Orthopedics - Oleksa A.P. 2006

Congenital and acquired deformities of the lower limb
Congenital deformities of the knee joint
Hoffa's disease and traumatic lipoarthritis

Hoffa (Hoffa A., 1904) first described chronic hyperplasia of the alar folds of the knee joint and classified it as a distinct nosological entity. Diamant-Berger and Sicard (1931) included Hypertrophy of the infrapatellar fat pad of the knee joint in this disease and introduced the term "lipoarthritis".

The fat pads and alar folds fill the space in the knee between the anterior articular surfaces and the synovial membrane, acting as Shock absorbers. During knee joint movements, they cushion the tension on the membrane, facilitate metabolic processes, and regulate the quantity and quality of synovial fluid, as they are richly supplied with Blood and Lymphatic vessels.

The underlying cause of the disease is chronic trauma to the anterior aspect of the knee joint, which is most common in women, as well as in men whose occupations require kneeling (such as miners, floor layers, and others), or after long hikes, among other factors.

Due to frequent loading and trauma, a chronic inflammatory process develops in the fat pads and alar folds located beneath the patellar ligament, extending into the knee under the synovial membrane. This chronic inflammation leads to hypertrophy, sclerosis, and induration of the fat pads. Initially, the disease is asymptomatic; however, if the enlarged alar folds become impinged between the articular surfaces of the knee, they undergo further hypertrophy and trauma, causing pain and restricting full extension of the knee. Occasionally, Hoffa's disease is accompanied by synovitis, which further limits joint mobility.

When the patient stands on their toes, the pain intensifies, and a protrusion of the fat pads becomes visible on both sides of the patellar ligament, which diminishes in a relaxed standing position. The patient experiences discomfort while walking and feels better when sitting. Palpation reveals a firm, elastic, hypertrophied fat pad on both sides of the patellar ligament, which may be painless. The pain increases significantly with a sudden, abrupt extension of the knee.

In acute cases of alar fold impingement, the limb is immobilized with a plaster splint, and thermal therapies are prescribed (heating pad, UHF therapy, paraffin Applications). After one to two weeks, the patient can return to work.

In cases of frequent impingement and pain that lead to reduced working capacity, the patient is advised to undergo surgery—excision of the fat pad and alar folds.

Surgical technique. The knee joint cavity is opened through a parapatellar incision and inspected to rule out other pathology. The synovial membrane beneath the alar folds is then incised, sparing the transverse meniscal ligament. The fat pad is gradually mobilized using blunt dissection, brought into the wound with a clamp, and excised en bloc with the alar folds. Bleeding vessels supplying the fat pad are coagulated. The knee joint is drained, and the wound is closed in layers.

Postoperatively, the limb is immobilized for 5-7 days, after which knee mobilization exercises are initiated, and Muscle massage and physical therapy are performed. After three weeks, the patient can return to work.

Structure/19.html">The Importance of intraoperative hemostasis must be emphasized, as the fat pads are highly vascularized, and their resection leads to bleeding. Following the removal of the alar fat folds, it is virtually impossible to hermetically seal the knee joint cavity with sutures; this can lead to hemarthrosis, requiring joint aspiration and lavage on the second or third postoperative day.

We concluded that extirpation of the fat pad can prevent hemarthrosis, as two or three Arteries supplying the fat pad from the margo tibiae region are clearly visible and accessible for coagulation.

Hypertrophy of the alar folds and fat pads often occurs As a result of chronic inflammatory processes in the knee joint, accompanied by synovitis and proliferative changes. Typically, this is observed in tuberculous gonarthritis and, particularly, in rheumatoid Arthritis. Our long-term observations of more than 100 operated patients confirm the efficacy of these surgical interventions.