What is the recommended treatment for Grade 3 chondromalacia (chondrosis)?

Treatment of Grade 3 Chondrosis (Chondromalacia)

For Grade 3 chondromalacia in adults over 20 years of age, cartilage excision with drilling of the subchondral bone is the recommended surgical treatment, while in adolescents and athletes, patellar tendon transfer should be performed. 1

Initial Management Approach

Conservative Treatment First

• All patients with Grade 3 chondromalacia should undergo a minimum of 6 months of conservative management before considering surgical intervention 2
• Conservative management achieves an 82% success rate in athletes with patellofemoral syndromes, making surgery necessary in only a minority of cases 3
• Conservative therapy includes quadriceps strengthening exercises, activity modification, and anti-inflammatory medications 3

When Conservative Treatment Fails

After 6 months of failed conservative management with persistent patellofemoral pain, arthroscopic evaluation and treatment should be pursued 2

Surgical Treatment Algorithm Based on Patient Age and Grade

For Adolescents and Athletes with Grade III Changes

Patellar tendon transfer (medial transfer) is the procedure of choice, achieving 60% satisfactory results 1

• This approach is specifically indicated for younger, active patients with Grade I, II, or III cartilage changes 1
• Avoid patellectomy in this population as results are significantly worse in patients below 20 years of age 1

For Adults Over 20 Years with Grade III Changes

Cartilage excision combined with drilling of the subchondral bone achieves 35% satisfactory results and is the appropriate initial surgical option 1

• This procedure involves removing damaged cartilage and creating microfractures in the underlying bone to stimulate healing 1

For Grade IV Changes (Any Age)

Patellectomy becomes the treatment of choice when Grade IV changes are present, achieving 77% overall satisfactory results 1

• Primary patellectomy yields 82% satisfactory outcomes compared to 62% when performed after a previously unsuccessful operation 1
• This represents a definitive salvage procedure when cartilage damage is severe 1

Arthroscopic Treatment Options

Arthroscopic Lavage

• Produces early remission across all etiological groups of chondromalacia 2
• Minimal morbidity with this approach 2

Arthroscopic Shaving

• Offers particular advantage in post-traumatic chondromalacia 2
• Can be combined with lavage for enhanced benefit 2

Lateral Release

• Indicated when patellar maltracking is identified as the underlying cause 2
• Lateral release plus shaving and lavage benefits patients with maltracking patellae and approximately half of idiopathic cases 2
• Critical caveat: In patients with unstable patellae, lateral release produces good results in only 25% of cases, making it a poor choice in this subgroup 2

Advanced Cartilage Restoration Techniques

Autologous Chondrocyte Implantation (ACI)

For full-thickness Grade III-IV lesions in carefully selected patients, second-generation ACI with hyaluronan-based scaffolds can be considered 4

• Achieves 91% normal or nearly normal knees at 5-year follow-up 4
• Mean subjective scores improve from 46 to 70 points at 5 years 4
• Important limitation: Patients with multiple and patellar lesions show significant decline in outcomes between 2 and 5 years 4
• This represents a more advanced option for younger patients with isolated lesions 4

Critical Prognostic Factors

Poor Prognostic Indicators

• Age under 20 years, especially in women, correlates with worst outcomes regardless of procedure 1
• Grade IV cartilage changes have significantly worse results than Grade III 1
• Quadriceps weakness after any procedure predisposes to unsatisfactory results 1

Reassuring Long-term Data

• Extensive late radiological degenerative changes in the knee are not typically seen after these procedures 1

Common Pitfalls to Avoid

• Do not perform patellectomy as first-line treatment in adolescents or athletes with Grade III changes - results are poor in this population and patellar tendon transfer is superior 1
• Do not proceed directly to surgery without adequate conservative trial - 82% of athletes respond to conservative management 3
• Do not perform lateral release in patients with patellar instability - only 25% achieve good results 2
• Ensure adequate quadriceps rehabilitation post-operatively, as weakness predicts poor outcomes 1