Anterior Knee Pain – can it be treated surgically?

The condition of having anterior knee pain - which used to be called 'patellofemoral pain syndrome' - is a very common disorder. The majority of patients can successfully be treated without surgery.

Treatment of your Anterior Knee Pain (AKP) or Patellofemoral Pain (PFP) usually consists of a mixture of physiotherapy-guided quadriceps and hip exercises, core stability training, and eventually foot orthoses, braces and tape. If you are one those unlucky enough to have chronic anterior knee pain and you have done a lot of rehabilitation without improving your problem. Perhaps you have been told to live with your pain by your doctor based on the good model "Functional Envelope" developed by Scott Dye, but in your case you might think that is not the best option. If so you should read more since surgery might be the right option. Eventually follow the debate from the Scandinavian Sports Congress in 2018 and see my presentation on the topic "Anterior Knee Pain - When and how to do surgery?"  HERE.

Surgery for anterior knee pain?

Surgery for anterior knee pain is very complicated and you should look for a surgeon with a special interest in the patellofemoral joint - someone who can examine you competently and correctly interpret your MRI (please see site on MRI since only very few orthopaedic surgeons and radiologist can look for the very special things they are supposed to look at). I normally say that "there is nothing you cannot operate on without risk of making it worse". So be alert and skeptical to what your surgeon might suggest you and eventually get a second opinion from another patellofemoral surgeon - not just a standard orthopaedic surgeon. A solution that is possible is just to live with the pain and reduce your level of activity to a lower level. The knee surgeon, Scott Dye, has for years spoken for the 'functional envelope', and this could be a solution for you.

Possible surgical solutions
  1. Arthroscopic debridement
  2. Arthroscopic plica resection (read here) 
  3. Lateral retinaculum lengthening (or lateral release)
  4. Tibial tubercle medialisation (Fulkerson osteotomy)
  5. Distalisation of the tibial tubercle
  6. Arthroscopic trochleoplasty
  7. ​Lateral patella facetectomy
  8. Femoral rotational osteotomy
  9. Tibial rotational osteotomy
  10. Patellofemoral cartilage restoration
  11. Resection arthroplasty
  12. Patellofemoral arthroplasty
Arthroscopic debridement

Arthroscopic debridement can occasionally be a solution, if the knee is locking or catching and there is no malalignment - meaning that the kneecap is tracking normally in the groove




Chronic anterior knee pain

Back in 1998 we did a follow-up on patients having anterior knee pain and found, that about half of the patients continue to have light pain for many years and about one out of 10 continues to have severe chronic pain. You can download a PDF copy here. These results have been confirmed by several others. For the small group of patients having severe chronic pain, a number of anatomical factors can cause the patella to maltrack or cause the pressure in the patellofemoral joint to increase. These issues can stress the cartilage (chondromalacia patellae) and this can cause inflammation or increased pressure that eventually leads to pain.

Eventually go to Facebook on either trochleoplasty or lars blond + trochleoplasty and read more

Is there a relationship between AKP and patellofemoral arthritis?

With respect to whenever or not the clinical entity called anterior knee pain (AKP) or patellofemoral pain syndrome (PFPS) or chondromalacia patellae leads to arthritis this relationship has now been revealed. It seems that some severely troubled patients end up having arthritis. See the study from Conchie et al. 

http://www.ncbi.nlm.nih.gov/pubmed/27180253

The Scandinavian Congress on Sports Medicine 2018 - take a look at the symposium on anterior knee pain on this youtube video

Lateral retinaculum lengthening

If you are one of those troubled by chronic anterior knee pain it might be that you are having hyperpressure syndrome. This is mostly caused by a tight lateral retinaculum (a kind of ligament that stabilise the patella - see image). 

Tilt of your kneecap

When your retinaculum is tight, this can cause the patella to tilt. Often this tilt can be seen on an MRI scan. A lateral lengthening can in these situations often help to unload the cartilage forces and thereby reduce the pain. You should always undergo an MRI scan to rule out if the tilt is caused by trochlear dysplasia, because doing a lateral release in these cases, there is a risk of making the kneecap unstable, making it subluxate or even dislocate.

The medial and lateral retinacula (singular=retinaculum) help to stabilise the patella

Lateral lengthening technique

Lateral lengthening or release is a name of an operating technique where the outer ligament for the kneecap - which has two layers - is lengthened by the technique you see below, splitting both layers but in different places so that the final result is a lengthening.

Anterior knee pain and tibial tubercle osteotomy

Anterior knee pain can in some cases be helped by unloading the patellofemoral joint via the procedure of transposition of the tibial tubercle (TTT), either medially (Elmslie Trillat osteotomy) or anteriorly (Fulkerson osteotomy) - again depending on the MRI findings. If the tibial tubercle is externally rotated, it can be a good idea to have this corrected.

In some patient anterior knee pain is caused by a high riding kneecap (patella alta) and this can also be corrected by doing a distalisation of the tibial tubercle, ,that is moving it downwards.

Fulkerson Osteotomy
Fulkerson Osteotomy candidate

Here you see light patellofemoral osteoarthritis and patella tilt and patellar overhang. The patient responded well on a Fulkerson Osteotomy and lengthening of the laterale retinaculum

Patella Alta

Patella Alta means a high riding patella. The result is that on bending the knee the kneecap reaches the trochlea groove too late, and the result is increased wear of the cartilage on the rear of the kneecap - this causes pain. The problem can be helped out with a distalisation of the tibial tubercle, efficiently pulling the kneecap down into a better position to engage in the groove at the right time. Read more here

Hoffa Fat Pad Impingement

Hoffa Fat Pad Impingement is a very common explanation for having anterior knee pain. However Hoffas Fat Pad Impingement is not a diagnosis but something seen on MRI. Hoffa Fat Pad Impingement is cause by maltracking of the patella into the trochlear groove and in most circumstances is based upon Patella Alta

Plica Synovialis The parapatellar plica and Infrapatellar plica is closely related to the Hoffa Fat Pad and often the pain is more related to those two plicaes and not the Hoffa. Read a little more about the plicaes here

Fad Pad Impingement - see more here

Corpus Hoffa is seen as orange

References for Hoffa Fat Pad Impingement

1            Matcuk GR, Cen SY, Keyfes V, et al. Superolateral Hoffa fat-pad edema and patellofemoral maltracking: Predictive modeling. Am J Roentgenol 2014;203:207–12.

2            Tsavalas N, Karantanas AH. Suprapatellar fat-pad mass effect: Mri findings and correlation with anterior knee pain. Am J Roentgenol 2013;200:291–6.

3            Widjajahakim R, Roux M, Jarraya M, et al. Relationship of Trochlear Morphology and Patellofemoral Joint Alignment to Superolateral Hoffa Fat Pad Edema on MR Images in Individuals with or at Risk for Osteoarthritis of the Knee: The MOST Study. Radiology 2017;284:806–14.

4            Luyckx T, Didden K, Vandenneucker H, et al. Is there a biomechanical explanation for anterior knee pain in patients with patella alta?: influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg Br 2009;91:344–50.

5            AL-Sayyad MJ, Cameron JC. Functional outcome after tibial tubercle transfer for the painful patella alta. Clin Orthop Relat Res 2002:152–62.

6            Jibri Z, Martin D, Mansour R, et al. The association of infrapatellar fat pad oedema with patellar maltracking: A case-control study. Skeletal Radiol 2012;41:925–31.

Anterior Knee Pain and increased femoral anteversion

A malrotated hip, making the knee go inwards (increased anteversion of the femur) can also lead to anterior knee pain due to increased forces on the joint. It needs to be ruled out by clinical examination and in severe cases by a CT scan or special MRI scan. The malrotation can be corrected by a femoral rotational osteotomy. Beneath you see a figure demonstrating a left femur with severe increased internal rotation, causing the patella to dislocate or maltrack causing pain on the outer site of the kneecap. 

A malrotated hip, making the knee go inwards (increased anteversion of the femur), can also lead to anterior knee pain due to increased forces on the joint. It needs to be ruled out by clinical examination and in severe cases by a CT scan or special MRI scan. The malrotation can be corrected by a femoral rotational osteotomy. Beneath you see a figure demonstrating a left femur with severe increased internal rotation, causing the patella to dislocate or maltrack causing pain on the outer site of the kneecap.

This image is looking up the femur bone, from the knee up to the pelvis. The left femur (to the right of the image) shows that the shaft of the femur is rotated inwards compared to the other side. The this patient responded well on femoral rotation osteotomy.

Arthroscopic trochleoplasty 

Maybe your Anterior knee pain is caused by severe trochlear dysplasia. If you have trochlear dysplasia you are having too much bone in the groove containing the patella. The groove can be flat or dome shaped and consequently this can increase your pressure in the joint. By unloading the joint pressure by an arthroscopic trochleoplasty this can likely reduce the pressure and consequently your anterior knee pain. Please check this paper

Arthroscopic Trochleoplasty

Trochlear Dysplasia 

Before trochleoplasty

Imidiately after trochleoplasty

Left you see a axial view of a 36 year old women. She had severe anterior knee pain for 20 years. During her patellofemoral arthroplasty surgery there were no cartilage left in the patellofemoral joint. If she just have had a trochleoplasty when she was younger, this may have given her 20 years without pain and likely this soulc also have prevented the development of osteoarthritis

Patellofemoral resurfacing prosthesis

The Hemicap wave prosthesis in an inlay type. It is my experience that by reaching the knee from a lateral approach (outer site of the knee cap) you will get fast recovery and there is full weightbearing from day one. The surgery is performed as one day surgery and often you will be able to drive a car safely after 3-4 weeks. Read more here

Patellofemoral prosthesis Hemicap Wave

Below you see the Hemicap Wave prosthesis for severe patellofemoral osteoathritis. I have very good experience using the inlay prosthesis. The surgery is performed by one day surgery and you are allowed free range of movement and full weight bearing from day one.

Patellofemoral osteoarthritis

In cases of symptomatic osteoarthritis in the patellofemoral joint, several options exist. Some patient may have symptoms relief by a lateral lengthening, a lateral patella facetectomy, a TTT or a trochleoplasty or cartilage procedures such as microfracture or autologous cartilage transplantation and finally some patients needs to be treated by a patellofemoral prosthesis. Treatments with stemcells is on the exprimental level and right now we are testing adipose stem cell transplantations.

Anterior Knee Pain and Trochlear Dysplasia and osteoarthritis

In some special selected cases I have done a "Resection Arthrosplasty". This is in cases with severe anterior knee pain, trochlear dysplasia and arthritis. Alternative to a prosthesis, a new groove to the patella is made. Apparently this unloads the patella in such a degree that the pain diminishes significantly. Download the Editorial paper from the KSSTA journal by clicking below.  

Resection Arthroplasty

before

after