What are the treatment options for a patient with advanced chondromalacia (cartilage softening) and loss of the lateral patellar surface with high-grade chondral (cartilage) loss?

Treatment of Advanced Chondromalacia with High-Grade Lateral Patellar Chondral Loss

For advanced chondromalacia with high-grade lateral patellar surface loss, osteochondral autograft transplantation (OAT) is the recommended surgical treatment for young patients (<40 years), while patellectomy should be considered for older adults or those with Grade IV changes who have failed other interventions. 1, 2

Initial Conservative Management

Conservative treatment should be attempted first, though it serves primarily as a temporizing measure and does not address the underlying cartilage defect 3:

• First-line oral analgesic: Acetaminophen (paracetamol) for pain control, though efficacy is uncertain and likely small 4
• NSAIDs: Use when acetaminophen is insufficient, but recognize long-term gastrointestinal and cardiovascular risks 4
• Patellofemoral bracing: Conditionally recommended for significant impact on ambulation, joint stability, or pain 4
• Kinesiotaping: Conditionally recommended for knee joint involvement 4
• Physical therapy: Semi-squat exercises (closed kinetic chain) are significantly more effective than straight leg raise exercises (open kinetic chain) for reducing Q angle, crepitation, and increasing quadriceps strength 5

Conservative management should be attempted for at least 6 months before considering surgical intervention 6.

Surgical Treatment Algorithm Based on Patient Age and Lesion Grade

For Patients <40 Years Old with High-Grade Defects

Osteochondral Autograft Transplantation (OAT/Mosaicplasty) is the preferred treatment 1:

• Indications: Grade IV lesions between 1-2.5 cm² (100-250 mm²) in young patients 1
• Outcomes: At midterm follow-up, mean Kujala score of 90.42 ± 6.7 and WOMAC score of 95 ± 3.6 1
• Graft integration: Median MOCART score of 75 points on MRI, demonstrating good osseous integration and excellent chondral surface filling 1
• Technical considerations: Median of 1 autograft used (range 1-3 plugs) for defects up to 250 mm² 1

This is the only technique that achieves true hyaline cartilage replacement 1.

For Patients >20 Years Old with Grade III-IV Changes

Patellectomy provides the best long-term outcomes 2:

• Success rate: 77% satisfactory results overall, with 82% success for primary patellectomy versus 62% for salvage patellectomy after failed prior surgery 2
• Specific indications: Adults with Grade III changes or any patient (adult or adolescent) with Grade IV changes 2
• Long-term data: Follow-up ranging 2-30 years (average 7 years) shows no extensive late radiological degenerative changes 2

Alternative Surgical Options for Specific Scenarios

Microfracture (for smaller, contained defects) 3:

• Indications: Focal, contained lesions <4 cm² with minimal osteoarthritis 3
• Technique: Debride friable cartilage, create perpendicular edge of healthy cartilage, then create 3-4mm deep holes spaced 3-4mm apart in subchondral bone to bring marrow cells and growth factors into the defect 3
• Outcomes: Mean 93% ± 17% fill at second-look arthroscopy (mean 17 ± 11 months) with good-quality cartilage macroscopically 3

Arthroscopic debridement with lateral release 6:

• Indications: Post-traumatic chondromalacia or maltracking patellae 6
• Outcomes: Lavage produces early remission in all groups; shaving offers particular advantage in post-traumatic cases; lateral release plus shaving beneficial in maltracking patellae 6
• Success rate: Only 25% satisfactory results with shaving alone at long-term follow-up 2

Patellar tendon transfer 2:

• Indications: Adolescents and athletes with Grade I, II, or III changes 2
• Success rate: 60% satisfactory results 2

Critical Prognostic Factors

Negative prognostic indicators 2:

• Age <20 years, especially females
• Grade IV cartilage changes
• Quadriceps weakness after any procedure
• Unstable patellae (lateral release produces good results in only 25% of patients) 6

What NOT to Do

Avoid stem cell injections: The American College of Rheumatology/Arthritis Foundation does not recommend stem cell injections for cartilage regeneration due to concerns regarding heterogeneity and lack of standardization 4.

Monitoring and Follow-Up

Long-term monitoring is essential as chondromalacia may progress to osteoarthritis if not properly managed 4. Regular assessment for symptom recurrence or progression is advised 7.