Patellofemoral disorders
The patella (kneecap)
is one of the three bones that make up the knee. It begins within the quadriceps tendon and ends where the patella tendon begins. The patella tendon inserts
at the tibial tubercle - sometimes known as the knob of the knee. It protects the knee from a direct blow and is positioned to maximize the mechanical efficiency of
quadriceps muscles. The patella forms a joint with the front part of the distal femur called the trochlea groove. In a healthy patellofemoral joint, there is
symmetrical contact of the patella upon the trochlea groove.
One common malfunction of the patellofemoral joint, sometimes known as chondromalacia, or softening of the cartilage of the patella (kneecap), is associated with
anterior (front) knee pain, difficulty walking up stairs and pain after prolonged sitting. Some patients also report an uncomfortable grinding sensation in the
kneecap. The condition is aggravated when the knee is bent for extended periods. It is a condition that causes the slick cartilage surface of the patella
to soften. This can arise from excessive pressure across the patellofemoral joint, as in obese individuals and those with a combination of weak quadriceps and
tight hamstrings.
The other common malfunction of the patellofemoral joint is called patella instability.
In this condition, the patella may not symmetrically strike the femur. It may strike to the outside of the groove. In the most severe cases, the
patella may dislocate off the side of the femur and require a manipulation to replace it. More often, the abnormal patella only partially dislocates.
This is called subluxation. When this happens, pain is felt in the front of the knee and may cause an unstable sensation within the kneecap. The
knee may pop or feel as though it is unable to support weight. Examining such a patient reveals a knock-kneed tendency in the lower limbs.
The medical term for this is "valgus." These patients have swelling, and tenderness around the kneecap. Regularly they become apprehensive
and fearful if the kneecap is moved to the outside.
Over time, this tendency - combined with an injury or other factors - may cause the cartilage surfaces to break down. When this happens, patients
will complain of anterior knee pain, which grows progressively worse with daily activities. The result is arthritis of the patellofemoral joint.
As always, the best treatment is non-surgical. In the acute stage, ice and elevation takes place in the form of the Cryo/Cuff®,
which both compresses and cools the inflamed area. Medications such as Ibuprofen, as well as nutritional supplements, are helpful. Occasionally a knee brace
is used, but the best brace is always a strong quadriceps muscle.
Patients are advised to lose unnecessary weight, and perform a series of exercises including hamstring stretching, and closed chain quadriceps
drills using the Step Box. The Step Box is a simple and inexpensive device used for the performance of closed
chain knee extension exercises on both legs - six sets of 25 reps each day. As strength increases, reps increase to 50. When patients are able
to do 50 reps at two inches of excursion, excursion is moved to four inches, and then six and on to eight as each level is comfortably achieved.
Later a program of biking and more difficult closed chain exercises are added.
Patella Realignment Surgery
Patella Realignment Surgery is indicated for patients, who have ongoing anterior knee pain, subluxation or dislocations of the
patella, and/or patellofemoral arthritis that is non responsive to conservative treatment.
About the Procedure
The operative procedure includes general anesthesia, a diagnostic and/or surgical arthroscopy to more directly identify and
confirm the problem and correct any other intra-articular abnormalities such as torn menisci and chondral surface pathology.
Following the arthroscopy, a lateral retinacular release is performed with a thermal instrument through an arthroscopic portal.
A six-centimeter side-to-side incision is then made just above the knob of the knee (tibial tubercle). The tibial tubercle and
its attached patella tendon is separated from the tibia and moved forward and medially toward the inside. This corrects the poor
alignment of the kneecap on the femur. It is secured with one or two screws, and the wound is neatly closed with sutures that
will dissolve on their own. It is then covered with a dressing.
Medication
An anesthesiologist is a doctor of medicine who administers and monitors the anesthetic administered to the patient. They
carefully monitor the patient throughout the surgery.
Torradol is a non-narcotic pain medication given to patients in the operating room and taken by mouth four times per day
for three days. It will limit a patient's need for stronger narcotic drugs.
Precautions are also taken to avoid deep vein thrombosis (blood clot), which is a serious complication that may follow lower
limb surgery. The condition could be fatal if the blood clot separated and traveled to the lung, resulting in a pulmonary
embolus. Therefore, Lovenox, an anticoagulant or blood thinner, is administered in the recovery room and prescribed to patients
for ten days post-surgery. It is administered just as insulin, by subcutaneous injections. The nursing staff will instruct
family members on this simple injection.
Pain following Patella Realignment Surgery can be moderate, so patients are encouraged to fill prescriptions on or before the
day of surgery. Patients are prescribed a mild to moderate narcotic analgesic (Class 3), which are taken as directed on the
prescription - usually not more than one to two pills every three to four hours. Most of these Class 3 medications are
combinations of Hydrocodone and Acetaminophen (the active ingredient in Tylenol). Hydrocodone is an effective medication
for relief of pain and is NOT Codeine.
These medications frequently cause nausea and/or constipation - often times becoming more annoying than post-surgical pain -
in which case two Tylenol every four hours is a good alternative. Though patients who take Torradol will have a limited
need for the narcotics.
Wound Care and Avoiding Infection
Since arthroscopic surgery uses water under pressure to inflate the joint, surgical dressings will become moist and
appear to be very bloody - though it is primarily draining water mixed with a small amount of blood. Patients should
not be alarmed, but may reinforce their dressing if it becomes saturated.
Infection is a serious complication following orthopaedic surgery, which is why antibiotics are given by vein at the time
of surgery. Additional postoperative antibiotics are unnecessary and could even serve to mask an infection, making treatment
harder.
Patients are responsible for daily wound care and may remove the compression stocking and shower the day after surgery.
The Tielle Bandage is left over the wounds, though, and the Plastizote pad and compression stocking are replaced following
the shower. On postoperative day five, patients may remove the Tielle Bandage and wash the cuts with ordinary soap and water.
If the steristrips remain on, they should be left in place. But, if they fall off, the cuts may be washed with soap and water,
then cleaned with Hydrogen Peroxide applied to a gauze pad. They are then left open to dry.
Regaining Mobility
In order for patients to enjoy a rapid return to sports and daily activities, it is very important to control postoperative
swelling that invariably leads to stiffness. A stiff knee does not return to sports, therefore steps are taken to control
swelling and prevent stiffness. One of the most effective methods is placing a drain into the wounds to drain blood and edema
fluid. These are removed the first postoperative day. Compression stockings are then placed on the legs and a Cryo/Cuff®
(cold therapy compression) is used to further minimize swelling by applying both cold therapy and compression. Both knees rest
straight with two pillows under the heels and nothing under the crease of the knees.
Four times every hour, patients must actively put their knee through a range of motion from straight to a complete bend - heel
touching buttock. These Active Range of Motion exercises are critical for a successful return to sports and optimal recovery.
The exercise is begun by fully extending the knee and placing several towels or firm pillows under the heel and a single towel
held by both hands under the forefoot. As toes are pulled toward the head, assisted hy the towel held in both hands, the patient
pushes the back of their knee down toward the bed. This enables the knee to hyperextend.
For flexion, the patient grabs the back of both thighs and pulls them to his or her chest. As the hips come up, the quadriceps
remains relaxed and the knees fall into the fully bent position. When this is in progress, patients concentrate on exhaling and
relaxing their legs. As relaxation occurs, the knees are fully bent and the cycle is repeated.
On the eighth postoperative day, patients are generally able to resume regular sedentary activities. A follow up visit is
made at this time.
On the fourth postoperative day, the stationary bicycle is introduced. The seat is set at a comfortable level and resistance
is minimized. Patients who stay on the bike at least one hour per day have shown to make excellent progress. As time progresses,
the seat is lowered to maximize knee flexion, and light resistance is introduced. At this time we also add the Step Box. The
Step Box is a simple and inexpensive device used for the performance of closed chain knee extension exercises on both legs -
six sets of 25 reps each day. As strength increases, reps increase to 50. When patients are able to do 50 reps at two inches
of excursion, excursion is moved to four inches, and then six and on to eight as each level is comfortably achieved.
Running and swimming may begin at four weeks, but other sports only as tolerated. Patients are encouraged to take the recovery
one step at a time, rather than over exerting and suffering a setback. Athletes following these instructions are generally on the
field and ready to play by month three.
