Hoffa's disease: causes, symptoms, diagnosis and treatment

Causes of the disease

Among the factors causing lipoarthritis of the knee joints are:

Intense physical activity associated with professional activities. In this case, there is a constant force impact on the knee joints as a result of jumping, running, and sudden squats. Against the background of physical processes, the disease develops in athletes, ballet dancers, professional runners, and acrobats.
Constant loads of moderate nature. The knees experience this type of impact during repetitive work, such as working in garden beds.
Changes in hormonal balance. Degeneration of adipose tissue can develop in women during the premenopausal and menopausal periods. In this case, the pathogenesis is associated with the influence of hormonal changes on the ability of tissues to regenerate independently.
Knee joint injuries. Significant traumatic impact can damage the pterygoid ligaments and cause meniscal rupture, which leads to hemorrhages into the adipose tissue and inflammation.

Normally, adipose tissue in the area of the knee joint ensures stability of the joint, reduces friction between the osteochondral elements, and evenly distributes the load on the legs. With constant physical activity, microdamage to adipose tissue is inevitable. Repeated hemorrhages and compression between the surfaces of the femur and tibia lead to an inflammatory process, hypoxia of the soft tissues of the knee, and impaired local circulation.

Although the inflammation is of aseptic origin, it is invariably accompanied by the accumulation of fibrin and hemosiderin. Macrophages begin an attack on the body's own fat cells in the area of the pathological focus. The result of these processes is the replacement of elastic adipose tissue with denser and coarser connective tissue - degeneration of the knee ridges develops.

Treatment

The basic principles of treatment for Hoffa disease are as follows:

decreased proliferation activity in the area of the pterygoid folds;
elimination of blockage by fatty bodies of the knee joint;
elimination of inflammation;
restoration of muscle function;
restoration of leg support;
restoration of motor stereotype.

In the early stages of lipoarthritis, the introduction of long-acting hormonal drugs into the area of the pterygoid folds of the knee joint can reduce proliferation and inflammation. If conservative treatment is insufficient, arthroscopic surgery “resection of the Hoffa fatty body” is performed - this is a method of radical treatment of the disease.

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Symptoms of the disease

In case of injury to the knee joints, the disease can develop rapidly. Most often, the pathological focus appears gradually, which means that symptoms do not appear immediately. From the moment of the first degeneration of adipose tissue until the manifestation of a specific clinic, a significant period of time can pass.

The first thing the patient feels is pain, which is localized in the anterior part of the knee joint. Painful sensations intensify during movements. Hoffa's disease is characterized by a dependence of pain on the position of the knee joint. When the leg is bent at the knee, the pain decreases, and when the leg is extended, it becomes more intense. Over time, the pain becomes intense at night.

When walking, squatting, or running, the patient feels a crunching sensation in the affected knee joint. Edema of the limb, swelling of the anterior and lower zones of the knee are visually determined. The longer Hoffa's disease develops, the greater the limitations in flexion and extension of the affected joint.

Patients note areas of bulging fatty tissue around the patella. When feeling the knee, a crunching sensation appears under the fingers on both sides of the patella.

Worsening of the pathological process leads to atrophy of the quadriceps femoris muscle (quadriceps). It can be moderate or significant, depending on the amount of fibrosis. After some time, patients present with gait disturbances and lameness.

Against the background of infringement of adipose tissue by the corresponding parts of the tibia and femur, a blockade of the knee joint may occur. Exacerbation of inflammation is the main factor in synovitis and gonarthrosis.

List of used literature and sources

Bell DJ Fat pad impingement syndromes of the knee // radiopaedia.com – 2021. – URL: https://radiopaedia.org/articles/fat-pad-impingement-syndromes-of-the-knee (07.20.2018).
Gary A. Howell, MD [Electronic resource] // Radsourse: website. – 2008. – URL: https://radsource.us/patellar-fat-pad-abnormalities/ (access date: 07/20/2018).
Prefemoral Fat Pad Impingement Syndrome: Identification and Diagnosis / Borja MJ / The American Journal of Orthopedics. – 2013. – 42 (1): 9-11 – Mode of access: https://www.amjorthopedics.com/article/prefemoral-fat-pad-impingement-syndrome-identification-and-diagnosis (Date of access: 20.07 .2018).
Suprapatellar Fat-Pad Mass Effect: MRI Findings and Correlation With Anterior Knee Pain / Tsavalas N. / American Journal of Roentgenology. – 2013. – No. 3. – Mode of access: https://www.ajronline.org/doi/pdf/10.2214/AJR.12.8821 (Date of access: 07/20/2018).

Hoffa's disease in children

Hoffa's knee disease in children is rarely diagnosed, since in childhood there are practically no main risk factors for this pathology. The disease can develop in a child as a result of injury to the knee joints.

After a short period of time, the child develops characteristic symptoms:

pain in the injured knee;
limitation of joint mobility;
swelling of the knee and surrounding soft tissues.

When trying to bend or straighten the damaged knee joint, the child feels an internal crunch. In parallel with this, there is a limitation of mobility, the inability to fully straighten the leg at the knee.

Arthroscopy

Arthroscopy
Arthroscopy is a relatively new method of low-traumatic surgical intervention on the joints. Initially, it was used only for visual diagnosis of various pathological conditions of large joints (knee, shoulder, hip joint).

The principle is to insert a small special tube (arthroscope) into the joint cavity, equipped with a video camera and lighting, which allows the doctor performing the procedure to assess the condition of the tissues and structures on the monitor screen.

As this method of diagnostic invasive manipulation developed and improved, special tubes equipped with microinstruments began to be additionally introduced into the knee cavity. At the same time, under visual control on the monitor, the doctor can carry out various manipulations.

The main feature of this diagnostic and treatment method is a significant reduction in damage to the tissues and structures of the joint, since small incisions are made to access pathologically altered structures and introduce an arthroscope.

Diagnostics

Diagnosis of Hoffa's disease is carried out by orthopedic traumatologists. Establishing a correct diagnosis is important for determining therapeutic tactics. First of all, a complete history taking is important. The hormonal status of a woman after 45 years of age is clarified. In young patients, the nature of professional activity, the fact of sports loads, and previous injuries are determined.

To determine the condition of the knee joints, a comprehensive examination is prescribed:

MRI. MRI images visualize the structure of soft tissues and ligaments of the articulation. In the case of lipoarthritis, pronounced hypertrophy of prepatellar adipose tissue is determined. The greatest intensity is localized above the lower pole of the patella. Foci of fibrin and hemosiderin are identified.
Arthropneumography. Used when it is impossible to perform MRI. To obtain complete information, a lateral photograph of the knee joint is taken. The images determine the boundaries of adipose tissue, its hypertrophy, and the presence of calcifications in the pterygoid ligaments.
Ultrasound. Shows the condition of soft tissues, disturbance or preservation of local blood flow.
Arthroscopy. Minimally invasive surgery on the knee joint is performed for acute injuries (sports, work injuries), in case of suspected meniscus tear.

The data obtained during hardware diagnostics is carefully analyzed to avoid making an erroneous conclusion. It is important to differentiate Hoff's disease from ruptures of intra-articular ligaments, deforming arthrosis, bursitis, and synovitis.

Arthroscopic findings

The infrapatellar fold runs anterior to the anterior cruciate ligament (ACL) and its anatomy is highly variable. However, all anatomical variations, from the absence of a fold to complete separation of the medial and lateral compartments. Normally, the fold extends from the upper parts of the intercondylar space to the fat body.

Classification

A large number of classification descriptions of the infrapatellar fold have been proposed. Wachtler (1979) identifies 5 types, and some of them have several subtypes. This classification is interesting from a scientific point of view, but has little clinical significance.

The following anatomical variants are especially important:

Insulated cord.

The fold is an isolated cord located anterior to the ACL. Two and even three free strands of the infrapatellar fold have been described.

Reticulate fold.

The anterior edge of the fold has a network-like appearance and is widely woven into the ACL. In most cases, such a fold is difficult to separate from the ACL.

No fold.

In the absence of the infrapatellar fold, a direct view of the ACL is available.

Differences between the infrapatellar fold and the ACL

A novice arthroscopist may mistake a tight, band-like fold for an intact ACL. When identifying a thickened and scarred fold, attention should be paid to the course of the ACL, which originates on the posteromedial surface of the lateral femoral condyle. In contrast, the infrapatellar fold begins much more anterior to the roof of the intercondylar space. The ACL insertion can be better viewed by placing the tip of the arthroscope lateral to the crease and bringing the knee into a partial figure-four position.

Scar changes in the fold (which can be mistaken for the ACL) cause tension in the fat pad. Arthroscopic manipulations in the acute period of injury can lead to bleeding from the tissue of the fold, as well as to its partial or complete rupture.

knee arthroscopy

knee arthroscopy
The service of diagnosing and treating pathological conditions or traumatic injuries to knee structures using arthroscopy is carried out only in a specialized medical institution, which must be equipped with the necessary equipment. Typically, such institutions include public or private traumatology or orthopedic clinics.

This technique is prescribed by an orthopedic traumatologist after a preliminary examination of the patient. At an appointment with a specialist, you can find out where it is best to perform the manipulation, as well as how much knee arthroscopy costs. Reviews about a specific medical clinic can be read on the Internet on specialized websites or forums.

Advantages

Less traumatic procedure due to the absence of the need to dissect a significant amount of tissue.
Shorter postoperative period.
Less time-consuming and more complete rehabilitation of the knee in functional terms.
The ability to fully diagnose pathology or damage to knee structures.
Low probability of developing various postoperative complications, including bleeding, secondary bacterial infection.
A shorter period of time required for a patient’s stay in a medical hospital (compared to an open access operation after arthroscopy, the patient’s stay is reduced to 3-5 days instead of 14 days).

Such advantages of diagnostic and therapeutic arthroscopy reduce the overall cost of treatment for various pathologies or traumatic injuries of the knee.