28 knees had improved clinical PF function and 18 knees did not. This difference was statistically significant (p=0.001) and indicated that improved PF-OA staging might concomitantly predict improved clinical PF function. In 38 knees with preoperative stage 3 PF-OA, improved PF-OA staging was associated with improved clinical PF function (p<0.001).

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4. Discussion 

In this study, 78.1% of the knees in elderly patients with isolated stage 2 or 3 PF-OA associated with lateral patellar subluxation had satisfactorily improved clinical PF function after treatment by lateral retinacular release with drilling chondroplasty (Table 1). Improved clinical PF function was achieved in 84.0% of the knees with preoperative stage 2 PF-OA and 52.6% knees with stage 3 PF-OA (p<0.001, Table 2). Congruence angle was improved in 85.6% of all knees and improved congruence angle was highly associated with improved clinical PF function (p<0.001). The average improvement of congruence angle was 6.4°, which included 7.3° in knees with stage 2 PF-OA, but only 2.6° in knees with stage 3 PF-OA (p<0.001). Improvement of PF-OA staging was observed in 77.1% of the knees: 82.8% in knees with preoperative stage 2 and 52.6% in stage 3 PF-OA (p<0.001).

The theoretical basis for using combined techniques for combined disorders includes: 1) lowering lateral traction forces by lateral retinacular release so that deterioration of PF-OA may be prevented [15], [25], [26], [27] and 2) inducing growth of fibrocartilage by drilling through subchondral plates (bone marrow stimulation technique) so that PF pain may be reduced [28], [29]. Improved PF-OA staging in the present study might be due to regeneration of tissues from the marrow of the underlying cancellous bone [30]. The principle was similar in spongialization (Ficat 1979), lateral facetectomy (Yercan 2005), microfracture (Mithoefer 2006), and the present technique [17], [30], [31]. The 78.1% success rate for the relatively simple surgical technique reported in this study compared favorably with other more complex and invasive surgical methods. Concomitantly, the severity of PF-OA may be represented by radiological staging [22].

Several biomechanical studies of the PF joint have been published previously [20], [32], [33], [34], [35]. Patellar tracking is affected by many complex factors. In normal anatomy, the static stabilizers are bone morphology and the passive stabilizers are ligament and capsule. The medial active stabilizer of the patella is the vastus medialis and the lateral active stabilizers are the vastus lateralis [15], [35]. When the knee is flexed, the fascia lata also displaces posteriorly due to its poor extensibility. Although the fascia lata is not directly connected to the patella, the patella is pulled laterally by way of the lateral retinaculum [6], [15], [26]. Additionally, the quadriceps vector caused by a quadriceps angle (Q angle) enforces the lateral translation force [3]. Under most situations, the patella is always tilted or subluxed laterally. Interrupting the connection between the fascia lata and the patella can reduce the lateral traction forces. Theoretically, stresses on the lateral facet of the patella and the lateral femoral condyle are reduced [25], [27]. In the current study, either improved congruence angle or PF-OA staging significantly improved PF function (p<0.001).

Surgical treatment has been advocated in cases when conservative treatment for isolated patellar malalignment has failed [1], [13]. These techniques have included lateral retinacular release, proximal or distal realignment procedures or patellectomy [1], [36], [37], [38], [39], [40]. Surgical treatment is also suggested for failed conservative treatment in isolated PF-OA [9], [15]. Suggested treatment includes lateral release, various chondroplasties, tibial tubercle transfer, cartilage grafting or PF or total knee arthroplasty [9], [10], [11], [14], [15], [18], [19], [25], [28], [31], [41], [42], [43]. Although each technique has unique advantages and disadvantages, by combining lateral retinacular release and drilling chondroplasty, the current technique achieves acceptable results. Most importantly, the described technique is relatively simple and has a minimal complication rate.

A medical literature review indicates that the success rate for lateral retinacular release in isolated patellar malalignment is 46-85%, and the success rate for drilling chondroplasty in isolated PF-OA is 68-83% [28], [29], [40], [44], [45], [46], [47]. Thus far, no studies have reported the use of combined techniques for combined disorders. In the present series, all patients had relatively more severe PF-OA (stage 2 or 3) [22]. Simply lateral release to treat such cases is not safe because the lesion site is not treated [15]. Combined techniques can treat both disorders and have achieved a 78% success rate. However, the success rate is inferior when PF-OA is more severe (p<0.001).

The role of lateral retinacular release for treating patellar malalignment is controversial and is commonly considered more appropriate in mild cases or in adolescent patients [9], [25], [40]. Similarly, drilling chondroplasty is questionable in PF-OA, in which case the microfracture technique is recommended [9], [15], [17], [41]. However, without severe anatomic deformity, e.g. hypoplasia of the lateral femoral condyle (trochlear dysplasia) or valgus knee, lateral retinacular release should be feasible [2], [15], [25], [44], [45], [46]. The drilling technique could be improved in accordance with the microfracture principle by sharpening the pin end and lowering the speed of the power driver [28], [29], [48]. The current study achieved a comparable result to more complex invasive techniques.

Different osteotomy procedures have been developed to treat PF-OA. Maquet and Hauser procedures have reportedly produced poor results and are no longer indicated [9], [14]. A series of anteromedial tibial tubercle transfers performed by Fulkerson achieved a 85% success rate in patellar articular lesions, but complications of proximal tibial fractures or vascular injuries were noted [14], [15], [31], [49], [50], [51]. Autologous cartilage implantation may have an 84% success rate, but it is relatively complex and requires some periods of protected weight bearing [9], [14], [16], [19], [43]. PF arthroplasty has a high success rate (96% in 5years) with an immediate effect, which may be used whenever possible [18], [52]. However, its high price may limit its wide use in some countries [9], [19], [52]. Total knee arthroplasty is an aggressive procedure, of which complications may be difficult to handle (e.g. deep infection or periprosthetic fractures) [53], [54]. Moreover, normally patients with total knee arthroplasty cannot fully squat (average, 0º-110º knee flexion) but 72.6% of patients in the present series can squat [55], [56], Therefore, it may be used as a last resort in some countries [19]. Thus, compared with these techniques, the current technique may worth performing.

The reported 67% success rate of the microfracture technique in treating articular cartilage defects of the knee may be comparable to that of the method described here [16], [17]. The mechanisms of both techniques are similar. Subchondral bone plates are penetrated by pierced instruments, and mesenchymal stem cells can eventually cover the articular surface and form fibrocartilage [15], [31], [41]. Drilling has been criticized in that it produces local heat, which may compromise cells around the path of the drill [17], [41]. Technically, this disadvantage can be overcome by adequately sharpening the end of Kirschner wires and using a lower speed power driver. Contrarily, the subchondral bone plate of the lateral patellar facet in PF-OA is often so sclerotic and hard that penetration with awls may be ineffective [17]. Under such situations, drilling is normally practicable. The current study achieved a 78.1% success rate at 4year follow-up.

In medial literature, isolated PF-OA had also been successfully treated with lateral retinacular release and partial lateral facetectomy by Yercan et al [31]. In that study, 11 cases were treated and relief of pain was significantly achieved. However, they used total Knee Society Score to evaluate the knee function, which included both tibiofemoral and PF joints. Basically, the mechanism to treat PF-OA between Yercan's and our techniques should be similar: lateral retinacular release and exposure of subchondral cancellous bone [28], [29], [44], [45], [46], [47], [57]. Thus, lateral facet pressure was reduced and the fibrocartilage formed [15], [26], [27], [28], [29]. The Yercan's technique removed 1 to 1.5cm of lateral border of the patella, which let the radiological follow-up become difficult.

In the present study, all patients were aged 65-78years (average, 72years). Although DXA (dual-energy X-ray absoptiometry) was not used to detect osteoporosis, osteopenia or osteoporosis should be common. However, it won't affect the procedure.

The limitations of this study include the following caveats. First, 19 patients with 33 knees (14.1%) are lost to follow-up and it may deeply affect the evaluation of a success rate. Generally, it is a very difficult work for completely avoiding such a defect. However, in the medical literature more than an 80% rate of follow-up in clinical studies has been considered the evidence of level one (seeing instructions to authors in the journal of the American volume of the Joint and Bone Surgery). The present series has a follow-up rate of 85.9%. Second, articular cartilage could not be directly inspected at the latest follow-up [15], [17]. Additionally, cartilage-sensitive magnetic resonance imaging was not performed [17]. Thus, the effect of functional improvement could not be quantitatively attributed to new fibrocartilage. The relative accuracy of PF radiographs to represent the amount of articular cartiage present may require further proof. Third, this study used a modified Kujala scoring system to evaluate improvement of clinical PF function [24]. This scoring system is currently not widely used, so our results could not be compared with those from previously reported articles. The scoring system was chosen in the current study due to its specificity to the PF joint. Other scoring systems normally included both tibiofemoral and PF joints with a focus on the former [10], [11], [16], [17], [49].

In conclusion, isolated PF-OA associated with patellar malalignment is not uncommon. Combined lateral retinacular release with drilling chondroplasty is a feasible alternative for treatment of PF-OA associated with patellar malalignment in elderly patients where knee arthroplasty is not performed due to various reasons. Advantages of this combined surgical technique include a less invasive procedure, minimal complication rate, and an acceptable success rate of 78%. Although patients cannot recover completely, early surgical treatment may achieve a high rate of satisfactory outcomes.

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References 

  1. Grelsamer RP. Current concepts review. Patellar malalignment. J. Bone Jt. Surg. 2000;82A:1639–1650
  2. Biedert RM, Warnke K. Correlation between the Q angle and the patella position: a clinical and axial computed tomography evaluation. Arch. Orthop. Trauma Surg. 2001;121:346–349
  3. Wilson T. The measurement of patellar alignment in patellofemoral pain syndrome: are we confusing assumptions with evidence?. J. Orthop. Sports Phys. Ther. 2007;37:330–341
  4. Elias DA, White LM. Imaging of patellofemoral disorders. Clin. Radiol. 2004;59:543–557
  5. van Huyssteen AL, Hendrix MR, Barnett AJ, Wakeley CJ, Eldridge JD. Cartilage-bone mismatch in the dysplastic trochlea: an MRI study. J. Bone Jt. Surg. 2006;88B:688–691
  6. Arendt E. Anatomy and malalignment of the patellofemoral joint: its relation to patellofemoral arthrosis. Clin. Orthop. Relat. Res. 2005;436:71–75
  7. Haim A, Yaniv M, Dekel S, Amir H. Patellofemoral pain syndrome: validity of clinical and radiological features. Clin. Orthop. Relat. Res. 2006;451:223–228
  8. Cahue S, Dunlop D, Hayes K, Song J, Torres L, Sharma L. Varus-valgus alignment in the progression of patellofemoral osteoarthritis. Arthritis Rheum. 2004;50:2184–2190
  9. Saleh KJ, Arendt EA, Eldridge J, Fulkerson JP, Minas T, Mulhall KJ. Symposium. Operative treatment of patellofemoral arthritis. J. Bone Jt. Surg. 2005;87A:659–671
  10. Laskin RS, van Steijn M. Total knee replacement for patients with patellofemoral arthritis. Clin. Orthop. Relat. Res. 1999;367:89–95
  11. Thompson NW, Ruiz AL, Breslin E, Beverland DE. Total knee arthroplasty without patellar resurfacing in isolated patellofemoral osteoarthritis. J. Arthroplasty. 2001;16:607–612
  12. Davies AP, Vince AS, Shepstone L, Donell ST, Glasgow MM. The radiological prevalence of patellofemoral osteoarthritis. Clin. Orthop. Relat. Res. 2002;402:206–212
  13. Donell ST, Glasgow MMS. Isolated patellofemoral osteoarthritis. Knee. 2007;14:169–176
  14. Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am. J. Sports Med. 1990;18:490–496
  15. Fulkerson JP. Disorders of the patellofemoral joint. 4th ed.. Philadelphia: Lippincott Williams & Wilkins; 2004;
  16. Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy. 2005;21:1066–1075
  17. Mithoefer K, Williams RJ, Warren RF, Spock CR, Jones EC, Wickiewicz TL. Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique.Surgical technique. J. Bone Jt. Surg. Am. 2006;88:294–304
  18. Ackroyd CE, Newman JH, Evans R, Eldridge JD, Joslin CC. The Avon patellofemoral arthroplasty: five-year survivorship and functional results. J. Bone Jt. Surg. 2007;89B:310–315
  19. Fulkerson JP. Alternatives to patellofemoral arthroplasty. Clin. Orthop. Relat. Res. 2005;436:76–80
  20. Ahlbäck S. Osteoarthrosis of the knee: a radiographic investigation. Acta. Radiol. Scand. 1968;277S:7–72
  21. Schutzer SF, Ramsby GR, Fulkerson JP. Computed tomographic classification of patellofemoral pain patients. Orthop. Clin. North Am. 1986;17:235–248
  22. Iwano T, Kurosawa H, Tokuyama H, Hoshikawa Y. Roentgenographic and clinical findings of patellofemoral osteoarthrosis with special reference to its relationship to femorotibial osteoarthrosis and etiologic factors. Clin. Orthop. Relat. Res. 1990;252:190–197
  23. Merchant AC. Patellofemoral imaging. Clin. Orthop. Relat. Res. 2001;389:15–21
  24. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9:159–163
  25. Alemdaroglu KB, Cimen O, Aydogan NH, Atlihan D, Iltar S. Early results of arthroscopic lateral retinacular release in patellofemoral osteoarthritis. Knee. 2008;15:451–455
  26. Fulkerson JP, Gossling HR. Anatomy of the knee joint lateral retinaculum. Clin. Orthop. Relat. Res. 1980;153:183–188
  27. Ostermeier S, Holst M, Hurschler C, Windhagen H, Stukenborg-Colsman C. Dynamic measurement of patellofemoral kinematics and contact pressure after lateral retinacular release: an in vitro study. Knee Surg. Sports Traumatol. Arthrosc. 2007;15:547–554
  28. Childers JC, Ellwood SC. Partial Chondrectomy and subchondral bone drilling for chondromalacia. Clin. Orthop. Relat. Res. 1979;144:114–120
  29. McCarroll JR, O'Donoghue DH, Grana WA. The surgical treatment of chondromalacia of the patella. Clin. Orthop. Relat. Res. 1983;175:130–134
  30. Ficat RP, Ficat C, Gedeon P, Toussaint JB. Spongialization: a new treatment for diseased patellae. Clin. Orthop. Relat. Res. 1979;144:74–83
  31. Yercan HS. Selmi T, Neyret P. The treatment of patellofemoral osteoarthritis with partial lateral facetectomy. Clin. Orthop. Relat. Res. 2005;436:14–19
  32. Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clin. Orthop. Relat. Res. 1979;144:9–15
  33. Maquet P. Biomechanics and osteoarthritis of the patellofemoral joint. Orthop. Rev. 1985;14:126–127
  34. Heng RC, Haw CS. Patello-femoral pain syndrome: diagnosis and management from an anatomical and biomechanical perspective. Curr. Orthop. 1996;10:256–266
  35. Grelsamer RP, Klein JR. The biomechanics of the patellofemoral joint. J. Orthop. Sports Phys. Ther. 1998;28:286–298
  36. Hughston JC, Walsh WM. Proximal and distal reconstruction of the extensor mechanism for patellar subluxation. Clin. Orthop. Relat. Res. 1979;144:36–42
  37. Sim FH, McDonald DJ. The Hauser procedure revised. Orthop. Rev. 1985;14:135–140
  38. Fulkerson JP, Schutzer SF. After failure of conservative treatment for painful patellofemoral malalignment: lateral release or realignment. Orthop. Clin. North Am. 1986;17:283–288
  39. Kelly MA, Insall JN. Patellectomy. Orthop. Clin. North Am. 1986;17:289–295
  40. Unneberg K, Reikeras O. The effect of lateral retinacular release in idiopathic chondromalacia patellae. Arch. Orthop. Trauma Surg. 1988;107:226–227
  41. Steadman JR, Rodkey WG, Rodrigo JJ. Microfracture: surgical technique and rehabilitation to treat chondral defects. Clin. Orthop. Relat. Res. 2001;391:362–369Suppl
  42. Aderinto J, Cobb AG. Lateral release for patellofemoral arthritis. Arthroscopy. 2002;18:399–403
  43. Torga Spak R, Teitge RA. Fresh osteochondral allografts for patellofemoral arthritis: long-term follow-up. Clin. Orthop. Relat. Res. 2006;444:193–200
  44. Merchant AC, Mercer RL. Lateral release of the patella: a preliminary report. Clin. Orthop. Relat. Res. 1974;103:40–45
  45. McGinty JB, McCarthy JC. Endoscopic lateral retinacular release: a preliminary report. Clin. Orthop. Relat. Res. 1981;158:120–125
  46. Larson RL. The unstable patella in the adolescent and preadolescent. Orthop. Rev. 1985;14:156–162
  47. Panni AS, Tartarone M, Patricola A, Paxton EW, Fithian DC. Long-term results of lateral retinacular release. Arthroscopy. 2005;21:526–531
  48. O'Driscoll SW. Current concepts review. The healing and regeneration of articular cartilage. J. Bone Jt. Surg. 1998;80A:1795–1812
  49. Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP. Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer. Am. J. Sports Med. 1997;25:533–537
  50. Shetty AA, Tindall AJ, Nickolaou N, James KD, Ignotus P. A safe zone for the passage of screws through the posterior tibial cortex in tibial tubercle transfer. Knee. 2005;12:99–101
  51. Kline AJ, Gonzales J, Beach WR, Miller MD. Vascular risk associated with bicortical tibial drilling during anteromedial tibial tubercle transfer. Am. J. Orthop. 2006;35:30–32
  52. Board TN, Mahmood A, Ryan WG, Banks AJ. The Lubinus patellofemoral arthroplasty: a series of 17 cases. Arch. Orthop. Trauma Surg. 2004;124:285–287
  53. Wang JW, Wang CJ. Supracondylar fractures of the femur above total knee arthroplasty with cortical allograft struts. J Arthroplasty 202;17:365--72.
  54. Leone JM, Hanssen AD. Management of infection at the site of a total knee arthroplasty. J. Bone Jt. Surg. 2005;87:2335–2348Am
  55. Keblish PA, Varma AK, Greenwald AS. Patellar resurfacing or retention in total knee arthroplasty. A prospective study of patients with bilateral replacements. J. Bone Jt. Surg. 1994;76B:930–937
  56. Parvizi J, Hassen AD, Spangehl MJ. Total knee arthroplasty following proximal tibial osteotomy: risk factors for failure. J. Bone Jt. Surg. 2004;86A:474–479
  57. Sheehy P, Burdett RG, Irrgang JJ, VanSwearingen J. An electromyographic study of vastus medialis oblique and vastus lateralis activity while ascending and descending steps. J. Orthop. Sports Phys. Ther. 1998;27:423–429

PII: S0968-0160(10)00006-2

doi:10.1016/j.knee.2010.01.005

The Knee
Volume 18, Issue 1 , Pages 24-29, January 2011

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