Advanced Patellofemoral Cartilage Lesions in Patients Younger Than 50 Years of Age: Is There an Ideal Operative Option?


      The purpose of this review was to determine if there is an ideal operation for large symptomatic articular cartilage lesions on the undersurface of the patella in young patients.


      A systematic search of PubMed was conducted to determine the outcome of operations performed for large patellar lesions in young patients. Inclusionary criteria were English language, original clinical trials published from 1992 to 2012, patellar lesions 4 cm2 or larger, mean patient age 50 years or younger, and all evidence levels.


      Of 991 articles identified, 18 met the inclusionary criteria, encompassing 840 knees in 828 patients. These included 613 knees that underwent autologous chondrocyte implantation (ACI) (11 studies), 193 knees that had patellofemoral arthroplasty (PFA) (5 studies), and 34 knees that underwent osteochondral allografting (OA) (2 studies). The mean patient age was 37.2 years and the mean follow-up was 6.2 years. Long-term follow-up (>10 years) was available in only 4 studies (2 PFA, 1 ACI, 1 OA). All studies except one were Level IV and none were randomized or had a control group. Twenty-one outcome instruments were used to determine knee function. When taking into account knees that either failed or had fair/poor function, the percentage of patients who failed to achieve a benefit averaged 22% after PFA and 53% after OA and ranged from 8% to 60% after ACI. In addition, all 3 procedures had unacceptable complication and reoperation rates.


      The combination of failure rates and fair/poor results indicated that all 3 procedures had unpredictable results. We concluded that a long-term beneficial effect might not occur in one of 3 ACI and PFA procedures and in 2 of 3 OA procedures. We were unable to determine an ideal surgical procedure to treat large symptomatic patellar lesions in patients 50 years or younger.

      Level of Evidence

      Level IV, systematic review of Level I to IV studies.
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        • Mouzopoulos G.
        • Borbon C.
        • Siebold R.
        Patellar chondral defects: A review of a challenging entity.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1990-2001
        • van Jonbergen H.P.
        • Poolman R.W.
        • van Kampen A.
        Isolated patellofemoral osteoarthritis. A systematic review of treatment options using the GRADE approach.
        Acta Orthop. 2010; 81: 199-205
        • Harris J.D.
        • Siston R.A.
        • Pan X.
        • Flanigan D.C.
        Autologous chondrocyte implantation: A systematic review.
        J Bone Joint Surg Am. 2010; 92: 2220-2233
        • Benthien J.P.
        • Schwaninger M.
        • Behrens P.
        We do not have evidence based methods for the treatment of cartilage defects in the knee.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 543-552
        • Mithoefer K.
        • Hambly K.
        • Della Villa S.
        • Silvers H.
        • Mandelbaum B.R.
        Return to sports participation after articular cartilage repair in the knee: Scientific evidence.
        Am J Sports Med. 2009; 37: 167S-176S
        • Nakamura N.
        • Miyama T.
        • Engebretsen L.
        • Yoshikawa H.
        • Shino K.
        Cell-based therapy in articular cartilage lesions of the knee.
        Arthroscopy. 2009; 25: 531-552
        • Vasiliadis H.S.
        • Wasiak J.
        • Salanti G.
        Autologous chondrocyte implantation for the treatment of cartilage lesions of the knee: A systematic review of randomized studies.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1645-1655
        • Vavken P.
        • Samartzis D.
        Effectiveness of autologous chondrocyte implantation in cartilage repair of the knee: A systematic review of controlled trials.
        Osteoarthritis Cartilage. 2010; 18: 857-863
        • Macmull S.
        • Jaiswal P.K.
        • Bentley G.
        • Skinner J.A.
        • Carrington R.W.
        • Briggs T.W.
        The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae.
        Int Orthop. 2012; 36: 1371-1377
        • Vanlauwe J.J.
        • Claes T.
        • Van Assche D.
        • Bellemans J.
        • Luyten F.P.
        Characterized chondrocyte implantation in the patellofemoral joint: An up to 4-year follow-up of a prospective cohort of 38 patients.
        Am J Sports Med. 2012; 40: 1799-1807
        • Vasiliadis H.S.
        • Lindahl A.
        • Georgoulis A.D.
        • Peterson L.
        Malalignment and cartilage lesions in the patellofemoral joint treated with autologous chondrocyte implantation.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 452-457
        • Pascual-Garrido C.
        • Slabaugh M.A.
        • L'Heureux D.R.
        • Friel N.A.
        • Cole B.J.
        Recommendations and treatment outcomes for patellofemoral articular cartilage defects with autologous chondrocyte implantation: Prospective evaluation at average 4-year follow-up.
        Am J Sports Med. 2009; 37: 33S-341S
        • Gobbi A.
        • Kon E.
        • Berruto M.
        • et al.
        Patellofemoral full-thickness chondral defects treated with second-generation autologous chondrocyte implantation: Results at 5 years' follow-up.
        Am J Sports Med. 2009; 37: 1083-1092
        • Gigante A.
        • Enea D.
        • Greco F.
        • et al.
        Distal realignment and patellar autologous chondrocyte implantation: Mid-term results in a selected population.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 2-10
        • Niemeyer P.
        • Steinwachs M.
        • Erggelet C.
        • et al.
        Autologous chondrocyte implantation for the treatment of retropatellar cartilage defects: Clinical results referred to defect localisation.
        Arch Orthop Trauma Surg. 2008; 128: 1223-1231
        • Farr J.
        Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes.
        Clin Orthop Relat Res. 2007; 463: 187-194
        • Steinwachs M.
        • Kreuz P.C.
        Autologous chondrocyte implantation in chondral defects of the knee with a type I/III collagen membrane: A prospective study with a 3-year follow-up.
        Arthroscopy. 2007; 23: 381-387
        • Kreuz P.C.
        • Steinwachs M.
        • Erggelet C.
        • et al.
        Importance of sports in cartilage regeneration after autologous chondrocyte implantation: A prospective study with a 3-year follow-up.
        Am J Sports Med. 2007; 35: 1261-1268
        • Minas T.
        • Bryant T.
        The role of autologous chondrocyte implantation in the patellofemoral joint.
        Clin Orthop Relat Res. 2005; : 30-39
        • Torga Spak R.
        • Teitge R.A.
        Fresh osteochondral allografts for patellofemoral arthritis: Long-term followup.
        Clin Orthop Relat Res. 2006; 444: 193-200
        • Jamali A.A.
        • Emmerson B.C.
        • Chung C.
        • Convery F.R.
        • Bugbee W.D.
        Fresh osteochondral allografts: Results in the patellofemoral joint.
        Clin Orthop Relat Res. 2005; : 176-185
        • van Jonbergen H.P.
        • Werkman D.M.
        • Barnaart L.F.
        • van Kampen A.
        Long-term outcomes of patellofemoral arthroplasty.
        J Arthroplasty. 2010; 25: 1066-1071
        • Butler J.E.
        • Shannon R.
        Patellofemoral arthroplasty with a custom-fit femoral prosthesis.
        Orthopedics. 2009; 32: 81
        • Sisto D.J.
        • Sarin V.K.
        Custom patellofemoral arthroplasty of the knee.
        J Bone Joint Surg Am. 2006; 88: 1475-1480
        • Merchant A.C.
        A modular prosthesis for patellofemoral arthroplasty: Design and initial results.
        Clin Orthop Relat Res. 2005; : 40-46
        • Kooijman H.J.
        • Driessen A.P.
        • van Horn J.R.
        Long-term results of patellofemoral arthroplasty. A report of 56 arthroplasties with 17 years of follow-up.
        J Bone Joint Surg Br. 2003; 85: 836-840
        • Ackroyd C.E.
        • Newman J.H.
        • Evans R.
        • Eldridge J.D.
        • Joslin C.C.
        The Avon patellofemoral arthroplasty: Five-year survivorship and functional results.
        J Bone Joint Surg Br. 2007; 89: 310-315
        • Odumenya M.
        • Costa M.L.
        • Parsons N.
        • Achten J.
        • Dhillon M.
        • Krikler S.J.
        The Avon patellofemoral joint replacement: Five-year results from an independent centre.
        J Bone Joint Surg Br. 2010; 92: 56-60
        • van Wagenberg J.M.
        • Speigner B.
        • Gosens T.
        • de Waal Malefijt J.
        Midterm clinical results of the Autocentric II patellofemoral prosthesis.
        Int Orthop. 2009; 33: 1603-1608
        • Argenson J.N.
        • Flecher X.
        • Parratte S.
        • Aubaniac J.M.
        Patellofemoral arthroplasty: An update.
        Clin Orthop Relat Res. 2005; 440: 50-53
        • Cartier P.
        • Sanouiller J.L.
        • Khefacha A.
        Long-term results with the first patellofemoral prosthesis.
        Clin Orthop Relat Res. 2005; : 47-54