Patella chondromalacia
Contents:
Description:
The chondromalacia of a patella is a destruction of a cartilage of a back (joint) surface of a patella. With transition of degenerative process and to other components of a femoral and patellar joint (a joint cartilage of condyles of a hip, a bone) usually use the term "arthrosis of a femoral and patellar joint". Both states often are followed by pain. The cartilaginous vystilka has no own innervation therefore pain can be explained with excess load of the subject bone when thinning a cartilage. Disturbance of an integrity of a cartilaginous vystilka can be different expressiveness — from the small centers of a softening to through defects with a bone exposure. The etiology of a degeneration of a cartilage is also various and includes damages owing to a direct injury, dislocation or instability of a patella, and also its wrong situation.
Patella Chondromalacia symptoms:
* Anamnesis and complaints
o Pain in front department of a knee joint at an exercise stress, for example at rise on a ladder, run or squats.
o Injury of front department of a knee joint or dislocation of a patella.
* Physical signs
o the Exudate and crepitations in a knee joint though it is not pathognomonic signs and happen not always.
o Atrophy or weakness four-head of a muscle of a hip.
o Pain when narrowing a crack of a femoral and patellar joint during movements in a knee joint.
* Radiodiagnosis
o Are possible typical symptoms of arthrosis, but it is normal of the roentgenogram more often.
o At a X-ray analysis in an axial projection (legs are bent in knees on 45 °) or KT quite often find an excess inclination and an incomplete dislocation of a patella.
o For additional inspection use MRT.
* Arthroscopy
o the Arthroscopy — a reference diagnostic and medical method.
o Allows to specify weight of defeat and its localization and to choose a treatment method.
Patella Chondromalacia reasons:
Arises after an injury - rough or insignificant or against the background of an intermittent trauma and especially - lateral shifts of a patella. The centers of a razvolokneniye, amotio and a softening of a cartilage appear on the limited site, usually in a medial part of a joint surface, and can extend to all this surface, causing thinning of a cartilage, defects and consolidation of a subchondral bone in a late stage.
Treatment of the Chondromalacia of a patella:
Conservative treatment.
Treatment is usually begun with conservative methods: rest, NPVS, change of the mode of trainings. After that appoint the program of rehabilitation which cornerstone the extension of extensor muscles, an ileal and tibial path, the sheaves holding a patella and back group of muscles of a hip is. Important also accumulation of force by the four-head of a muscle, especially slanting part of a medial wide muscle, as main limiter of mobility of a patella. Consider that because of weakness of this muscle in comparison with a lateral wide muscle the patella is exposed to an outside incomplete dislocation. The strengthening exercises of small amplitude for the four-head of a muscle and raising of direct legs weaken reaction of a femoral and patellar joint to this imbalance. Except exercises it is possible to appoint elastic bandaging of a knee joint, fixing of a patella a bandage or an orthosis, and the patient should explain an essence of a disease and to encourage him. Most of patients with the isolated arthrosis of a femoral and patellar joint of similar treatment have enough to facilitate symptoms. However the remaining pain, an exudate and crepitation in combination with an incomplete dislocation of a patella indicate the progressing degeneration; in that case it is necessary to pass to other ways of treatment.
Surgical treatment.
There is a set of options of surgical treatment of arthrosis of a femoral and patellar joint. Most of them is directed to recovery of the correct anatomic provision of a femoral and patellar joint, a small part — to regeneration of a cartilaginous vystilka. In hard cases the konturirovaniye of joint surfaces and a patellektomiya is shown.
The arthroscopy of a knee joint is not only the important diagnostic, but also medical procedure. Though expediency of washing of a cavity of a joint and removal patholologically of the changed fabrics during an arthroscopy remains a subject of disputes, the value of this inspection is obvious to definition of a stage of a disease and planning of surgical treatment. Arthroscopic lavage for a short time reduces pains and improves function due to removal of the died-off fabrics and proteoglycans which are formed at an inflammation. But as the cause of illness at this manipulation is not removed, symptoms usually arise again.
At arthroscopic definition of a stage of a disease widely use system of Auterbridzha because of its simplicity and reproducibility of results. The system is based on definition of localization, a form, the size and depth of defect. Defects of the I degree represent soft thickenings, sometimes swellings. Deepenings and cracks with a diameter less than 1 cm are characteristic of the II degree. Damages of the III degree look as the deep cracks with a diameter more than 1 cm reaching a bone. And at last, the exposure of a subchondral bone is characteristic of the IV degree.
Lavage and removal of the died-off fabrics are suitable for injuries without signs of instability of a patella more, than for degenerative defeats of not traumatic nature. At an inclination of a patella and the minimum damage of joint surfaces, first of all an outside facet, at an arthroscopy it is possible to mobilize lateral edge of a patella. This intervention is reasonable only at clinically explicit inclination of a patella of beztyazhely injuries of a joint. In general arthroscopic lavage and removal patholologically of the changed fabrics with mobilization of lateral edge of a patella or without it are justified at defeats of the I—II degree; at the III—IV degree the long-term results usually bad. At the expressed degeneration of a cartilage apply an arthroscopic chondroplasty. Techniques of an abrasive and microslot-hole chondroplasty include mechanical penetration into the subject bone with introduction to defects of the mesenchymal stem cells of marrow stimulating regeneration of fibrocartilage fabric. The arthroscopic chondroplasty is carried usually out to people more young by 30 years with accurately delimited damages of the III degree; at more severe defeats it is contraindicated.
Additional methods are directed to recovery of a hyaline (joint) cartilage. For regeneration of a cartilage carry out implantation of own chondrocytes, change osteoarticular auto-or allotransplant, to plastic by the fragmented osteoarticular transplant (mosaic plastics). The detailed description of these methods is not included into tasks of the present edition, but the flavor about them nevertheless should be given. Implantation of own chondrocytes is carried out at the major through defects of a cartilaginous vystilka of a condyle of a hip which are shown clinically. At first prepare the patient's chondrocytes, then cultivate them and place under a periosteal rag, on the defect of a joint surface cleared of pathological fabrics. According to the long cooperated researches, good and excellent results managed to be received in 79% of cases. The method is shown to young people (20 — 50 years) by the active patient with isolated (2 — 4 cm2) traumatic defects of a cartilaginous vystilka of condyles of a hip. Results of completion of defects of a patellar surface of a femur or patella it is much worse. Contraindications include an extensive osteoarthrosis, instability or an inclination of a patella with an incomplete dislocation and a meniscectomy in the past.
Change of an osteoarticular autograft and mosaic plastics are interesting that they for completion of deep defects use own unimpaired cartilage. However exact recovery of a relief of a joint surface requires considerable technical skill. Besides, the quantity of donor zones is limited and complications in places of a harvesting of cartilage are not excluded. Bone хряшевые allotransplants usually apply at big (10 cm2 or more) defects of condyles of a hip and often after unsuccessful use of other methods. In fresh allotransplants chondrocytes are more viable, but at the same time possess a bigger immunogenicity and increase risk of transmission of infection. Moreover, fresh allotransplants are complex in the address and demand from the surgeon and sick accurate planning of terms of intervention for rather short time. Freshly frozen allotransplants cause immune responses less often and give big freedom in the choice of terms of operation, but at the same time both viability of chondrocytes, and long-term viability of a transplant is lower. Patellektomiya and planimetric plastics of a patella is used at the extensive injuries of a patella causing considerable dysfunctions because of pain and also if other ways of treatment did not give desirable effect. Results of techniques are ambiguous. The operations demanding movement of large volumes of fabrics: an osteotomy, transfer and rise in tuberosity of a tibial bone and other — will be discussed in the section devoted to an inclination and an incomplete dislocation of a patella.
