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Cartilage Restoration in the Patellofemoral Joint

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Cartilage Restoration in the Patellofemoral Joint A Review Paper Cartilage Restoration in the Patellofemoral Joint Betina B. Hinckel, MD, PhD, Andreas H. Gomoll, MD, and Jack Farr II, MD malalignment, deconditioning, muscle imbalance Abstract and overuse) and can coexist with other lesions Although patellofemoral (PF) chondral in the knee (ligament tears, meniscal injuries, and lesions are common, the presence of cartilage lesions in other compartments). There- a cartilage lesion does not implicate a fore, careful evaluation is key in attributing knee chondral lesion as the sole source of pain. pain to PF cartilage lesions—that is, in making a As attributing PF pain to a chondral lesion “diagnosis by exclusion.” is “diagnosis by exclusion,” thorough From the start, it must be assessment of all potential structural appreciated that the vast majority and nonstructural sources of pain is the of patients will not require surgery, key to proper management. Commonly, and many who require surgery Take-Home Points for pain will not require cartilage multiple factors contribute to a patient’s ◾ Careful evaluation is symptoms. Each comorbidity must be restoration. One key to success key in attributing knee identified and addressed, and the carti- with PF patients is a good working pain to patellofemoral lage lesion treatment determined. relationship with an experienced cartilage lesions—that is, Comprehensive preoperative assess- physical therapist. in making a “diagnosis by exclusion.” ment is essential and should include a ◾ Initial treatment is non- thorough “core-to-floor” physical exam- Etiology The primary causes of PF carti- operative management ination. Treatment of symptomatic chon- focused on weight loss dral lesions in the PF joint requires specific lage lesions are patellar instabil- and extensive “core-to- technical and postoperative management, ity, chronic maltracking without floor” rehabilitation. which differs significantly from manage- instability, direct trauma, repetitive ◾ Optimization of anatomy ment involving the tibiofemoral joint. microtrauma, and idiopathic. and biomechanics is Attending to all these details makes the crucial. outcomes of PF cartilage treatment repro- Patellar Instability ◾ Factors important in ducible. These outcomes may rival those of Patients with patellar instability surgical decision-making include defect location chondral repair in the tibiofemoral joint. often present with underlying anatomical risk factors (eg, troch- and size, subchondral bone status, unipolar vs lear dysplasia, increased Q-angle/ bipolar lesions, and previ- tibial tubercle-trochlear groove ous cartilage procedure. atellofemoral (PF) pain is often a component [TT-TG] distance, patella alta, and ◾ The most commonly of more general anterior knee pain. One unbalanced medial and lateral soft used surgical proce- Psource of PF pain is chondral lesions. As tissues2). These factors should be dures—autologous these lesions are commonly seen on magnetic addressed before surgery. chondrocyte implantation, resonance imaging (MRI) and during arthrosco- Patellar instability can cause osteochondral autograft transfer, and osteo- py, it is necessary to differentiate incidental and cartilage damage during the chondral allograft—have symptomatic lesions.1 In addition, the correlation dislocation event or by chronic demonstrated improved between symptoms and lesion presence and subluxation. Cartilage becomes intermediate-term severity is poor. damaged in up to 96% of patellar outcomes. PF pain is multifactorial (structural lesions, dislocations.3 Most commonly, the Authors’ Disclosure Statement: Dr. Gomoll reports that he is a paid consultant/advisory board member for Vericel, Joint Restoration Foundation, LifeNet, Smith & Nephew, and NuTech Medical. Dr. Farr reports that he is a paid consultant/advisory board member for Arthrex, Osiris Therapeutics, Vericel, and Zimmer Biomet; receives research/institutional support from Arthrex, RTI Biologics, Vericel, and Zimmer Biomet; and holds a design patent for a DePuy Synthes patellofemoral arthroplasty device. Dr. Hinckel reports no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com September/October 2017 The American Journal of Orthopedics ® 217 Cartilage Restoration in the Patellofemoral Joint A B Figure 1. (A) Lateral femoral condyle osteochondral lesion, caused by patellar dislocation, is predominantly cartilaginous. (B) Fixation of predominantly cartilaginous fragment with No. 1 monofilament resorbable transosseous sutures. damage consists of fissuring and/or fibrillation, but can cause patellar instability. A common combi- chondral and osteochondral fractures can occur as nation is trochlear dysplasia, increased TT-TG or well. During dislocation, the medial patella strikes TT-posterior cruciate ligament distance, and lateral the lateral aspect of the femur, and, as the knee soft-tissue contracture. These are often seen in PF collapses into flexion, the lateral aspect of the joints that progress to lateral PF arthritis. As lateral proximal lateral femoral condyle (weight-bearing PF arthritis progresses, lateral soft-tissue contrac- area) can sustain damage. In the patella, typically ture worsens, compounding symptoms of laterally the injury is distal-medial (occasionally crossing based pain. With respect to cartilage repair, these the median ridge). A shear lesion may involve the joints can be treated if recognized early; however, chondral surface or be osteochondral (Figure 1A). once osteoarthritis is fully established in the joint, In an osteochondral lesion, the area of cartilage facetectomy or PF replacement may be necessary. damage is often larger than the bony fragment indicates (Figure 1A), and even small fractures Direct Trauma visible on radiographs can portend extensive car- With the knee in flexion during a direct trauma over tilage damage. In addition, isolated cartilage flaps the patella (eg, fall or dashboard trauma), all zones can occur; if suspected, they should be assessed of cartilage and subchondral bone in both patella with MRI. The extent of cartilage damage is related and trochlea can be injured, leading to macrostruc- to the magnitude of energy required to cause the tural damage, chondral/osteochondral fracture, or, dislocation and/or to the frequency of events. In with a subcritical force, microstructural damage and more normal anatomy, more energy is required chondrocyte death, subsequently causing cartilage to provoke a dislocation, and damage to articular degeneration (cartilage may look normal initially; cartilage is greater. In recurrent patellar dislocation, the matrix takes months to years to deteriorate). each event can cause additional injury, and the size Direct trauma usually occurs with the knee flexed. of the lesion tends to increase with the number Therefore, these lesions typically are located in the of dislocations.4 Patellar dislocation can result in distal trochlea and superior pole of the patella. chronic patellar subluxation, or dislocations that often lead to recurrent or chronic patellar instabil- Repetitive Microtrauma ity. With recurrent instability, the medial patellar Minor injuries, which by themselves do not imme- facet becomes damaged as it displaces out of the diately cause apparent chondral or osteochondral trochlea during subluxation and dislocation events. fractures, may eventually exceed the capacity of With lateral patellar maltracking, the contact area natural cartilage homeostasis and result in repet- is reduced. With overall similar PF forces, a smaller itive microtrauma. Common causes are repeat- contact area results in increased point loading, thus ed jumping (as in basketball and volleyball) and increasing stress and promoting cartilage wear. prolonged flexed-knee position (eg, what a baseball catcher experiences), which may also be associat- Chronic Maltracking Without Instability ed with other lesions caused by extensor apparatus Chronic maltracking is usually related to anatomical overload (eg, quadriceps tendon or patellar tendon abnormalities, which include the same factors that tendinitis, and fat pad impingement syndrome). 218 The American Journal of Orthopedics ® September/October 2017 www.amjorthopedics.com B. B. Hinckel et al Idiopathic ment, standard radiographs (weight-bearing knee In a subset of patients with osteochondritis sequence and axial view; full limb length when dissecans, the patella is the lesion site. In another needed), computed tomography, and MRI can be subset, idiopathic lesions may be related to a ge- used. netic predisposition to osteoarthritis and may not Meaningful evaluation requires MRI with be restricted to the PF joint. In some cases, the PF cartilage-specific sequences, including standard joint is the first compartment to degenerate and is spin-echo (SE) and gradient-recalled echo (GRE), the most symptomatic in a setting of truly tricom- fast SE, and, for cartilage morphology, T2-weighted partmental disease. In these cases, treating only fat suppression (FS) and 3-dimensional SE and the PF lesion can result in functional failure, owing GRE.5 For evaluation of cartilage function and to disease progression in other compartments. metabolism, the collagen network, and proteogly- Even mild disease in other compartments should can content in the knee cartilage matrix, consider- be carefully evaluated. ation should be given to compositional assessment techniques, such as T2 mapping, delayed gadolini- History and Physical Examination um-enhanced MRI of cartilage, T1ρ imaging, sodium Patients often
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