Vicente Sanchis-Alfonso, MD, PhDVicente Sanchis-Alfonso, MD, PhD Department of Orthopaedic Surgery...
Transcript of Vicente Sanchis-Alfonso, MD, PhDVicente Sanchis-Alfonso, MD, PhD Department of Orthopaedic Surgery...
Vicente Sanchis-Alfonso, MD, PhDDepartment of Orthopaedic Surgery
Hospital Arnau de VilanovaValencia, Spain
UNDERSTANDING PATELLOFEMORAL PAIN
CONSENSUS MEETING
Role of Hypoxia in the Genesis ofAnterior Knee Pain
Anterior Knee Pain
LATERALRETINACULUM Infrapatellar
Fat Pad
INFLUENCING FACTORS
Gender Psychological Instability
Synovium
Subchondral Bone
Overload
ORIGIN
No relation between the result (satisfactory vs non-satisfactory) andthe presence or absence of PFM (χ2 = 0.025, p=0.875)
PFM18 / 21 - satisfactory result (85.7%)
3 / 21 - poor result (14.3%)
NO PFM14 / 16 – satisfactory result (87.5%)
2 / 16 – fair result (12.5%)
What have we learned from realignment surgery?
Sanchis-Alfonso et al, 2006
Pre-op Post-op 6 months Post-op 13 years
Satisfactory centralization at long-term follow-up in 16 cases (43.24%)
A RADIOGRAPHICAL PMF MAY NOT BE REAL
It could induce us to indicate a realignment surgery that could provoke an iatrogenic
PFM leading to a worsening of preoperative symptoms
Preop stress CT in extension
Postop stress CT in extension
Right
Right Left
Left
25 yo F / Medial Patellar Instability After Insall´s Proximal RealignmentPreop Gait Analysis
Postop Gait Analysis
We look PFM as representing internal load shifting within the patellofemoral joint that may
lower the threshold (i.e., decrease of the Envelope of Function) for the initiation and persistence of loss of tissue homeostasis
leading to the perception of patellofemoral pain. Pain always denotes loss of tissue homeostasis.
Hyperinnervation in the lateral retinaculum is a factor implicated in the pathogenesis of
anterior knee pain
Sanchis-Alfonso et al, 1998
Severe pain vs moderate-light pain (p = 0.03; F = 4.93)
Innervation adopting mainly a perivascular location
Sanchis-Alfonso et al, 1998, 2000 & 2005
Severe pain (94%) vs moderate-light pain (30%) (p = 0.005)
We believe that homeostasis in the knee region ofanterior knee pain syndrome patients could be disturbed by
vascular problems
We hypothesize that periodic short episodes of ischemia due to vascular
bending could be implicated in pain in mostof the cases of young patients with anterior
knee pain syndrome
Lesions that are a consequence of ischemia (I)
Sanchis-Alfonso et al, 2005
Myxoid stromaldegeneration
Infarcted foci of theconnective tissue
HypervascularizationWe have found higher values in the number of vesselsin the lateral retinaculum of patients with severe pain
than in those with moderate or light pain (p = 0.03; F = 4.58)
Factor VIII
Sanchis-Alfonso et al, 2005
2
1200
1000
800
600
400
200
0
12 0
000
8
6
40
2
Vascular innervationYes
No
Sanchis-Alfonso et al, 2005
VESS
ELS
IN 5
HO
T SP
OTS
PAIN SCORE1
n = 31
HypoxiaHypoxia
VEGFVEGF
HypervascularizationHypervascularization
NGFNGF
HyperinnervationHyperinnervation
Neural sprouting Neural proliferationin vessel walls
NeuronsNeurons
Ischemia
Role of hypoxia in the genesis of anterior knee pain
Clinical findingsSandow MJ, Goodfellow JW. The natural history of anterior knee pain in adolescents. J Bone Joint Surg 1985; 67-B: 36-38.
Selfe J, Karki A, Stvens D. A review of the role of circulatory deficit in the genesis of patellofemoral pain. Physical Therapy Reviews. 2002; 7: 169-172.
Selfe J, Harper L, Pedersen I, et al. Cold legs: a potential indicator of negative outcome in the rehabilitation of patients with patellofemoral pain syndrome. Knee 2003; 10: 139-143.
Gelfer Y, Pinkas L, Horne T, et al. Symptomatic transient patellar ischemia following total knee replacement as detected by scintigraphy. A prospective, randomized, double-blind study comparing the mid-vastus to the medial para-patellar approach. Knee 2003; 10: 341-345.
Naslund J. Patellofemoral pain syndrome. Clinical and pathophysiological considerations. Thesis. Karolinska Institutet. Stockholm. 2006.
Pathogenesis of Anterior Knee Pain
HypoxiaHypoxia
NGFNGFFree nerve endingsFree nerve endings Substance PSubstance P
PAINPAIN
Mast cellsMast cellsHistamineHistamine
HyperinnervationHyperinnervation
Prostaglandin E2Bone resorption