When is surgery recommended for chondromalacia of the knee?

Surgery for Chondromalacia of the Knee

Surgery is not recommended for chondromalacia of the knee (degenerative knee disease) as conservative management is the preferred first-line treatment with better outcomes for morbidity, mortality, and quality of life. 1, 2

Conservative Management: The First-Line Approach

Conservative management should be implemented for at least 6-8 weeks before considering any surgical intervention:

• Structured exercise therapy focusing on:

  • Quadriceps and hamstring strengthening
  • Range of motion exercises
  • Low-impact aerobic activities 2

• Pain management options:

  • Oral or topical NSAIDs
  • Intra-articular corticosteroid injections (providing short-term relief up to 3 months) 2

• Additional interventions:

  • Weight management
  • Activity modification 2

Evidence Against Arthroscopic Surgery

The BMJ guidelines strongly recommend against arthroscopic knee surgery for degenerative knee disease because:

1. It does not provide clinically meaningful improvements in pain or function compared to conservative management
2. It requires recovery time of 2-6 weeks and time off work
3. It carries surgical risks without demonstrated benefits 1

Limited Exceptions for Surgical Consideration

Surgery should only be considered in very specific circumstances:

• After failing a complete course of conservative management for at least 6-8 weeks
• When symptoms significantly impact quality of life
• In the presence of true mechanical symptoms like locked knee (not just clicking or catching) 2

Outcomes of Different Treatment Approaches

Historical data shows varying outcomes for surgical interventions:

• Arthroscopic chondroplasty showed 78% subjective satisfaction in older studies, but more recent high-quality evidence contradicts these findings 3
• Modified tibial tubercle osteotomy showed 72% good or excellent results in patients who failed conservative management, but this is a more invasive procedure reserved for specific cases 4

Common Pitfalls to Avoid

• Rushing to surgical intervention: Evidence shows conservative management is as effective as surgery for most cases of mild degenerative knee disease 2
• Overreliance on MRI findings: Asymptomatic meniscal tears are common, especially in patients over 35 2
• Inadequate trial of conservative therapy: Ensure at least 6-8 weeks of proper conservative management before considering other interventions 2

Patient Monitoring

Regular assessment of pain levels and functional improvement is necessary to monitor the effectiveness of conservative management. Consider progression of physical therapy as tolerated, with repeat imaging only if symptoms significantly worsen or change in character 2.