Total Knee Replacement, partial knee replacement MJRC India

Anterior Knee Pain

Causes
Patello femoral pain due to malalignenment, instability Tendinitis of the quadriceps tendon, patellar tendon, tendon bursitis, post-operative neuroma, effusion due to inflammatory and infective causes. In this link I shall only discuss patellar softening ( chondromalacia)due to malalignment.Chondromalacia without malalignment can exist and is called idiopathic chondromalacia. Four theories are cited as the cause. a) Malalignment of the patella b)a tight lateral retinaculum leading to increased forces on the lateral facet. c)Dysplasia of the medial muscles with stronger lateral muscles. d)a biochemical cause with pressure breakdown of the proteoglycans. High impact sports such as football, running can lead to pain. Weak thigh muscles often are a cause in younger individuals.

Anatomical background
The knee joint is formed by the union of three bones, namely the femur (thigh bone), the tibia (leg bone) and the Patella (knee cap). The Patella is a floating bone in the tendon of the powerful thigh muscle. It sits in a pulley like groove in the lower end of the femur. The tibia and femur join with each other at the knee joint. The inner surface of all these bones is lined with smooth articular cartilage. Overuse, abnormal stresses, injuries or malalignment can lead to a softening of this cartilage. This leads to anterior knee pain. This is a very common symptom. It results from increased friction due to roughness at the contacting surfaces of the kneecap and the femur. Increased anteversion of the femur and external tibial torsion can predispose to an abnormally aligned patella. The tibial tubercle may be situated more laterally.

Symptoms
Pain at the front of the knee while descending or ascending stairs or rising from a squatting position. There is pain while sitting with the knee flexed at 90 degrees as in the cinema theatre or at home while watching TV. The patient feels a grating sensation inside the knee or complains that the fluid inside the knee has dried out. The pain can be sometimes felt in the back of the knee.
Age groups involved and etiology

Young growing boys and girls often complain of this symptom. Women in middle age are more prone to develop patell femoral arthritis. Elderly individuals with knock knee and bow legged deformities also develop anterior knee pain. In these individuals it is more likely due to patello femoral osteoarthritis which is a more advanced condition with complete loss of the cartilage down to bone. There can be a history of injury but often it develops insiduosly.

Prevention
Once the pain has developed you should avoid squatting for prolonged periods, use of stairs or sporting activities until the pain has settled. Orthopaedician in India do not obtain the relevant x rays and scans to diagnose the condition accurately.

Treatment
In the initial stages avoidance or restriction of the sporting activity helps. Muscle building especially of the inner thigh muscles after consultation with your Orthopaedic surgeon can work. R (Rest) I(ice) C(compression or crepe bandage) E(elevation) and anti inflammatory medication may be advised. A brace with a hole cut out in the front and lateral support to support the knee-cap can help. Persistence of pain may call for a radiological evaluation by sky line views, CT and MR scans. Arthroscopic assessment is carried of the patello femoral and tibio-femoral joints If the surgeon feels that there is a mal-alignment or mal-tracking problem and muscle strengthening exercises have not worked, then a lateral release surgery and tibial tubercle transfer is necessary. Another approach is chondroplasty or microfracture or debridement in case of advanced changes without malalignment. For end stage arthritis a patello femoral replacement(Knee cap replacement) is available with improved results. Total knee replacement is the final operation in those patients with involvement of other compartments. Patellectomy was done for this condition earlier but is done less frequently these days.