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Is patellofemoral joint osteoarthritis an under-recognised outcome of anterior cruciate ligament reconstruction? A narrative literature review
Adam G Culvenor,1 Jill L Cook,2 Natalie J Collins,3,4 Kay M Crossley1,3
1

Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia 2 Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia 3 Department of Mechanical Engineering, The University of Melbourne, Parkville, Australia 4 Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia Correspondence to Dr Kay M Crossley, Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Building 84A, St Lucia, Queensland 4072, Australia; k.crossley@uq.edu.au Received 18 June 2012 Accepted 3 September 2012 Published Online First 4 October 2012

ABSTRACT Patellofemoral joint (PFJ) osteoarthritis (OA) is a prevalent disease capable of being a potent source of knee symptoms. Although anterior cruciate ligament (ACL) injury and reconstruction (ACLR) are wellestablished risk factors for the development of tibiofemoral joint OA, PFJ OA after ACL reconstruction has gone largely unrecognised. This is despite the high prevalence of anterior knee pain after ACLR, which can reduce the capacity for physical activity and quality of life. The susceptibility of the PFJ to degenerative change after ACLR may have implications for current rehabilitation strategies. This review summarises the evidence describing the prevalence of PFJ OA after ACLR and examines why this compartment may be at increased risk of early onset OA after ACLR. Strategies that address the modiable factors for risk of PFJ OA may aid in alleviating joint loads and symptoms for people after ACLR.

understanding of the PFJ after ACLR and inform appropriate rehabilitation strategies.

PREVALENCE OF PFJ OA AFTER ACLR Radiographic evaluation of PFJ OA after ACLR

Patellofemoral joint OA is characterised by loss of articular cartilage, osteophyte formation, subchondral bone change and synovitis affecting the patella or femoral trochlea groove. In contrast to more than 100 studies that have been published on TFJ OA after ACL injury and reconstruction,6 only 17 studies have reported radiographic PFJ OA after ACLR, with a prevalence ranging from 11% to 90% (median 36%), 215 years after surgery.7 8 1529 Most radiographic PFJ OA after ACLR was classied as mild (84%), although moderate (15%) and severe (1%) PFJ OA was also observed (table 1). While few studies evaluated PFJ OA less than 5 years after ACLR, it appears that the prevalence increases with time since surgery. Furthermore, in those studies that described OA prevalence in both knee compartments, the PFJ and TFJ appear to be similarly affected by radiographic OA ( gure 1). Notably, the median prevalence of PFJ OA 1015 years after ACLR is almost 50%, and the median age of all individuals studied is 38 years. The prevalence and variability of PFJ OA after ACL injury and reconstruction appears similar to TFJ OA (10 90%, 1020 years after ACL injury)6 and they frequently coexist,8 18 as occurs in the general population.2 The large variability in PFJ OA prevalence may reect the range of radiographic diagnostic criteria used (table 1). The Kellgren and Lawrence (KL) classication system30 considers both osteophytes and joint space narrowing ( JSN), whereas the International Knee Documentation Committee (IKDC)31 and Fairbank classication systems32 emphasise JSN for dening OA. The Osteoarthritis Research Society International atlas33 scores JSN and marginal osteophytes separately in the lateral and medial PFJ compartments. Despite commonly being used to dene PFJ OA, the original KL-grading criteria was described for the TFJ alone30 and thus may not be appropriate to dene PFJ OA. Studies in this review used a variety of scoring systems, and three studies did not use a recognised classication method to dene PFJ OA.16 24 25 Other variability in the studies arose from heterogeneous populations (differing on eligibility criteria such as combined injuries or preoperative radiographic OA), varying radiographic methods (different weight-bearing status and knee exion angles) and different surgical procedures which are

INTRODUCTION
The patellofemoral joint (PFJ) is increasingly recognised as an important contributor to knee joint osteoarthritis (OA).1 2 Indeed, radiographic PFJ OA may be more common than tibiofemoral joint (TFJ) OA in community-based studies,2 3 and more strongly associated with knee symptoms than TFJ OA.4 5 Anterior cruciate ligament (ACL) injury and reconstruction (ACLR) are well-established risk factors for TFJ OA, with degenerative radiographic changes in 1090% of individuals 1020 years after the injury.6 It appears that the PFJ may also be vulnerable to OA development following ACLR.7 8 Given that ACLR surgery is typically performed on people younger than 30 years, early onset of OA may occur some 15 years sooner than expected in the general population.9 10 Owing to limited conservative treatment strategies for OA, early onset OA after ACLR ultimately increases the likelihood of joint replacement surgery at a younger age. Thus, given its potential impact on physical function11 and quality of life,12 PFJ OA may represent an important consideration in those who have undergone ACLR. Rehabilitation following ACLR focuses on returning to physical activity and sport,13 with surgical success often measured by a timely ability to achieve this goal.14. However, if the PFJ is at risk of developing OA after ACLR, then rehabilitation may also need to focus on reducing the risk factors for PFJ disease and symptoms. This narrative review aims to: (1) describe the prevalence of PFJ OA after ACLR; (2) evaluate why the PFJ may be predisposed to degenerative change after ACLR and (3) enhance

To cite: Culvenor AG, Cook JL, Collins NJ, et al. Br J Sports Med 2013, 47, 6673. 1 of 8

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Table 1 Summary of studies that report prevalence of PFJ OA after ACLR using an established radiographic classification system
Radiological methods Follow-up age (years) (meanSD; (range)) 39 (2761) 41 (2977) 30 38 (2657) 42 (2266) 38 (2268) 27 (1838) 3418 31 (2640) 43 (2669) 42 (3159) 40 (38 to 41) 30 (1951) Knee WB angle () no yes NR no yes no no no yes yes yes yes yes 45 30 NR 45 NR 45 40 45 40 NR 50 30 30 Grading system ACLR delay (months) (meanSD; (range)) Years since ACLR (mean (range)) 10 (813) 15 (1417) 2 11 (1015) 11 (912) 7 (59) 6 (57) 8 (220) 9 (112) 13 12 (516) 13 5 PFJ OA prevalence (%)

Study Ahn et al Bourke et al28* Breitfuss et al17 Cohen et al18* Hertel et al29 Jarvela et al19 Keays et al20 21* Li et al22 Lohmander et al8 Murray et al23* Neuman et al7* Salmon et al27 Sajovic et al26
15

N 117 118 41 62 67 100 56 249 31 83 22 49 54

PFJ view Merchant Skyline Tangential Merchant Skyline Merchant Skyline Merchant Skyline Skyline Skyline Skyline Lateral

Mild 49 11 25 ( Mild) 52 6 34 36 10 20 ( Mild) 65 47( Mild) 26 17

Mod. Severe 9 0 NA 23 13 12 0 1 NA 10 NA 0 2 3 1 NA 0 0 1 0 0 NA 1 NA 0 0

IKDC 4357 IKDC 76% were <3 months Fairbank Chronic deficiency Fairbank 16 (0.596) IKDC 11 (0152) IKDC 20 (0240) Modified KL 3438 KL 19 (0308) OARSI 36 (0132) IKDC 30 (0312) OARSI 48 (4132) IKDC 54% were <3 months IKDC 24 (184)

*Studies that excluded those with pre-operative radiographic OA in either compartment. The two papers by Keays et al20 21 are reported as one study cohort as the same group of participants were used and same prevalence reported in both papers. Median (95% CI). ACLR delay, time between anterior cruciate ligament injury and anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee; KL, Kellgren and Lawrence; N, number of participants with x-rays at follow-up; NA, not applicable; NR, not reported; OA, osteoarthritis; OARSI, Osteoarthritis Research Society International; PFJ, patellofemoral joint; WB, weight-bearing.

also likely to contribute to the variability in PFJ OA prevalence observed.

Inuence of graft type on PFJ OA after ACLR

The relationship between ACLR and PFJ OA has mostly been investigated in those with a bone-patellar tendon-bone (BPTB) autograft reconstruction, which was the predominant surgical technique for many years.34 The investigation of PFJ OA after BPTB autograft reconstruction is not surprising given that this procedure harvests the patellar tendon and some bone from the

patella, which are intimately related to the PFJ. This type of reconstruction has been associated with PFJ symptoms.35 36 Recently, hamstring tendon autograft use has increased in popularity and has minimal direct effect on the extensor mechanism. However, despite more frequent rates of PFJ OA noted after BPTB than hamstring tendon autograft (41% compared to 30%20; 30% compared to 16%22) the between-graft differences in PFJ OA prevalence were not signicant20 and did not predict radiographic PFJ OA.22 Although further research is required to conrm these ndings, the current literature suggests that hamstring tendon autograft may not protect against PFJ OA development after ACLR. The potential reasons for this are discussed later in this review. Thus, PFJ OA should be considered in any individual who has undergone ACLR, irrespective of graft type.

Arthroscopic and MRI evaluation of PFJ OA after ACLR

Although radiography remains the most accessible and utilised tool to assess OA, it is unable to detect early-stage joint disease, such as derangement of articular cartilage.37 More sensitive methods to detect changes in articular cartilage may provide valuable insight into onset and progression of PFJ OA. Detection of pre-radiographic joint changes is pertinent after ACL injury, given the likelihood that early changes may lead to longer term more severe structural joint changes and pain.6 A number of studies have utilised arthroscopy and MRI to assess PFJ articular cartilage damage, with current evidence suggesting that pre-radiographic PFJ OA is both present and progressive after ACLR. At second-look arthroscopy, approximately 18 months after ACLR, 3057% of individuals demonstrated deterioration of PFJ cartilage since ACLR.3841 Thus, ACLR does not appear to protect the PFJ from progression of degenerative change. Remarkably, by 711 years after ACL injury, irrespective of conservative or surgical management, individuals have been shown to be 30 times more likely to have patellar cartilage loss on MRI compared with baseline (time of ACL injury) (95% CI 8 to 115).42
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Figure 1 Prevalence of patellofemoral joint and tibiofemoral joint osteoarthritis after anterior cruciate ligament reconstruction. Median and IQR of only studies that used an established classication system to assess PFJ OA. Tibiofemoral OA reported as medial and lateral compartment combined or in studies that report compartmental distribution of TFJ OA alone, the compartment with the highest OA prevalence is included. ACLR, anterior cruciate ligament reconstruction; PFJ OA, patellofemoral joint osteoarthritis; TFJ OA, tibiofemoral joint osteoarthritis.
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PFJ symptoms after ACLR
Knee OA can be dened by radiographic abnormalities alone or in combination with knee symptoms.43 It is important to consider knee pain and symptoms in the diagnosis of OA, as radiographs alone do not dene the clinical syndrome since many patients with radiographic changes are asymptomatic.43 Patellofemoral pain is common after ACLR, particularly with a BPTB autograft, with up to 40% of people reporting anterior knee pain during activity 10 years after ACLR.36 Indeed, patellofemoral pain is said to be one of the most serious and troublesome complications that compromises nal outcome after ACLR.40 This pain is typically attributed to graft site morbidity, from removal of the middle third of the patellar tendon and associated bone, rather than PFJ degeneration. Knee exion contracture (ie, loss of knee extension), which can increase PFJ contact forces, has also been positively correlated with patellofemoral pain.44 Although symptoms and radiographic ndings are often poorly correlated in all OA,45 46 the PFJ has been shown to be a potent source of knee OA symptoms, more so than the TFJ.47 Even isolated mild radiographic PFJ OA can be associated with considerable symptoms that impact substantially on activities of daily living.11 47 Therefore, despite the majority of PFJ OA being of mild severity after ACLR, it may still have important implications for pain and function after ACLR. There are minimal investigations regarding the relationship between radiographic PFJ OA and knee symptoms after ACLR. Jarvela et al19 found signicant differences in subjective reports of pain and function on the Lysholm rating scale between those who were classied as having mild, moderate or severe PFJ OA. However, others have not found this association using alternative patient-reported measures (IKDC subjective score).23 Neuman et al7 noted a non-signicant trend towards worse symptoms in individuals with radiographic PFJ OA on the Knee Injury and Osteoarthritis Outcome Score. The discrepancies that exist in the association between knee symptoms and radiographic PFJ OA may in part be explained by studies associating symptoms with either the presence of any PFJ OA,7 23 or with different levels of radiographic PFJ OA severity.19 Nonetheless, while further research of PFJ OA symptoms after ACLR is required, these ndings highlight that anterior knee pain symptoms should be monitored post-ACLR, and the potential relationship with radiographic PFJ OA considered.

Concomitant damage to articular cartilage and inammation after ACL injury

The substantial force required for ACL rupture, or the instability associated with ACL deciency, may damage articular cartilage and subchondral bone, both in the PFJ and TFJ. Moderate-to-severe cartilage lesions affecting the PFJ are observed in 213% of ACL injured knees,24 40 48 with mild lesions observed in 1529%.38 40 41 49 50 Most importantly, concomitant damage to the articular cartilage, noted at the time of ACLR, predicts longterm radiographic OA in the PFJ and TFJ.21 22 Li et al22 reported the OR for PFJ and TFJ OA in those with articular cartilage damage in the same compartment at the time of ACLR to be 3.7 (95% CI 1.2 to 10.9) and 4.3 (95% CI 2.0 to 9.3), respectively. The time delay between injury and ACLR may also affect PFJ49 and TFJ51 cartilage detrimentally, secondary to ongoing instability. However, femoral trochlea cartilage thinning has been shown to occur 2 years after ACL injury, irrespective of conservative management or early ACLR.52 The initiation of cytokine and protease cascades in the acute phase of ACL rupture is often associated with damage to the type II collagen network, aggrecan and other components of joint cartilage,6 which may be sufcient to initiate cartilage degeneration. Inammatory markers generally diminish with time but may be present for years after ACL injury, at similar levels to those in OA.6 Furthermore, ACLR surgery creates additional intra-articular trauma, which may prolong or initiate a further inammatory response.38 53 Increased concentrations of inammatory biomarkers occur in both serum54 and synovial uid,55 with potential consequences for all joint compartments, including the PFJ. The articular cartilage lesions, observed at the time of ACLR, may be particularly vulnerable to progressing into more severe degenerative joint change in the presence of prolonged inammation before and after ACLR.

Meniscal injury and meniscectomy

Meniscal and ACL injuries frequently coexist.56 Systematic reviews highlight that meniscal tears and/or surgery are established risk factors for TFJ OA after ACL injury57 and in non-ACL injured populations.58 Meniscectomy has also been shown to predict PFJ OA in those with7 21 and without12 ACL injury. The OR for PFJ OA 20 years after medial and lateral meniscectomy without ACL injury was 2.6 (95% CI 1.1 to 6.6) and 5.3 (95% CI 1.9 to 15.0), respectively.12 Although approximately one-third of those who went on to develop PFJ OA in this cohort had PFJ cartilage changes at the time of meniscectomy12, the development of PFJ OA in the remaining two-thirds must be attributed to alternate factors. Similarly, in those with an ACL injury, meniscectomy at the time of ACLR was associated with PFJ OA (r=0.45) at 6 year follow-up.21 An injured or resected meniscus could have mechanical effects on TFJ transverse plane rotation59 or frontal plane alignment, which may alter PFJ contact pressure.60 61 Although no studies have evaluated PFJ alignment after meniscectomy, altered frontal plane moments have been observed after partial meniscectomy compared with healthy controls.62 63 Further research is required to investigate the mechanical effects of meniscal injury and surgery, and the relationship with PFJ mechanics and subsequent PFJ morbidity. However, from the available literature, it appears that meniscus preservation, where possible after ACL injury, may protect the PFJ from OA development.

Summary of PFJ OA prevalence after ACLR

Current evidence indicates that PFJ OA is prevalent after ACLR. Although most radiographic changes are mild, PFJ OA has the potential to adversely affect pain and function after ACLR, thus highlighting the importance for clinicians to consider the PFJ during postoperative rehabilitation. PFJ articular cartilage degeneration appears to be progressive after ACLR, which likely contributes to the development of radiographic PFJ OA over time.

PROPOSED CONTRIBUTORS TO PFJ OA DEVELOPMENT AFTER ACLR

Injury and reconstruction of the ACL can have adverse effects on all knee compartments; however there are events that occur during an ACL injury and after reconstruction that may have specic implications for the PFJ. Such events include concomitant damage to articular cartilage and meniscus, inammation, biomechanical changes and quadriceps strength decits, which may contribute to a greater risk of developing PFJ OA after ACLR.
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Tibiofemoral biomechanics inuence patellofemoral load

Knee biomechanics may provide valuable insight into why an ACLR places the PFJ at risk of developing OA. It is wellCulvenor AG, et al. Br J Sports Med 2013;47:6670. doi:10.1136/bjsports-2012-091490

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established that TFJ biomechanics, including joint motions and loads are altered following ACL injury64 and do not appear to be restored with either a BPTB or hamstring autograft reconstruction.6568 Altered TFJ kinematics after ACLR are hypothesised to contribute to the initiation and progression of TFJ OA by changing cartilage load distribution.6971 Although the biomechanics of the PFJ are different to the TFJ, evidence from cadaver and modelling studies indicate that changes in TFJ mechanics can alter PFJ alignment and stress.72 73 Therefore, alterations in TFJ kinematics have the potential to affect PFJ mechanics and predispose to PFJ OA initiation or progression. Injury to the ACL disrupts antero-posterior stability in the sagittal plane and rotatory stability in the transverse plane.64 Although reconstruction normally restores antero-posterior and rotatory stability, it does not consistently restore transverse plane rotation range of motion (ROM).71 Most studies concur that greater tibial rotation ROM, or external rotation offset (decreased internal rotation/increased external rotation) is evident in the ACLR knee compared to the uninjured knee65 67 7483 and healthy controls.67 68 77 8082 84 This is likely to have signicant implications for the PFJ, given that experimentally induced tibial external rotation is associated with increased lateral patellar tilt and rotation85 and PFJ load60 ( gure 2A). Indeed, Van de Velde et al86 found that abnormal patellar rotation, tilt and lateral shift in cartilage contact occurred in vivo after ACL injury and was not restored with ACLR. These altered transverse plane TFJ and PFJ kinematics may predispose PFJ cartilage to degenerative change, theoretically preceding the development of PFJ OA. Not all studies noted abnormalities in tibial rotation after ACLR.8790 The inconsistencies in study ndings may be attributed to difculties in accurately measuring tibial rotation using three-dimensional motion analyses, and differences in task (eg, high-demand vs low-demand) or ACLR technique (eg, singlebundle or double-bundle). For example, there is preliminary evidence that a more obliquely placed femoral tunnel may correct abnormal tibial rotation more effectively,68 82 9193 but may not be associated with PFJ OA development.94 Both the doublebundle and oblique-tunnel orientation techniques require further investigation into their ability to restore transverse plane kinematics, and thus the ability to protect the PFJ and TFJ from unaccustomed load and OA development or progression. In the frontal plane, an increased external knee adduction moment (internal knee abduction moment) has been observed 5 years after ACLR and may present a potential mechanism for medial TFJ OA development.95 Although these results were not corroborated by different studies at 20 months96 or 6 years97 after ACLR, altered TFJ alignment in the frontal plane can affect PFJ loading patterns by increasing load on the medial or lateral patellar facet, and potentially predispose the PFJ to OA98 ( gure 2B). Notably, TFJ valgus alignment may be of particular relevance for PFJ OA considering that an external knee abduction moment (internal knee adduction moment) is a risk factor for PFJ pain in adolescents.99 Interventions aimed at correcting frontal plane malalignment, such as gait retraining, hamstring and hip abductor strengthening, knee braces or medially or laterally wedged shoe inserts, which attempt to optimise TFJ load,100 may also be important for PFJ alignment and stress.

Loss of knee range of motion

In the sagittal plane, increasing TFJ exion angles progressively increase both PFJ contact area and pressure due to the resultant quadriceps and patellar tendon forces101 ( gure 2C). This is important after ACLR given that an inability to achieve full knee extension has been shown to occur in up to 21% of individuals10 102 103 and has been associated with the presence of PFJ OA7 19 and TFJ OA.10 102 Knee extension loss subjects the PFJ to a constant heightened compressive load in weight-bearing101 and is positively correlated with patellar irritability and patellofemoral symptoms.44 Loss of knee exion after ACLR has also been associated with PFJ OA.7 It is thus imperative for early postoperative rehabilitation strategies, as recommended by Shelbourne and Nitz,104 to focus on achieving full knee extension and exion to prevent longer term abnormal PFJ loading.

Quadriceps strength and vasti co-ordination

Muscle weakness is one of the earliest and most frequent ndings in people with knee OA105 and may be a greater risk factor for PFJ OA than TFJ OA. In a rabbit model, experimental quadriceps weakness induced retropatellar cartilage degeneration, which was not seen in TFJ cartilage.106 Similarly, greater quadriceps strength protected against lateral PFJ cartilage loss in humans,107 but this relationship was not found in the TFJ.107 108 Since quadriceps strength decits may persist for up to 6 years after ACLR,20 quadriceps weakness after ACLR may play a role in the development of PFJ OA. However, the only study to specically evaluate the relationship between quadriceps strength and PFJ OA found no association,21 thus the relationship between quadriceps weakness and PFJ OA development remains unclear. A further consideration for the relationship between quadriceps strength and PFJ OA after ACLR is the co-ordinated activation of all four quadriceps components. Optimal PFJ biomechanics relies on the interaction between the vastus medialis obliquus (VMO) and vastus lateralis.109 Inhibition or delayed onset of the VMO occurs in the presence of knee pain110 111 and effusion,112 113 which is common after ACLR.36 If alteration of the VMO function (lower magnitude and/or delayed onset timing) is present after ACLR, increased lateral PFJ stress may follow, potentially contributing to the pathogenesis of PFJ symptoms and OA. This requires further investigation in an ACLR cohort.

Figure 2 Schematic drawing demonstrating how the patellofemoral joint is affected by; (A) transverse plane external tibial rotation; (B) frontal plane malalignment and (C) sagittal plane knee exion.

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Summary of proposed contributing factors to PFJ OA after ACLR
Factors with potential to contribute to the development of PFJ OA after ACLR have been proposed. Inammation and concomitant damage to the PFJ articular cartilage or meniscus at the time of, or after ACL injury and reconstruction may make the PFJ vulnerable to degeneration. The inability of an ACLR to fully restore knee biomechanics and the prolonged ROM and strength decits that may occur even after rehabilitation may further promote derangement of the PFJ and, combined with compromised articular cartilage, lead to PFJ OA. Another factor with potential to contribute to the development of PFJ OA after ACLR, which has rarely been considered in the literature is the impact of physical activity and return to sport.7 While measurement and reporting of physical activity is challenging, these measures should be considered in future trials. Higher patellofemoral loads may be experienced by individuals who return to sport/physical activity compared to those who do not, especially if biomechanical features that increase PFJ stress are evident after ACLR. Future studies could also investigate if either specic rehabilitation exercises have the potential to reduce PFJ stress after ACLR121 or whether there are commonly used exercises in ACLR rehabilitation that increase PFJ stress, which should be modied or avoided. This review has proposed several theoretical mechanisms for the development and progression of PFJ OA after ACLR. However, more controlled longitudinal studies to investigate surgical, biochemical, biomechanical and musculoskeletal risk factors, associated with the early changes assessed from MRI and more advanced degeneration from radiographs, are needed. Knowledge surrounding these risk factors may enable modication of rehabilitation goals or surgical technique to address decits associated with the development or progression of PFJ OA and symptoms after ACLR.

RECOMMENDATIONS AND FUTURE RESEARCH DIRECTIONS

The proposed factors involved in the development of PFJ OA require research to optimise the outcome after ACLR and minimise the burden of PFJ OA. Increasing awareness that the PFJ is an important compartment to consider after ACLR will encourage future studies to image the PFJ compartment more frequently, using appropriate imaging methods, and report specic compartmental distribution of OA. Although it would be valuable to compare PFJ OA prevalence between surgical and conservative management after ACL injury, it was not possible in this review. The two studies that compared PFJ OA prevalence between the two management options only performed ACLR on those participants who failed conservative management, thus biasing the surgical cohort.7 8 Therefore, welldesigned studies, ideally randomised controlled trials, are required to elucidate if conservative or surgical management has a greater impact on long-term PFJ health and symptoms. Identifying pathophysiological and biochemical changes during the initial stages of PFJ OA development may highlight potential risk factors leading to disease onset and progression. The emergence of MRI and quantitative image analysis promise more sensitive methods for diagnosis and evaluation of articular cartilage derangement and early OA changes. Such methods include T2-weighted MRI mapping and the delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) technique, which evaluate glycosaminoglycan concentration to indicate cartilage biochemical status. A number of classication systems to describe early OA changes from MRI have recently been established,114116 and should be utilised in future studies to evaluate the PFJ after ACLR. Although MRI remains expensive in clinical practice, all routine radiographs should at least include a skyline view. In addition, clinicians should be more alert to complaints of patellofemoral pain after ACLR and more focused on preventing patellofemoral paina likely predictor of PFJ OA.117 While this review has not specically investigated risk factors for ACL injury, there is emerging evidence that ACL injury shares some similar risk factors as patellofemoral pain. Hip and knee kinematics, specically excessive hip internal rotation118 and increased external knee abduction moment (internal knee adduction moment),99 have been shown to be risk factors for patellofemoral pain and are likely to contribute to high knee valgus loads when landing from a jump.119 Furthermore, prospective measures of dynamic knee valgus during landing predict ACL injury risk.120 The link between patellofemoral pain and ACL injury may enable preventative strategies to target both problems simultaneously and reduce both ACL injuries, and hence ACLR, and post-traumatic PFJ OA. Future research could investigate whether the kinematics that drive an ACL rupture are also risk factors for the development of PFJ OA.

CONCLUSION
This review concludes that PFJ OA may be an under-recognised outcome of ACLR, and be at least as common as TFJ OA. The symptomatic and functional implications of PFJ OA and its inuence on the short-term and long-term outcomes after ACLR are not known, despite the potential for PFJ OA to be a potent source of knee symptoms. Factors that may lead to the wellestablished link between TFJ OA and ACL injury and reconstruction can also affect the PFJ compartment. Articular cartilage lesions, inammation, meniscal injury and resection, quadriceps strength decits and altered biomechanics may all contribute to the increased risk of PFJ OA after ACLR. Optimising surgical technique, management of postinjury and postoperative inammation, and pursuing a targeted rehabilitation may assist in preventing or ameliorating PFJ OA after ACLR.

What this study adds There is a high prevalence of patellofemoral joint (PFJ) osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR). Several mechanisms exist for PFJ OA after ACLR. The importance of addressing factors contributing to PFJ OA development and/or progression during ACLR rehabilitation programmes.

Contributors All authors contributed to the conception, design, writing and revisions of this review. Funding The authors would like to acknowledge funding support for AC from Arthritis Victoria and an Australian Postgraduate Award, and for NC from a National Health and Medical Research Council postdoctoral fellowship. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.

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REFERENCES
1 2 3 Hinman RS, Crossley KM. Patellofemoral joint osteoarthritis: an important subgroup of knee osteoarthritis. Rheumatology 2007;46:105762. Duncan R, Hay E, Saklatvala J, et al. Prevalence of radiographic osteoarthritis: it all depends on your point of view. Rheumatology 2006;45:75760. Szebenyi B, Hollander A, Dieppe P, et al. Associations between pain, function, and radiographic features in osteoarthritis of the knee. Arthritis Rheum 2006;54:2305. Kornaat P, Bloem J, Ceulemans R, et al. Osteoarthritis of the knee: association between clinical features and MR imaging ndings. Radiology 2006;239:81117. Hunter DJ, March L, Sambrook PN. The association of cartilage volume with knee pain. Osteoarthritis Cartilage 2003;11:7259. Lohmander LS, Englund PM, Dahl LL, et al. The long-term consequence of anterior cruciate ligament and meniscus injuries. Am J Sport Med 2007;35:175669. Neuman P, Kostogiannis I, Friden T, et al. Patellofemoral osteoarthritis 15 years after anterior cruciate ligament injurya prospective cohort study. Osteoarthritis Cartilage 2009;17:28490. Lohmander S, Ostenberg A, Englund M, et al. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccor players twelve years after anterior cruciate ligament injury. Arthritis Rheum 2004;50:314552. Carey J, Dunn W, Dahm D, et al. A systematic review of anterior cruciate ligament reconstruction with autograft compared with allograft. J Bone Joint Surg Am 2009;91:224250. Shelbourne KD, Gray T. Minimum 10-year results after anterior cruciate ligament reconstruction. Am J Sport Med 2009;37:47180. Duncan R, Peat G, Thomas E, et al. Does isolated patellofemoral osteoarthritis matter? Osteoarthritis Cartilage 2009;17:11515. Englund M, Lohmander LS. Patellofemoral osteoarthritis coexistent with tibiofemoral osteoarthritis in a meniscectomy population. Ann Rheum Dis 2005;64:17216. Myklebust G, Bahr R. Return to play guidelines after anterior cruciate ligament surgery. Br J Sport Med 2005;39:12731. Ardern C, Webster K, Taylor N, et al. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery. Am J Sport Med 2011;39:53843. Ahn JH, Kim JG, Wang JH, et al. Long-term results of anterior cruciate ligament reconstruction using bone-patellar tendon-bone: an analysis of the factors affecting the development of osteoarthritis. Arthroscopy 2012;28:111423. Berg EE. Template versus freehand bone-patellar tendon-bone harvest for anterior cruciate ligament reconstruction: its effect on patellofemoral morbidity. J South Orthop Assoc 2001;10:6572. Breitfuss H, Frohlich R, Povacz P, et al. The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendona problem for the patellofemoral joint? Knee Surg Sports Traumatol Arthrosc 1996;3:1948. Cohen M, Amaro J, Ejnisman B, et al. Anterior cruciate ligament reconstruction after 10 to 15 years: association between meniscetomy and osteoarthrosis. Arthroscopy 2007;23:62934. Jarvela T, Paakkala T, Kannus P, et al. The incidence of patellofemoral osteoarthritis and associated ndings 7 years after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft. Am J Sport Med 2001;29:1824. Keays SL, Bullock-Saxton JE, Keays AC, et al. A 6-year follow-up of the effect of graft site on strength, stability, range of motion, function, and joint degeneration after anterior cruciate ligament reconstruction. Am J Sport Med 2007;35:72939. Keays SL, Newcombe PA, Bullock-Saxton JE, et al. Factors involved in the development of osteoarthritis after anterior cruciate ligament surgery. Am J Sport Med 2010;38:45563. Li RT, Lorenz S, Xu Y, et al. Predictors of radiographic knee osteoarthritis after anterior cruciate ligament reconstruction. Am J Sport Med 2011;39:2595603. Murray JRD, Lindh AM, Hogan NA, et al. Does anterior cruciate ligament reconstruction lead to degenerative disease? Thirteen-year results after bone-patellar tendon-bone autograft. Am J Sport Med 2011;40:40413. Rosenberg TD, Franklin JL, Baldwin GN, et al. Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction. Am J Sport Med 1992;20:51926. Roth JH, Kennedy JC, Lockstadt H, et al. Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction. Am J Sport Med 1985;13:32136. Sajovic M, Vengust V, Komadina R, et al. A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: Five-year follow-up. Am J Sport Med 2006;34:193340. Salmon L, Russell V, Refshauge K, et al. Long-term outcome of endoscopic anterior cruciate ligament reconstruction with patelllar tendon autograft: minimum 13-year review. Am J Sport Med 2006;34:72132. 28 Bourke HE, Gordon DJ, Salmon LJ, et al. The outcome at 15 years of endoscopic anterior cruciate ligament reconstruction using hamstring tendon autograft for isolated anterior cruciate ligament rupture. J Bone Joint Surg Br 2012;94:6307. Hertel P, Behrend H, Cierpinski T, et al. ACL reconstruction using bone-patellar tendon-bone press-t xation: 10-year clinical results. Knee Surg Sports Traumatol Arthrosc 2005;13:24855. Kellgren J, Lawrence J. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16:494502. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sport Med 2001;29:60013. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br 1948;30:66470. Altman RD, Hochberg M, Murphy WA Jr, et al. Atlas of individual radiographic features in osteoarthritis. Osteoarthritis Cartilage 1995;3(Suppl A):370. Hospodar SJ, Miller MD. Controversies in ACL reconstruction: bone-patellar tendon-bone anterior cruciate ligament reconstruction remains the gold standard. Sports Med Arthrosc 2009;17:2426. Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sport Med 2003;31:56473. Pinczewski L, Lyman J, Salmon L, et al. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sport Med 2007;35:56474. Pollard TCB, Gwilym SE, Carr AJ. The assessment of early osteoarthritis. J Bone Joint Surg Br 2008;90:41121. Asano H, Muneta T, Ikeda H, et al. Arthroscopic evaluation of the articular cartilage after anterior cruciate ligament reconstruction: a short-term prospective study of 105 patients. Arthroscopy 2004;20:47481. Meyers JF, St. Pierre RK, Sutter JS, et al. Arthroscopic evaluation of anterior cruciate ligament reconstructions. Arthroscopy 1986;2:15561. Shino K, Nakagawa S, Inoue M, et al. Deterioration of patellofemoral articular surfaces after anterior cruciate ligament reconstruction. Am J Sport Med 1993;21:20611. Wang H, Ao Y, Chen L, et al. Second-look arthroscopic evaluation of the articular cartilage after primary single-bundle and double-bundle anterior cruciate ligament reconstructions. Chin Med J 2011;124:35515. Potter HG, Jain SK, Ma Y, et al. Cartilage injury after acute, isolated anterior cruciate ligament tear. Am J Sport Med 2012;40:27685. Altman RD, Asch E, Bloch D, et al. Development of criteria for the classication and reporting of osteoarthritis. Arthritis Rheum 1986;29:103949. Sachs RA, Daniel DM, Stone ML, et al. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sport Med 1989;17:7605. Creamer P, Lethbridge-Cejku M, Hochberg MC. Factors associated with functional impairment in symptomatic knee osteoarthritis. Rheumatology 2000;39:4906. Hannan MT, Felson DT, Pincus T. Analysis of the discordance between radiographic changes and knee pain in osteoarthritis of the knee. J Rheumatol 2000;27:151317. Duncan R, Peat G, Thomas E, et al. How do pain and function vary with compartmental distribution and severity of radiographic knee osteoarthritis? Rheumatology 2008;47:17047. Hjermundrud V, Bjune T, Risberg M, et al. Full-thickness cartilage lesion do not affect knee function in patients with ACL injury. Knee Surg Sports Traumatol Arthrosc 2010;18:298303. Oksam A, Dmytruk V, Proust J, et al. Patellar chondropathy prevalence at anterior cruciate ligament reconstruction: analysis of 250 cases. Orthop Traumatol Surg Res 2009;95:369. Tria AJ, Alicea JA, Cody RP. Patella baja in anterior cruciate ligament reconstruction of the knee. Clin Orthop Relat Res 1994;299:22934. Murrell GAC, Maddali S, Horovitz L, et al. The effects of time course after anterior cruciate ligament injury in correlation with meniscal and cartilage loss. Am J Sport Med 2001;29:914. Frobell R. Change in cartilage thickness, posttraumatic bone marrow lesions, and joint uid volumes after acute ACL disruption. J Bone Joint Surg Am 2011;93:1096103. Taskiran E, Taskiran D, Duran T, et al. Articular cartilage homeostasis after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 1998;6:938. Kong SY, Stabler TV, Criscione LG, et al. Diurnal variation of serum and urine biomarkers in patients with radiographic knee osteoarthritis. Arthritis Rheum 2006;54:2496504. Lohmander LS, Atley LM, Pietka TA, et al. The release of crosslinked peptides from type II collagen into human synovial uid is increased soon after joint injury and in osteoarthritis. Arthritis Rheum 2003;48:31309. Neuman P, Englund M, Kostogiannis I, et al. Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study. Am J Sport Med 2008;36:171725.

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Review
57 58 59 60 iestad B, Engebretsen L, Storheim K, et al. Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sport Med 2009;37:143443. Papalia R, Del Buono A, Osti L, et al. Meniscectomy as a risk factor for knee osteoarthritis: a systematic review. Br Med Bull 2011;99:89106. Netravali NA, Giori NJ, Andriacchi TP. Partial medial meniscectomy and rotational differences at the knee during walking. J Biomech 2010;43:294853. Lee T, Morris G, Csintalan R. The inuence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther 2003;33:68693. Huberti HH, Hayes WC. Patellofemoral contact pressures: the inuence of Q-angle and tendofemoral contact. J Bone Joint Surg Am 1984;66:71524. Sturnieks DL, Besier T, Hamer PW, et al. Knee strength and knee adduction moments following arthroscopic partial meniscectomy. Med Sci Sports Exerc 2008;40:9917. Sturnieks DL, Besier TF, Mills PM, et al. Knee joint biomechanics following arthroscopic partial meniscectomy. J Orthop Res 2008;26:107580. Chaudhari AMW, Briant PL, Bevill SL, et al. Knee kinematics, cartilage morphology, and osteoarthritis after ACL injury. Med Sci Sports Exerc 2008;40:21522. Deneweth JM, Bey MJ, McLean SG, et al. Tibiofemoral joint kinematics of the anterior cruciate ligament-reconstructed knee during a single-legged hop landing. Am J Sport Med 2010;38:18208. Gao B, Zheng NQ. Alterations in three-dimensional joint kinematics of anterior cruciate ligament-decient and -reconstructed knees during walking. Clin Biomech 2010;25:2229. Georgoulis AD, Ristanis S, Chouliaras V, et al. Tibial rotation is not restored after ACL reconstruction with a hamstring graft. Clin Orthop Relat Res 2007;454:8994. Webster KE, Feller JA. Alterations in joint kinematics during walking following hamstring and patellar tendon anterior cruciate ligament reconstruction surgery. Clin Biomech 2011;26:17580. Andriacchi T, Mundermann A. The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis. Curr Opin Rheumatol 2006;18:51418. Andriacchi TP, Briant PL, Bevill SL, et al. Rotational changes at the knee after ACL injury cause cartilage thinning. Clin Orthop Rel Res 2006;442:3944. Stergiou N, Ristanis S, Moraiti C, et al. Tibial rotation in anterior cruciate ligament (ACL)-decient and ACL-reconstructed kneesa theoretical proposition for the development of osteoarthritis. Sports Med 2007;37:60113. Hsieh YF, Draganich LF, Ho SH, et al. The effects of removal and reconstruction of the anterior cruciate ligament on patellofemoral kinematics. Am J Sport Med 1998;26:2019. Hsieh Y-F, Draganich LF, Ho SH, et al. The Effects of removal and reconstruction of the anterior cruciate ligament on the contact characteristics of the patellofemoral joint. Am J Sport Med 2002;30:1217. Tashman S, Collon D, Anderson K, et al. Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sport Med 2004;32:97583. Tashman S, Kolowich P, Collon D, et al. Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Rel Res 2007;454:6673. Webster KE, McClelland JA, Wittwer JE, et al. Three dimensional motion analysis of within and between day repeatability of tibial rotation during pivoting. Knee 2010;17:32933. Chouliaras V, Ristanis S, Moraiti C, et al. Effectiveness of reconstruction of the anterior cruciate ligament with quadrupled hamstrings and bone-patellar tendon-bone autografts. Am J Sport Med 2007;35:18996. Chouliaras V, Ristanis S, Moraiti C, et al. Anterior cruciate ligament reconstruction with a quadrupled hamstrings tendon autograft does not restore tibial rotation to normative levels during landing from a jump and subsequent pivoting. J Sports Med Phys Fitness 2009;49:6470. Ristanis S, Giakas G, Papageorgiou CD, et al. The effects of anterior cruciate ligament reconstruction on tibial rotation during pivoting after descending stairs. Knee Surg Sports Traumatol Arthrosc 2003;11:3605. Ristanis S, Stergiou N, Patras K, et al. Follow-up evaluation 2 years after ACL reconstruction with bone-patellar tendon-bone graft shows that excessive tibial rotation persists. Clin J Sport Med 2006;16:11116. Ristanis S, Stergiou N, Patras K, et al. Excessive tibial rotation during high-demand activities is not restored by anterior cruciate ligament reconstruction. Arthroscopy 2005;21:13239. Ristanis S, Stergiou N, Siarava E, et al. Effect of femoral tunnel placement for reconstruction of the anterior cruciate ligament on tibial rotation. J Bone Joint Surg Am 2009;91:21518. Scanlan SF, Chaudhari AMW, Dyrby CO, et al. Differences in tibial rotation during walking in ACL reconstructed and healthy contralateral knees. J Biomech 2010;43:181722. Webster KE, Feller JA. Tibial rotation in anterior cruciate ligament reconstructed knees during single limb hop and drop landings. Clin Biomech 2012;27:4759. 85 Heegaard JH, Leyvraz PF, Hovey CB. A computer model to simulate patellar biomechanics following total knee replacement: the effects of femoral component alignment. Clin Biomech 2001;16:41523. Van de Velde SK, Gill TJ, DeFrate LE, et al. The effect of anterior cruciate ligament deciency and reconstruction on the patellofemoral joint. Am J Sport Med 2008;36:11509. Georgoulis AD, Papadonikolakis A, Papageorgiou CD, et al. Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament-decient and reconstructed knee during walking. Am J Sport Med 2003;31:759. Isberg J, Faxen E, Laxdal G, et al. Will early reconstruction prevent abnormal kinematics after ACL injury? Two-year follow-up using dynamic radiostereometry in 14 patients operated with hamstring autografts. Knee Surg Sports Traumatol Arthrosc 2011;19:163442. Kanisawa I, Banks AZ, Banks SA, et al. Weight-bearing knee kinematics in subjects with two types of anterior cruciate ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 2003;11:1622. Lam M, Fong D, Yung P, et al. Knee rotational stability during pivoting movement is restored after anatomic double-bundle anterior cruciate ligament reconstruction. Am J Sport Med 2011;39:10328. Webster KE, Palazzolo SE, McClelland JA, et al. Tibial rotation during pivoting in anterior cruciate ligament reconstructed knees using a single bundle technique. Clin Biomech 2012;27:4804. Misonoo G, Kanamori A, Ida H, et al. Evaluation of tibial rotation stability of single-bundle vs. double-bundle anterior cruciate ligament reconstruction during high-demand activitya quasi-randomsied trial. Knee 2012;19:8793. Tsarouhas A, Iosidis M, Kotzamitelos D, et al. Three-dimensional kinematic and kinetic analysis of knee rotational stability after single- and double-bundle anterior cruciate ligament reconstruction. Arthroscopy 2010;26:88593. van Eck CF, Keays SL, Illingworth KD, et al. Letter to the Editor. Am J Sport Med 2010;38:NP12. Butler RJ, Minick KI, Ferber R, et al. Gait mechanics after ACL reconstruction: implications for the early onset of knee osteoarthritis. Br J Sport Med 2009;43:36670. Webster KE, McClelland J, Palazzolo SE, et al. Gender differences in the knee adduction moment after anterior cruciate ligament reconstruction surgery. Br J Sport Med 2012;46:3559. Hall M, Stevermer CA, Gillette JC. Gait analysis post anterior cruciate ligament reconstruction: knee osteoarthritis perspective. Gait Posture 2012;36:5660. Elahi S, Cahue S, Felson DT, et al. The association between varusvalgus alignment and patellofemoral osteoarthritis. Arthritis Rheum 2000;43:187480. Myer GD, Ford KR, Barber Foss KD, et al. The incidence and potential pathomechanics of patellofemoral pain in female athletes. Clin Biomech 2010;25:7007. Reeves ND, Bowling FL. Conservative biomechanical strategies for knee osteoarthritis. Nat Rev Rheumatol 2011;7:11322. Hungerford SS, Barry M. Biomechanics of the patellofemoral joint. Clin Orthop Rel Res 1979;144:915. Roe J, Pinczewski L, Russell V, et al. A 7-year follow up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: differences and similarities. Am J Sport Med 2005;33:133745. Hui C, Salmon L, Kok A, et al. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with the patellar tendon autograft for isolated anterior cruciate ligament tear. Am J Sport Med 2011;39:8998. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sport Med 1990;18:2929. Palmieri-Smith RM, Thomas AC, Karvonen-Gutierrez C, et al. Isometric quadriceps strength in women with mild, moderate, and severe knee osteoarthritis. Am J Phys Med Rehabil 2010;89:5418. Rehan Youssef A, Longino D, et al. Muscle weakness causes joint degeneration in rabbits. Osteoarthritis Cartilage 2009;17:122835. Amin S, Baker K, Niu J, et al. Quadriceps strength and the risk of cartilage loss and symptom progression in knee osteoarthritis. Arthritis Rheum 2009;60:18998. Brandt KD, Heilman DK, Slemenda C, et al. Quadriceps strength in women with radiographically progressive osteoarthritis of the knee and those with stable radiographic changes. J Rheumatol 1999;26:24317. Elias JJ, Kilambi S, Goerke DR, et al. Improving vastus medialis obliquus function reduces pressure applied to lateral patellofemoral cartilage. J Orthop Res 2009;27:57883. Cowan S, Bennell K, Hodges P, et al. Delayed onset of electromyographic activity of vastus medialis obliquus relative to vastus lateralis in subjects with patellofemoral pain syndrome. Arch Phys Med Rehabil 2001;82:1839. Hodges P, Bennell K, Mellor R, et al. Experimental anterior knee pain replicates aspects of muscle dysfunction in patellofemoral pain. J Sci Med Sport 2003;6:96. Torry MR, Decker MJ, Viola R, et al. Intra-articular knee joint effusion induces quadriceps avoidance gait patterns. Clin Biomech 2000;15:14759. Spencer JD, Hayes KC, Alexander IJ. Knee joint effusion and quadriceps reex inhibition in man. Arch Phys Med Rehabil 1984;65:1717.

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Review
114 Peterfy CG, Guermazi A, Zaim S, et al. Whole-Organ Magnetic Resonance Imaging Score (WORMS) of the knee in osteoarthritis. Osteoarthritis Cartilage 2003;12:17790. Hunter DJ, Lo GH, Gale D, et al. The reliability of a new scoring system for knee osteoarthritis MRI and the validity of bone marrow lesion assessment: BLOKS (Boston-Leeds Osteoarthritis Knee Score). Ann Rheum Dis 2008;67:20611. Hunter DJ, Guermazi A, Lo GH, et al. Evolution of semi-quantitative whole joint assessment of knee OA: MOAKS (MRI Osteoarthritis Knee Score). Osteoarthritis Cartilage 2011;19:9901002. Utting MR, Davies G, Newman JH. Is anterior knee pain a predisposing factor to patellofemoral osteoarthritis? Knee 2005;12:3625. 118 Boling MC, Padua DA, Marshall SW, et al. A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the joint undertaking to monitor and prevent ACL injury ( JUMP-ACL) cohort. Am J Sport Med 2009;37:210816. Powers CM. The inuence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010;40:4251. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes. Am J Sport Med 2005;33:492501. Escamilla RF, Zheng N, Macleod TD, et al. Patellofemoral joint force and stress during the wall squat and one-leg squat. Med Sci Sports Exerc 2009;41:87988.

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Is patellofemoral joint osteoarthritis an under-recognised outcome of anterior cruciate ligament reconstruction? A narrative literature review
Adam G Culvenor, Jill L Cook, Natalie J Collins, et al. Br J Sports Med 2013 47: 66-70 originally published online October 4, 2012

doi: 10.1136/bjsports-2012-091490

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