What is the treatment for advanced chondromalacia?

Treatment of Advanced Chondromalacia

For advanced chondromalacia that has failed conservative management, surgical intervention with tibial tubercle osteotomy or arthroscopic procedures (shaving, lateral release, lavage) should be pursued, as these provide significant pain relief and functional improvement in 72-82% of patients. 1, 2

Initial Conservative Management (First-Line)

Before considering surgery, a comprehensive 3-6 month trial of conservative treatment is mandatory:

Exercise Therapy

• Semi-squat exercises (closed kinetic chain) are superior to straight leg raises (open kinetic chain) for reducing pain, crepitation, and Q angle while increasing quadriceps strength 3
• Start with 20 exercises twice daily, increasing by 5 repetitions every 2 days 3
• Focus on vastus medialis strengthening, which is the key to successful management 4
• Conservative management achieves 82% success rates when properly implemented 5

Pharmacological Management

• NSAIDs for pain control during the rehabilitation phase 4
• Paracetamol (acetaminophen) can be used as an alternative, though efficacy is uncertain and likely small; use for limited duration only 6
• Tramadol (with or without paracetamol) is an alternative when NSAIDs are contraindicated, though no specific evidence exists for chondromalacia 6

Adjunctive Therapies

• Chondroitin sulfate (800-1200 mg daily) may provide symptomatic relief and has a favorable safety profile compared to long-term NSAIDs 6, 7
• Glucosamine has limited evidence specifically for chondromalacia but is safe with mild adverse effects 7
• Ice application and physical therapy modalities (high-intensity galvanic stimulation, ultrasound) 4

Surgical Management (When Conservative Treatment Fails)

Indications for Surgery

Surgery should be considered when:

• Persistent pain after 6 months of adequate conservative management 1
• Significant functional limitation despite rehabilitation 2
• Failed conservative treatment with documented compliance 5, 2

Surgical Options

Arthroscopic Surgery

Arthroscopic lavage, shaving, and lateral release provide good outcomes with minimal morbidity 1:

• Lavage alone produces early remission in all patient groups 1
• Shaving offers particular advantage in post-traumatic cases 1
• Lateral release plus shaving and lavage is beneficial for maltracking patellae and 50% of idiopathic cases 1
• Results reviewed at 1 and 5 years show sustained benefit 1

Modified Tibial Tubercle Osteotomy (Fulkerson Procedure)

For well-aligned patellofemoral joints with advanced chondromalacia, modified tibial tubercle osteotomy achieves 72% good-to-excellent results at 5-year follow-up 2:

• Mean Kujala knee score improves from 39.2 to 57.7 (p < 0.001) 2
• Visual analogue pain score improves from 7.8 to 5.0 2
• Patients with lowest pre-operative Kujala scores benefit most 2
• Younger patients benefit more than older patients 2
• Outcome is independent of chondromalacia grade 2
• Minimal complications (6% screw removal rate, no major complications) 2

Important Surgical Considerations

• Only 8-18% of patients ultimately require surgery when conservative management is properly implemented 5
• Arthroscopic surgery has minimal morbidity and useful role in management 1
• For unstable patellae, lateral release produces good results in only 25% of patients 1

Common Pitfalls to Avoid

1. Premature surgical intervention: Ensure full 6-month trial of conservative management before surgery 5, 1
2. Inadequate vastus medialis strengthening: This is the cornerstone of conservative treatment success 4
3. Using open kinetic chain exercises: Semi-squat exercises are significantly more effective than straight leg raises 3
4. Expecting surgery to work for unstable patellae: Lateral release has poor outcomes (25% success) in this subgroup 1
5. Overlooking patient age: Older patients have less favorable surgical outcomes 2

Treatment Algorithm

1. Initial presentation: Begin semi-squat exercise program with NSAIDs and consider chondroitin sulfate 3, 4, 7
2. 3-6 month mark: Assess response; 82% should improve with conservative care 5
3. Failed conservative treatment: Proceed to arthroscopy with lavage ± shaving ± lateral release based on etiology 1
4. Persistent symptoms in well-aligned joints: Consider modified tibial tubercle osteotomy, especially in younger patients with severe baseline symptoms 2