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BLOG: Thoughts on anterior knee pain
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I often come across diffuse disproportionate patellar cartilage softening in patients with anterior knee pain resistant to conservative treatment. Personally, I believe it is a major factor for the persistence of pain in young people and it is probably related to aberrant mechanics in most cases.
If there is over-softening of the cartilage only in the lateral patellar facet and visible patellofemoral maltracking, isolated anteromedialization of the tibial tubercle should work. If patella over-softening is diffuse with concomitant severe trochlear dysplasia and the patient complains about severe anterior knee pain (AKP), lateral patellar instability and patellofemoral maltracking, I do a deepening trochleoplasty associated to a medial patella-femoral ligament (MPFL) reconstruction. In cases in which all the following are present: diffuse disproportionate cartilage softening; disabling AKP; failure of adequate physical therapy treatment; and normal patellofemoral tracking, my option is a fresh patellar allograft transplantation. I am happy with this surgical technique. In all aforesaid situations, the results I get are good and these surgeries are predictable, given proper indications and surgical precision.
Patients with AKP show different degrees of disability in their everyday life, regardless of how intense their pain is. In all patients with AKP, including those with severe structural anomalies, I always evaluate the psychological status as we have demonstrated the main responsibility for disability in patients with AKP is not the pain, but the associated psychological factors.
I think it is interesting to describe the type of patients I see with patellofemoral pathology. I work in a public hospital that serves a population of 350,000 and I see all the patellofemoral pathologies. I am also a referral surgeon in patellofemoral pathology, which is why I see a lot of complex revision surgeries from other hospitals of the region of Valencia and its surrounding areas. On the other hand, I have a private practice that allows me to evaluate complex cases throughout Spain and I perform a lot of revision surgeries. Finally, I participate in an STS (ie, surgeon-to-surgeon) program that allows me to see and re-operate on many complex cases throughout Spain. Therefore, I see all injuries — from the simplest pathology to the most complicated. The revision surgeries, that is the reoperations, allow me to learn a lot. I am “lucky” to have experience based on a wide variety of different cases. Indeed, seeing such varied patellofemoral pathology has allowed me to have a more realistic vision of this problematic pathologic entity. Each treatment technique has its indication because there are many types of patients with AKP. Each treatment should be tailor-made as every patient is different.
In my eyes, most patients with AKP are helped with good physiotherapy. However, working in a public health system means you cannot choose your colleagues. I work with good therapists who solve many cases. At the same time, I also see patients treated by bad therapists who cause a lot of iatrogenia, which I learn from. Moreover, the latter carry out therapeutic techniques that have no medical or scientific basis.
Most of my surgeries for AKP are to solve iatrogenia due to previous surgeries that are not indicated or performed correctly. In my surroundings, one example is trochleoplasty, which is catching on among under-skilled surgeons who overuse it. I do accept trochleoplasty, according to the technique described by David Dejour, as a great technique but in selected cases and always perform a thick flap to avoid the alteration of subchondral bone and cartilage.
I suppose the overuse of this technique will backfire on its reputation. Something similar happened with tibial tubercle anteromedialization osteotomy (Fulkerson´s osteotomy), which is effective when properly performed for the right indications. However, it had been incorrectly indicated many times and therefore the results were bad. Many surgeons I know base the indication of tibial tubercle anteromedialization only in the presence of a tibial tuberosity–trochlear groove distance of greater than 20 mm. This is a big mistake and it is a source of surgical failures. From my point of view, we must not use imaging numbers to treat a patient. These are only to help. The key is the physical examination. I believe that in most cases the “villain of the picture” is not the surgical technique itself, but the incompetent performance by the orthopedic surgeon. We must never forget the principles of Hippocratic medicine: “Primum non nocere.” We must not cause harm or make an already bad situation worse.
From my point of view, there are predictable primary surgeries to treat AKP if these are well indicated and performed, such as the anteromedialization of the tibial tubercle, massive allograft transplantation or rotational osteotomies of the tibia or femur. Rotational osteotomy, as I learned from Robert Teitge, is the surgery that has struck me the most and at the same time, it is the one that has brought the most satisfactory results in selective and demanding AKP cases. On the other hand, I believe there are other surgeries, such as focal synovectomies, that are not predictable. There are patients on whom I perform a focal synovectomy and have good results and other patients with the same characteristics and the same surgery goes wrong and beforehand, I cannot predict who will go well and who will not. This is the problem and why I am carrying out a study with functional brain magnetic resonance. I hope this allows me to predict the results of such treatment and be able to offer optimal treatments to patients with AKP associated with hyperalgesia or allodynia, which are difficult problems. For this reason, I am working with radiologists specialized in the brain and a well-trained neurophysiologist. This topic is exciting. I have many patients for this study because many doctors send patellofemoral pathology away.
Unfortunately, nowadays, many younger orthopedic surgeons base their surgical indications on an MRI, as if they were operating an image instead of a person. The art of conversation with a patient and the physical examination are most important and are too often neglected, with the unfortunate outcome of a failed patellofemoral surgery.
In my eyes, AKP is one of the most intriguing orthopedic pathologies from a clinical point of view because it obliges us to “think out of the box,” to look deeper into the anatomy, biomechanics, biology, anatomic pathology, physiopathology and psychology. I believe AKP is a great stimulus for orthopedic intellectual development.
Vicente Sanchis-Alfonso, MD, PhD, is a staff orthopedic surgeon in the department of orthopedics at Hospital Arnau de Vilanova in Valencia, Spain.
Disclosure: Sanchis-Alfonso reports no relevant financial disclosures.