282 / 460
The Treatment Evolution of Patellofemoral Degeneration, Arthritis, and Arthroplasty
281
orthopedic surgeon came to visit Professor
Ficat in Toulouse. His name was David S.
Hungerford. Trained in England and Germany,
Dr Hungerford provided a timely intellectual
vector between European and North American
orthopedics. The emerging concepts to which
he was introduced regarding the importance of
lower extremity alignment, the “Law of Knee
Valgus”, and the implication to the forces
exerted upon the knee and patellofemoral joint
by malalignment would form a foundation of
thought for much of his career. In addition,
Ficat would impress upon his protege the
potential role of intraosseous hypertension not
only in avascular necrosis of the femoral head,
but as a source of patella pain. Dr Hungerford
would return to assume a leadership position at
The Johns Hopkins Hospital, Baltimore. There
he began applying much of what he had learned
in his travels. Two young physicians who came
under his influence were Dr Leadbetter and
Dr Fulkerson. Ficat and Hungerford would
culminate their collaboration in the publication
in 1977 of the most comprehensive treatise up
to the time on disorders of the patellofemoral
joint [4]. The patella was no longer forgotten.
It is important to consider historical
developments in one discipline in the overall
context of technological and societal trends of
the same period. The 1970’s and 80’s were a
dynamic era in the treatment of knee disorders
with respect to: 1) increased diagnostic
capability, eg. arthroscopy, CT, arthrography,
and MRI; 2) the development of reliable knee
arthroplasty, both total and partial; and 3) the
rise of aerobic fitness exercise and wellness
awareness. Patients developed increasing
expectation of improved functional outcomes
with every newly announced advance.
Coincidently, this stimulated the birth and
growth of a whole new orthopaedic
subspecialty-orthopaedic sports medicine. Of
course, in modern Europe there was a long
association of medicine and sport dating back
to the reinstitution of the Olympic Games with
the founding of the Federation Internationale
de Medicine du Sport (FIMS) in 1928.
However, in North America the professional
recognition of the subspecialty began in 1964.
It was then that Dr Jack Hughston started the
planning of what would formally become in
1972 the American Orthopaedic Society for
Sports Medicine. With the blooming of running
exercise, recreational sport, and women’s
athletics, anterior knee pain soon became the
most common knee complaint in the outpatient
orthopedic clinic worldwide.
During this period many surgeons made
contributions to defining the pathology of
chondromalacia, to the correction of
patellofemoral instability and to identifying
the factors contributing to progressive patello
femoral articular degeneration. Ficat wrote
extensively about the pathology of degenerative
cartilage and fibrillation. He wrote, “the causes
of disorders of articular cartilage are the same
as those of degenerative joint disease… the
three main etiological factors are trauma,
structural disorders, and mechanical problems,
such as dysplasia, patellar instability, and joint
overload” [9]. In 1978, he introduced his
concept of lateral retinacula release for “lateral
hyperpressure syndrome” [10]. The approach
was facilitated by Merchant and Metcalf;
however Ficat forewarned that not all chondral
disease was either progressive or symptomatic
and that the surgery of the chondromalacia is
essentially a surgery of the pain and therefore,
always keeps a bit ofmystery [9]. Unfortunately,
arthroscopic lateral release remains to this day
one of the most over utilized and misapplied of
operations. Radin summed up the operative
strategy of the time when he wrote, “cartilage
fibrillation does not necessarily progress. There
appears to be different mechanical factors
involved in the initiation and the progression of
cartilage changes in osteoarthrosis. This means
there is some rationale behind what we see
clinically happening after successful osteotomy
or other operations that lower the stress on
degenerating joints, and it means that if we can
do something about the level of stress and,
therefore, the level of bone remodeling in
patients with fibrillation, we may be able to
keep that cartilage from further degenerating”
[12]. With such observations, reducing
symptom producing instability and the
unloading of injured or degenerative patello
femoral cartilage became a prime surgical
motive. Chambat reported the long term results
of distal medial realignment for instability [11].