Abstract. Introduction. To investigate the impact medial opening wedge high tibial osteotomy (MOWHTO) has on the progression of patellofemoral OA, patella height and contact pressure within the patellofemoral joint (PF). Methods. A systematic review was conducted in January 2022 according to PRISMA guidelines. Each study was graded as per the MINORS criteria for non-randomised trials. The ICRS cartilage grade of the PF joint at the initial MOWHTO surgery and at second look surgery was compared and relative risk of progression of PF OA was calculated. Evaluation of patella height was assessed by Caton-Deschamps index, Blackburne-Peel index or Insall-Salvati ratio pre and post MOWHTO. Cadaveric studies assessing contact pressures in the PF after MOWHTO were included. Results. Forty-two studies comparing 2,419 patients were included. The mean age was 53.1 years (16–84), 61.3% female. The risk of progression of PF OA was highest in the uniplanar and biplanar MOWHTO with proximal tubercle osteotomy groups (RR= 1.28-1.51, I2= 0%), compared to biplanar MOHWTO with distal tubercle osteotomy (RR= 0.96-1.04, I2 = 0%). Patella height was not affected after biplanar MOWHTO and distal tubercle osteotomy. (P<0.001). Cadaveric studies demonstrate that PF contact pressures increase with more severe corrections (10°) but suggest biplanar MWOHTO and distal tubercle osteotomy induces lower contact pressures within the PF joint than other OWHTO techniques. Conclusion. This novel systematic review demonstrates that biplanar MOWHTO and distal tubercle osteotomy causes lower contact pressures in the PF joint, less severe progression of PF OA and has minimal impact on patella height

Abstract. Introduction. Isolated patellofemoral joint(PFJ) osteoarthritis affects approximately 10% of patients aged over 40 years and treatment remains controversial. Our aim was to evaluate long term functional and radiological outcomes following PFJ arthorplasty with the Femoro Patella Vialli (FPV) prosthesis as this evidence is lacking in literature. Methodology. A retrospective review of prospectively collected PROMS in patients undergoing Patellofemoral arthroplasty. Single centre trial. Between 2004 and 2008, 101 FPV patellofemoral arthroplasties were performed in 80 patients with isolated patellofemoral joint osteoarthritis. Data was collected as a part of routine follow-up for up to 6 years and additional long term data was collected at 16 years. Results. At 6 year follow up the mean OKS was 29 and by 16 year follow up it was 26 which was not a statistically significant drop. 22 patients (29 knees) had died, 32 (32%) had been revised, 25 to total knee replacement using primary arthroplasty components. Mean OKS in the revised group was 27 which was not a statistically significant difference when compared to the unrevised group. Mean time to revision was 4 years. The cumulative survival analysis of the FPV implant was 76% at 5 years, 64% at 10 years. Conclusion. Our findings suggest the FPV patellofemoral prosthesis provides good pain relief and clinical outcomes however, the survivorship for this particular implant maybe lower as compared to the available literature. Patient reported outcomes are maintained over the implant life and are no worse once revised implying a staged approach to arthroplasty is reasonable

Complications involving the patellofemoral joint are a source of anterior knee pain, instability, and dysfunction following total knee arthroplasty. “Overstuffing” the patello-femoral joint refers to an increase in the thickness of the patellofemoral joint after a total knee replacement compared to the preoperative thickness. While biomechanical studies have indicated that overstuffing the patellofemoral joint may lead to adverse clinical outcomes, limited clinical evidence exists to support this notion. The purpose of this study is to evaluate the effect of changing the thickness of the patellafemoral joint on functional outcomes following total knee arthroplasty. Our institutional arthroplasty database was used to identify 1347 patients who underwent a primary total knee arthroplasty between 2006 and 2012 with the same component design. Standard preoperative and postoperative anteroposterior, lateral, and skyline radiographs were collected and measured for patello-femoral overstuffing. These measurements included anterior patellar displacement, anterior femoral offset, and anteroposterior femoral size. These measurements were correlated with patient outcome data using WOMAC, KSS scores, and postoperative range of motion. Multiple linear regression analysis was used to assess the association between stuffing and functional outcomes. A total of 1031 patients who underwent total knee arthroplasty were included. Increased anterior patellar displacement, a measure of patellofemoral joint thickness, was associated with decreased WOMAC scores (p=0.02). Anterior femoral offset (p=0.210) and anteroposterior femoral size (p=0.091) were not significantly associated with patient functional outcomes. Postoperative range of motion (ROM) was not associated with patellofemoral stuffing (p=0.190). The current study demonstrated that functional outcomes are adversely affected by patellofemoral overstuffing. Based on these results, caution is encouraged against increasing the thickness of the patellofemoral joint, particularly on the patellar side of the joint

Abstract. Introduction. Isolated patellofemoral osteoarthritis accounts for 10% of knee osteoarthritis. Many of these will not require arthroplasty solutions, but for those who are sufficiently symptomatic, patellofemoral joint (PFJ) replacement has been shown to be an effective procedure. The National Joint Registry (NJR) has shown a higher revision rate for this operation, particularly in younger patients (males <55 years 13.3% failure at 5 years, females 9.6%). The aim of this study is to report on the medium-term outcome of the Avon patellofemoral joint arthroplasty in patients under 55 from a non-design centre. There is no other published case series on this young patient cohort. Methodology. 50 Avon PFJ replacements (Stryker, Kalamazoo USA) were undertaken in 46 patients under 55 years old (range 35 – 54, mean 48.8) between 2010 and 2022 for end-stage isolated PFJ arthritis shown on Xray and MRI scan. The outcome measure was all-cause revision rate. This was assessed by review of clinical notes, imaging and NJR data. Results. The mean follow up was 5.8 years (range 6 months to 12.9 years). Only one patient had a revision procedure (for progressive osteoarthritis) which was 3 years after the primary procedure. This patient has had no further surgery. The implant survival rate was 97.2% at 5 years and 97.2% at 10 years. Conclusion. This study shows that patellofemoral joint replacement with the Avon prosthesis can give a satisfactory revision rate in the medium term in patients under 55 if carefully selected

Introduction. Experimental wear simulation of an all-polymer knee implant has shown an equivalent rate of wear of UHMWPE tibial components against PEEK-OPTIMA™ and cobalt chrome femoral components of a similar initial geometry and surface topography. However, when the patella is resurfaced with an UHMWPE patella button, it is important to also ascertain the wear of the patella. Wear debris from the patella contributes to the total volume of wear debris produced by the implant which should be minimised to reduce the potential for osteolysis and subsequent implant loosening. The aim of this study was to investigate the wear of the patellofemoral joint in an all-polymer knee implant. The wear of UHMWPE patellae articulating against PEEK-OPTIMA™ femoral components was compared to UHMWPE articulating against cobalt chrome femoral components. Materials and Methods. Six mid-size (size C) PEEK-OPTIMA™ femoral components (Invibio Knee Ltd., UK) and six cobalt chrome femoral components of similar initial surface topography and geometry were coupled with 28mm all-polyethylene GUR1020 patellae (conventional, EO sterile) (Maxx Orthopaedics, USA). The implants were set up in a ProSim 6 station electromechanical knee simulator (Simulation Solutions, UK) which was modified for testing the patellofemoral joint. 3 million cycles (MC) of wear simulation was carried out under kinematics aiming to replicate a gait cycle adapted for an electromechanical simulator from previous work by Maiti et al. The simulator used has six degrees of freedom of which four were controlled; axial force up to 1200N, flexion/extension 22°, superior-inferior (SI) displacement (22mm) and Abduction-adduction (AA) (4°). The SI and AA were displacement controlled and driven through the patella. The medial-lateral displacement and tilt (internal/external rotation) of the patella were passive so the patella button was free to track the trochlear groove. The lubricant used was 25% bovine serum supplemented with 0.03% sodium azide to retard bacterial growth. The wear of patellae was determined gravimetrically with unloaded soak controls used to compensate for the uptake of moisture by the UHMWPE. The mean wear rate ± 95% confidence limits were calculated and statistical analysis was carried out using ANOVA with significance taken at p<0.05. Results. The mean wear rates of the UHMWPE patellae were 0.26±0.21 mm. 3. /MC and 0.35±0.17 mm. 3. /MC against PEEK-OPTIMA™ and cobalt chrome femoral components respectively. There was no significant difference in wear rate against the different femoral component materials (P=0.38). Against both femoral component materials, a ‘bow tie’ shaped wear scar was evident on the patellae typical of that seen in retrieval studies and reported in previous experimental wear simulation of the patellofemoral joint. Conclusion. The wear rate of the UHMWPE patellae was low against both PEEK-OPTIMA™ and cobalt chrome femoral components and comparable to previous work by Vanbiervliet et al. This study further shows that in terms of its wear performance, PEEK-OPTIMA™ has promise as an alternative bearing material to cobalt chrome in the femoral component of total knee replacements

Introduction: The normal relationships of the patellofemoral joint provide a basis for the evaluation of patients with patellofemoral abnormalities. Previous studies have often described the patellofemoral joint using X-rays which are encumbered with projectional inaccuracies. We have used CT to describe the geometry of this joint and its relationship to the tibiofemoral joint in terms of angles and distances. Materials and method: 33 patients had a CT scan prior to medial unicompartmental knee replacement. These patients have minimum patellofemoral joint disease. Special software was used to convert the scans to 3D and measure the distances and angles. The flexion axis of the tibiofemoral joint was found as the line connecting the centres of the spheres fitted to posterior femoral condyles. These two centres and femoral head centre form a frame of reference for reproducible femoral alignment. The trochlear geometry was defined by fitting circles and spheres to slices and surfaces, then constructing an axis through their centres. The geometry of the patella was established by fitting two planes to the proximal and anterior extra-articular surfaces of the patella. The relationships between these planes and the rest of the patella were explored. Results: The deepest points on the trochlear groove can be fitted to a circle with radius of 23mm (stdev 4mm) and an rms of 0.3mm. This centre is offset by 21mm (stdev 3mm) at an angle of 68° (stdev 8°) from the line connecting the midpoint between the centres of the femoral condyles and a point in the piriform fossa. On either end of this line, the articular surface of the trochlea can be fitted to spheres of radius 30mm (stdev 6mm) laterally and 27mm (stdev 5mm) and an rms of 0.4mm medially. The centres of the circle and the two spheres fall on a line with an rms of 1.1mm. The anterior and proximal patellar planes could be described as flat surfaces (rms of 0.4 and 0.3mm). The median ridge could be described as a straight line (rms of 0.2mm). The angle between planes was 112° (stdev 5°); the average angle between the proximal plane and the line on the medial ridge was 62° (stdev4°). The functional centre of the patella was defined as a point in the centre of 2 planes orthogonal to the sagital plane from the midpoint between the most proximal and most distal points on the median ridge. The length, width and thickness of the patellae were measured at 22mm +/−4mm, 47mm +/− 3mm and 24 mm+/− 2 mm. Discussion: This investigation has allowed us to characterise the patello-femoral joint geometry. The knowledge of the shapes of the surfaces of this joint and their relationships may help identify and explain the aetiology of patello-femoral dyplasia and other pathologies. It may also be of use in planning and performing joint reconstruction and may have implications for the design of patello-femoral replacements and the rules governing their position

Background. Despite the excellent clinical success of total knee arthroplasty (TAK), controversy remains concerning whether or not to resurface the patella. This has led to a number of randomized controlled trials. Randomized controlled trials constitute the most reliable source of evidence for the evaluation of the efficacy of a potential intervention. But most of these studies include all degree of osteoarthritis of the patellofemoral joint. So we did this prospective study to compare clinical and radiological outcomes after TKA with or without patellar resurfacing in patients with grade IV osteoarthritis on patellofemoral joint. Materials and Methods. 123 cases (93 patients) with Kellgren-Lawrence grade IV osteoarthritis on patellofemoral joint were enrolled for this study. At the operating room, they were randomly assigned to undergo patella resurfacing (62 cases) or patella retention (61 cases). Among them, 114 cases that could be followed for more than 2 years were included in this study (resurfacing group; 59 cases, retention group; 55 cases). When patellar retention was performed, osteophytes of the patella were removed and marginal electrocauterization was carried out. Preoperative and postoperative clinical outcomes were evaluated and compared regarding the Hospital for Special Surgery Patellar (HSSP) score (total 100 point; anterior knee pain, functional limitation, tenderness, crepitus, Q-strength). We also compared Hospital for Special Surgery (HSS) and WOMAC scores, and range of motion (ROM). We also compared radiological outcomes at the final follow up, with regards to mechanical axis of the lower limb, patella tilt and patella congruence angle between two groups. Results. Average HSSP score was 85 in resurfacing group, 83 in retention group, which were showing no significant differences between groups (p=.75). Anterior knee pain subscale also showed no significant differences between groups (40 in resurfacing group, 36 in retention group, p= 0.52). HSS score improved to 94 points in resurfacing group and 95 points in retention group showing no significant difference (p=.92). While WOMAC score and range of motion was 32 point and 128°±10.5° in resurfacing group, respectively, they were 29 point and 126°±11.5° in retention group, without significant inter-group difference (p>.05). There were no differences between two groups in mechanical axis of the lower limb and patella tilt, patella congruence (p>0.05). Conclusion. Clinical and radiological outcomes were ‘good’ after TKA with or without patellar resurfacing in patients with high grade osteoarthritis of the patellofemoral joint without significant differences. Thus, this study suggested that TKA without patellar resurfacing is a good treatment option in patients with high grade osteoarthritis of the patellofemoral joint

Abstract. INTRODUCTION. 10% of patients with knee osteoarthritis (OA) have disease confined to the patellofemoral joint (PFJ). The main surgical options are total knee replacement (TKR) and PFJ replacement (PFJR). PFJR has advantages over TKR, including being less invasive, bone preserving, allowing faster recovery and better function and more ‘straight forward’ revision surgery. We aim to compare the clinical results of revised PFJR with primary TKR taking into consideration the survival length of the PFJR. METHODOLOGY. Twenty-five patients (21 female) were retrospectively identified from our arthroplasty database who had undergone revision from PFJR to TKR (2006–2019). These patients were then matched with regards to their age at their primary procedure, sex and total arthroplasty life (primary PFJ survival + Revision PFJ time to follow up) up to point of follow-up with a group of primary TKRs implanted at the same point as the primary PFJR. RESULTS. Mean survival of the PFJs revised were 4.2 years. In the PFJR revision group (mean arthroplasty life 7.8 years) mean Oxford knee score (OKS) at latest follow up was 27.8. In the primary knee group (mean arthroplasty life 7.5 years) mean OKS was 32.4. This difference was not statistically significant. All PFJR revisions were performed using primary prostheses. CONCLUSION. PFJR provides comparable clinical outcome even after revision surgery to TKR as primary TKRs at midterm follow up and should be considered in all patients meeting the selection criteria. Given comparable proms and straight forward revisions, staged arthroplasty to preserve bone-stock is a reasonable choice

We report the results of patellofemoral joint replacement done at our institution for predominantly patellofemoral arthritis. Patellofemoral joint replacement has always been a controversial subject, particularly in elderly patients where a more predictable result can be obtained with TKA. Patellofemoral joint replacement surgery was commenced at our institute in 2002 using the Avon design (Stryker corp, UK,) pioneered at the Avon Orthopaedic centre, Southmead, Bristol, UK. We report retrospective analysis of 43 consecutive Patellofemoral replacements done in 39 patients between 2002 and 2006, with a minimum of 6 months follow-up. 38 patients (5 bilateral) were available for review while 1 patient died 3 years after the operation following unrelated causes. They were all assessed clinically and radiologically on the last follow up. Follow-up ranged from 6 to 56 months, average being 21 months. Females outnumbered males by 3:1. All patients were scored pre and postoperatively using Melbourne Knee scoring system (Bartlett et al) and Knee Functional Score. The average Melbourne Knee score increased from 10 to 25 postoperatively, while the knee functional score increased from 57 to 85. Postoperative flexion ranged from 100–140°, average being 116°. Commonest complication was clicking (17%), half of which resolved by arthroscopic lateral release. 87% patients graded the result as excellent or good, while 2% (1 patient) rated it as poor. 59% patients had radiologically proven early tibiofemoral arthritis preoperatively, out of which progression was noted in 28% at the last follow-up. No complications related to deep infection or loosening were noted, and one knee needed revision on account of progression of lateral compartment arthritis. With revision as the end point, the survivorship was 97.7% at average of 2 years after surgery

To assess the clinical outcomes of patients undergoing ACI in the patellofemoral joint. Level of evidence. Therapeutic study, Level II-1 (prospective cohort study). In a prospective study to determine the clinical effectiveness of autologous chondrocyte implantation 130 patients reached a minimum follow up of two years (range, 2–9 years, average 56.5 months) after treatment involving the patellofemoral articulation. There were 77 men (59%) and 53 women (41%) with an average age of 37.5 years (range, 15-57years). The treatment groups included I) isolated patella, n = 14; II) isolated trochlea, n = 15; III) patella plus trochlea, n = 5; IV) weight bearing condyle plus patella n = 19; V) weight bearing condyle plus trochlea, n = 52; VI) weight bearing condyle plus patella plus trochlea n = 25. The average surface area per patella, n = 63, was 4.72 cm2 and per trochlea, n = 98, was 5.8cm2. The average resurfacing per knee, n = 130, was 11.03cm2. This prospective outcome study demonstrated a significant postoperative improvement in quality of life as measured by the SF-36; WOMAC, Knee Society Score, modified Cincinnati Score and a patient satisfaction survey. There were 16 failures (12%) as a result of a patella or trochlea failure. Eighty percent of patients rated their outcomes as good or excellent, 18% rated outcome as fair, and 2% rated outcome as poor. ACI is effective in the patellofemoral joint and specifically is a complementary intervention for those patients that will predictably do poorly with an isolated Fulkerson Tibial Tubercle osteotomy

We report our experience with LCS Patellofemoral joint replacement. Between September 2003 and November 2007, 66 consecutive patients were reviewed retrospectively who underwent LCS patellofemoral joint replacement. There were 13 males and 51 females with a mean age of 61.6 years (range 43–78). The average follow-up was 22 months (range 11–51 months). To assess the outcome, revision for any cause was taken as the end point for this study. A total of 14 (21.2%) revision operations were carried out at an average of 15.6 months (range 8–29 months) from the initial operation. The reasons for revision were mal-tracking of patella (3), dislocated patellar button (2), persistent unexplained pain (5) and progression of arthritis (4). Amongst the remaining 52 patients, 8 are still experiencing pain and not entirely satisfied with the procedure. 42 patients (63%) have a satisfactory outcome so far. All of them who underwent revision to a total knee replacement were satisfied with their outcome with relief in their symptoms. Revision to a total knee replacement is not a straightforward procedure, especially removing the metal backed patellar component. The revision rate of over 21% is unacceptably high to recommend the procedure as a routine. Based on our experience, we conclude that LCS patellofemoral replacement should be used with caution

Introduction. Anterior knee pain following total knee arthroplasty continues to be prevalent and may result from abnormal loading of the patellofemoral joint. The kinematics and biomechanics of the patellofemoral joint are complex, and trochlear design likely plays a principle role in affecting patellofemoral contact. As such, understanding the implications of trochlear design on patellofemoral contact remains important. The goal of the present study was to characterize trochlear wear of retrieved femoral components, which may help elucidate the details regarding patellofemoral kinematics and contact properties in relation to design features. Materials and Methods. Retrieved femoral components featuring a single design (cobalt-chrome, posterior stabilized, cemented components with fixed bearing design) were included in the study. Components were selected based on similar time-in-vivo, age, and BMI. The trochlea of femoral components was consistently divided into six equal zones. Trochlear wear and surface damage in each zone were assessed using visual inspection under low-magnification light microscopy and light profilometry. Results. Ten implants were selected and were used for the topographical analysis. The implants were selected based on time-in-vivo (33.6 months±18), BMI (40.4 kg/m. 2. ±13.2), patient age (67.9 years old±13.3) and gender (6 males, 4 females). Revision diagnosis across the implants were infection (n=6), instability (n=2), loosening (n=1), and fracture (n=1). All zones of the trochlea of retrieved femoral components showed evidence of wear on visual assessment, however, surface profilometry showed that the amount of wear in the retrieved components was not significantly different from a new, unused reference component (p>0.05). In fact, surface skeweness was higher in the new component (p=0.026). Modes of wear included scratches (100%), striations (65%), pitting (43%), and delamination (13%). Zone 1, which includes the raised lateral flange, tended to have more damage than the other zones, but this was statistically non-significant (p=0.634). No significant differences were found between the remaining trochlear zones with respect to wear based on visual assessment and light-microscopy (p=0.634) or surface profilometry (p=0.469). No significant differences were found with between proximal and distal wear (p>0.05) as well as medial and lateral trochlear wear (p>0.05). Conclusions. Femoral components exhibit trochlear wear after in-vivo use. The amount of wear, however, is not substantially different from its new state and may represent early polishing. While the raised lateral flange zone trended towards greater wear than other zones, this was not statistically significant. Overall, with modern trochlear design, there was no evidence of asymmetric or abnormal loading of the trochlea. Longer term retrieval studies are required to assess patterns of femoral component wear and determine the clinical correlation of these findings

The aim of this study was to document the thickness of the patellofemoral joint before and after unicompart-mental joint replacement and to correlate these data with knee outcome scores. Seventeen patients (22 knees) who underwent Patello-femoral replacement with FPV (Wright Medical) prosthesis between 2006 and 2008 were identified retrospectively and analyzed using chart and radiological review. Oxford and AKSS knee scores were gathered prospectively pre-operative and at follow-up. Trochlear height was measured using lateral radiograph of the knee by measuring the distance between anterior distal femoral cortex and the highest point of trochlea. Trochlear height was compared pre and postoperatively. The range of movement and the Oxford and American knee society knee scores at six weeks postoperatively were noted. Association between increased trochlear height and improved range of motion was studied. All but two patients regained full knee extension. Postoperative mean range of flexion of the knee joint was 114 degrees. The mean Oxford knee score at 6 weeks postoperatively was 21 points. The mean American Knee Society Knee Score was 85 points and function score 60 points. We found the average trochlear height to be 6.2 mms pre and 9.7 mms post operatively with an average increase of 3.5 mms. We found no relationship between range of motion of the knee and knee function and trochlear height. This is important because there has been concern that ‘overstuffing’ of the patellofemoral joint can lead to stiffness and failure of resolution of pain post-operatively. Rather it appears that the FPV prosthesis restores the previous anatomical thickness of this compartment. We conclude that FPV Patello-femoral replacement results in correct anatomical reconstruction of the trochlear height. This should in turn result in durable improvements in pain and function

Materials and Methods: The institution’s prospective database of unicompartmental knee replacements was reviewed for all Oxford Phase III Unicompartmental Knee Replacement (Biomet, UK) undertaken from January 2004 to July 2007. This identified a total of 645 procedures undertaken. We included all cases where there was pre-operative skyline radiographs and American Knee Scores, Oxford Knee Score and SF-12 data, in addition to skyline radiographs, OKS and SF-12 data with a minimum of 2 years follow-up. All patients without this baseline and follow-up data were excluded. This provided a total of 196 knees (162 patients). Using Altman’s nomogram, the sample size was calculated to be 85 for a power of 90%, with an α significance level of 0.05. Using this database, digital radiographs were assessed using the institution’s PACS system. Pre-operative and follow-up skyline radiographs following Jones et al’s (1993) patellofemoral scoring system were examined by four assessors utilising Jones’ patellofemoral scoring system. In addition, in cases where patellofemoral joint changes were evident, each assessor acknowledged whether this involved the medial, lateral or bilateral aspects of the patellofemoral joint. Intra-observer reliability was made comparing the four assessors. Statistical analysis was performed, using the Statistical Package for the Social Sciences (SPSS) 16.0 for Windows (SPSS Inc, Chicago, Illinois). In order to determine whether changes in patellofemoral joint status related to patients function or quality of life, the difference in OKS and SF-12 from pre-operative to the follow-up period was assessed. Results: There was a statistically significant progression of patellofemoral osteoarthritis as found on the preoperative and postoperative radiographs (p< 0.01, Mann Whitney), there was a correlation between a low OKS and Jones patellofemoral score (P< 0.05, Mann-Whitney). However, there was no correlation between the site of patellofemoral involvement and outcome scores. Conclusion: Due consideration should be taken when offering medial unicompartmental knee replacement to patients with patellofemoral involvement and this is independent of the site of patellofemoral involvement

From September 1995 to March 2003, 15 patellofemoral joint replacements were done on 13 patients. The mean age of the one man and 12 women was 62 years. Osteoarthritis was the reason for surgery in 13 of the 15 knees. In the other two it was post-traumatic arthritis. Three different products were used: Avon (eight), Link Lubinus (five) and LCS patellofemoral prostheses (two). One patient has subsequently been revised to a total knee replacement. Recommendations are made regarding selection of patients and implants

Aim: The aim of this study was to asses the accuracy of skyline radiographs in the assessment of the patellofemoral joint, when compared to open intraoperative assessment. Methods: Eighty nine patients undergoing knee replacement surgery were included in the study. Skyline radiographs were obtained preoperatively. These radiographs were assessed and graded by an experienced musculoskeletal radiologist using the Altman and Ahlbäck classifications. The grades were calculated for both the medial and lateral facets of the PFJ. Intraoperative assessment of the Patellofemoral joint was undertaken at the time of surgery. The damage was graded using the modified Collins classification (0: Normal, 1: Superficial damage, 2: Partial thickness cartilage loss, 3: Focal Full thickness cartilage loss < 2cm2, 4: Extensive full thickness cartilage loss < 2cm2). Data was obtained for the Medial Facet, Lateral Facet and Trochlea. Results: Spearman’s rank correlation coefficient between the radiographic and macroscopic changes within the lateral PFJ were poor with both the Altman 0.22 (p=0.0350) and Ahlbäck 0.24 (p=0.018). The correlation of the medial PFJ was slightly better with a coefficient for Altman 0.42 (P< 0.0001) and Ahlbäck 0.34 (P> 0.001). Conclusion: In conclusion skyline radiographs provide a poor to moderate preoperative assessment of the degree of osteoarthritis within the patella-femoral joint. This has significant implications for establishing radiographic criteria for planning patella-femoral joint replacement

In some regions in Asia or Arab, there are lifestyles without chair or bed and sitting down on a floor directly, by flexing their knee deeply. However, there are little data about the joint angles, muscle forces or joint loads at such sitting postures or descending to and rising from the posture. In this study, we report the knee joint force and the muscle forces of lower limb at deep squatting and kneeling postures. The model to estimate the forces were constructed as 2D on sagittal plane. Floor reacting force, gravity forces and thigh-calf contact force were considered as external forces. And as the muscle, rectus and vastus femoris, hamstrings, gluteus maximus, gastrocnemius and soleus were taken into the model. The rectus and vastus were connected to the tibia with patella and patella tendon. First the muscle forces were calculated by the moment equilibrium conditions around hip, knee and ankle joint, and then the knee joint force was calculated by the force equilibrium conditions at tibia and patella. For measuring the acting point of the floor reacting force, thigh-calf contact force and joint angles during the objective posture, we performed the experiments. The postures to be subjected were heel-contact squatting (HCS), heel-rise squatting (HRS), kneeling and seiza (Japanese sedentary kneeling), as shown in the Fig.1. The test subjects were ten healthy male, and the average height was 1.71[m], weight was 66.1[kgf] and age was 21.5[years]. The thigh-calf contact force and its acting point were measured by settling the pressure distribution sensor sheet between thigh and calf. Results were normalized by body weight, and shown in Fig.1. The thigh-calf contact force was the largest at the heel-rise squatting posture (1.16BW), and the smallest at heel-contact squatting (0.60BW). The patellofemoral and the tibiofemoral joint forces were shown in the figure. Both forces were the largest at the heel-contact squatting, and were the smallest at the seiza posture. And it might be estimated that the thigh-calf contact force acted anterior when the ankle joint dorsiflexed, and the force was larger when the hip joint extended. The thigh-calf contact force might be decided by not only the knee joint angle but also the hip and ankle joints. As a limitation of this study, we should mention about the effect of the neglected soft tissues. It could be considerable that the compressive internal force of the soft tissues behind a knee joint substance the tibiofemoral force, and then the real tibiofemoral force might be smaller than the calculated values in this study. Then, the tensile force of quadriceps also might be smaller, and then the patellofemoral joint force is also small

Patellofemoral complications in total knee arthroplasty (TKA) are common. Patellar tracking can be adversely affected by component positioning, soft tissue imbalance and bony deformity. Lateral patellar release rates reported in the literature vary from 6– 40%. Computer assisted surgery has largely been confined to the tibio-femoral component of total knee replacement. However, with recently developed software, it can be used to visualise and quantify patellar tracking and thus guide the precise extent and site of lateral patellar release. The aim of this early study was to define the diagnostic envelope for identification and quantisation of patella maltracking using a current generation patella navigation system. Our previous prospective analysis of 100 patients undergoing primary TKA identified pre-operative radiographic indices that correlate with maltracking of the patellofemoral joint. 20 cases were subsequently selected for computer assisted total knee replacement surgery. The navigation system (Vector Vision (BrainLab) version 1.6) was used to achieve accurate alignment and position of the femoral and tibial components. All knee replacements were performed using a posterior cruciate-retaining prosthesis. The femoral component was of a ‘patella-friendly’ design with inbuilt 3 degrees external rotation, and the patella was resurfaced in all cases with a biconvex inlay patellar prosthesis. Patellar tracking was assessed intra-operatively using an additional patellar array and patella tracking-specific software. Real-time displays of patella shift, tilt, rotation and circle radii during multiple flexion-extension cycles were obtained. Where necessary, an ‘outside-to-in’ release of the lateral retinacular complex was performed. The navigation system was used to provide contemporaneous feedback on the effect of the soft tissue releases on the tracking characteristics of the patella component on the prosthetic trochlea. Primary outcomes included the sensitivity and specificity of the system for peri-operative patella maltracking; secondary outcomes included the definition of interventional endpoints and correlation of intra-operative tracking data with post-operative x-rays. The demographic data for the 20 patients enrolled in this study was essentially unremarkable. As compared to standard intra-operative clinical evaluation of patella tracking, the computer navigation system is equally sensitive and specific, and it can potentially detect more subtle instances of maltracking that may elude conventional clinical evaluation. We present patterns of patellar tracking during the surgery for patient with and without pre-operative patellar maltracking. However, the significance of this is unknown without longer-term outcome data. Patella shift abnormalities that were detected by the system, but not tilt, correlated with clinical judgement of patella maltracking (p< 0.05). Soft tissue balancing of the patella can now be performed by observing precise changes in shift and tilt. This can be as important as component alignment for optimising patellar tracking and minimising patellofemoral complications

Since 1987, autologous chondrocyte implantation (ACI) has been performed in Gothenburg, Sweden in more than 1600 patients. Out of the first 442 patients operated with ACI, 153 (35%) had patella lesions and 91 (21%) had trochlea lesions. Forty two patients (9.5%) had kissing lesions of the patellofemoral joint. The aim of the study was to evaluate the current clinical status of operated patients. Lysholm and Tegner-Wallgren self-assessment questionnaires were used. The patients were requested to compare their current status to previous states and to report whether they would do the operation again. Concomitant realignment procedures of the patellofemoral joint were also recorded and preoperative scores were also assessed from the medical files. Patients were divided into groups according to the location of lesion. All the groups showed a significant improvement compared with the preoperative assessment. Over 90% of the treated patients were satisfied with the ACI and would have undergone the procedure again. It seems that correcting the coexisting background factors with realignment, stabilizing or unloading procedures is improving the results over time. Despite the initial controversy about the results and indication for ACI in patellofemoral lesions, it is clear that ACI provides a satisfactory result even for the difficult cases with concomitant patellar instability. Our study reveals preservation of the good results and of high level of patients’ activities, even 10 to 20 years after the implantation

Traditionally, the results of autologous chondrocyte implantation (ACI) in the patellofemoral joint have been considered inferior to those in the weightbearing femoral condyles. This study investigated the clinical effectiveness of patellofemoral ACI in a large, single-surgeon cohort. This study reviewed prospectively collected data of patients treated with ACI for defects of the trochlea and/ or patella with a minimum follow-up of 2 years. Clinical outcomes were evaluated by SF-36; WOMAC, Knee Society Score, modified Cincinnati Score and a patient satisfaction survey. 130 patients reached a minimum follow-up of 2 years (2–9 years, average 56.5 months) after treatment involving the patellofemoral articulation. There were 77 men (59%) and 53 women (41%), the average age at the time of implantation was 37.5 years (15–57 years). The treatment groups included. isolated patella (n = 14);. isolated trochlea (n = 15);. patella plus trochlea (n = 5);. weight-bearing condyle plus patella (n = 19);. weightbearing condyle plus trochlea (n = 52);. weightbearing condyle plus patella plus trochlea (n = 25). The average surface area of patellar and trochlear defects was 4.7 cm2 (n = 63) and 5.8 cm2 (n = 98), respectively. The average resurfacing per knee was 11 cm2. There were 16 failures (12%) that could be attributed to a patellar or trochlear defect. 80% of patients rated their outcome as good or excellent, 18% rated their outcome as fair, and 2% rated outcome as poor. ACI of the patellofemoral articulation provided a Significant improvement in quality of life as measured by functional scores and patient satisfaction survey. The failure rate was comparable to ACI used in other locations, such as the weightbearing femoral condyles