Approach Considerations
The most common symptomatic plica is medial parapatellar plica. Surgical intervention for plica syndrome should be considered when symptoms have persisted and efforts at nonoperative management have failed for a period typically approaching 6 months. Permanent modification of athletic activity is usually another option, but patients rarely find it acceptable. Moreover, surgical treatment offers such predictable results that withholding treatment could arguably be considered ethically questionable. Longer periods between symptom onset and surgical treatment appear to be associated with cartilage damage. [37]
Patients with absolute contraindications for surgical treatment include those who are considered unfit for surgery from a medical standpoint. Active soft-tissue infection around the knee that precludes the use of standard arthroscopic portals is another contraindication. Relative contraindications include hypercoagulability syndromes that predispose the patient to thrombotic complications, as well as excessive risk for reflex sympathetic dystrophy (RSD).
Medical Therapy
Medical treatment of plica syndrome has been driven largely by empiric evidence. A structured program of stretching and strengthening exercises often leads to some improvement. This may include short-arc quadriceps extension exercises (terminal ~20° of extension). These exercises are aimed at optimizing patellofemoral biodynamic relationships in an effort to control symptoms.
A patellar knee sleeve worn during sporting activities (usually a neoprene-type brace) may also be a useful adjunct for many athletes. In addition, nonsteroidal anti-inflammatory drugs (NSAIDs) are a time-tested and confirmed aid for many athletes with plica syndrome.
Surgical Therapy
Surgical therapy for plica syndrome is virtually always arthroscopic. The arthroscopic surgeon must exclude other potential intra-articular causes of knee pain and then address any pathologic plicae. Plica resection may be performed with arthroscopic hand instruments, a motorized soft-tissue resector, or certain commercially available electrothermal devices.
Preparation for surgery
The preoperative phase of treatment involves optimizing the patient's knee strength and flexibility in an effort to streamline postoperative rehabilitation. Preoperative preparation of the patient also involves education and appropriate goal setting. For instance, the patient should understand that therapeutic exercises typically begin shortly after surgery (hours to days) and that a full return to sports can be realized soon thereafter (days to weeks). Patients who know this in advance tend to achieve these goals quite readily.
Operative details
After arthroscopic evaluation establishes that no other intra-articular abnormalities must be addressed, the plica can be resected. With whatever tools work best, the plica should be resected back to a point where it no longer impinges on articular structures. With beefy synovitic plicae extending into the patellofemoral joint space (typically ≥ 50%; see the first image below), this may require extensive debridement (see the second image below). With tough, fibrotic plicae draping over the medial femoral condyle, this may involve little more than disruption of the tight band.
Plica syndrome. Preoperative appearance of medial parapatellar plica (a 4+ plica by the Jee classification, extending across more than two thirds of the medial facet of the patella).
Plica syndrome. Postoperative appearance of the same patient as in Image 5 after plical resection.
At times, even a suprapatellar plica may lead to symptoms. Strover et al reported on an arthroscopic technique demonstrating the pathomechanics of such suprapatellar plicae. [38] They recommended that the arthroscope should be inserted through a lateral suprapatellar portal. Proximal visualization is then optimized.
In those patients whose suprapatellar plica is symptomatic, progressive flexion of the knee results in the plical tissue becoming taut. It also makes contact with the medial femoral condyle and even becomes entrapped between the quadriceps tendon and the medial femoral condyle. [38]
Postoperative Care
Postoperatively, the patient is started on a structured course of therapeutic exercise that initially emphasizes reestablishment of active quadriceps control and firing. This progresses to regaining full range of motion and then full strength. The patient concludes therapeutic recovery by gradually performing more and more sport-specific exercises until a controlled reentry to the sport is achieved.
Complications
Complications of surgical treatment of plica syndrome are really complications associated with arthroscopic surgery of the knee. These include septic arthritis, neurapraxias or neuromas, and synovial fistulae. RSD may also occur after such surgery. The incidence of each of these complications is extremely low (< 1% in most cases). Only patients with particular risk factors (eg, diabetes, steroid dependence, or history of RSD) may be at significantly higher risk.
Long-Term Monitoring
Follow-up care focuses on confirmation that symptoms have abated. True recurrence of the original plical pathology is quite rare and is more likely to represent either an incomplete resection or entirely new knee pathology. Continued use of a patellar stabilizing-type brace is preferred by many patients.
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Plica syndrome. Typical appearance of a large beefy medial parapatellar plica.
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Plica syndrome. Patient pointing to the painful area of her knee.
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Plica syndrome. The inferomedial quadrant is usually the most painful region by physical examination. This area is highlighted by several X's in this figure. A painful taut band of tissue that emanates from the central portion of the medial patella may often be palpated (3 o'clock position on the figure).
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Plica syndrome. Axial MRI demonstrating abundant medial plical tissue.
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Plica syndrome. Preoperative appearance of medial parapatellar plica (a 4+ plica by the Jee classification, extending across more than two thirds of the medial facet of the patella).
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Plica syndrome. Postoperative appearance of the same patient as in Image 5 after plical resection.
