Patellofemoral Chondrosis and Instability in the Middle Aged Patient

The case presented in this chapter is a 40-year-old sedentary female with right knee pain and instability. She has recurrent low energy patellar dislocations and has failed conservative management. Her diagnoses include bipolar patellofemoral chondrosis, incompetent medial soft tissue restraints, lateral patellar retinacular tightness, abnormal axial alignment, and underlying trochlear dysplasia. Expert opinion regarding overall treatment plan and management of each individual clinical problem is presented. Suggested options for cartilage treatment include benign neglect, MACI, osteochondral allograft, and patellofemoral arthroplasty. Concomitant procedures considered include lateral retinacular lengthening versus release, tibial tubercle osteotomy with medialization and/or anteriorization, and MPFL reconstruction. The authors conclude with their chosen strategy focusing on treatment of the joint as an “organ.” Ultimately this complex patellofemoral joint preservation case demonstrates that four experienced orthopedic surgeons from around the globe can have very different approaches to a challenging problem. The literature provides support for various treatment plans without a definitive answer as to which is ultimately correct. The authors believe it is imperative to define a problem list before performing any major procedure. The surgeon can systematically address each contributing factor to maximize the opportunity for success and to reduce the risk of surgical morbidity.