Isolated patellofemoral osteoarthritis

doi:10.1016/j.knee.2006.11.002

The Knee

Volume 14, Issue 3, June 2007, Pages 169-176

https://doi.org/10.1016/j.knee.2006.11.002 Get rights and content

Abstract

Isolated patellofemoral osteoarthritis is now recognised to be more common than previously thought. The features and management are reviewed, including the various surgical options in symptomatic patients. The evidence base for managing patellofemoral osteoarthritis is behind that for the tibiofemoral joint. All treatments are based on uncontrolled observational case series, typically retrospectively reviewed. Fortunately the majority of patients with isolated patellofemoral degenerative changes do not need surgical treatment. Those who are symptomatic can usually be successfully treated with weight loss and quadriceps strengthening exercises.

Introduction

Several recent reports of results of patellofemoral arthroplasty suggest that the surgical treatment of isolated patellofemoral arthritis remains controversial [1], [2], [3], [4]. In patients with degenerative arthritis of the knee, about half have arthritis in the patellofemoral joint. McAlindon et al. [5] have reported in a community survey in the UK of asymptomatic 240 knees that 19% of men and 34% of women over 55 years old have radiographic changes of osteoarthritis isolated to the patellofemoral joint. In a population of 174 (206 knees) over 60 year-olds presenting to secondary care with knee pain 18.5% of men and 17.1% of women had isolated patellofemoral osteoarthritis [6]. With the increasing popularity for unicompartmental knee replacement it is important to consider the patellofemoral joint as a separate entity to the tibiofemoral joint [4], [7].

Section snippets

Anatomy

The patellofemoral joint includes the entire extensor mechanism of the knee, namely the quadriceps tendon, patella and patellar ligament. The patella is a sesamoid bone that acts as a marker for the alignment of the whole extensor mechanism. The trochlear groove and an arch of articular cartilage around the intercondylar notch make up the femoral side of the joint. The patella only articulates with the tibia at the tibial spines. It is also worth realising that intercondylar notch osteophytes

Extensor mechanism malalignment

In the presence of normal patellofemoral anatomy later degenerative change is unlikely [10]. A retrospective review of patients presenting with patellofemoral arthritis showed a higher rate of previous adolescent anterior knee pain than patients presenting with medial tibiofemoral arthritis [11].

Abnormalities of the alignment of the extensor mechanism are well known and are described by analysis of radiographic images. As a screening measure the sulcus angle of greater than 140° is a useful

Clinical presentation of patellofemoral osteoarthritis

Iwano et al. [19] reviewed 66 patients with patellofemoral osteoarthritis of whom 42 were bilateral and 61 were women. The mean age was 63 years (range 36 to 84 years). The study group was 108 knees of which 64 had isolated patellofemoral osteoarthritis. The other 44 knees had tibiofemoral osteoarthritis as well. They looked at seven clinical features:

•
Pain on grinding the patella (the patella being moved both medio-laterally and infero-superiorly)
•
Crepitation on grinding the patella
•
Crepitation

Imaging the patellofemoral joint for osteoarthritis

Although isolated patellofemoral osteoarthritis is common, many rheumatologists and orthopaedic surgeons in the United Kingdom do not routinely ask for a tangential patella, or skyline view. The lateral X-ray of the knee is unreliable in assessing the degree and pattern of patellofemoral osteoarthritis. This can be classified anatomically as, medial, lateral or global according to its site (Fig. 2), as well as by the amount of joint space narrowing. Merchant et al. [21] staged the severity of

Conservative

In the majority of cases standard conservative measures will control the symptoms of pain from patellofemoral arthritis; building up the quadriceps muscle and losing weight. However there is no standardised method of treatment and there has been no validation of any particular technique [22].

Operative

Outcomes from operations for isolated patellofemoral arthritis are difficult to find. Most papers review an operation, and include isolated PFOA amongst a number of other diagnoses. Therefore the true

Conclusions

The evidence base for managing isolated patellofemoral osteoarthritis lags behind that for the tibiofemoral joint. All treatments are based on uncontrolled observational case series, typically retrospectively reviewed, often mixed in with other diagnoses. Fortunately the majority of patients with isolated patellofemoral degenerative changes are not symptomatic and do not need treatment. Those who are symptomatic rarely need surgical intervention, just advice to lose weight and build up

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The effects of a sleeve knee brace during stair negotiation in patients with symptomatic patellofemoral osteoarthritis
2024, Clinical Biomechanics
The patellofemoral joint is an important source of pain in knee osteoarthritis. Most biomechanical research in knee osteoarthritis has focused on the tibiofemoral joint during level walking. It is unknown what happens during stair negotiation in patients with patellofemoral joint osteoarthritis, a task commonly increasing pain. Conservative therapy for patellofemoral joint osteoarthritis includes the use of a sleeve knee brace. We aimed to examine the effect of a sleeve knee brace on knee biomechanics during stair negotiation in patellofemoral joint osteoarthritis patients.
30 patellofemoral joint osteoarthritis patients (40–70 years) ascended and descended an instrumented staircase with force plates under two conditions – wearing a Lycra flexible knee support (Bioskin Patellar Tracking Q Brace) and no brace (control condition). Knee joint kinematics (VICON) and kinetics were recorded.
During stair ascent, at the knee, the brace significantly reduced the maximal flexion angle (2.7⁰, P = 0.002), maximal adduction angle (2.0⁰, P = 0.044), total sagittal range of motion (2.0⁰, P = 0.008), total frontal range of motion (1.7⁰, P = 0.023) and sagittal peak extension moment (0.05 Nm/kg, P = 0.043) compared to control. During stair descent, at the knee, the brace significantly reduced the maximal flexion angle (1.8⁰, P = 0.039) and total sagittal range of motion (1.5⁰, P = 0.045) compared to control.
The small changes in knee joint biomechanics during stair negotiation observed in our study need to be investigated further to help explain mechanisms behind the potential benefits of a sleeve knee brace for painful patellofemoral joint osteoarthritis.
Miscellaneous Complex Pathological Conditions of the Knee
2020, Evidence-Based Management of Complex Knee Injuries: Restoring the Anatomy to Achieve Best Outcomes
Although infrequent, some pathological conditions of the knee are often misdiagnosed. Several miscellaneous complex knee pathological conditions and their treatments are outlined. Patellofemoral arthritis, when refractory, can be treated with an arthroscopic partial lateral facetectomy of the patella using a motorised burr to decrease the pain associated with the patellofemoral arthritis. Additionally, symptomatic fabella syndrome can be a difficult diagnosis to make, is often misdiagnosed and can be treated with an open excision. Snapping hamstrings are also often misdiagnosed; they are caused by friction between the hamstrings of the pes tendons medially and can be treated with sectioning or harvesting the gracilis or semitendinosus from their insertion on the anteromedial tibia. Symptomatic decreased knee extension in the setting of osteoarthritis is often the result of bony osteophyte overgrowth of the femoral notch. Arthroscopic notchplasty can be an effective adjunct in restoring knee extension in otherwise highly functional patients. Symptomatic proximal tibiofibular joint instability most often results from disruption of the posterior tibiofibular ligaments and can present as both pain over the posterolateral knee with deep squats or dysaesthesias along the common peroneal nerve distribution. Reconstruction of these ligaments is outlined as an effective treatment for this condition. Finally, severe patella baja is a condition that can be debilitating and difficult to treat. Patellar tenotomy to allow proximal migration is described as a valid technique for restoring range of motion and function.
Arthroscopic Patellar Lateral Facetectomy
2017, Arthroscopy Techniques
Citation Excerpt :
However, these procedures are more invasive and are associated with more complications.14 Patellar lateral facetectomy is described in the literature as a safe procedure to treat isolated PFOA, and it does not affect a potential patellar replacement, if needed.15 Marten and De Rycke16 reported good-to-moderate results in 90% of 20 patients in a prospective case series, with a mean follow-up of 2 years.
Isolated patellofemoral osteoarthritis is relatively prevalent, with the lateral facet of the patella being the most commonly affected portion. This pathology can be a result of a patellar maltracking syndrome, patella instability, or idiopathic degenerative changes. A thorough diagnostic work-up with a physical examination and imaging studies are mandatory for a proper diagnosis and to rule out other causes of patellofemoral knee pain. These patients are often treated nonoperatively with exercises for patella mobility, intra-articular injections, braces, patellar tracking, quadriceps balance and strength, and activity modification. Patients with lateral patellar pain that is refractory to nonoperative management, and who have a clear bony deformity on the patella overriding the lateral aspect of the trochlea, can benefit from surgical intervention. We recommend an arthroscopic lateral patellar facetectomy because the joint can be dynamically assessed, treated, and re-evaluated intraoperatively to ensure that normal bony contact has been restored.
Patellofemoral joint arthroplasty
2017, Orthopaedics and Trauma
Citation Excerpt :
Similar to tibiofemoral OA, conservative management is the essence of the initial treatment of PFOA. The majority of patients with isolated PFOA can be managed conservatively, with weight loss and quadriceps strengthening exercises being the mainstay of treatment,8 whilst patellar taping and patellar bracing also have the potential to also alleviate symptoms.9 Understanding the recruitment of core muscles and the role of hamstring-quadriceps balance is vital in the non-operative management of PFOA.
Isolated patellofemoral osteoarthritis (PFOA) is symptomatic in around 10% of people aged over 55 years. This article presents a review of the treatment of PFOA with isolated patellofemoral arthroplasty (PFA). PFA has evolved in patient selection, surgical technique and implant design since its inception in the 1950s. Despite good clinical outcomes and survivorship being reported in the literature from a number of implants, PFA still remains a controversial subject due to high revision rates reported from large registries such as the National Joint Registry (NJR). Whilst patient selection and intra-operative techniques to optimize extensor mechanism function and avoid dynamic ‘overstuffing’ of the patellofemoral joint are key to the success of PFA, they are often overlooked. More recently, concomitant procedures to address patellar instability, tibiofemoral malalignment and patellofemoral malalignment have been performed to optimize PFA outcomes. With attention to detail in patient selection and surgical technique, using appropriate implants, PFA can lead to improved clinical outcomes and high survivorship for the treatment of isolated severe PFOA.
Epidemiological characteristics of patellofemoral osteoarthritis in elderly Koreans and its symptomatic contribution in knee osteoarthritis
2016, Knee
Many studies have reported the prevalence of knee osteoarthritis (OA) but have invariably focused on the tibiofemoral (TF) joint and overlooked the patellofemoral (PF) joint. Accordingly, little epidemiological information is available regarding the PF OA. The purpose of the current study was to document the epidemiological characteristics of PF OA in elderly Koreans.
Radiographic assessment was performed for 681 elderly (≥ 65 years old) Koreans recruited from a community, and symptom severity was evaluated using Western Ontario and McMaster Universities Index (WOMAC) and Short Form-36 (SF-36) scales. Prevalence of different categories of knee OA (isolated PF OA, isolated TF OA and combined PF and TF OA) was calculated. The symptoms of isolated PF OA group and non-OA group were compared.
The overall prevalence of OA was 22.0% in the PF compartment and 34.1% in the TF compartment. The prevalence of isolated PF OA, isolated TF OA, and combined PF and TF OA was 3.8%, 17.8%, and 19.2%, respectively. Female sex, aging, and obesity were not associated with isolated PF OA. No significant differences were found in any clinical outcome scales between the isolated PF and non-OA groups.
This study documents that OA in the PF joint is common in elderly Koreans, but isolated PF OA is rare. Demographic risk factors are not associated with isolated PF OA, suggesting that isolated PF OA may have a different pathophysiology from other types of knee OA. Our study also indicates that the presence of isolated PF OA should not be construed to be responsible for clinical symptoms.
Arthroscopy in the management of knee osteoarthritis
2014, Knee

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ReviewIsolated patellofemoral osteoarthritis

Abstract

Introduction

Section snippets

Anatomy

Extensor mechanism malalignment

Clinical presentation of patellofemoral osteoarthritis

Imaging the patellofemoral joint for osteoarthritis

Conservative

Operative

Conclusions

J Arthroplast

Arthroscopy

Knee

Curr Orthop

Knee

Arthroscopy

Arthroscopy

Curr Orthop

J Arthroplast

Knee

Symposium. Operative treatment of patellofemoral arthritis

J Bone Jt Surg Am Vol

Alternatives to patellofemoral arthroplasty

Clin Orthop

The appropriate use of patellofemoral arthroplasty: an analysis of reported indications, contraindications, and failures

Clin Orthop

Radiographic patterns of osteoarthritis of the knee in the community: the importance of the patellofemoral joint

Ann Rheum Dis

The radiological prevalence of patellofemoral osteoarthritis

Clin Orthop

Patellofemoral arthritis

J Bone Jt Surg Am Vol

Patello-femoral joint mechanics and pathology. Functional anatomy of the patello-femoral joint

J Bone Jt Surg Br Vol

The synovial folds of the patellofemoral joint: a dynamic study

Clin Anat

The sulcus angle and malalignment of the extensor mechanism of the knee

J Bone Jt Surg

Dysplasia of the femoral trochlea

Rev Chir Orthop

Patellofemoral osteoarthritis after patellar dislocation

Clin Orthop

Das femoropatellare Schmerzsyndrom. Konservative und operative Therapie im Longzeitvergleich (10–20 Jahre) und ihre therapeutischen Konsequenzen

Z Orthop Ihre Grenzgeb

A modified Hauser procedure for recurrent dislocation of the patella. A long-term follow-up study with special reference to osteoarthritis

Arch Orthop Trauma Surg

Roentgenographic and clinical findings of patellofemoral arthrosis

Clin Orthop

The association of obesity with osteoarthritis of the hand and knee in women: a twin study

J Rheumatol

Roentgenographic analysis of patellofemoral congruence

J Bone Jt Surg Am Vol

Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation

J Orthop Sports Phys Ther

Resection arthroplasty of the patella

J Bone Jt Surg Br Vol

Facetectomy of the patella in patellofemoral osteoarthritis

Acta Orthop Belg

The treatment of patellofemoral osteoarthritis with partial lateral facetectomy

Clin Orthop

Patellofemoral arthritis resulting from malalignment. A long-term evaluation of treatment options

Orthop Rev

Is patellectomy compatible with an army career?

J R Army Med Corps

Review
Isolated patellofemoral osteoarthritis