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Surgical strategies for chondral defects of the patellofemoral joint: a systematic review

Journal of Orthopaedic Surgery and Research volume 17, Article number: 524 (2022) Cite this article

Abstract

Background

The management of chondral defects of the patellofemoral joint is debated, and definitive evidence is lacking. This study systematically updated and summarised the current literature on the surgical management of isolated chondral defects of the patellofemoral joint, discussing techniques, outcome, pitfalls, and new frontiers.

Methods

This systematic review was conducted according to the 2020 PRISMA statement. In August 2022, PubMed, Web of Science, Google Scholar, and Embase databases were accessed with no time constrain. All the clinical studies investigating the surgical management of chondral defects of the patellofemoral joint were retrieved. Articles which reported data on patients with advanced to severe osteoarthritis were not eligible. Only studies with a minimum 24 months follow-up were considered. Studies which mixed results of patellofemoral and tibiofemoral joints were not considered.

Results

Data from 10 studies (692 procedures) were retrieved. The mean follow-up was 46.9 ± 18.2 months. The mean age of the patients was 34.0 ± 6.1 years, and the mean BMI was 25.9 ± 0.8 kg/m2. The mean duration of symptoms before the index surgery was 81.0 ± 24.0 months. The mean defect size was 3.8 ± 0.8 cm2. All the PROMs improved from baseline to last follow-up: VAS 0–10 (P = 0.04), Tegner (P = 0.02), Lysholm (P = 0.03), and International Knee Documentation Committee (P = 0.03). The rate of hypertrophy was 5.6% (14 of 251), the rate of progression to total knee arthroplasty was 2.4% (2 of 83), the rate of revision was 16.9% (29 of 136), and the rate of failure was 13.0% (16 of 123).

Conclusion

Current surgical strategies may be effective to improve symptoms deriving from chondral defects of the patellofemoral joint. The limited and heterogeneous data included for analysis impact negatively the results of the present study. Further clinical studies are strongly required to define surgical indications and outcomes, and the most suitable technique.

Introduction

Chondral defects of the knee are common [1, 2]. Hyaline cartilage has limited regenerative capacities, and residual chondral defects are common [3, 4]. Non-symptomatic chondral defects are identified in up to 72% of patients undergo knee arthroscopy [5, 6]. Symptomatic chondral defects reduce considerably the quality of life and the participation to recreational activities of affected patients [7]. The management of patients with chondral defects is controversial, with unpredictable outcomes [8, 9]. Within the knee, chondral defects of the patellofemoral joint are common [10]. Chondral defects of the patellofemoral joint can lead to persistent anterior knee pain, and, if left untreated, to early osteoarthritis [7, 11, 12]. Bone marrow stimulating surgical strategies, such as microfractures, are commonly performed for smaller defects [8, 9]. Autologous Matrix-Induced Chondrogenesis (AMIC) represent a further evolution of microfractures: a resorbable membrane is placed over the defect to stabilise the bone marrow-derived blood clot [13]. Autologous chondrocyte implantation (ACI), first generation (periosteal patch, pACI), second generation (chondral patch, cACI), and third generation (matrix-induced ACI, mACI), has been widely performed in the patellofemoral joint [14,15,16]. Current evidence on the surgical management of chondral defects of the patellofemoral joint is limited and mainly arises from studies which combined results with those of the femorotibial joint [17,18,19,20]. Few clinical trials which exclusively focused on the management of isolated chondral defects of the patellofemoral joint have been published [21,22,23,24,25,26,27,28,29,30]. This study systematically updated and summarised the current evidence on the surgical management of isolated chondral defects of the patellofemoral joint, discussing techniques, patient reported outcome measures (PROMs), pitfalls, and new frontiers.

Materials and methods

Eligibility criteria

All the clinical trials investigating the surgical management of chondral defects of the patellofemoral joint were accessed. Given the authors’ language capabilities, articles in English, German, Italian, French, and Spanish were eligible. Only level I to IV of evidence, according to the Oxford Centre of Evidence-Based Medicine [31], were considered. Reviews, opinions, letters, and editorials were not considered. Only studies published in peer reviewed journals were considered. Animal, in vitro, biomechanics, computational, and cadaveric studies were not eligible. Articles which reported data on patients with advanced to severe osteoarthritis were not eligible. Studies which evaluated only the morphological quality of the newly formed cartilage were not eligible, nor were those reporting data from patients who previously underwent total knee arthroplasty (TKA). Only studies which reported the outcomes of patients undergoing surgical management for isolated chondral injuries of the patellofemoral joint (retropatellar, trochlear, or both) were considered. Only studies with a minimum 24 months follow-up were eligible. Studies which mixed results of patello- and tibiofemoral joints were not considered, nor were those which did not report quantitative data on the outcomes of interest.

Search strategy

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement [32]. The PICOT framework was followed for the initial search:

  • P (Problem): chondral defects of the patella;

  • I (Intervention): surgical intervention;

  • C (Comparison): baseline to follow-up improvement;

  • O (Outcomes): PROMs and complications;

  • T (Timing): minimum 24 months follow-up.

In August 2022 PubMed, Web of Science, Google Scholar, and Embase databases were accessed with no time constrain. The following keywords were used in combination using the Boolean operators AND/OR: knee, patella, patellofemoral, kneecap, chondral, cartilage defect, ailment, injury, damage, chondropathy, management, treatment, graft, surgery, intervention, patient reported outcome measures, PROMs, IKCD, Lysholm, Tegner, VAS, visual analogue scale, pain, function, joint, outcome, failure, reoperation, and revision.

Selection and data collection

The database search was conducted by two authors (F.M & A.B.) independently. All the resulting titles were carefully inspected and, if suitable, the abstract was accessed. The full-text of the abstracts which matched the topic was accessed. The bibliography of the full-text articles was also screened by hand to identify further articles. Disagreements were debated and the final decision was made by a third author (**).

Data items

Two authors (F.M & A.B.) independently conducted data extraction. Generalities of the included studies were retrieved: author and year, journal, study design, mean length of the follow-up, mean age of the patients, mean length of the symptoms prior the index procedure, and mean defect size. Data with regard to the following PROMs were collected at baseline and at last follow-up: Visual Analogue Scale (VAS), Tegner Activity Scale [33], Lysholm Knee Scoring Scale [34], and International Knee Documentation Committee (IKDC) [35]. Data on the following complications were also collected: rates of hypertrophy, failure, and revision surgery. The rate of progression to TKA was also retrieved. Patients with persistent symptoms of chondral damage were considered as failures.

Study risk of bias assessment

The study risk of bias assessment was performed by two authors (F.M & A.B.) independently. The risk of bias graft tool of the Review Manager software (The Nordic Cochrane Collaboration, Copenhagen) was used. The following biases were considered for analysis: selection, detection, reporting, attrition, and other source of bias.

Synthesis methods

The statistical analyses were conducted by the main author (F.M.) using the IBM SPSS Software. For continuous data, the mean difference (MD) and standard error (SE) were evaluated. The confidence intervals (CI) were set at 95% in all the comparisons. The t test was also performed, with values of P < 0.05 considered statistically significant.

Results

Study selection

A total of 1644 articles were identified during the preliminary database search. Of them, 445 were excluded as they were duplicates. A further 1185 studies were excluded with reason: not focusing on patellofemoral joint (N = 901), study type/design (N = 197), and mixed patellofemoral and tibiofemoral data (N = 41), including patients with osteoarthritis or only evaluated the quality of the new formed cartilage (N = 34), language limitations (N = 9), and short follow-up (N = 3). Finally, further 4 studies were excluded as they did not report quantitative data under the outcomes of interest. The literature search resulted in 10 articles (Fig. 1).

Fig. 1
figure 1

Flow chart of the literature search

Full size image

Study risk of bias assessment

As a result of the lack of random sequence generation in most studies, the risk of bias tool evidenced a moderate risk of selection bias. Assessor blinding was seldom performed; thus, the risk of detection bias was moderate-high. However, the overall good quality of the investigations led to a moderate to low risk of attrition and reporting biases. The risk of other bias was moderate. Concluding, the risk of bias graph evidenced a moderate to low risk of publication bias (Fig. 2).

Fig. 2
figure 2

Methodological quality assessment

Full size image

Study characteristics and results of individual studies

Data from 692 procedures were retrieved. The mean follow-up was 46.9 ± 18.2 months. The mean age of the patients was 34.0 ± 6.1 years, and the mean BMI was 25.9 ± 0.8 kg/m2. The mean duration of the symptoms before the index surgery was 81.0 ± 24.0 months. The mean defect size was 3.8 ± 0.8 cm2. Generalities of the studies are shown in Table 1.

Table 1 Generalities and patient baseline of the included studies
Full size table

Results of syntheses

All the PROMs improved from baseline to last follow-up (Table 2): VAS 0–10 (− 1.8; P = 0.04), Tegner (+ 1.8; P = 0.02), Lysholm (+ 13.5; P = 0.03), and IKDC (+ 23.5; P = 0.03).

Table 2 Results of PROMs
Full size table

The rate of hypertrophy was 5.6% (14 of 251), the rate of progression to TKA was 2.4% (2 of 83), the rate of revision was 16.9% (29 of 136), and the rate of failure was 13.0% (16 of 123).

Discussion

According to the main findings of the present study, current surgical strategies for chondral defects of the patellofemoral joint may be effective to improve symptoms. VAS, Tegner, Lysholm, and IKDC scores statistically significantly improved from baseline to last follow-up. The improvement of the PROMs overcome the minimum clinically important difference (MCID) [36,37,38,39,40]. However, the rate of complications was relatively high. The rate of hypertrophy was 5.6%, the rate of patients undergoing TKA was 2.4% (2 of 83), the rate of revision was 16.9% (29 of 136), and the rate of failure was 13.0% (16 of 123). Few authors reported the rate of complications: we assume that some authors did not report clearly whether complication were found. This may underestimate the number of patients who had experienced no complication.

Among the included studies, several techniques for cartilage regeneration have been used. PACI has been widely used to address chondral defects. Cultured autologous chondrocytes, harvested from healthy cartilage, are injected under a periosteal flap sutured over the defect [41]. PACI was burdened by a high rate of hypertrophy, which was attributed to the use of the periosteal flap [16, 42,43,44,45,46]. Indeed, in the present study, graft hypertrophy was almost seen only in patients who underwent pACI [26, 27]. To overcome this complication, collagen-membrane cover ACI (cACI) has been introduced, substituting the periosteal flap with a resorbable membrane [23, 47]. CACI evolved in mACI, in which the harvested and cultured autologous chondrocytes are seeded directly on a biodegradable scaffold, either a collagen type I/III matrix or hyaluronan matrix membrane [48]. The loaded matrix allows chondrocytes expansion and is secured with fibrin into the chondral defect in a second step surgery. Compared to the previous generation, mACI allows less invasive approaches (mini-arthrotomy or arthroscopy), avoids graft suture, and allows shorter surgical time [48]. Despite the good results in PROMs in long-term studies [49], these techniques are technically demanding, require two different surgical interventions, and are burdened by donor site morbidity, higher costs, and long recovery times [27, 48]. AMIC avoids cartilage harvest and external expansion, and is performed in a single surgical session. Different to ACI, which requires expanded autologous chondrocytes, AMIC exploits the potential of bone marrow-derived mesenchymal stem cells.

Most authors performed the procedures in patients with patellofemoral instability [21, 22, 26,27,28,29,30]. Up to 96% of patients following a patellar dislocation demonstrated cartilage damage at the patellofemoral joint [50,51,52,53,54]. Approximately 85% of patients following a patellar dislocation demonstrated focal patellar chondropathy at MRI, while 47% evidenced chondral damage in the trochlea [55,56,57,58,59,60]. The medial chondral facet and median crest of the patella were more commonly affected than the lateral patellar facet and femoral trochlea [51, 61,62,63,64,65,66,67,68,69,70]. Whether to combine a chondral procedure with a proximal or distal alignment to restore the appropriate patellar tracking is unclear. Patellofemoral instability is multifactorial, and its management is challenging [71]. The rate of re-dislocation after conservative management of first patellar dislocation ranges from 15 to 71% [72,73,74,75,76,77,78,79,80,81,82,83]. Surgery is reserved for patients who demonstrate loose bodies or large osteochondral defects [84,85,86]. There is a growing trend to manage surgically the first patellar dislocation [87, 88]. Previous investigations compared surgical versus conservative management for first patellofemoral dislocations, suggesting that patients may benefit from surgery immediately after the first acute patellar dislocation [89,90,91,92,93,94,95,96,97,98]. A recent meta-analysis found that the risk of re-dislocation was 2.44 times greater in the conservative group, with a 10% worse Kujala score at approximately 5 years follow-up compared to a group of patients who underwent immediate surgery [99]. However, the management of the first patellar dislocation remains unclear [100], and international recommendations are lacking.

This systematic review presents several limitations which impact the reliability of the conclusions. In the current literature, several studies reported data on chondral procedures in the patellofemoral joint; however, most authors did not focus exclusively on the patellofemoral joint. Evidence focusing exclusively on the patellofemoral joint is limited and heterogeneous. Studies which focused on chondral procedures for patellar defects used different surgical procedures, including AMIC [25, 28, 30], pACI [26, 27, 29], cACI [23], mACI [22,23,24, 26], and ACI augmented with bone marrow concentrate [21, 27]. In this respect, results from the present investigation are not fully generalisable. Additional between studies heterogeneities should be discussed. Most authors performed the chondral procedures in patients with patellofemoral instability. Patients who experienced acute or recurrent patellar dislocations have different patterns of chondral injuries [54, 101, 102]. Several risk factors which predispose to patellofemoral instability have been described, such as patella alta, malalignment syndromes, ligamentous hyperlaxity, and dysplasia [103,104,105,106]. Recent studies demonstrated that most patients with patellofemoral instability have two or more coexistent pathoanatomical risk factors which synergistically predispose to the dislocation. Therefore, the results are strongly influenced by the underlying subjective pathoanatomical susceptibility to instability. Future investigations should clarify the outcome of combined patellofemoral and chondral procedures, to establish the proper surgical management. Furthermore, some authors performed the chondral procedures in isolation [22, 25], while some others combined the procedure with proximal or distal alignments to restore physiological patellar tracking [21, 22, 26,27,28,29]. Eight studies focused on isolated retropatellar chondral injuries [22, 23, 25,26,27,28,29,30], one only on isolated trochlear injuries [22], and two reported data from mixed locations [21, 24]. Two studies enhanced ACI with autologous bone marrow aspirate concentrate [21, 27]. Moreover, most studies used a collagenic I/III porcine derived membrane, while Buda et al. 2018 [21] used a hyaluronic membrane. Most authors considered only patients with no previous chondral intervention on the knee [25, 29]; other authors considered also revision settings [22, 23, 26]. Finally, most authors included only patients with single unipolar patellofemoral joint focal defects [21, 22, 25, 28, 29], while others included also patients with mixed locations [23]. The impact of these variables on the surgical outcomes is unknown. However, given the lack of quantitative data available in the literature, further subgroup analyses were not possible. Given these limitations in original studies, additional subgroups analyses were not possible, and results from the present study must be interpreted with caution. Further clinical studies to define eligibility criteria, surgical indications and techniques are strongly required.

Conclusions

Surgical strategies may be effective to improve symptoms of chondral defects of the patellofemoral joint. The rate of complications was relatively high. The limited and heterogeneous data included for analysis impact negatively the generalisability of the results of the present study. Further clinical studies are strongly required to define surgical indications and outcomes, and the most suitable technique.

Availability of data and materials

The datasets generated during and/or analysed during the current study are available throughout the manuscript.

Abbreviations

MCID:

Minimum clinically important difference

BMC:

Bone marrow concentrate

ACI:

Autologous chondrocyte implantation

AMIC:

Autologous matrix-induced chondrogenesis

VAS:

Visual analogue scale

IKDC:

International Knee Documentation Committee

MD:

Mean difference

SE:

Standard error

CI:

Confidence intervals

AMIC:

Autologous Matrix-Induced Chondrogenesis

ACI:

Autologous chondrocyte implantation

pACI:

Periosteal patch autologous chondrocyte implantation

cACI:

Chondral patch autologous chondrocyte implantation

mACI:

Matrix-induced autologous chondrocyte implantation

PROMs:

Patient reported outcome measures

TKA:

Total knee arthroplasty

References

  1. Richter DL, Schenck RC Jr, Wascher DC, et al. Knee articular cartilage repair and restoration techniques: a review of the literature. Sports Health. 2016;8:153–60.

    Article  PubMed  Google Scholar 

  2. Maheshwer B, Polce EM, Paul K, et al. Regenerative potential of mesenchymal stem cells for the treatment of knee osteoarthritis and chondral defects: a systematic review and meta-analysis. Arthroscopy. 2021;37:362–78.

    Article  PubMed  Google Scholar 

  3. Atala A, Irvine DJ, Moses M, et al. Wound healing versus regeneration: role of the tissue environment in regenerative medicine. MRS Bull. 2010;35:597–606.

    Article  CAS  Google Scholar 

  4. Buckwalter JA. Articular cartilage injuries. Clin Orthop Relat Res. 2002;402:21–37.

    Article  Google Scholar 

  5. Curl WW, Krome J, Gordon ES, et al. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy. 1997;13:456–60.

    Article  PubMed  CAS  Google Scholar 

  6. Figueroa D, Calvo R, Vaisman A, et al. Knee chondral lesions: incidence and correlation between arthroscopic and magnetic resonance findings. Arthroscopy. 2007;23:312–5.

    Article  PubMed  Google Scholar 

  7. Heir S, Nerhus TK, Rotterud JH, et al. Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: a comparison of knee injury and osteoarthritis outcome score in 4 patient categories scheduled for knee surgery. Am J Sports Med. 2010;38:231–7.

    Article  PubMed  Google Scholar 

  8. Filardo G, Kon E, Berruto M, et al. Arthroscopic second generation autologous chondrocytes implantation associated with bone grafting for the treatment of knee osteochondritis dissecans: Results at 6 years. Knee. 2012;19:658–63.

    Article  PubMed  Google Scholar 

  9. Bertho P, Pauvert A, Pouderoux T, et al. Treatment of large deep osteochondritis lesions of the knee by autologous matrix-induced chondrogenesis (AMIC): preliminary results in 13 patients. Orthop Traumatol Surg Res. 2018;104:695–700.

    Article  PubMed  Google Scholar 

  10. Aroen A, Loken S, Heir S, et al. Articular cartilage lesions in 993 consecutive knee arthroscopies. Am J Sports Med. 2004;32:211–5.

    Article  PubMed  Google Scholar 

  11. Samim M, Smitaman E, Lawrence D, et al. MRI of anterior knee pain. Skelet Radiol. 2014;43:875–93.

    Article  Google Scholar 

  12. Figueroa D, Calvo Rodriguez R, Donoso R, et al. High-grade patellar chondral defects: promising results from management with osteochondral autografts. Orthop J Sports Med. 2020;8:2325967120933138.

    Article  PubMed  PubMed Central  Google Scholar 

  13. de Girolamo L, Schonhuber H, Vigano M, et al. Autologous matrix-induced chondrogenesis (AMIC) and AMIC enhanced by autologous concentrated bone marrow aspirate (BMAC) allow for stable clinical and functional improvements at up to 9 years follow-up: results from a randomized controlled study. J Clin Med. 2019;8:392.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Basad E, Wissing FR, Fehrenbach P, et al. Matrix-induced autologous chondrocyte implantation (MACI) in the knee: clinical outcomes and challenges. Knee Surg Sports Traumatol Arthrosc. 2015;23:3729–35.

    Article  PubMed  Google Scholar 

  15. Basad E, Ishaque B, Bachmann G, et al. Matrix-induced autologous chondrocyte implantation versus microfracture in the treatment of cartilage defects of the knee: a 2-year randomised study. Knee Surg Sports Traumatol Arthrosc. 2010;18:519–27.

    Article  PubMed  Google Scholar 

  16. Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg Br. 2005;87:640–5.

    Article  PubMed  CAS  Google Scholar 

  17. Volz M, Schaumburger J, Frick H, et al. A randomized controlled trial demonstrating sustained benefit of Autologous Matrix-Induced Chondrogenesis over microfracture at five years. Int Orthop. 2017;41:797–804.

    Article  PubMed  Google Scholar 

  18. Anders S, Volz M, Frick H, et al. A randomized, controlled trial comparing autologous matrix-induced chondrogenesis (AMIC(R)) to microfracture: analysis of 1- and 2-year follow-up data of 2 centers. Open Orthop J. 2013;7:133–43.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Chung JY, Lee DH, Kim TH, et al. Cartilage extra-cellular matrix biomembrane for the enhancement of microfractured defects. Knee Surg Sports Traumatol Arthrosc. 2014;22:1249–59.

    Article  PubMed  Google Scholar 

  20. Sadlik B, Puszkarz M, Kosmalska L, et al. All-arthroscopic autologous matrix-induced chondrogenesis-aided repair of a patellar cartilage defect using dry arthroscopy and a retraction system. J Knee Surg. 2017;30:925–9.

    Article  PubMed  Google Scholar 

  21. Buda R, Baldassarri M, Perazzo L, et al. A useful combination for the treatment of patellofemoral chondral lesions: realignment procedure plus mesenchymal stem cell-retrospective analysis and clinical results at 48 months of follow-up. Eur J Orthop Surg Traumatol. 2019;29:461–70.

    Article  PubMed  Google Scholar 

  22. Ebert JR, Fallon M, Smith A, et al. Prospective clinical and radiologic evaluation of patellofemoral matrix-induced autologous chondrocyte implantation. Am J Sports Med. 2015;43:1362–72.

    Article  PubMed  Google Scholar 

  23. Macmull S, Jaiswal PK, Bentley G, et al. The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae. Int Orthop. 2012;36:1371–7.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Meyerkort D, Ebert JR, Ackland TR, et al. Matrix-induced autologous chondrocyte implantation (MACI) for chondral defects in the patellofemoral joint. Knee Surg Sports Traumatol Arthrosc. 2014;22:2522–30.

    Article  PubMed  Google Scholar 

  25. Migliorini F, Eschweiler J, Maffulli N, et al. Management of patellar chondral defects with autologous matrix induced chondrogenesis (AMIC) compared to microfractures: a four years follow-up clinical trial. Life (Basel). 2021;11:141.

    PubMed  Google Scholar 

  26. Niemeyer P, Pestka JM, Kreuz PC, et al. Characteristic complications after autologous chondrocyte implantation for cartilage defects of the knee joint. Am J Sports Med. 2008;36:2091–9.

    Article  PubMed  Google Scholar 

  27. Teo BJ, Buhary K, Tai BC, et al. Cell-based therapy improves function in adolescents and young adults with patellar osteochondritis dissecans. Clin Orthop Relat Res. 2013;471:1152–8.

    Article  PubMed  Google Scholar 

  28. Tradati D, De Luca P, Maione A, et al. AMIC-autologous matrix-induced chondrogenesis technique in patellar cartilage defects treatment: a retrospective study with a mid-term follow-up. J Clin Med. 2020;9:1184.

    Article  PubMed  PubMed Central  Google Scholar 

  29. von Keudell A, Han R, Bryant T, et al. Autologous chondrocyte implantation to isolated patella cartilage defects. Cartilage. 2017;8:146–54.

    Article  Google Scholar 

  30. Waltenspul M, Suter C, Ackermann J, et al. 2021. Autologous matrix-induced chondrogenesis (AMIC) for isolated retropatellar cartilage lesions: outcome after a follow-up of minimum 2 years. Cartilage:19476035211021908.

  31. Howick JCI, Glasziou P, Greenhalgh T, Carl Heneghan, Liberati A, Moschetti I, Phillips B, Thornton H, Goddard O, Hodgkinson M. 2011. The 2011 Oxford CEBM levels of evidence. Oxford Centre for Evidence-Based Medicine Available at https://www.cebmnet/indexaspx?o=5653.

  32. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372: n71.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Briggs KK, Lysholm J, Tegner Y, et al. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009;37:890–7.

    Article  PubMed  Google Scholar 

  34. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10:150–4.

    Article  PubMed  CAS  Google Scholar 

  35. Higgins LD, Taylor MK, Park D, et al. Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Joint Bone Spine. 2007;74:594–9.

    Article  PubMed  Google Scholar 

  36. Agarwalla A, Liu JN, Garcia GH, et al. 2020. Return to sport following isolated lateral opening wedge distal femoral osteotomy. Cartilage:1947603520924775.

  37. Jones KJ, Kelley BV, Arshi A, et al. Comparative effectiveness of cartilage repair with respect to the minimal clinically important difference. Am J Sports Med. 2019;47:3284–93.

    Article  PubMed  Google Scholar 

  38. Mostafaee N, Negahban H, Shaterzadeh Yazdi MJ, et al. Responsiveness of a Persian version of Knee Injury and Osteoarthritis Outcome Score and Tegner activity scale in athletes with anterior cruciate ligament reconstruction following physiotherapy treatment. Physiother Theory Pract. 2020;36:1019–26.

    Article  PubMed  Google Scholar 

  39. Todd KH, Funk KG, Funk JP, et al. Clinical significance of reported changes in pain severity. Ann Emerg Med. 1996;27:485–9.

    Article  PubMed  CAS  Google Scholar 

  40. Kelly AM. Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Acad Emerg Med. 1998;5:1086–90.

    Article  PubMed  CAS  Google Scholar 

  41. Brittberg M, Lindahl A, Nilsson A, et al. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994;331:889–95.

    Article  PubMed  CAS  Google Scholar 

  42. Driesang IM, Hunziker EB. Delamination rates of tissue flaps used in articular cartilage repair. J Orthop Res. 2000;18:909–11.

    Article  PubMed  CAS  Google Scholar 

  43. Henderson I, Tuy B, Oakes B. Reoperation after autologous chondrocyte implantation. Indications and findings. J Bone Joint Surg Br. 2004;86:205–11.

    Article  PubMed  CAS  Google Scholar 

  44. Kreuz PC, Steinwachs M, Erggelet C, et al. Classification of graft hypertrophy after autologous chondrocyte implantation of full-thickness chondral defects in the knee. Osteoarthr Cartil. 2007;15:1339–47.

    Article  CAS  Google Scholar 

  45. Micheli LJ, Browne JE, Erggelet C, et al. Autologous chondrocyte implantation of the knee: multicenter experience and minimum 3-year follow-up. Clin J Sport Med. 2001;11:223–8.

    Article  PubMed  CAS  Google Scholar 

  46. Zeifang F, Oberle D, Nierhoff C, et al. Autologous chondrocyte implantation using the original periosteum-cover technique versus matrix-associated autologous chondrocyte implantation: a randomized clinical trial. Am J Sports Med. 2010;38:924–33.

    Article  PubMed  Google Scholar 

  47. Niemeyer P, Salzmann G, Feucht M, et al. First-generation versus second-generation autologous chondrocyte implantation for treatment of cartilage defects of the knee: a matched-pair analysis on long-term clinical outcome. Int Orthop. 2014;38:2065–70.

    Article  PubMed  Google Scholar 

  48. Brittberg M. Cell carriers as the next generation of cell therapy for cartilage repair: a review of the matrix-induced autologous chondrocyte implantation procedure. Am J Sports Med. 2010;38:1259–71.

    Article  PubMed  Google Scholar 

  49. Makris EA, Gomoll AH, Malizos KN, et al. Repair and tissue engineering techniques for articular cartilage. Nat Rev Rheumatol. 2015;11:21–34.

    Article  PubMed  CAS  Google Scholar 

  50. Guerrero P, Li X, Patel K, et al. Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study. Sports Med Arthrosc Rehabil Ther Technol. 2009;1:17.

    PubMed  PubMed Central  Google Scholar 

  51. Nomura E, Inoue M, Kurimura M. Chondral and osteochondral injuries associated with acute patellar dislocation. Arthroscopy. 2003;19:717–21.

    Article  PubMed  Google Scholar 

  52. Sanders TG, Paruchuri NB, Zlatkin MB. MRI of osteochondral defects of the lateral femoral condyle: incidence and pattern of injury after transient lateral dislocation of the patella. AJR Am J Roentgenol. 2006;187:1332–7.

    Article  PubMed  Google Scholar 

  53. Potter HG, Linklater JM, Allen AA, et al. Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998;80:1276–84.

    Article  PubMed  CAS  Google Scholar 

  54. Migliorini F, Pilone M, Eschweiler J, et al. High rates of damage to the medial patellofemoral ligament, lateral trochlea, and patellar crest after acute patellar dislocation: magnetic resonance imaging analysis. Arthroscopy. 2022;38:2472–9.

    Article  PubMed  Google Scholar 

  55. Zaidi A, Babyn P, Astori I, et al. MRI of traumatic patellar dislocation in children. Pediatr Radiol. 2006;36:1163–70.

    Article  PubMed  Google Scholar 

  56. Vollnberg B, Koehlitz T, Jung T, et al. Prevalence of cartilage lesions and early osteoarthritis in patients with patellar dislocation. Eur Radiol. 2012;22:2347–56.

    Article  PubMed  Google Scholar 

  57. Paakkala A, Sillanpaa P, Huhtala H, et al. Bone bruise in acute traumatic patellar dislocation: volumetric magnetic resonance imaging analysis with follow-up mean of 12 months. Skelet Radiol. 2010;39:675–82.

    Article  Google Scholar 

  58. Seeley M, Bowman KF, Walsh C, et al. Magnetic resonance imaging of acute patellar dislocation in children: patterns of injury and risk factors for recurrence. J Pediatr Orthop. 2012;32:145–55.

    Article  PubMed  Google Scholar 

  59. Zhang GY, Zheng L, Feng Y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in adults: an MRI evaluation. Injury. 2015;46:2413–21.

    Article  PubMed  Google Scholar 

  60. Zheng L, Shi H, Feng Y, et al. Injury patterns of medial patellofemoral ligament and correlation analysis with articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in children and adolescents: an MRI evaluation. Injury. 2015;46:1137–44.

    Article  PubMed  Google Scholar 

  61. Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella. A correlative pathoanatomic study. Am J Sports Med. 1996;24:52–60.

    Article  PubMed  CAS  Google Scholar 

  62. Nomura E, Inoue M. Second-look arthroscopy of cartilage changes of the patellofemoral joint, especially the patella, following acute and recurrent patellar dislocation. Osteoarthr Cartil. 2005;13:1029–36.

    Article  CAS  Google Scholar 

  63. Saragaglia D, Banihachemi JJ, Refaie R. Acute instability of the patella: is magnetic resonance imaging mandatory? Int Orthop. 2020;44:2299–303.

    Article  PubMed  Google Scholar 

  64. Callewier A, Monsaert A, Lamraski G. Lateral femoral condyle osteochondral fracture combined to patellar dislocation: a case report. Orthop Traumatol Surg Res. 2009;95:85–8.

    Article  PubMed  CAS  Google Scholar 

  65. Maletius W, Lundberg M. Refixation of large chondral fragments on the weight-bearing area of the knee joint: a report of two cases. Arthroscopy. 1994;10:630–3.

    Article  PubMed  CAS  Google Scholar 

  66. Mashoof AA, Scholl MD, Lahav A, et al. Osteochondral injury to the mid-lateral weight-bearing portion of the lateral femoral condyle associated with patella dislocation. Arthroscopy. 2005;21:228–32.

    Article  PubMed  Google Scholar 

  67. Megremis P, Megremis O, Margariti R. Late repair, one year after a knee twisting injury, of a missed femoral trochlea osteochondral fragment, with bioabsorbable nails, in a 14-year-old boy. J Am Acad Orthop Surg Glob Res Rev. 2019;3: e040.

    PubMed  PubMed Central  Google Scholar 

  68. Stanitski CL. Articular hypermobility and chondral injury in patients with acute patellar dislocation. Am J Sports Med. 1995;23:146–50.

    Article  PubMed  CAS  Google Scholar 

  69. Stanitski CL, Paletta GA Jr. Articular cartilage injury with acute patellar dislocation in adolescents. Arthroscopic and radiographic correlation. Am J Sports Med. 1998;26:52–5.

    Article  PubMed  CAS  Google Scholar 

  70. von Engelhardt LV, Raddatz M, Bouillon B, et al. How reliable is MRI in diagnosing cartilaginous lesions in patients with first and recurrent lateral patellar dislocations? BMC Musculoskelet Disord. 2010;11:149.

    Article  Google Scholar 

  71. Fithian DC, Paxton EW, Stone ML, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114–21.

    Article  PubMed  Google Scholar 

  72. Maenpaa H, Lehto MU. Patellar dislocation. The long-term results of nonoperative management in 100 patients. Am J Sports Med. 1997;25:213–7.

    Article  PubMed  CAS  Google Scholar 

  73. Moiz M, Smith N, Smith TO, et al. Clinical outcomes after the nonoperative management of lateral patellar dislocations: a systematic review. Orthop J Sports Med. 2018;6:2325967118766275.

    Article  PubMed  PubMed Central  Google Scholar 

  74. Larsen E, Lauridsen F. Conservative treatment of patellar dislocations. Influence of evident factors on the tendency to redislocation and the therapeutic result. Clin Orthop Relat Res. 1982;171:131–6.

    Article  Google Scholar 

  75. Arendt EA, Askenberger M, Agel J, et al. Risk of redislocation after primary patellar dislocation: a clinical prediction model based on magnetic resonance imaging variables. Am J Sports Med. 2018;46:3385–90.

    Article  PubMed  Google Scholar 

  76. Balcarek P, Oberthur S, Hopfensitz S, et al. Which patellae are likely to redislocate? Knee Surg Sports Traumatol Arthrosc. 2014;22:2308–14.

    Article  PubMed  Google Scholar 

  77. Jaquith BP, Parikh SN. Predictors of recurrent patellar instability in children and adolescents after first-time dislocation. J Pediatr Orthop. 2017;37:484–90.

    Article  PubMed  Google Scholar 

  78. Zhang GY, Ding HY, Li EM, et al. Incidence of second-time lateral patellar dislocation is associated with anatomic factors, age and injury patterns of medial patellofemoral ligament in first-time lateral patellar dislocation: a prospective magnetic resonance imaging study with 5-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2019;27:197–205.

    Article  PubMed  Google Scholar 

  79. Hevesi M, Heidenreich MJ, Camp CL, et al. The recurrent instability of the patella score: a statistically based model for prediction of long-term recurrence risk after first-time dislocation. Arthroscopy. 2019;35:537–43.

    Article  PubMed  Google Scholar 

  80. Christensen TC, Sanders TL, Pareek A, et al. Risk factors and time to recurrent ipsilateral and contralateral patellar dislocations. Am J Sports Med. 2017;45:2105–10.

    Article  PubMed  Google Scholar 

  81. Sillanpaa PJ, Peltola E, Mattila VM, et al. Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow-up study. Am J Sports Med. 2009;37:1513–21.

    Article  PubMed  Google Scholar 

  82. Yeoh CS, Lam KY. Tibial tubercle to trochlear groove distance and index in children with one-time versus recurrent patellar dislocation: a magnetic resonance imaging study. J Orthop Surg (Hong Kong). 2016;24:253–7.

    Article  PubMed  CAS  Google Scholar 

  83. Sanders TL, Pareek A, Hewett TE, et al. High rate of recurrent patellar dislocation in skeletally immature patients: a long-term population-based study. Knee Surg Sports Traumatol Arthrosc. 2018;26:1037–43.

    PubMed  Google Scholar 

  84. Stefancin JJ, Parker RD. First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat Res. 2007;455:93–101.

    Article  PubMed  Google Scholar 

  85. Buchner M, Baudendistel B, Sabo D, et al. Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment. Clin J Sport Med. 2005;15:62–6.

    Article  PubMed  Google Scholar 

  86. Clark D, Metcalfe A, Wogan C, et al. Adolescent patellar instability: current concepts review. Bone Joint J. 2017;99-B:159–70.

    Article  PubMed  CAS  Google Scholar 

  87. Fukushima K, Horaguchi T, Okano T, et al. Patellar dislocation: arthroscopic patellar stabilization with anchor sutures. Arthroscopy. 2004;20:761–4.

    Article  PubMed  Google Scholar 

  88. Hing CB, Smith TO, Donell S, et al. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev. 2011;2:CD008106.

    Google Scholar 

  89. Apostolovic M, Vukomanovic B, Slavkovic N, et al. Acute patellar dislocation in adolescents: operative versus nonoperative treatment. Int Orthop. 2011;35:1483–7.

    Article  PubMed  PubMed Central  Google Scholar 

  90. Bitar AC, Demange MK, D’Elia CO, et al. Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med. 2012;40:114–22.

    Article  PubMed  Google Scholar 

  91. Camanho GL, Viegas Ade C, Bitar AC, et al. Conservative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella. Arthroscopy. 2009;25:620–5.

    Article  PubMed  Google Scholar 

  92. Christiansen SE, Jakobsen BW, Lund B, et al. Isolated repair of the medial patellofemoral ligament in primary dislocation of the patella: a prospective randomized study. Arthroscopy. 2008;24:881–7.

    Article  PubMed  Google Scholar 

  93. Ji G, Wang S, Wang X, et al. Surgical versus nonsurgical treatments of acute primary patellar dislocation with special emphasis on the MPFL injury patterns. J Knee Surg. 2017;30:378–84.

    Article  PubMed  Google Scholar 

  94. Lee HL, Yau WP. Management of traumatic patellar dislocation in a regional hospital in Hong Kong. Hong Kong Med J. 2017;23:122–8.

    PubMed  CAS  Google Scholar 

  95. Petri M, Liodakis E, Hofmeister M, et al. Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial. Arch Orthop Trauma Surg. 2013;133:209–13.

    Article  PubMed  CAS  Google Scholar 

  96. Regalado G, Lintula H, Kokki H, et al. Six-year outcome after non-surgical versus surgical treatment of acute primary patellar dislocation in adolescents: a prospective randomized trial. Knee Surg Sports Traumatol Arthrosc. 2016;24:6–11.

    Article  PubMed  Google Scholar 

  97. Sillanpaa PJ, Mattila VM, Maenpaa H, et al. Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. A prospective randomized study. J Bone Joint Surg Am. 2009;91:263–73.

    Article  PubMed  Google Scholar 

  98. Sillanpaa PJ, Maenpaa HM, Mattila VM, et al. Arthroscopic surgery for primary traumatic patellar dislocation: a prospective, nonrandomized study comparing patients treated with and without acute arthroscopic stabilization with a median 7-year follow-up. Am J Sports Med. 2008;36:2301–9.

    Article  PubMed  Google Scholar 

  99. Migliorini F, Driessen A, Quack V, et al. Surgical versus conservative treatment for first patellofemoral dislocations: a meta-analysis of clinical trials. Eur J Orthop Surg Traumatol. 2020;30:771–80.

    Article  PubMed  Google Scholar 

  100. Vetrano M, Oliva F, Bisicchia S, et al. I.S.Mu.L.T. first-time patellar dislocation guidelines. Muscles Ligaments Tendons J. 2017;7:1–10.

    Article  PubMed  PubMed Central  Google Scholar 

  101. Migliorini F, Marsilio E, Oliva F, et al. Chondral injuries in patients with recurrent patellar dislocation: a systematic review. J Orthop Surg Res. 2022;17:63.

    Article  PubMed  PubMed Central  Google Scholar 

  102. Migliorini F, Marsilio E, Cuozzo F, et al. Chondral and soft tissue injuries associated to acute patellar dislocation: a systematic review. Life (Basel). 2021;11:1360.

    PubMed  Google Scholar 

  103. Malagelada F, Rahbek O, Sahirad C, et al. Results of operative 4-in-1 patella realignment in children with recurrent patella instability. J Orthop. 2018;15:13–7.

    Article  PubMed  Google Scholar 

  104. Katagiri H, Miyatake K, Watanabe T, et al. Validity of intraoperative observation of graft length change pattern for medial patellofemoral ligament reconstruction. J Orthop. 2020;21:131–6.

    Article  PubMed  PubMed Central  Google Scholar 

  105. Hadley CJ, Tucker BS, Lombardi NJ, et al. Combined MPFL reconstruction and tibial tubercle osteotomy for patellar instability: a retrospective review of 23 patients. J Orthop. 2021;28:49–52.

    Article  PubMed  PubMed Central  Google Scholar 

  106. Surendran S. Patellar instability: changing beliefs and current trends. J Orthop. 2014;11:153–6.

    Article  PubMed  PubMed Central  Google Scholar 

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Open Access funding enabled and organized by Projekt DEAL. This research received no external funding.

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Authors and Affiliations

  1. Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany

    Filippo Migliorini, Alice Baroncini, Christian Weber & Frank Hildebrand

  2. Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany

    Filippo Migliorini & Andreas Bell

  3. Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy

    Nicola Maffulli

  4. School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, ST4 7QB, England

    Nicola Maffulli

  5. Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, London, E1 4DG, England

    Nicola Maffulli

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  1. Filippo Migliorini
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FM contributed to literature search, data extraction, methodological quality assessment, statistical analyses, and writing; NM contributed to supervision and revision; AB contributed to literature search, data extraction, methodological quality assessment, and writing; GV, CW, and FH contributed to revision and supervision. All authors have agreed to the final version to be published and agree to be accountable for all aspects of the work.

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Professor Maffulli is the Editor in Chief of the Journal of Orthopaedic Surgery and Research.

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Migliorini, F., Baroncini, A., Bell, A. et al. Surgical strategies for chondral defects of the patellofemoral joint: a systematic review. J Orthop Surg Res 17, 524 (2022). https://doi.org/10.1186/s13018-022-03419-4

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Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X