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1. PATELLAR CARTILAGE LESIONS
Dr.RAJAT JANGIR
Professor
Mahatma Gandhi Hospital, Jaipur

2. PATELLA CHONDRAL LESIONS
OFTEN MISSED DIAGNOSED
Subtle clinical symptoms
Difficulties in localizing on physical examination
Difficulties in visualizing plain radiographs

3. Lorentzon, R., Alfredson, H. & Hildingsson, C. Treatment of deep cartilage defects of the
patella with periosteal transplantation. Knee Surgery 6, 202–208 (1998).
Usually, these lesions are recognized accidentally during the treatment of another pathology

4. CAUSES
SPORTS
TRAUMA
excessive
lateral
position of
the patella
on the
trochlea
lateral
compression
RTA
causing
patella
fracture or
dislocation
Huberti HH, Hayes WC (1984) Patellofemoral contact pressures. The influence of q-angle and
tendofemoral contact. J Bone Joint Surg Am 66:715–724
Abnormal
Patellofemoral Stress

5. abnormally
loaded
abnormally
aligned
normally loaded
MIXTURE
Making understanding of the PF biomechanics more difficult
BIOMECHANICS

6. abnormally
loaded
abnormally
aligned
normally loaded
MIXTURE
Making understanding of the PF biomechanics more difficult
• TROCHLEAR DYSPLASIA
• PATELLA ALTA
• LATERALISED TIBIAL TUBEROSITY
• VALGUS KNEE
• ANTEVERSION OF HIP
• MPFL INSUFFICIENCY
• PATELLAR/QUADRICEPS TENDINITIS
• RETINACULAR TIGHTNESS,
• HOFFA’S FAT PAD SYNDROME
• POSTERIOR CAPSULAR CONTRACTURE
• HAMSTRINGS TIGHTNESS
• ILIOTIBIAL BAND TIGHTENS

7. CLINICAL SYMPTOMS
Anterior Knee Pain
Clicking
Instability
impairing daily activities

8. CLINICAL SYMPTOMS
Asymptomatic
Recognized accidentally on MRI or during Arthroscopy
Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG (1997) Cartilage injuries: a review of 31,516
knee arthros- copies. Arthroscopy 13:456–460

9. INCIDENCE
Increasingly being reported
Aaron et al reported 11% incidence of ICRS grade 3 or 4 chondral lesions
in 993 consecutive arthroscopies, among which 23% were patellar defects.
Isolated Outerbridge grade III patellar chondral defects were reported in
more than 20% of patients younger than 40 years in a study by Curl et al

10. LOCATION
• Most frequent site of cartilage lesion (72%) is a roughly elliptical area with the
major diameter parallel to the transverse axis of the patella, not affecting the
upper and lower thirds of the patella [45].
• The lateral and medial facets are affected in 7 and 21% of cases, respectively
[45].

11. ARTHROSCOPY
Gold standard- Direct vision
MR sensitivity 100%, a specificity of 50% and a relatively
high accuracy of 81.5%
MRI allows staging of chondral defects and might detect
very early cartilage lesions not diagnosed in arthroscopy

12. • Type I : Inferior pole
• Type II: Lateral facet
• Type III: Medial facet
• Type IVa : Proximal pole
• Type IVb : Panpatellar injury
Possible biomechanics - strategizing the treatment
Fulkerson classification (location)

13. ARTHROSCOPY – GOLD STANDARD

14. 36 % Full thickness lesions
14% Asymptomatic
DEPENDENCE ON MRI IS NOT JUSTIFIED

15. DECISION MAKING IS NOT LINEAR
SYMPTOMS
CARTILAGE
INJURY
MENISCUS
TEAR
SUBCHONDRL
BONE LESIONS
LIAGMENT
INJURY
MALALIGNMENT
No reliable correlation between
Clinical symptoms and Articular cartilage status

16. PATIENT-CENTERED APPROACH
Patients Symptoms
Concomitant knee pathology
Correlation of Imaging findings
Intraarticular and subchondral findings
Goals and expectations

17. PATIENT-CENTERED EVALUATION
• History
• Risk factors Age Sex BMI
• Alignment
• Instability
• Locking
Symptoms will not always represent the degree of cartilage damage

18. PATIENT-CENTERED EVALUATION
Performance demand
Return to Sports
Return to ADL
Prophylactic treatment for the expectation of disease progression at the
initial onset of symptoms is not recommended – unpredictable nature

19. CRITERIA FOR SURGERY
Unacceptable Pain and dysfunction
Concomitant Pathology Considered
Nonsurgical treatment considered
Risk-Benefit ratio for Patients Goals

20. NON SURGICAL CARE
The benefits of exercise overweighs and insufficient evidence that activity
increases the progression
Physical activity and dedicated rehab

21. CORRECT ALL COMORBIDITIES AT SOME POINT ALONG THE TREATMENT CONTINUUM
ALIGNMENT
MENISCAL
DEFICIENCY
INSTABILITY
SC
BONE

22. YOUNG WITH PF OVERLOAD - BIOMECHANICS
REHABILITATION
MUCH LONGER
REHAB
PATELLAR/QUADRICEPS
TENDINITIS
RETINACULAR
TIGHTNESS
HOFFA’S FAT PAD
SYNDROME
POSTERIOR CAPSULAR
CONTRACTURE
HAMSTRINGS
TIGHTNESS
ILIOTIBIAL BAND TIGHTENS
Release Rarely !
Only if very tight
Treatment of CHONDRAL LESION

23. YOUNG WITH INSTABILITY – BIOMECHANICS
TROCHLEAR DYSPLASIA PATELLA ALTA LATERALISED TIBIAL
TUBEROSITY
MEDIAL LAXITY
PRIMARY/ SECONDARY
TIGHT LATERAL
RETINACULA
TROCHLEOPLASTY TT TRANSFER LATERAL RELEASE
ASSOCIATED INSTABILITY
Treatment of CHONDRAL LESION

24. THERE IS MORE THAN ONE RIGHT ANSWER
FIBR0US
EASIER
HYALINE
COMPLEX
DBR MF OATS MACI OAG

25. SYMPTOMATIC PF CHONDRAL LESION
PF- TTO TF-DFO/HTO
MALALIGNMENT
REPAIR TRANSPLANT
LIGAMENT RECONSTRUCTION
MENISCUS
INSTABILITY

26. MARROW-STIMULATION PROCEDURES
Very difficult to do microfracture on the patellar chondral under-surface as the required
angle and forces to do the microfracture are not supported by the MOVING PATELLA
ABRASIOCHONDROPLASTY is a good alternative to do the marrow stimulation to promote
fibrocartilage formation
DEGENERATIVE LESION IN ELDERLY
SMALL LOCALISED CHONDRAL LESION IN YOUNG.

27. OCT
Difficult to perform in patella as compared to femoral condyle
Subchondral bone is much harder in the patella - much higher forces to cut a cylinder
Surface is concavo- convex making achievement of congruency more challenging
Most lesions are on apex which is a narrow summit -higher chances of incongruency
there are limited donor areas

28. OCT
Though technically demanding, the decreasing failure rates of OCT are
being reported.
Nho et al [23] reported 67-100% cartilage fill at a mean 28.7 months
on MRI, while Astur et al [24] reported full graft integration at 2 years
follow up with a significant improvement in all the scores; both the series
having lesion size from 1.65 to 2.5 cm

30. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI)
KNOWN DISADVANTAGE
TWO STAGE SURGERY
HIGHER COST
Hyaline (like)
cartilage
repair
Provides
excellent
congruency
No size and
Shape
restrictions

31. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI)

32. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI)
There is enough evidence in literature providing long term good results of ACI
The results of patellar ACI had been historically reported as inferior to those of
femoral ACI.
However, most of the poor results can be attributed to either use of older generations
(1st/ 2nd generation) of ACI or ignorance in simultaneous treatment of abnormal
biomechanics.

33. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI)
Gillogly and Arnold reported only 4% failure of ACI at minimum 5 years follow up, while
treating patellar cartilage defect along with anteromedialisation of tibial tuberosity.
A level III studies by Ebert J R et al [26] compared matched groups of tibiofemoral MACI (2nd
generation ACI) patients (n=94, medial; n=33, lateral) with patella--trochlear MACI patients
(n=35, patella; n=32, trochlea) using KOOS, VAS and SF-36 clinical scores at 24 months.
Patellofemoral group showed a statistically significant improvement similar to tibiofemoral
group, when biomechanical correction was simulta- neously performed for the patellar mal-
tracking.

34. BMAC
Mixture of the various marrow elements and MSC harvested from the bone marrow.
Easy harvest, easy processing methods and easy ethical clearances if not manipulated
can either be injected into the joint, or culture expanded and used in conjunction with the scaffolds
Preliminary studies that have shown better but also variable results
future researchers -components that influence these results in the different preparations .

35. REALIGNMENT PROCEDURES OF EXTENSOR MECHANISM
• Symptomatic defects of the patella located distally and laterally are often
treated initially with an AMZ with or without a microfracture procedure, as
these have historically managed well with AMZ alone
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 Jul-Aug;25(4):533-7.

36. OSTEOTOMY INDICATIONS
INDICATION TREATMENT
• TT-TG >20 mm Medialize tibial tubercle
• Patella alta (IS >1.3) Distalize tibial tubercle
• Focal chondral lesion Anteriorize tibial tubercle

37. ANTERIORISE TT
MAQUET PROCEDURE
PF CHONDRAL LESIONS
REDUCE CONTACT STRESS

38. MEDIALISE TT
TRILLAT PROCEDURE
INSALL INDEX <1.3
GRADE 2 OR LESS CHONDROMALACIA AT
ARTHROSCOPY

39. INSALL INDEX OF LESS THAN
1.3
GRADE 3 OR 4
CHONDROMALACIA ON
ARTHROSCOPY
SYMPTOMATIC LATERAL FACET
OR DISTAL POLE ARTHRITIS
FULKERSON OBLIQUE OSTEOTOMY

40. UNLOADING WITH A REALIGNMENT PROCEDURE IS DESIRABLE TO
MAXIMIZE THE CLINICAL OUTCOME OF ACI
Henderson IJ, Lavigne P (2006) Periosteal autologous chondro- cyte implantation for patellar chondral
defect in patients with normal and abnormal patellar tracking. Knee 13:274–279

41. TAKE HOME MESSAGE
Treatment depends on a thorough understanding of abnormal biomechanics.
Any significantly abnormal biomechanics must be treated first or simultaneously
The selection between various methods of cartilage repair depends on many factors
like size of lesion, occupational demands, surgeon’s experience and logistics.
Often the corrected biomechanics lead to healing of the cartilage lesion, not
requiring a definitive cartilage repair surgery

42. Thank You