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Chondromalacia of the Patella

- See: Patella and Patellofemoral Function

- Discussion:
     - chondromalacia describes softening & fissuring of articular hyaline cartilage;
     - chondromalacia may result from an excessive load on patellofemoral joint, but disuse may be a contributing factor;
     - most common in yound women;
     - relationship between chondrosis & subsequent arthrosis is unclear;
     - contributing factors:
            - weakness and tightness of quadriceps muscle;
            - genu valgum;
            - increased Q angle
            - patella alta

- Clinical Features and Exam:
     - pts may report anterior knee pain, esp. while climbing stairs;
     - compression of patella may cause pain along medial & lateral retinacula & patellar ligament;
     - compression of the patella during flexion & extension of knee may elicits crepitation and discomfort;
     - patellar tracking
            - best seen when examiner is seated in front of pt & takes knee through full passive and active ROM.
     - crepitus:
            - may be a normal finding in young people;
     - misc signs:
            - excessive tibial rotation
            - foot pronation

- Radiograpic Features:
     - is best seen on a slightly over exposed lateral x-ray;
     - axillary radiograph will determine which facet is involved;
     - usually it will involve the medial facet;
     - Agliettis, et. al. (1983)
            - 53 patients w/ chondromalacia:
            - Q angle was 20 deg (versus 15 deg;)
            - LT/LP differed only in the males = 1.08 versus 1.01
            - congruence angle = - 2 deg (sig diff. for males and fem)
            - Patellar pain and incongruence. I: Measurements of incongruence.

- Stages:
         - I:   swelling and softening of the cartilage;
         - II:  fissuring w/in the softened areas
         - III: fasciclations of articular cartilage almost to level of subchondral bone;
         - IV:  destruction of cartilage w/ subchondral bone exposed;
                   - histologically, stage IV is virtually indistinguishable from DJD;
                   - there is no unequivical progression from stage I to IV;

- Non Operative Treatment:
    - reduced strenuous activities;
    - exercises to stretch & strengthen quadriceps muscle are started;
    - avoid stressing  the painful arc of motion;
    - immobilization is a contributing cause of chondromalacia and its contributing cause of chondromalacia & its subsequent symptoms;
    - reference: Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial.

- Operative:
     - debridement:
            - Partial lateral patellar facetectomy for treatment of arthritis due to lateral patellar compression syndrome.
     - lateral retinacular release:
            - little proven benefit if chondromalacia is 2nd to patella alta;
     - distal realignment procedures:
            - as noted by Morshuis, et al, distal realignment procedures result in satisfactory results in about 2/3 patients who have patellofemoral pain and x-ray evidence of arthrosis but nearly all patients w/ patellofemoral pain w/o x-ray evidence of arthrosis had good or excellent results;
                      - Anteromedialization of the tibial tuberosity in the treatment of patellofemoral pain and malalignment.

Miyakawa patellectomy

An electron microscopic study of early pathology in chondromalacia of the patella.

Resurfacing of the knee with fresh osteochondral allograft.

Treatment of chondromalacia patellae by lateral retinacular release of the patella.

Insall proximal realignment for disorders of the patella.

Chondromalacia patellae. A prospective study.

Long-term results for the McKeever patellar resurfacing prosthesis used as a salvage procedure for severe chondromalacia patellae.

Chondromalacia patellae in athletes. Clinical presentation and conservative management.

Physical Therapy for Patellofemoral Pain. A Randomized, Double-Blinded, Placebo-Controlled Trial.

Alternatives to Total Knee Replacement:     Autologous Hamstring Resurfacing Arthroplasty

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