John P. Fulkerson
Many alternatives for articular resurfacing, such as cell-based, metal/plastic, osteochondral allograft, autologous transplant, etc., have become available. The reasoning is to cover the painful, broken-down articular surface and the pain will go away. With metal and plastic, few would argue that the result is likely to be reduced pain, as the painful surface is completely removed and replaced with durable surfaces that are not innervated. This, however, is not desirable in younger patients.
Allograft osteochondral transplants are similar, but longevity is questionable. Cell-based implants are often accompanied by an unloading osteotomy. Is the resurfacing necessary or would unloading alone be sufficient? Certainly, the cost is less with unloading alone.
Unloading a painful articular lesion alone works well when properly planned. Typical lateral patellofemoral arthrosis results from chronic focal overload on the lateral patella in most patients with lateral patella maltracking, so unloading this with an anteromedial tibial tubercle transfer reduces and usually eliminates pain.
With regard to the patella, the question is whether to unload alone, unload and resurface, or replace. I believe, having done about 1,500 anteromedializations of the patella, that unloading alone is the best alternative in most younger patients with painful distal and/or lateral patella articular breakdown. I have yet to see evidence to the contrary.
John P. Fulkerson, MD, is a clinical professor of orthopedic surgery at the University of Connecticut School of Medicine and practices at Orthopedic Associates of Hartford in Farmington, Conn. He is also president of The Patellofemoral Foundation.
Disclosure: Fulkerson reports he receives royalties from DJO Global and is a patent holder for DJO Global.