Does chondromalacia patella require drainage or surgery?

Does Chondromalacia Patella Require Drainage or Surgery?

Chondromalacia patella does not require drainage and should be managed conservatively first, with surgery reserved only for patients who fail an adequate trial of conservative treatment (typically 6 months) and have specific indications based on lesion grade and patient characteristics. 1, 2

Initial Conservative Management (First-Line Treatment)

Conservative treatment should be attempted first in all patients with chondromalacia patella, as it achieves success in approximately 82% of cases. 2 This approach includes:

• Paracetamol (acetaminophen) as the preferred first-line oral analgesic for pain control, though efficacy is uncertain and likely small 1
• NSAIDs when paracetamol is insufficient, recognizing that long-term use carries gastrointestinal and cardiovascular risks 1
• Isometric quadriceps exercises to prevent quadriceps wasting, which predisposes to poor outcomes 3
• Patellofemoral braces for patients with significant impact on ambulation, joint stability, or pain 1
• Kinesiotaping for knee joint involvement 1
• Diagnostic intra-articular anesthetic and steroid injections can serve both diagnostic and therapeutic purposes 4

A minimum 6-month trial of conservative management is recommended before considering surgical intervention. 5

Surgical Indications (When Conservative Treatment Fails)

Surgery is indicated only after failed conservative management and depends on the Outerbridge Classification grade and lesion characteristics:

For Contained, Full-Thickness Defects <4 cm² with Minimal Osteoarthritis:

• Microfracture is the first-line surgical option, involving debridement of friable cartilage, creation of perpendicular edges of healthy cartilage, and creation of 3-4mm deep holes spaced 3-4mm apart in subchondral bone 1
• This technique achieves mean 93% ± 17% fill at second-look arthroscopy with good-quality cartilage 1
• Critical caveat: Microfracture should NOT be performed for partial-thickness patellar chondral delamination with an intact basal layer, as the technique requires exposed subchondral bone 1

For Lesions 2-6 cm²:

• Microfracture remains first-line for acetabular lesions 1
• Mosaicplasty or single-plug osteochondral allograft is considered for femoral head lesions 1

For Lesions >6 cm²:

• Conversion to total hip arthroplasty should be considered in appropriate candidates 1

Historical Surgical Approaches (Based on Grade and Age):

• Arthroscopic lavage and shaving produced early remission in all groups, with particular advantage in post-traumatic cases 5
• Lateral release plus shaving and lavage was beneficial in patients with maltracking patellae 5
• Patellectomy historically achieved 77% satisfactory results overall (82% for primary procedures), recommended for Grade IV changes in adults, though this is now less commonly performed 6

Important Caveats and Pitfalls

• Quadriceps weakness after any procedure predisposes to unsatisfactory results, making preoperative quadriceps function critical 3, 6
• Results are worst in patients below 20 years of age, especially women, and in those with Grade IV changes 6
• 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 1
• Long-term monitoring is essential as chondromalacia may progress to osteoarthritis if not properly managed 1
• Only 8% of patients in prospective studies ultimately required surgical treatment after appropriate conservative management 2

Drainage is Not Indicated

There is no role for drainage in chondromalacia patella management. The condition involves cartilage softening and degeneration, not a fluid collection requiring aspiration. Any effusion present is managed with conservative measures including NSAIDs and activity modification.