Patello-Femoral OA - Lucy Dennell 18/6/2002

Patellofemoral arthritis- treatment

Nonnoperative treatment

Weight loss/quads strengthening/modification of activities

Surgical Options

Surgical Options

Lateral release/Chondroplasty ( Spongialisation )/Tibial tubercle elevation/Patellar osteotomy/Patellectomy/Patellar resurfacing/Patellofemoral joint replacement/TKR

Lateral release

Lateral release

Usually performed with some other procedure such as chondroplasty, tibial tubercle elevation, or patellofemoral joint replacement

Abstracts of papers imply that alone it is suited to younger patients with patellofemoral pain or instability or minimal patellofemoral arthrosis

Chondroplasty such as shaving of the cartilage surface yielded poor results

(Bentley 1978)

Spongialisation is a technique described by Ficat involving removal of all articular cartilage and subchondral bone leaving a completely exposed cancellous bony bed. The term spongialisation comes from exposure of the "spongiosa" portion of the cancellous bone. It is an extension of the technique of perforation of the subchondral plate suggested by Pridie to allow ingrowth of fibrous tissue A method of resurfacing. Also, allows removal of the painful well innervated subchondral bone

Spongialisation is a technique described by Ficat involving removal of all articular cartilage and subchondral bone leaving a completely exposed cancellous bony bed. The term spongialisation comes from exposure of the "spongiosa" portion of the cancellous bone. It is an extension of the technique of perforation of the subchondral plate suggested by Pridie to allow ingrowth of fibrous tissue A method of resurfacing. Also, allows removal of the painful well innervated subchondral bone

Spongialisation is a technique described by Ficat involving removal of all articular cartilage and subchondral bone leaving a completely exposed cancellous bony bed. The term spongialisation comes from exposure of the "spongiosa" portion of the cancellous bone. It is an extension of the technique of perforation of the subchondral plate suggested by Pridie to allow ingrowth of fibrous tissue A method of resurfacing. Also, allows removal of the painful well innervated subchondral bone

Ficat RP et al Clin Orth. 1070;144:74-83 claimed 79% good or excellent results at av 15 months follow up in 85 pts. Some pts had additional lateral releases or tubercle advancement

This technique did not take off because of unpredictable and incomplete regeneration.

Tibial tubercle elevation

Maquet, a Belgian, first described his osteotomy in 1963(in French).

Maquet P Advancement of the tibial tuberosity Clin Orth 1976;115:225., was proposed for both chondromalacia patellae and pf osteoarthritis.

Its aim is to reduce articular pressures across the pfj

This has been confirmed subsequently by other authors in cadaveric and biomechanical studies.

In a nutshell the lever arm of patellar tendon is lengthened

In a nutshell the lever arm of patellar tendon is lengthened

In a nutshell the lever arm of patellar tendon is lengthened

The angle subtended by the pat ligament and quads mechanism is made more obtuse.

Both resulting in a decrease force required by the quadriceps and a decreased joint reaction force in both the pfj and the tibio femoral joint.

For a 2cm advancement of tt a 50% decrease in joint reaction force.

For a full explanation of mechanics see;

Maquet P Mechanics and osteoarthritis of the patellofemoral joint. CORR 1979; 144:70-73   (which has 6 references all by a certain P Maquet)

Despite his claims as a final solution to the problem of pfa it has not been widely adopted.

Despite his claims as a final solution to the problem of pfa it has not been widely adopted.

Despite his claims as a final solution to the problem of pfa it has not been widely adopted.

Author

Rappoport LH et al The Hospital for Special Surgery New York

Title

The Maquet osteotomy

Reference

Orthopaedic clinics of North America Vol 23, No. 4, 1992, 645-656

Summary

Highlights the main objections to the Maquet osteotomy namely the high complication rate. Although jr force decreased, contact stresses change. Points out that the optimal level of elevation of the tubercle has not been established. Recommends the Maquet osteotomy be reserved for young pts with chondromalacia or post patellectomy but NOT for pf oa

Critique

A review article of 14 other papers with differing and often subjective outcome measures. A good overview of the whole subject.

Patellectomy

Patellectomy

Results in a reduction of the quads force lever arm

Decreased flexion esp when ascending and descending stairs

An increase of 15-30% of force required across PFJ

Increased instability. Poor cosmesis.                         

A salvage procedure

Patellar resurfacing and arthroplasty

Mckeever 1955 anatomically shaped cobalt chromium alloy prosthesis attatched to bone w transfixation screw. Poor results at FU

Mckeever 1955 anatomically shaped cobalt chromium alloy prosthesis attatched to bone w transfixation screw. Poor results at FU

Mckeever 1955 anatomically shaped cobalt chromium alloy prosthesis attatched to bone w transfixation screw. Poor results at FU

Author

Argenson JNA et al Aix-Marseille University , France



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