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“The longer we keep studying the subject… the
more we are in danger of soon knowing nothing
certain about it!”
Mark Twain
The evolution of surgical treatment options for
symptomatic patellofemoral chondral degene
ration and its promoting causes has paralleled
the evolution of all scientific and surgical
thought [1]. It is a history fraught with at best,
misconception and at worst, dogma. It is a
history dominated by a multifactorial elusive
symptom – refractory knee pain. It is a history
characterized by a progression from reliance
solely on the physical exam and the
intraoperative appearance of the joint surface
to one of intensive histologic, biochemical,
biomechanical, anatomic and radiologic study.
It is a history in which operative approach has
evolved from a philosophy of unknowing
expedient extirpation and expendibility, ie
patellectomy, to one of critical conservation.
And it is a history in which the French and
Lyonnaise Orthopaedic tradition has figured
prominently. Two technologies that have had
great influence on present day thinking of the
salvage of the painful worn patella have been
total knee arthroplasty and biological articular
cartilage restoration and/or transplantation.
Ironically, total knee arthroplasty has played
the role of both stimulating the development of
isolated patellofemoral arthroplasty as well as
setting a “gold standard” against which attempts
at isolated patellofemoral replacement are often
criticized [2]. In this article, when and how
some of these sentinel historical influences
have evolved and contributed to present day
surgical beliefs will be explored.
In the Beginning… the
Patellofemoral Pre-Dawn Age
In 1803, Hey coined the term “internal
derangement” (often usage includesmechanical
derangement) to denote any disorder of the
knee joint [1]. It was a term that served it’s
purpose as there were no radiologic tools or
operative options to further define the structural
implications of the diagnosis. Undoubtly, many
of these derangements involved arthritic
disease. With the advent of radiographs,
arthritis was recognized to present in two
prevalent forms – atrophic and hypertrophic.
The former was later recognized as most often
rheumatologic and the latter the result of
abnormal loads and forces leading to
subchondral sclerosis and osteophytosis.
Furthermore, this so called osteoarthritis
became considered as a degenerative process
The Treatment Evolution
of Patellofemoral
Degeneration, Arthritis,
and Arthroplasty:
An Historical Account of How a
Forgotten Joint Became the Center of
World Attention
W.B. Leadbetter