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In the treatment of patellofemoral complications, the surgical treatment should address the primary pathology as well as the changes induced by the failed procedure. Cutting normal ligaments, removing articular cartilage, or transferring tendons to an abnormal position usually create new problems and should be performed cautiously.

Efficacious treatment of chondral and osteochondral defects of the patellofemoral surfaces represents an ongoing challenge for the orthopedic surgeon. Treatment options for such full-thickness cartilage defects are discussed in this chapter. Combination of different cartilage repair techniques and appropriate treatment of the underlying biomechanical factors should represent the adequate treatment strategy for these problematic lesions. “Traditional” resurfacing techniques have not stood well to time, based in large part on the poor biomechanical characteristics of the fibrocartilage reparative tissue. During the last decade, efforts have focused on ways to furnish a hyaline or hyaline-like gliding surface for full-thickness lesions. These burgeoning new methodologies embrace several surgical procedures: autologous osteochondral transplantation methods (including osteochondral mosaicplasty); chondrocyte implantation; periosteal and perichondrial resurfacement; allograft transplantation; and also tissue engineering. Experimental background, operative techniques, and clinical results of these new procedures are detailed in this overview.

The early and medium-term experiences with these techniques have provoked a cautious optimism among basic researchers and clinicians alike. Autologous osteochondral mosaicplasty can be an alternative in the treatment of small and medium-sized full-thickness lesions, not only the femorotibial surfaces but also in the patellofemoral junction. The major attractions of the mosaicplasty are the ease of the one-step procedure, relatively brief rehabilitation period, excellent clinical outcome, and low cost. Autologous chondrocyte transplantation represents a promising option in the treatment of larger full-thickness defects. It does require a relatively expensive two-step procedure and longer rehabilitation period, but it seems to be an appropriate treatment of larger defects as well. Similar to other techniques, patellotrochlear use of the chondrocyte transplantation results in less favorable clinical outcome compared with femoral condylar application.

Present recommendations for the transplantation of mushroom-shaped osteochondral allografts are elected cases of advanced degenerative lesions of the patellar surface. The possible indications for perichondrial flapping, biomaterials, and transplantation of engineered tissues have to be cleared.

Full-thickness cartilage damage of the patellotrochlear junction can involve associated problems, not infrequently traumatic or biomechanical in origin. Congenital shape anomalies of the patellotrochlear surfaces, traction malalignment problems, patellofemoral hyperpression, as well as posttraumatic disorders represent the most common background of symptomatic deep cartilage lesions of the patellofemoral junction. Recognition and treatment of these abnormalities are essential to ensure a favorable and enduring outcome. Effective treatment of full-thickness defects on the patellotrochlear surfaces requires careful patient selection, a comprehensive operative plan, and a well-organized treatment course.

Full-thickness patellar cartilage defects are troublesome injuries often associated with disabling anterior knee-pain and inability to take part in regular daily activities. Today, there are many methods in use with the purpose of treating cartilage defects; however, despite many years of research there is no method that scientifically has been proven to be superior to others. Consequently, there is no treatment of choice for this condition.

We have used autologous periosteum transplantation since 1991. It is well known that the cells in the cambium layer of the periosteum are pluripotent and can differentiate into hyaline (or hyaline-like) cartilage, especially in a joint environment and under the influence of continuous passive motion. At our clinic, autologous periosteum transplantation alone, followed by continuous passive motion (CPM) in the immediate postoperative period and non-weightbearing loading for 3 months, has shown promising clinical results. The best clinical results have been achieved on traumatic (fracture, contusion, dislocation) cartilage defects, where 54 out of 77 patients (70%) have been clinically graded as excellent or good at follow-up (>2 years postoperatively). For nontraumatic patellar cartilage defects (chondromalacia NUD) the results are poor, with only 35% of patients being graded as excellent or good. Therefore, we believe that nontraumatic patellar cartilage defects (chondromalacia NUD) are less suitable for treatment with autologous periosteum transplants, and are at our clinic no longer included for this type of treatment.

We report the clinical results of an anterior interval release for recalcitrant anterior knee pain associated with decreased patellar mobility after anterior cruciate ligament (ACL) reconstruction.

Thirty consecutive patients with recalcitrant anterior knee pain and decreased patellar mobility after ACL reconstruction underwent an arthroscopic lysis of adhesions and scar of the distal patella tendon from the proximal anterior tibia (anterior interval release). Anterior knee pain was initially treated nonoperatively. Failure of nonoperative treatment was defined by recalcitrant anterior knee pain and no improvement in functional outcome, assessed by Lysholm scores and patient questionnaires. Minimum clinical followup was 2 years. All anterior interval release procedures were also performed by the senior author using a high inferolateral viewing portal in order to arthroscopically evaluate the anterior interval between the patella tendon and tibia. Prior to anterior interval release, Lysholm score averaged 68 (range 18–90). Postoperative Lysholm score averaged 85 (range 68–100) (P < 0.0001). Postoperative range-of-motion did not change significantly. Postoperative instability examinations were all graded zero using the International Knee Documentation Committee (IKDC) system. Average patient satisfaction at follow-up was 8.0 (1 = very dissatisfied; 10 = very satisfied).

Early operative intervention with an anterior interval release has been shown in this series to result in significantly improved functional outcomes in the treatment of recalcitrant anterior knee pain after ACL reconstruction.

There is no substitute for a thorough history and a complete and careful physical examination. The history and physical examination still remain the first step for making an accurate diagnosis of anterior knee pain and patellar instability above any technique of diagnostic image. Imaging studies are a second step and can never replace the former. Surgical indications should not be based only on methods of image diagnosis as there is a poor correlation between clinical and image data. Finally, arthroscopy should be used judiciously and no realignment surgery should be based solely on the arthroscopic analysis of the patellofemoral congruence.

In the treatment of patellofemoral complications, the surgical treatment should address the primary pathology as well as the changes induced by the failed procedure. Cutting normal ligaments, removing articular cartilage, or transferring tendons to an abnormal position usually create new problems and should be performed cautiously.

Anterior knee pain following reconstruction of the anterior cruciate ligament is a problem that has plagued many patients. After extensively studying patients with this problem and comparing them to those that do not suffer from this entity, we have concluded that this is most often due to a loss of full hyperextension. Prevention of this by proper preoperative, intraoperative, and postoperative management can be successfully performed. Prevention should be the number-one concern. If anterior knee pain after ACL reconstruction does occur, the symptoms can usually be alleviated through nonoperative means. Occasionally, surgical intervention may become necessary. Other causes for this pain syndrome are rare but with proper evaluation can easily be differentiated and treated.

We report the clinical results of an anterior interval release for recalcitrant anterior knee pain associated with decreased patellar mobility after anterior cruciate ligament (ACL) reconstruction.

Thirty consecutive patients with recalcitrant anterior knee pain and decreased patellar mobility after ACL reconstruction underwent an arthroscopic lysis of adhesions and scar of the distal patella tendon from the proximal anterior tibia (anterior interval release). Anterior knee pain was initially treated nonoperatively. Failure of nonoperative treatment was defined by recalcitrant anterior knee pain and no improvement in functional outcome, assessed by Lysholm scores and patient questionnaires. Minimum clinical followup was 2 years. All anterior interval release procedures were also performed by the senior author using a high inferolateral viewing portal in order to arthroscopically evaluate the anterior interval between the patella tendon and tibia. Prior to anterior interval release, Lysholm score averaged 68 (range 18–90). Postoperative Lysholm score averaged 85 (range 68–100) (P < 0.0001). Postoperative range-of-motion did not change significantly. Postoperative instability examinations were all graded zero using the International Knee Documentation Committee (IKDC) system. Average patient satisfaction at follow-up was 8.0 (1 = very dissatisfied; 10 = very satisfied).

Early operative intervention with an anterior interval release has been shown in this series to result in significantly improved functional outcomes in the treatment of recalcitrant anterior knee pain after ACL reconstruction.

Postoperative donor-site morbidity and anterior knee pain following ACL surgery may result in substantial impairment for the patient. The selection of graft, surgical technique and rehabilitation program can affect the occurrence of undesirable pain conditions.

The loss or disturbance of anterior sensitivity caused by intraoperative injury to the infrapatellar nerve(s) in conjunction with patellar tendon harvest is correlated with donor-site discomfort and an inability to kneel and knee walk.

The patellar tendon at the donor site displays significant clinical, radiographic, histological, and ultrastructural abnormalities several years after harvesting its central third. The donor-site discomfort correlates poorly with radiographic and histological findings after the use of patellar tendon autografts. The use of hamstring tendon autografts causes less postoperative donor-site morbidity and anterior knee problems than the use of patellar tendon autografts. There also appears to be a regrowth of the hamstring tendons within two years after the harvesting procedure. There is a lack of knowledge in terms of the course of the donor site after harvesting fascia lata autografts. Harvesting quadriceps tendon autografts appears to cause low donor-site morbidity.

Efforts should be made to spare the infrapatellar nerve(s) during ACL reconstruction using patellar tendon autografts as well as hamstring autografts. Reharvesting the patellar tendon cannot be recommended due to significant clinical, radiographic, histological, and ultrastructural abnormalities several years after harvesting its central third. It is important to regain full range of motion and strength after the use of any type of autograft to avoid future anterior knee pain problems.

Since randomized controlled trials have shown that the laxity measurements and clinical results following ACL reconstruction using hamstring tendon autografts are similar to those of patellar tendon autografts, we recommend the use of hamstring tendon autografts due to fewer donor-site problems.

This case outlines unsuccessful treatment performing medialization of the tibial tuberosity in recurrent patellar dislocation in patients with dysplastic trochlea. A distal correction is not sufficient and adequate to treat a proximal pathological situation on the femur. In contrast, it can be dangerous creating secondary pathologies. The goal of the surgical reconstruction must be the elimination of the real pathology. The pathology in recurrent patellar dislocations is in most cases a dysplastic trochlea and only a few dislocations are really traumatic. In addition to lateral normal x-rays, the axial CT-scans in 0± of knee flexion with and without quadriceps muscle contraction are the best imaging modality to demonstrate abnormal patellofemoral relationship. Medialization of the tibial tuberosity always includes the risk of overloading the medial patellofemoral and femorotibial joint.