CHONDROMALACIA

PHILIP
From

OF
and M.

THE

PATELLA
LONDON, ENGLAND

WILis,

P. S. ANDREWS
Hospital

B. DEVAS,
Sutton

the Middlesex

and the Bland

Institute

of Pathology

Chondromalacia senescence are often (the changes so described) polysaccharides before

is a precursor

of osteoarthritis.

It can,

perhaps,

be regarded

as an early

in the intervertebral discs that begin during the second decade of life but much more must be learnt about the chemistry of proteins and such an idea can be accepted. The articular cartilage of the patella

is involved earlier and more constantly than almost any other joint surface. The process often begins during the second decade of life, and by the age of thirty nearly everyone is affected. It is, however, in only a few individuals that the changes cause symptoms, and in fewer still that they progress to osteoarthritis. The late stage, osteoarthritis, has been familiar for the centuries. diagnosis has for the condition Descriptions received first in the of the but account articular early scant phases of the attention given of the knee, are patella in comparatively can the to now literature Budinger usually be recent, made of (1906, the patella, removing Ludloff the cartilage patella, in and with British 1908) which even some and who though precision, American described a clinical of chondromalacia

countries. Credit fissures

is generally cartilage

occurring

he considered

to be traumatic in thirteen with case good found in which another result. similar reported

in origin. He operated results that were, in the he excised in which almost he had all the removed

on fifteen patients, main, satisfactory. cartilage part covering of the in thirteen of forty-four.

the affected cartilage 1910 published one Axhausen previously (1919) with a

and

six years

In 1925 changes

L#{228}wenreported the results in twenty-six necropsies out Aleman of 220 several

operations and also that he had The term chondromalacia of the articular and in twenty few years, and and that

seems to have been introduced by cartilage of the patella in one-third this was the only lesion. There an in 1936 #{248}wre published pathological investigation, he had removed of the results. clinic, and also Wiberg surfaces,
operations;

(1928) who found degeneration knees on which he had operated, further reports during the next

were

extensive survey giving the results and his findings in thirteen operations.

of a painstaking clinical Chaklin (1939) stated

the articular cartilage of the patella thirty-eight In 1940 Karlson reported the results of operations the subsequent behaviour of seventy-one knees investigated (1944) (1945) the etiology with special reference reported treated more certain physico-chemical six soldiers by excision in whom and results. they clinical The had

times, but gave no details carried out in Alemans not subjected to operation. to the congruity of the joint and forty-one and Cave, Rowe cartilage. In 1948 patients reported

(1941) and

Hirsch Soto-Hall reported

investigations of the patella, removed the findings and total number

and

Yee

(1945)

eleven

Gray gave a summary of the morbid anatomy treated by excision of the patella with good is more than 200.

reported eight of operations

INCIDENCE

The metachromasia. often thirty.

first

microscopic The earliest

change macroscopic

in

the

articular

cartilage and

is

absence

of of the

the

normal

change

is swelling

softening

cartilage-

misnamed The next

oedema-which stage is fissuring

by one

is present in at least five and flaking (Fig. 2), and

of us (P. W.)

out of six people this can be found Meeting

by the age of in more than Orthopaedic

* A part of this paper was read Association on June 28, 1955.

at the Annual

of the Canadian

VOL.

38

B,

NO.

1, FEBRUARY

1956

95

96 half the population by thirty, by #{248}wre (1936) at post-mortem The

operation

THOMAS

FAIRBANK

BIRTHDAY

VOLUME

the incidence examination fissuring

increasing steadily thereafter. are shown in Table I. of the articular surface of the

The

figures

obtained is found at

frequency

with

which

patella

for removal of a semilunar cartilage is somewhat less than these figures suggest, perhaps because of the restricted view available. The severity of fissuring cannot readily be recorded statistically because estimation is a matter of personal judgment. Owre did not find at necropsy any example under the age of thirty that he could classify as severe, but there TABLE
INCIDENCE OF CHONDROMALACIA OF THE

I
PATELLA IN

I 24 NECROPSIES

(#{216}wRE)

Age 14-19

Numberof
18

Oedema
5

Fissuring
-

20-29 30-39 40-59 60-80

32 26
32

27 24
30

18 19
29

16

16

15

were nine between thirty and thirty-nine, and not in complete accord with clinical experience. is between patients by the twenty and thirty, and we have of this age and, indeed, natural selection of those to estimate how

forty often

over the age The commonest found advanced

of forty. age for changes

These findings are symptoms to arise at operation explained but it is clear on

in younger people. attending for clinical often chondromalacia

The discrepancy is probably examination of the knee. gives rise to symptoms

It is difficult

that the clinical diagnosis becomes more common as awareness of the condition increases; and it is more often seen at operation when it is deliberately sought. Some idea of the incidence is given by comparing the frequency with which chondromalacia with marked fissuring during the encountered has been observed at operation with the number Hospital, II. of meniscectomies including performed chondromalacia same period. The figures for the during meniscectomy, are shown Middlesex in Table II
AS SEEN THE SIE AT OPERATION PERIOD RELATED TO THE NUMBER (MIDDLESEX HOSPITAL)

TABLE
INCIDENCE OF OF CHONDROMALACIA MENISCECTOMIES OF THE PERFORMED PATELLA DURING

1950 Chondromalacia Meniscectomy 4 31

1951 2 24

1952 8 37

1953 5 29

1954 22 32

Jan./June 7 13

Total 48 166

NATURAL

HISTORY

The

natural

evolution

of chondromalacia

cannot

readily

be followed

because

the

precise

condition of the cartilage cannot be estimated with accuracy by clinical examination alone; and when there are symptoms severe enough to call for operation, the affected cartilage (or the patella) is generally removed and its subsequent behaviour cannot be observed. Nearly all adult knees show some of the pathological changes of chondromalacia, but these are generally restricted to a small part of the patella.
THE

Progress,
JOURNAL OF

in a large
BONE AND

majority,
JOINT SURGERY

is

P.

WILES,

P.

5. ANDREWS

AND

M. B. DEVAS

97

FIG.

FIG.

Figure 1-Erosion of the lower and inner quadrant surrounded fissuring, and covered with pannus. As seen at operation May

by areas Case 40.

of nodular

swelling

and

and inner quadrant

with

fissuring

above,

and

also

fissuring

1955. Figure of the lower and

2-Erosion of the lower outer quadrant. Pannus

is spreading

over

the lower

border.

FIG.

Figure

3-The

whole
The

3 surface

FIG.

of the patella
cartilage of the

is disintegrating.

osteoarthritis.

articular

patella

and

the

Patella inner

excised condyle

4 June 1955. of the femur

Figure has

4-Early been shed.

As seen at operation

after

excision

of the patella

October

1954.

lIt

#{149}

#{149}

#{149} .

Figure

5-Advanced

FIG. 5 osteoarthritis

with

Same
VOL.

patient 1,

as Figure
FEBRUARY

5 showing
1956

a large marginal osteophyte vertical scoring of femur.

FIG. 6 and vertical scoring. Figure 6As seen at operation June 1954.

38 B,
G

NO.

98 so slow start, rapid that there are

THOMAS

FAIRBANK

BIRTHDAY

VOLUME

no symptoms

throughout

life.

In a few

the

changes,

almost

from

the

are more widely ; there is a type

spread, and in some in which the entire

of these progress is rapid. Occasionally surface of the patella disintegrates and, by fragments examination, of articular cartilage. or even by inspecting the

it is very when the There is articular

knee is opened, the synovial fluid is clouded at present no sure way of telling by clinical

cartilage, whether progress will be slow or quick, nor is there a constant relation to any feature of the history, such as injury. The determining factor is more likely to be found in the chemical behaviour of the ground substance of the cartilage. Something is known about the average, or statistical, behaviour of chondromalacia after a clinical diagnosis has been made. Karlson (1940) re-examined seventy-one men who had been diagnosed army conscripts, no subjective severe
cause

in Alemans clinic between one and twenty years previously when they were and whose symptoms did not then warrant operative treatment. Ten had complaints, forty-five had a little trouble such as stiffness and fatigue after and sixteen had had absence from work. enough Thirty-five trouble were to make them radiographed change their work and seven showed or to slight

exertion, frequent

osteoarthritic changes We are fortunate knees operated upon

but none had advanced arthritis. enough to have seen and recorded for other conditions, the articular

the presence of fissuring cartilage being left intact.

in nineteen Seventeen

of these operations were between one and five years ago. In eleven knees only a small area of cartilage was affected ; four now have no symptoms, five have a little aching or swelling after exercise and two cannot be traced. The fissuring was of moderate severity in four: one now has a normal knee, two have troublesome symptoms and one cannot be traced.

Two
in

patients,

both

operated now that both the

upon have more are

three

years

ago,

then

had

severe signs the

and

extensive

changes These are to to

the cartilage, and observations suggest progress. Chondromalacic those on the be advanced the femur may It seems that degenerating. be opposing changes be more

clinical and widespread quite often seen but any

radiological the changes on the

of osteoarthritis. more likely they at sites corresponding

changes

femur

surface of the patella, in the patella without advanced than

this is by no means invariable. visible alteration in the femur, and occasionally the femur alone

There may or those in is affected.

the patella,

a rough patellar surface rubbing on the femur is not the only cause of the latters It may be that, as in the patella, a predisposing factor must be postulated. progresses sequence to osteoarthritis. of events can The course cannot be shown in a series likely to progress and intermediate of the changes, the

Chondromalacia of the patella sometimes followed in a single patient but a possible 1 to 6). The clinical at the time of diagnosis, of the the risk articular cartilage, of osteoarthritis. evidence suggests it involves only but the greater

(Figs. when, layers greater

that chondromalacia a small area of the the extent and

is less superficial severity

PATHOLOGY Naked-eye the articular just below distinct appearances-Chondromalacia cartilage. the centre. the It is situated The nodular blue, more area normal of the patella begins as a nodular swelling of part of often on the medial than the lateral facet, commonly is lustreless and grey or yellow in colour, and it is cartilage surrounding cartilage of the it. Fissures develop (Fig. 2). cartilage. in the The The into irregular flakes surrounding articular

from

glistening,

nodular zone and radiate from it, splitting the free edges of the flakes project above the surface
fissures viewed are from

usually directed obliquely the surface, do not stand (Fig. 14). They are firmly (1944) has demonstrated of cartilage in the cartilage. Some

into the depths of the cartilage so that the upright but lie like the tiles of a roof, partly attached to the underlying bone. that, at the stage is less than that when
THE

flakes, when overlapping

each the

other Hirsch elasticity

by elaborate methods areas of chondromalacia elasticity remains even

of nodular swelling, of the surrounding, is fissured, as can

SURGERY

undamaged

the
JOURNAL

cartilage
OF BONE

AND

JOINT

P.

WILES,

P.

S. ANDREWS

AND

M.

B. DEVAS

99

i,
I.

3.
s .1
* .

I $9
1, II
I a

$
I

S
I

I I
I,

,,

#{149}4

FIG.

FIG.

FIG.

Figure 7-Normal in superficial and

articular mid-zones,

staining

cartilage of patella stained H. and E., x 25. Figure 8-Loss also fissure extending into mid-zone. H. and E., x 20. of superficial and mid-zone and cysts in the latter. H. and E.,

9 of normal staining Figure 9-Irregular

x 50.

A
1

#{149}

,#{149}

#{149}

p
(.

FIG.

10

FIG.

11

FIG.

12

Figure lO-Hyperplasia of cartilage cells surrounded by areas of normal staining matrix. The line of calcified cartilage is broadened. H. and E., x 30. Figure 11-Loose body from knee joint of a case of chondromalacia showing cell nests and areas of normal staining matrix. H. and E., /K 25. Figure 12-Late stage of
chondromalacia showing degenerate cartilage marrow with spaces. ossification H. and E., and oedematous x 30. connective tissue in the

VOL.

38 B,

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FEBRUARY

1956

100 readily upright The gradually then less by rubbing

THOMAS

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BIRTHDAY

VOLUME

be shown by inserting a fine probe into position ; it snaps back into its original damaged cartilage, at first and the so much On opening raised above becomes thinner elastic and softer, with a finger.

a fissure position the level

and when

lifting the the probe surrounding

adjoining flake is withdrawn. articular

to an surface,

of the

flakes acquire so that small knees with

a shaggy appearance (Fig. 3). They are pieces of frayed cartilage can be detached cartilage changes such as these, it is common and The involves cartilage in the joint. area increases in this an area order. appearance of exposed

to find cartilaginous loose bodies with When the condition is progressive most becomes ulcer

rounded edges lying free the size of the damaged the lateral facet, 3). usually giving The

of the

medial

facet,

the

ridge

and

so thin that the underlying bone is exposed, surrounded by a rim of frayed cartilage (Fig. and margin They

rather like an bone increases 4 to 6). the synovial covered by a

and

eventually becomes eburnated Osteophytes develop at the membrane and capsular tissues.

often scored in a vertical of the patellar cartilage appear soft, as rounded

direction (Figs. where it joins masses of bone

thin, grey-white layer of cartilage. They do not occur in the nodular fissuring is deep or extensive and the cartilage is thin. This is the is reached by only a few people underthe age of forty-five but thereafter common. There is a close correlation between the sites of the cartilage formation.
border is the

phase, but later when the stage of osteoarthritis ; it it becomes increasingly damage and osteophyte damage, and the medial
is involved, osteophytes

The
usual

medial
site

facet

is the border. ; of ten femur

most
formation.

frequent
When

site
the

of cartilage
lateral facet

of osteophyte

tend that nine

to form along the lateral osteophytes will develop had The marginal patellar referred the naked-eye osteophytes. facets on the to as

The more severe patellae removed may show The changes medial those the patella hyperaemia

the lesion surgically in the part patella.

the greater for severe articular often Occasionally

is the probability chondromalacia, cartilage affected the which than are the

sometimes lateral, facets

mirror

lesions. resembling

is more

appearances

in the

patellar case

of the femur are involved although The synovial membrane shows some

is normal. and proliferation

in almost

every

of chondromalacia. over the outer rim vascular connective to the cartilage Histology-Normal layers plate, layer cells any

In a few, usually near an area of fissuring, of the articular cartilage (Figs. 1 and 2). This tissue covered by flattened synovial cells, is hyaline cartilage

a synovial pannus spreads pannus consists of relatively and it is so firmly adherent three poorly defined

as to be inseparable. articular cartilage deepest large and lies on the cells arranged

possessing

(Fig. 7). The and it contains run obliquely, decreases from layer of normal

line of calcified cartilage in vertical columns. layer they are parallel

over the chondro-osseous The cells in the transitional to the surface. The size of the seen in a deep

in the superficial

the deeper cartilage. and 7). No

zones towards the The matrix in the

surface. Mitotic figures are not deep zone is plentiful and stains it stains cartilage less deeply examined

blue with haematoxylin metachromatic (Fig. histological Nodular picture. when pinker reaction indicates (1953), that the matrix. Fissures-The

eosin, but nearer the surface fibres are visible in normal sign of chondromalacia, in the cartilage cells,

and appears by routine microscopical is changed and zones appear acid Schiff areas; Matthews therefore, of the the this

methods. swelling, which is the earliest There is no visible alteration with haematoxylin We have found, that there chondroitin methods,

but

has a typical the matrix

it is stained (Fig. 8). (P.A.S.),

and eosin using special is a decrease sulphuric have made

the superficial and transitional techniques such as the periodic of P.A.S. positive matrix in swollen acid content. Hirsch a similar deduction. alteration the surface,
THE

a decrease in the using biochemical earliest change

earliest

(1944) and It seems, structure the

AND

in chondromalacia
fissures run tangentially

is an
to

in the but
JOURNAL

chemical the
OF

deeper
BONE

fissures
JOINT

SURGERY

P.

WILES,

P.

S. ANDREWS

AND

M. B. DEVAS

101 when examined encircle is marked cartilage an with dark

more ground cells system

vertical or groups Benninghoff of fibres

is their of cells. (1925) arranged

course shows

(Fig. a fine,

8).

The

ground system

substance, of thin fibrils

illumination,

web-like

which

cartilage fissuring. orderly with in

The fibrils demonstrated in arcades. fibres, cartilage

appear to be intact even when there by maceration of normal articular Although the course of the fissures

corresponds any such fibres or by examination

that of Benninghoffs normal or degenerate with polarised

Thirty-one

we have not been able to demonstrate of the patella either by silver impregnation cartilage removed of the III. III
AND FISSURE

light. specimens been examined The results

of patellar

at operation fissures

on account compared with

of chondrothe loss of

malacia have metachromasia.

and the depths are shown in Table TABLE

CORRELATION

BETWEEN

LOSS

OF

METACHROMASIA

FORMATION

Fissure

formation

Metachromasia

None
Slight loss

Superficial 6
5

Half thickness 0
12

Full thickness 0
3

1 loss loss 0 0

Moderate Complete

Of three.

four specimens Of the twenty

with complete loss of metachromasia, deep specimens showing moderate loss of staining

fissures were of the matrix,

present three

in had

fissures reaching through altered staining reaction Cysts of cartilage-Cysts They appear as irregular nearer the surface substance with both. (Fig. gelatinous but never P.A.S. staining and

the full thickness. There is, therefore, correlation between the of the cartilage and the depth of the fissures. are often present in degenerate cartilage when there is fissuring. spaces, usually situated at the base of fissures, but sometimes 9). Although a majority are empty, a few contain a homogeneous with haematoxylin it is basophilic or and sometimes with eosin, eosinophilic, give a constant metachromic in thirteen areas in which of the staining appears

which stains sometimes It does not, whether in twenty them was

reaction. of the

Cysts were present cartilage around in one.

out of thirty-one surgical specimens; reduced, slightly in six, moderately there are focal and by a return The ground

completely

Hyperplasia the cartilage properties

of cartilage-In well cells show hyperplasia of the ground substance

established chondromalacia both by forming cell nests in and around the nests.

substance

to be streaming around the cell nests (Fig. 10). The process can be interpreted as an attempt at regeneration, but it remains circumscribed and the continuity of the cartilage is not restored. The cartilaginous loose bodies found in chondromalacia behave in a similar way (Fig. 11). Two specimens have been examined in which the articular cartilage had first been removed at operation the patella than hyaline and then, about a year later, the patella was excised. The articular surfaces of showed only in structure. a few areas A similar of regeneration, the new cartilage being appearance is often seen after mould of (1948). bone first underlying appear in the areas of fibrous rather arthroplasty of is the line

the hip, as first recorded by Smith-Petersen Bone and basal cartilage-The reaction proliferative. The changes begin when

chondromalacia and then

fissures

cartilage

of calcified cartilage increases in thickness (Fig. 10). As the fissuring extends into the cartilage the increase continues until the thickness of the line is doubled or trebled. New bone is formed in the basal zone and small blood vessels from the marrow spaces penetrate the layer of
VOL.

38 B,

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1956

102 calcified cartilage. after the cartilage A comparable

proliferates, producing

THOMAS

FAIRBANK

BIRTHDAY

VOLUME

There is no evidence is eroded. reaction takes place

cartilage of a

of ischaemic at the
type,

necrosis of
ossification

in the patella.
occurs

bone The
in

either surface the

before cartilage

or

edge

the

fibrous

and marrow which ossify advanced Occasionally

spaces form in the new bone. Thus are formed in the deeper parts to become osteophytes.
degeneration

deeper layers, expanding nodules of fibrocartilage This process occurs near areas of as an 15 and effort 16). at regeneration.

cartilage

and occurs

it also centre

can

be interpreted (Figs.

proliferation

at the

of a facet

FIG.

13
showing between the extent the medial

Section of a knee flexed 75 degrees of the congruity of the articulations

and lateral

patellar

facets and the femur.

Bone

cysts-The

bone

underlying

areas

in which

the

cartilage

has

been

destroyed

becomes

sclerosed, the surface

we have

and small cystic spaces filled with oedematous (Figs. 12 and 16). These cysts have stomata not seen any detritus from the joint inside them.

connective communicating

tissue

appear beneath with the joint, but

ETIOLOGY

The

earliest

demonstrable

change

in chondromalacia

of the not

patella

is an

alteration

in

the reaction of the cartilage matrix have maintained, but to a decrease

to staining. This is due in the chondroitin-sulphuric

to oedema, as many authors acid content. It begins in

the lower part of the medial facet of the patella, articular cartilage of the body. The reason Wiberg (1941). He cut slices of normal knee

which is said by Owre (1936) to be the thickest for this localisation has been investigated by joints frozen at different angles of flexion and

showed that, in the flexed knee, congruity between the medial articular surfaces of the patella and the femur was always less than between the lateral articular surfaces. We have confirmed Wibergs observation using a rapid-freeze technique (Fig. 13). The lateral facet of the patella is concave in two planes and makes contact with the femur through
THE JOURNAL OF BONE AND JOINT SURGERY

P. WILES,

P. S. ANDREWS

AND

M.

B. DEVAS

103

Figure 14-Fissuring of the inner and lower quadrant of the articular cartilage. Figure is developing in the middle of the lower and inner quadrant beneath fissured and partially

15-An

eroded

osteophyte cartilage.

FIG.

16

FIG.

17

Figure Figure

16-There 17-The

is a cyst in the bone entire surface ofthe

at the outer side, cartilage is rough

and an osteophyte and an osteophyte

is forming is forming

near the median ridge. at the outer margin.

much

of the

range
surface

of movement.
of

The

medial

facet

is, however, except even

slightly when the less contact

convex

and

it touches

the convex 60 degrees. and

stress

the

femur

The been

lower suggested

part

only at a single of the medial facet several writers

point, makes that

knee is flexed less than than the upper part, by of the mechanical hip, found

it has applied Harrison,

by

chondromalacia

is caused

to this surface. The supporting Schajowicz and Trueta (1953), more areas damage of the and to the femoral articular head.

evidence is not strong. when studying osteoarthritis

that there was weight-bearing

alternating pressure

cartilage at the non-weight-bearing than at the They suggested that normal movement with its to maintain the nutrition and slab radiographs do areas of bone (Figs. 14 that

of articular not show to

there

cartilage. a trabecular
Nevertheless association

rest exerted a pumping action which helped The patella is not a weight-bearing surface, pattern delineating stressed and non-stressed the
between

17).
is

localisation
pressure,

of
or

the
its

lesions
absence,

an

in the patella supports the thesis and the evolution of chondromalacia.

Whether this is so or not, it is our view that trauma is aggravating than as a primary factor, and that it acts cartilage. The final stage of osteoarthritis is regarded as bone and synovial membrane taking place as a reaction to to the liberation of free particles of degenerate cartilage

of importance more often as an by disrupting already degenerate the result of changes in cartilage, degeneration of the cartilage and the joint.

within

CLINICAL

FEATURES

Symptoms-The
may occur during

patient
adolescence

but it may the patient

VOL.

be precipitated as the cause.

NO.

is commonly a young adult or in early middle age, but symptoms and occasionally in childhood. The onset is often insidious, by a minor injury such as a blow or a twist which is regarded by Occasionally there is a history of a more violent injury several months
1956

38

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1, FEBRUARY

104
before

THOMAS

FAIRBANK

BIRTHDAY

VOLUME

the advice When exercise

when

symptoms is sought the onset and

first by pain, moving

begin.

Some

disability

may

have

been

present rather than

for

months pain;

or

years,

and after
time, is

only after a sudden is insidious there well

there

exacerbation. is at first discomfort There

going some

it is noticed for some

are, of discomfort symptoms

is not
and

localised.
is often

may
swelling

also
down

be discomfort
stairs. from Later effusion. the

after
feeling The

sitting

afterwards,

or when

replaced

however,

intermittent

and,

since

the

knee

returns such
advanced

to normal have
stage,

after not

a couple been given

of days, up.

games

as football the pain and

At a more

few,

which is reached by comparatively and swelling become constant, with

after stress.

exacerbation

disability, of work
A

most

games

There is considerable and the heavier types

are impossible. history of catching

of

the

knee

during

flexion or extension, but seldom both, is common. The patient may say that the knee lets him down. The detached
is is loose free.

catch, flake flexion and It

is

which is of cartilage when the extension

produced (Figs. lower when

by a 1 3 and
,

partly 18), is flake end

felt during

end the

of the upper

during

pressure

may be more applied to the occurs

. .

noticeable when a little patella during movement. there

.

Case

16-The

artlcular

FIG.

cartilage

18

#{149}

after

removal

True
.

locking
.

when
common

is a loose
in chondromalacia.

body

in

showing

a large

flap.

the

Jolnt,

as

is

qulte

intermittent

discomfort

or

pain

which

is

The worse

history can after sitting by a catch may continue with injury; those can

be or

summarised as one of after exercise, perhaps movement. There without getting there is gradual physical signs,

accompanied by a moderate effusion and sometimes may be a spontaneous remission, or mild symptoms worse. Sometimes there is an exacerbation associated deterioration Physical until
signs-A

during indefinitely sometimes

finally positive

the symptoms merge with diagnosis of chondromalacia

of osteoarthritis. be made by the

but neither the history nor the signs give a reliable indication of the severity of the pathological changes. The area of cartilage involved can usually be determined, but not the stage to which degeneration has progressed. There may be considerable disability and marked
tenderness

beneath

the

patella

when

there

is no

more

than

a little when

fissuring both

of the

cartilage, and signs

or the cartilage may are relatively slight.

be in a state

of advanced

disintegration

symptoms

A variety of physical patello-femoral crepitus peripatellar tissues against fat pads may
on

signs have been described but on active movement of the the edge of the bone, effusion, but are open to other The important patella against physical signs the femur. is gently rolled

several are of little diagnostic value: knee, pain caused by rubbing the and enlargement of the infrapatellar Patello-femoral the on the
may

be
grating

present

interpretations. are: With and it surface

crepitus the relation muscles

is

particularly I) Pain are patella patella femur. relaxed

misleading. the each and

knee femur. be comes

extended, The

quadrant surface ensure

in turn

of the push with the the

to the articular downwards to

of the femur varies, that all its articular

necessary to into contact

Pain may also be caused by pressure on the patella while the joint is moved actively or passively; as a rule it is felt only at certain points on the arc of movement. 2) Tenderness on pressure over the articular surface of the patella. This is accessible to palpation when the bone is displaced first to one side and then the other (Fig. 19). The amount
THE JOURNAL OF BONE AND JOINT SURGERY

P.

WILES,

P.

S. ANDREWS

AND

M.

B. DEVAS

105

it can

be displaced

varies

with

the

individual

but

often

the

whole

under-surface is very lax. there is a partly

except detached

the

median ridge 3) A catch flake

pressed

can be felt, and even on flexing or extending

that is exposed the knee can

when the capsule often be felt when

(Figs. 1, 3 and 18). It may against the femur, and it always occurs The presence of pain on grating the patella, diagnostic of chondromalacia provided

of cartilage

be easier to detect when the patella is gently at the same point on the arc of movement. together with tenderness beneath the patella, diseases such as rheumatoid arthritis have

are

other

.)

FIG.

19

Examining

for tenderness

beneath

the patella.

been
must

excluded.

Both

signs

must

be present

and

at exactly

the

same

part

of the

patella.

Care not been found to

also misinterpreted be greater Pain cartilage to find

to

be taken to ensure by the patient.

that the natural discomfort of the At operation the area of cartilage but only occasionally when a vascular pannus

examination involved less. covers part

has is often

than the physical signs suggested, and tenderness are usually severe (Figs. because the

of the articular

demonstrate

beneath

1 and 2). But when there is no pannus, an explanation of these signs is not easy articular cartilage contains no sensory nerve endings, nor have we been able them in abnormal cartilage. An obvious suggestion, so far as tenderness patella is concerned, is that the synovial membrane interposed between the finger area of synovial membrane is seldom tender operation it usually appears to be normal. fold (although this, when inflamed, causes be invaginated far enough. only in so far as they exclude the bone the bone is not involved and the joint other and the space cartilage aid of air

and the cartilage is inflamed. However, the same when pressed against the femur, and at subsequent Nor is the tenderness in the peripatellar synovial tenderness Radiographic disease. thickness at the margin of the examination-Radiographs In early of the and moderately cartilage is not patella)
because

are

it cannot of assistance

advanced chondromalacia greatly reduced, so both many attempts we could think on rare occasions

appear normal. We have made radiologically using every projection and other contrast media, but only

to demonstrate the articular of, both with and without the have they been successful.

DIFFERENTIAL

DIAGNOSIS
is, in our experience, nearly always correct,

A positive even when one surprising how

VOL.

diagnosis

of

chondromalacia

is well aware of the condition and often it is thought to be something

FEBRUARY

is constantly else. The

on the common

watch mistake

for

but it, it is is to call

38 B,

NO.

1,

1956

106 chondromalacia to recognise dislocation a tear it as a cause of the patella

THOMAS

FAIRBANK

BIRTHDAY

VOLUME

of the

medial

semilunar

cartilage,

and

next

in frequency

is the

failure

of loose bodies. is too well known

The association for the former

of chondromalacia to be overlooked

with recurrent (Macnab 1952);

but it is not so well known that dissecans of the femur. Systemic confusion provided reasonable care

the patella is often affected diseases such as rheumatoid is taken.

when there is osteochondritis arthritis are unlikley to cause

Injuries ofthe medialsemilunar cartilage-Most experienced surgeons will admit an appreciable error in the diagnosis of lesions of the semilunar cartilages. We have made this mistake nine times during the six years 1950 to 1955, an error of five per cent, and on each occasion there has been chondromalacia sufficiently advanced to account for the symptoms. The difficulty arises chiefly when there onset of symptoms, and if there is also tenderness lowest slight, Loose centre whether part of the joint. it is tempting bodies-Detached is a history of a twist, perhaps when there is complaint that caused by detached fragments In these circumstances, if the at football, which precipitated the the knee lets me down, especially of cartilage that have fallen to the patellar pain grow in and size tenderness and calcify in the femur. are but

to incriminate the semilunar cartilage. flakes of articular cartilage so often be suspected when there evidence of osteochondritis

in the knee,

that chondromalacia should or not there is radiological

are loose dissecans

bodies of the

TREATMENT The results of operation can be discovered by the ordinary methods of follow-up, but the difficulty in assessing conservative measures is that the precise condition of the articular cartilage is usually unknown. Neither the symptoms nor the signs are a reliable guide to the extent of degeneration. Moreover, in the absence of treatment, deterioration in some knees is rapid, in some it is slow, and others appear to recover. Until there is a clinical method of gauging accurately the condition of the cartilage and of following its course in individual patients the prognosis must remain uncertain and treatment can only be secundum artem. The problem of treatment may be presented to the surgeon in several ways : 1) after a clinical diagnosis of chondromalacia, or of chondromalacia associated with another disorder; 2) on discovery of chondromalacia at an operation performed for another condition that has been misdiagnosed, the symptoms really being due to that proved to be present, the chondromalacia having A clinical diagnosis may be made at any stage patients present themselves with trivial symptoms, are incapacitated. Treatment is hardly slight physical long continued, grades should deterioration. osteoarthritis only gives that been There is an infinite variation in doubt at the extremes. chondromalacia, or for another condition caused no symptoms, or only trivial ones. in the course of the disease because some whereas the more robust wait until they moderate to severe. and correspondingly

from trivial through With minor symptoms

signs it must be conservative. operation gives the best first be treated conservatively There to justify is insufficient operation for this

When the symptoms are incapacitating and chance of restoring function. The intermediate and operation considered only if there is continued as alone. to which It is our knees will ultimately to advise develop operation usually prospect already is reason practice

information

when it is indicated by the severity of the disability. Excision of the patella a good or a fair result, but seldom a perfect one, and there must be a reasonable this operation will leave the patient Discovery at operation offers rather made Small and the condition areas of swollen with a better knee a different problem can be seen. are probably off; found than he already has. because the exposure best left untouched, but has

of the cartilage or soft cartilage

if there

fissuring the affected cartilage may be shaved whole thickness. Lesions of this sort will be patella is inspected at every operation. Areas

it is usually quite often one

THE

unnecessary to remove the if the under-surface of the in diameter

OF BONE AND

up to about

inch

can

be shaved
SURGERY

JOURNAL

JOINT

P.

WILES,

P. 5. ANDREWS

AND

M.

B. DEVAS

107 not be everted and the

after
time

slightly
of recovery

enlarging
is not

the

incision

for

meniscectomy;

the

patella

need

materially

prolonged.

Advanced chondromalacia that has clearly been causing symptoms should be dealt with in the same way as if the operation were one of choice. In the absence of previous permission it may, however, be inadvisable to excise the patella. Conservative treatment-There is no evidence that conservative measures have any effect on the course of the complaint. Many patients with mild symptoms improve without treatment, and many improve with for some amelioration. of one hundred patients. few weeks,
for

it. However, During the Those with has

on The effect

the clinical impression is that treatment is responsible last three years we have treated conservatively upwards trivial symptoms have seldom attended for longer than been greater, they
course

a to

but

when

the disability

have
will

often
not

thought
be known

it worth
for some

while
years.

continue

months.

the

subsequent

#{149}-#{149}

FIG.

20

Case 28 after The injections. may consist methods of treatment

removal

of nearly

all the articular

cartilage

of the patella.

available

are

rest,

short-wave

diathermy,

and

intra-articular are trivial, occupations a

Diathermy is prescribed in every instance. only in avoiding games and all exercise

Rest, when that is not

the symptoms essential, but

involving complete and powerful extension of the knee, such as ballet dancing and walking races, should be stopped. With more severe symptoms immobilisation is desirable and bivalved plaster-of-Paris (or polythene) cylinder is applied with the knee flexed 15 degrees.

It is taken to reduce
contra-indicated.

off at night, the amount We

procedures

and to facilitate diathermy. Exercises of wasting of the quadriceps, but have no experience of intra-articular
have been practised-removal

without exercises
injection

resistance may be given against resistance are of hydrocortisone for affected articular our experience cartilage with

this and this

changes incision

complaint.
of

Operation-Two

the

excision

of the

patella.

Patelloplasty

has

not

been

attempted

because

operation performed for osteoarthritis has not been sufficiently encouraging. The patella is first inspected through a medial parapatellar incision, and if extensive are seen the incision is prolonged to allow the bone to be everted. The complete begins at a point in the mid-line one and a half inches above the patella, and extends for an inch, the of the 1,
FEBRUARY

downwards bone, of the

VOL.

splitting tibia. 1956

the

quadriceps. junction and

It then approaches

curves the

round mid-line

the

inner again

side at the

of the level

dividing tuberosity
NO.

musculo-tendinous

38 B,

108

THOMAS

FAIRBANK

BIRTHDAY

VOLUME

isan
affected finding other

Extensive

fissuring,

flaking

and

erosion

of a considerable

area

of the

articular

cartilage

indication to remove it, but whether this is best effected by shaving off the affected cartilage or by excising the patella is not yet established. Removal ofcartilage-This has been our practice when the area involved has not been greater than about one-third of the whole. With more extensive involvement we have removed the cartilage, if necessary, from the entire patella, when chondromalacia and permission to excise the patella has not been obtained. It has occasions after previous discussion with
TABLE
METHOD OF TREATMENT THE IN SIxTE-nva PATELLA SEEN

has been also been

a chance done on

the

patient.
IV

KNEES AT

WITH

CHONDROMALACIA

OF

OPERATION

Males Seen

Females
5

Total
19

at operation, or all articular excised number

a
.

not treated cartilage

. .

14

Part Patella Total

removed
. .

20
7

11
8

31
15

of knees

41
is sixty-two.

24

65*

The number should cartilage but area

of patients

concerned as well

Nodular, with The On a scalpel, bone a few is not

soft the

cartilage healthy a small exposed

be removed being remains femur of the bevelled

as fissured. margin the basal

This to leave layer same

is done a smooth way, but of cartilage

by shaving surface. (Fig. 20). extensive

at the with been

usually

covered has

occasions

treated

in the

affection of the femoral part of the joint is an indication for excision of the patella. Postoperative recovery is often rather slow, and although function may be restored sufficiently to permit light work after a month, physiotherapy may be necessary for much longer. Excision of the patella-This when it is performed for operation gives fracture. Function short-term is seldom results restored similar to completely those obtained to normal, but

the risk that a second operation of the knee is usually quite good, becomes obvious and this is most The patella, in younger people, expansion to such an extent that

may later become necessary is removed. The appearance but occasionally the contour of the knuckle of the femur unsightly. can usually be dissected out without injuring the quadriceps it needs repair. In older patients more fibres are inserted so attenuated after removal that suture is desirable. of the articular cartilage,

into the central part of the bone and it may become Restoration of function often takes rather longer than and manipulation may be necessary to restore full

flexion.

RESULTS

We have knees from

records

of the condition chondromalacia. already been made

of the articular Those under with the frank

cartilage

as seen

at operation are deliberately history

in sixty-five excluded nineteen

with marked this survey. Reference has

osteoarthritis of natural

heading

to the were The

knees in which the cartilage removal of all or part of the are

was left untouched. articular cartilage,

The remaining forty-six or by excision of the patella.

treated by particulars

detailed in Table V and the results are The result has been called good when and lead an ordinary life without discomfort. up to any ordinary strain. For example,

summarised in Table VI. the patient is able to follow his usual occupation The knees may not be perfect but they do stand the patient in Cases
THE

1 and
OF

26,
BONE

who
AND

had
JOINT

articular
SURGERY

JOURNAL

P.

WILES,

P. S. ANDREWS TABLE V

AND

M.

B. DEVAS

109

OPERATIVE

TREATMENT

OF

CHONDROMALACIA

(To

APRIL

1955)

number

Age

Sex

Occupation

diagnosis

Date of operation

4Time (weeks) normalto

#{149}

Date seen last

Result

Comment

ONE-THIRD

OF

ARTICULAR

CARTILAGE

REMOVED

22

engineer

Sanitary

Chondromalacia
Osteochondritis

Feb. 1952

16

May 1955

Good

Operation on both knees. This one causes no trouble. See Case 26

Loose fragment removed from femoral condyle. Now has no disability

16

Bank clerk

dissecans: Chondromalacia Chondromalacia Chondromalacia Chondromalacia.

Oct.

1953

22

Aug.

1955 Good

3 4

16 37

F M

Clerk Sales manager

Dec.

1953

8 13

Oct. 1954

Good

Obese. Now pupil nurse and knee causes no trouble Superficial scar tender. No other symptoms
removed.

May 1954

June 1955 Good

Torn

41

Heavy lorry driver

Torn

semilunar
cartilage

medial

June

1954

Bad

four

disability.

semilunar cartilage Patella excised months later continuing pain and

(See Case

for
44)

21

Metal

machinist

Chondromalacia
OF

Aug.

1954

14
CARTILAGE

Aug.

1955 Good
REMOVED

Now has no symptoms

TWO-THIRDS M School

ARTICULAR

Patella 7 15

excised

eight

Chondromalacia Torn medial semilunar

cartilage

Mar.

1952

Bad

months later. also affected. Semilunar

normal.

Other knee See Case 35 cartilage

19

Sept.

1953

Oct.

1954

Good Slow

Now no symptoms Oct. 1953 50 Aug. 1955 Good

free

16

School

Torn medial semilunar cartilage Multiple loose bodies Torn medial semilunar cartilage
Torn

of

to recover symptoms

but now

10

27

Doctor

Nov.

1953

10

Oct. 1954

Good

More than 100 cartilaginous loose bodies removed. Now has occasional ache

Industrial

11

24

chemist
P T

Nov.

1953

28

May 1954

Semilunar cartilage normal. Now in South Africa Now practically

Slow to

12

21

instructor

semilunar cartilage

medial

Apr.

1954

Sept.

1955 Good

normal

13

45

Flat

manager

Chondromalacia

May

1954

50

June

1955

Good

function
after

only

regain good but now has slight much swelling exercise cartilage Now has stiffness

14

23

R.A.F.

Torn

semilunar cartilage

June 1954

May 1955

Good
Torn

Semilunar normal.
occaslonal

15

18

Student

Torn medial semilunar

cartilage

June 1954

Aug.

1955 Good

semilunar cartilage removed. Now free of symptoms but other knee

beginning
trouble

to

cause

VOL.

38 B,

NO.

1, FEBRUARY

1956

1 10

THOMAS

FAIRBANK TABLE

BIRTHDAY

VOLUME

V-continued
Time

to

Date seen last

Result

number

Age Sex Occupation

Pre-operative diagnosis

operation Date of

(weeks) normal

Comment

TWO-THIRDS

OF

ARTICULAR

CARTILAGE
1954 12

REMOVED-continued
June 1955 Good Sometimes swells after

School
16 28 M games

and I

Torn

medial
Aug.

semilunar

________________________________________________________________________ -

master

cartilage

much
ofmedial

exercise

Torn

cruciate

Repair

ligament;

17

43

Inspector

of taxes

and

ligament

medial

Aug.

1954

June 1955

Bad

mernscectomy. and Knee deteriorating swells after moderate activity Free of all symptoms two months after
operation

Tom
18 20 M Student

medial
Jan. 1955 8 Mar. 1955
-

semilunar

cartilage 19 37 M Garage hand

Clerk

Loose
Loose

bodies
body

Mar.

1955

June

1955
-

At work

but still lacks

flexion

25 degrees

and
May 1955
-

20
21

28
22

osteochondritis
dissecans

Articular cartilage removed from femur

also

Librarian

Chondromalacia Torn medial semilunar

May

1954

May

1955

Good

Knee

sometimes

feels

stiff

22

33

Telephone

engineer

cartilage

June

1955

Torn

semilunar

cartilage

ALL

ARTICULAR

CARTILAGE Dec. 1951 16

REMOVED
Only symptom is

23

Housewife

Torn medial semilunar

cartilage

Aug.

1954 Good

aching
wet

in

weather

24

27

Secretary

Chondromalacia

Aug.

1952

Feb.

1954

Fair

Gross villous synovitis. Very slow recovery but now is usually free of symptoms and can walk miles; occasional episodes of stiffness and swelling Subsequently had patella excised elsewhere Operation on both knees.
miles. running See

25

15

Telephonist

Torn medial semilunar cartilage

June

1953

Bad

26

25

Sanitary engineer

Chondromalacia

Mar.

1954

12

June

1955 Good

No trouble pain after

twelve

except about some

Case

Torn
27 22 F Nurse

medial semilunar cartilage

Semilunar
May 1954 12 July

cartilage
for long

1955

Good

normal. is some Only achingsymptom after

kneeling

28

36

Technical staff B.B.C. Canteen manageress Transport executive

Secretary

Chondromalacia

Sept.

1954

27

Aug.

1955

Good

Now has no symptoms Still much disability;

excision of

29

43

Chondromalacia

Oct. 1954

July

1955

Bad

requires

patella

30
31

28
24

M
F

Chondromalacia Chondromalacia

Feb. 1955 Apr. 1955

July July

1955 1955

Good

Only
after

several

symptom

sets

is swelling
of tennis

No regained pain

butfullhasflexion not yet

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

P.

WILES,

P. 5. ANDREWS TABLE

AND

M. B. DEVAS

111

V-continued

number

Age

Sex

Occupation

Pre-operative diagnosis

operation Date of

Time (weeks) normal to

Date seen last

Result

Comment

PATELLA
32 34 F Clerk Chondromalacia June 1948

EXCISED 16
-

May

1955

Good
-

Aches

if

overdoes

it

33 34

32 25

M M

Air steward Salesman

Chondromalacia Chondromalacia

Feb. Aug.

1950 1950

June 1950
? Sept. 1954

Cannot Now
has

be traced
no symptoms tworight

Good

35
36

l5
16J

School

tChondromalacia patella. 1 Chondromalacia

left patella

Nov.

1952
1953

20
?

Sept.
Sept.

1954
1954

Fair
Fair

Previous removal thirds cartilage

patella gn (Case

Mar.

ladders long, acheclimbing if he stands

7). Now Both knees

and does not like

Transplantation
Recurrent tendon. Slow

patella
regaining

37

17

Shop
assistant

dislocation

with

Jan.

1953

60

May

1955

Fair

function.

Now

finds

chondromalacia
Chondromalacia Sept. 1953 24 Sept. 1954 Good

kneeling difficult and sometimes swells

Aches Several after
on

38

34

Housewife

sitting

for long opera-

previous

39

24

Housewife

Chondromalacia

May

1954

No

July

1955

Bad

tlons elsewhere.

same knee Unlikely ever function flexion.

to get good
40 33 F Saleswoman Chondromalacia June 1954
-

Aug.

1955

Good

Aches

10 degrees in cold

weather

41

27

Engineer

Chondromalacia

Aug.

1954

24

June

1955

Fair

Lacks and

50 degrees flexion has difficulty in

kneeling Chondromalacia
42 28 F Invoice ; Aug. Oct. 1954 1954 12 Apr. May 1955 1955 Good Fair

Transplantation
tendon

patellar
1945.

clerk

old recurrent

dislocation

Now has no symptoms

Still
Stillachesand

43

40

Hotel
manageress

Chondromalacia;
loose bodies

swells
exercise

after
occasionally

44

42

Heavy driverlorr

Chondromalacia

Oct. 1954

12

Aug.

1955

Fair

gives van. way. See Driving light Case a 5 Much muscle wasting before has not yet operation gained full and control Back at work but has not yet full flexion

45

19

Teaching

student
Clerk

Chondromalacia

Apr.

1955

July

1955

46

49

Chondromalacia

Apr.

1955

July

1955

cartilage because Removal

removed the knee

from both patellae, has that had all the cartilage knees have

had to give up his hobby removed hurts after about been treated in this way,

of long-distance twelve miles. nineteen being

running classified

of cartilage-Thirty-one

as good, one as fair, fair because a moderate is the patient in Case Three years after the
VOL.

five as bad, and six are recent or unknown. Only one has been called early result usually deteriorates quickly and becomes bad. The exception 24 who had a gross villous synovitis and has been very slow to recover. operation she is unconscious of her knee most of the time, and usually 1956

38 B,

NO.

1, FEBRUARY

1 12
can
lasting

THOMAS

FAIRBANK

BIRTHDAY

VOLUME

walk
a

miles
few

without any trouble, but occasionally days. The patients with bad results as the

there are episodes of stiffness and have either had the patella excised amount of cartilage removed

swelling later or increases.

are

likely The

to require further operation. results become less satisfactory the

However,

degeneration osteoarthritis, with cartilage removal extensive

bad results include two patients aged forty-three, and two with very extensive at the age of fifteen. The older patients, who are approaching the age of are probably better treated by excision of the patella. Very young patients degeneration are likely to have early involvement is done. of Better the femoral articular of cases for selection

and a lasting result is improbable whatever of cartilage should improve the results.
TABLE
RESULTS OF OPERATION

VI
(FoRTY-six

Csas)
Result

Nature

of operation Good Fair Bad

Recent or

Total

unknown Articular cartilage

.

removed:
. .

one-third two-thirds completely.

Patella excised
.

5 9

1
2

6 5 1 3 9

16
9 15 46

5 S
24

1 6
7

2 1 6

Total

The patients

only comparable operated upon

figures are those given by Karlson in Alemans clinic one to twenty years Of forty-eight made a functional (it is not stated

(1940) before,

who re-examined but he did not

the give

details of the amount of cartilage removed. without frank osteoarthritis), thirty-two had and three had not improved ; seven patients
evidence

knees with chondromalacia (but recovery, thirteen had improved in which group) had radiological occasions. operation followed the war. had that said

of osteoarthritis. Excision ofthepatella-The The results are not strikingly

patella good

has been removed but they compare

for chondromalacia on fifteen with those of the corresponding supposed. Royal Air normal of pain and Scott Force 55 per (1949) during cent

for recent fracture, which are not as brilliant up a number of men who had been operated He found
a variety

as is commonly upon in the as having complained operation prevents of choice cent

that
of

only troubles,

5 per

for

cent

regarded

themselves 79 per

knees;

the remainder

example,

were unable The long-term years. If complete to osteoarthritis,

they

to walk downstairs normally. results of the more conservative removal of all degenerate cartilage it
may

will not be known the reactive changes in properly selected

for some that lead cases.

well

become

the

procedure

SUMMARY

1. Chondromalacia, sometimes a precursor of osteoarthritis, is present in the articular cartilage of the patella of most people by the age of thirty; it causes symptoms in only a few, and it gives rise to osteoarthritis in fewer still. It may progress slowly or quickly but there is no clinical method of assessing the prognosis at an early stage.
THE JOURNAL OF BONE AND JOINT SURGERY

P. WILES, 2. The earliest change is swelling

P. 5. ANDREWS of the cartilage

AND associated

M. B. DEVAS with a decrease in the chondroitin

113

sulphuric bone, process 3. only articular The and

acid there

content are and signs are

of the reactive the and

matrix. changes etiology treatment symptoms, of the

for

Later in the discussed. are

the

cartilage

fissures bone Operation, in removing and

and

flakes

off to expose membrane.

the The

cartilage, discussed.

synovial which part has knees

and Mr

is described symptoms, there cartilage,

to thank

been are

performed whole given.

for the

when

disabling or in excision
Mr M.

may patella.
help with

consist The
the

or the

of the

results
many

in forty-six

It is a pleasure photomicrographs.

Turney

his

photographs,

P. Runnicles

REFERENCES
ALEMAN, AXHAUSEN,

0. (1928):

Chondromalacia
Die

posttraumatica

patellae.

Acta

Chirurgica
des

Scandinavica,
Kniegelenks. zur

63, 149.
Berliner Klinische Zeitschrift

G.

(1919):

umschriebenen

Knorpel-Knochenlasionen

Wochenschrift,
BENNINGHOFF, f#{252}r Zellforschung BUDINGER,

56, 265.

A. (1925):
und

Form

Mikroskopische

K. (l906):Ober
84, 311.

und Bau der Gelenkknorpel in ihren Beziehungen Anatomic, 2, 783. Ablosung von Gelenkteilen und verwandte Prozesse.
traumatische Knorpelrisse im

Funktion.

Deutsche
Zeitschrift Surgery,

Zeitschrift
f#{252}r Chirurgie, Gynecology

f#{252}r

Chirurgie,
BUDINGER,

K. (1908):
ROWE,

Ober

Kniegelenk.

Deutsche of the Patella.

92, 510. CAVE, E. F.,

and Obstetrics,
CHAKLIN,

C. R., and

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