What is the recommended treatment for a patient with medial plica syndrome and high-grade chondral fissuring along the medial patellar facet?

Treatment for Medial Plica Syndrome with High-Grade Chondral Fissuring

For patients with medial plica syndrome and high-grade chondral fissuring along the medial patellar facet, arthroscopic resection of the medial plica combined with appropriate treatment of the chondral damage is the recommended treatment when conservative measures fail.

Initial Conservative Management

Conservative treatment should be attempted first for medial plica syndrome, particularly in patients with recent onset of symptoms:

1. Physical Therapy and Exercise Program:

   • Quadriceps strengthening exercises
   • Hamstring stretching (patients commonly have tight hamstrings) 1
   • Activity modification and relative rest

2. Medication:

   • Non-steroidal anti-inflammatory drugs (NSAIDs)

3. Injections:

   • Intra-articular or intraplical corticosteroid injections if initial exercise program fails
   • Studies show 73% of patients may achieve complete relief with intraplical steroid injection 2

4. Adjunctive Therapies:

   • Kinesiology taping in combination with exercise has shown superior outcomes for pain relief and functional improvement compared to exercise alone 3

Indications for Surgical Intervention

Surgery should be considered when:

• Conservative treatment fails after 3-6 months
• Patient has persistent pain and functional limitations
• Evidence of mechanical symptoms (catching, pseudo-locking)
• MRI evidence of pathologic plica with associated chondral damage

Surgical Management

For the Medial Plica:

• Complete arthroscopic excision of the entire pathologic plica 4
• Early intervention is recommended before irreversible changes occur in the femoral condyle articular cartilage 5

For the Chondral Fissuring:

The treatment approach depends on the size and severity of the chondral lesion:

1. For lesions <2 cm²:

   • Microfracture is the first-line treatment 6
   • Debridement of the friable parts using a shaver
   • Freshening of the bed and edges using ringed curets
   • Creation of perpendicular holes 3-4 mm deep in the subchondral bone until bleeding is visualized
   • Holes should be spaced 3-4 mm apart to preserve subchondral bone bridges

2. For lesions 2-6 cm²:

   • Microfracture or suture repair if the chondral flap appears viable 6
   • For delaminated but healthy-appearing cartilage, repair with sutures or fibrin adhesive may be attempted

3. For larger lesions (>6 cm²) or those that fail other treatments:

   • Consider more advanced cartilage restoration techniques
   • Note that evidence for specific techniques is inconclusive 6

Post-Surgical Rehabilitation

Following arthroscopic treatment:

• Structured physical therapy program
• Progressive weight-bearing as tolerated
• Range of motion exercises
• Quadriceps and hamstring strengthening
• Gradual return to activities

Monitoring and Follow-up

• Clinical follow-up to assess symptom resolution
• Consider MRI to evaluate healing of the chondral lesion in patients who remain symptomatic 6
• Long-term monitoring is important as chondral injuries may lead to early osteoarthritis

Important Considerations and Pitfalls

1. Accurate Diagnosis: Medial plica syndrome can be misdiagnosed as meniscal tear or chondromalacia patellae 5

2. Timing of Intervention: Early intervention before irreversible cartilage damage occurs leads to better outcomes 5

3. Complete Plica Excision: During arthroscopy, complete excision of the whole plica should be achieved to prevent recurrence 4

4. Conservative Treatment Response: Young patients with shorter duration of symptoms tend to respond better to conservative treatment 4

5. Chondral Damage Assessment: The extent and location of chondral damage should be carefully evaluated during arthroscopy to guide appropriate treatment

6. Post-treatment Expectations: Patients should be counseled that even with appropriate treatment, some may develop early osteoarthritis due to the pre-existing cartilage damage

The combination of medial plica syndrome with chondral damage requires addressing both pathologies for optimal outcomes and to prevent progressive cartilage deterioration and early osteoarthritis.