Articular Cartilage Defects of Knee

Author: Patrick McCulloch

Topic updated on 01/21/13 11:51am

Introduction

Articular cartilage covers the articulating surfaces within joints
- functions include load transmission, lubrication, joint congruity
Cartilage injuries have limited spontaneous healing
- may progress to arthritis
Osteochondritis dissecans
- a pediatric articular lesion

Anatomy

See Articular Cartilage Basic Science

Classification

Outerbridge Arthroscopic Grading System
Grade 0	Normal cartilage
Grade I	Softening and swelling
Grade II	Partial thickness defect, fissures < 1.5cm diameter
Grade III	Fissures down to subchondral bone, diameter > 1.5cm
Grade IV	Exposed subchondral bone

ICRS (International Cartilage Repair Society) Grading System
Grade 0	Normal cartilage
Grade 1	Nearly normal (superficial lesions)
Grade 2	Abnormal (lesions extend < 50% of cartilage depth)
Grade 3	Severely abnormal (>50% of cartilage depth)
Grade 4	Severely abnormal (through the subchondral bone)

Presentation

Symptoms
- localized pain, effusion, mechanical symptoms
Physical exam
- joint effusion, focal tenderness

Imaging

Radiographs
- used to rule out arthritis, bony defects, and check alignment
- weight bearing 45 deg PA most sensitive for early joint space narrowing
- merchant view for patello-femoral joint
- double limb standing long films to check alignment
MRI
- most sensitive for evaluating focal defects
- Fat-suppressed T2, proton density, T2 fast spin-echo (FSE) offer improved sensitivity and specificity over standard sequences
- dGEMRIC (delayed gadolinium-enhanced MRI for cartilage) and T2-mapping are evolving techniques to evaluate cartilage defects and repair
CT scan
- better evaluation of bone loss
- used to measure TT-TG when evaluating the patello-femoral joint

Studies

Laboratory
- may be used to rule out inflammatory disease

Treatment

Nonoperative
- rest, NSAIDs, bracing
  - indications
    - first line of treatment when symptoms are mild
- corticosteroid injections, hyaluronic acid, glucosamine
  - indications
    - controversial
    - may provide symptomatic relief but healing of defect in unlikely
Operative
- debridement/chondroplasty vs. reconstruction techniques
  - indications
    - failure of nonoperative management
  - technique
    - treatment is individualized, there is no one best technique for all defects
    - decision-making algorithm is based on several factors
      - patient factors
        
        age
        
        skeletal maturity
        
        low vs. high demand activities
        
        ability to tolerate extended rehabilitation
      - defect factors
        
        size of defect
        
        location
        
        contained vs. uncontained
        
        presence or absence of subchondral bone involvement

Surgical Techniques

Debridement / Chondroplasty
- overview
  - goal is to debride loose flaps of cartilage
  - may relieve mechanical symptoms from loose chondral fragments
  - short-term benefit in 50-70% of patients
- benefits
  - include simple arthroscopic procedure, faster rehabilitation
- limitations
  - problem is exposed subchondral bone or layers of injured cartilage
  - unknown natural history of progression after treatment
Fixation of Unstable Fragments
- overview
  - need osteochondral fragment with adequate subchondral bone
- technique
  - debride underlying nonviable tissue
  - consider drilling subchondral bone or adding local bone graft
  - fix with absorbable or nonabsorbable screws or devices
- benefits
  - best results for unstable osteochondritis dissecans (OCD) fragments in patients with open physis
- limitations
  - lower healing rates in skeletally mature patients
  - nonabsorbable fixation (headless screws) should be removed at 3-6 months
Marrow Stimulation Techniques
- overview
  - goal is to allow access of marrow elements into defect to stimulate the formation of reparative tissue
  - includes microfracture, abrasion arthroplasty, osteochondral drilling
- microfracture technique
  - defect is prepared with stable vertical walls and the calcified cartilage layer is removed
  - awls are used to make punctate perforations through the subchondral bone
  - protected weight bearing and continuous passive motion (CPM) are used while mesenchymal stem cells mature into mainly fibrocartilage
- benefits
  - include cost-effectiveness, single-stage, arthroscopic
  - best results for acute, contained cartilage lesions less than 2x2cm
- limitations
  - poor results for larger defects
  - does not address bone defects
Osteochondral autograft / Mosaicplasty
- overview
  - goal is to replace a cartilage defect in a high weight bearing area with normal autologous cartilage and bone plug(s) from a lower weight bearing area
- technique
  - a recipient socket is drilled at the site of the defect
  - a single or multiple small cylinders of normal articular cartilage with underlying bone are cored out from lesser weight bearing areas (periphery of trochlea or notch)
  - plugs are then press-fit into the defect
- limitations
  - size constraints and donor site morbidity limit usage of this technique
  - matching the size and radius of curvature of cartilage defect is difficult
  - fixation strength of graft initially decreases with initial healing response
    - weight bearing should be delayed 3 months
- benefits
  - include autologous tissue, cost-effectiveness, single-stage, may be performed arthroscopically
Osteochondral allograft transplantation
- overview
  - goal is to replace cartilage defect with live chondrocytes in mature matrix along with underlying bone
  - fresh, refrigerated grafts are used which retain chondrocyte viability
  - may be performed as a bulk graft (fixed with screws) or shell (dowels) grafts
- technique
  - match the size and radius of curvature of articular cartilage with donor tissue
  - a recipient socket is drilled at the site of the defect
  - an osteochondral dowel of the appropriate size is cored out of the donor
  - the dowel is press-fit into place
- benefits
  - include ability to address larger defects, can correct significant bone loss, useful in revision of other techniques
- limitations
  - limited availability and high cost of donor tissue
  - live allograft tissue carries potential risk of infection
Autologous chondrocyte implantation (ACI)
- overview
  - cell therapy with goal of forming autologous "hyaline-like" cartilage
- technique
  - arthroscopic harvest of cartilage from a lesser weight bearing area
  - in the lab, chondrocytes are released from matrix and are expanded in culture
  - defect is prepared and chondrocytes are then injected under a periosteal patch sewn over the defect during a second surgery
- benefits
  - may provide better histologic tissue than marrow stimulation
  - long term results comparable to microfracture in most series
  - include regeneration of autologous tissue, can address larger defects
- limitations
  - must have full-thickness cartilage margins around the defect
  - open surgery
  - 2-stage procedure
  - prolonged protection necessary to allow for maturation
Patellar cartilage unloading procedures
- Maquet (tibia tubercle anteriorization)
  - indicated only for distal pole lesions
  - only elevate 1 cm or else risk of skin necrosis
  - contraindications
    - superior patellar arthrosis (scope before you perform the surgery)
- Fulkerson alignment surgery (tibia tubercle anteriorization and medialization
  - indications (controversial)
    - lateral and distal pole lesions
    - increased Q angle
  - contraindications
    - superior medial patellar arthrosis (scope before you perform the surgery)
    - skeletal immaturity
Matrix-associated autologous chondrocyte implantation
- overview
  - example is "MACI"
  - cells are cultured and embedded in a matrix or scaffold
  - matrix is secured with fibrin glue or sutures
- benefits
  - include ability to perform without suturing, may be performed arthroscopically
- limitations
  - 2-stage procedure
  - in worldwide use/evaluation- not available in the USA

Please Rate Educational Value!

4.0

Average 4.0 of 17 Ratings

Qbank (4 Questions)

TAG

(SBQ07.32) A patient with a symptomatic chondral defect undergoes the arthroscopic procedure seen in Figure A. The reparative tissue would best be described as which of the following? Topic

Review Topic

FIGURES: A

1. Fibrocartilage
2. Fibrous tissue
3. Elastofibroma
4. Hyaline cartilage
5. Chondromalacia

PREFERRED RESPONSE ▶

DISCUSSION: The figure is an arthroscopic photo of a microfracture procedure, which creates a reparative tissue best described as fibrocartilage. Microfracture is a marrow stimulation technique where stem cells from the medullary canal are given access to the base of the lesion by making small perforations in the subchondral bone. The rationale for this technique is based on these stem cells differentiating into cells that will produce an articular cartilage repair. However, biopsy findings in animals and humans have demonstrated primarily a fibrocartilagenous repair tissue and not true articular cartilage regeneration. The collagen type found in hyaline or articular cartilage is of the type II variety. Fibrocartilage possesses some type II, but is mostly type I and III cartilage.

Both the Intructional Course Lecture and the textbook by Buckwalter provide an in-depth review of articular cartilage biology and the background for chondral resurfacing techniques.

Incrorrect Responses:
2. Fibrous tissue is created by fibrocytes and lacks type II collagen.
3. Elastofibroma is a distractor (elastofibroma dorsi is a fibrous tumor with a predeliction for the scapulothoracic joint).
4. Hyaline cartilage is true articular cartilage with predominantly type II collagen. It also has columnar organization and a lamina splendens (which differentiates it from what has been called hyaline-like tissue).
5. Chondromalacia refers abnormal softening of the cartilage and is a common pathologic condition of the the knee.

REFERENCES:

1. Buckwalter JA, Mankin HJ: Articular cartilage: Degeneration and osteoarthritis, repair, regeneration, and transplantation. Instr Course Lect 1998;47:487-504

2. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 471-488

Question Authors:

Patrick McCulloch MD, Robert Boykin MD, Jeremy Stern MD,

Please Rate Educational Value!

4.0

Average 4.0 of 6 Ratings

TAG

(OBQ11.1) A 24-year-old female has moderate arthrosis of the medial facet of the patella and the medial femoral condyle. Which of the following procedures is contraindicated? Topic

Review Topic

1. Anterior (Maquet) tibial tubercle osteotomy
2. Anteromedial (Fulkerson) tibial tubercle osteotomy
3. Anterolateral tibial tubercle osteotomy
4. Medial opening wedge high tibial osteotomy
5. Lateral closing wedge high tibial osteotomy

PREFERRED RESPONSE ▶

DISCUSSION: Anteromedial (Fulkerson) tibial tubercle osteotomy is contraindicated in patients with significant arthrosis of the medial facet of the patella and the medial femoral condyle.

Anteromedial tibial tubercle osteotomy (Fulkerson procedure) involves the transfer of the tubercle to a more anterior and medial location. Changing the vector of the extensor mechanism can help reduce lateral patellar subluxation/dislocation and concomitantly unload areas of arthrosis on the distal and lateral aspects of the patella. When performing a tibial tubercle transfer, the surgeon should beware of proximal lesions or medial facet or condylar lesions. Thus, intact proximal and medial cartilage is required to obtain the maximum benefit from this procedure.

Pascual-Garrido et al, in a Level 4 study, reviewed 62 patients who underwent autologous chondrocyte implantation of the patellofemoral joint for defects an average size of 4cm(2). Those that underwent anteromedialization tended to have better clinical outcomes than those without realignment, however 44% of the patients still required a subsequent procedure.

Paulos et al, in a Level 3 study, prospectively followed 25 patients with a dislocating patella that underwent a derotational high tibial osteotomy, medial, or anteromedial tibial tubercle osteotomy. There were no dislocation recurrences in either group and 92% of the patients stated that they were happy with the results of their surgery and would undergo the procedure again.

Illustration A shows a video of a Fulkerson osteotomy being performed on a cadaveric specimen.

Illustrations: A

REFERENCES:

1. Pascual-Garrido C, Slabaugh MA, L'Heureux DR, Friel NA, Cole BJ. Recommendations and treatment outcomes for patellofemoral articular cartilage defects with autologous chondrocyte implantation: prospective evaluation at average 4-year follow-up. Am J Sports Med. 2009 Nov;37 Suppl 1:33S-41S. Epub 2009 Oct 27. PMID: 19861699 (Link to Abstract)

2. Paulos L, Swanson SC, Stoddard GJ, Barber-Westin S. Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med. 2009 Jul;37(7):1288-300. Epub 2009 Jun 2. PMID:19491333 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, John Badylak MD, Eric Shirley MD,

Please Rate Educational Value!

3.0

Average 3.0 of 17 Ratings

TAG

(OBQ10.257) Following a medial femoral condyle osteochondral autograft mosaicplasty, which of the following statements best describes the fixation of the graft? Topic

Review Topic

1. Graft fixation strength increases linearly with time until subchondral union at 3 months
2. Graft fixation strength initially decreases during the early healing phase, and then increases with subchondral bone healing
3. Graft fixation strength does not change during the first 3 months following surgery
4. Graft fixation strength is enhanced by early weight bearing
5. Graft fixation strength initially increases over the first 6 weeks, then recedes with bony remodeling

PREFERRED RESPONSE ▶

DISCUSSION: Following mosaicplasty, appropriate post-operative rehabilitation and weight-bearing status must be based upon the fixation of the osteochondral autograft plugs. Whiteside et al performed a porcine study evaluating the fixation strength of osteochondral autograft mosaicplasty during the first week following implantation. The graft fixation was notably weaker one week following surgery due to the post-operative response and host remodeling. These results suggest that protected weight bearing should be used until the osteochondral plugs have healed into the subchondral bone, generally by 3 months. However, early non-weight bearing motion is important to prevent stiffness and protect the joint surfaces with synovial fluid.

REFERENCES:

1. Tyler TF, Johnson C, Jenkins WL. Rehabilitation following osteochondral injury to the knee.nee. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:257-262.

2. Whiteside RA, Bryant JT, Jakob RP, Mainil-Varlet P, Wyss UP. Short-term load bearing capacity of osteochondral autografts implanted by the mosaicplasty technique: an in vitro porcine model. J Biomech. 2003 Aug;36(8):1203-8. PMID:12831747 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 6 Ratings

TAG

(OBQ08.94) A 32-year-old female is referred to you for definitive treatment of a symptomatic focal chondral defect on her medial femoral condyle. A photograph from a recent diagnostic arthroscopy shows the defect (Figure A), which measured 20 x 25mm after debridement. What surgical treatment would you recommend? Topic

Review Topic

FIGURES: A

1. Osteochondral autograft
2. Osteochondral allograft
3. Microfracture
4. Chondroplasty
5. Abrasion arthroplasty

PREFERRED RESPONSE ▶

DISCUSSION: Based on the age of this patient and the size of this lesion (2 x 2.5 = approx 5cm square) an osteochondral allograft plug is the best choice. The results of microfracture are better for contained defects less than 2cm square. Autografts are generally reserved for smaller defects as well because harvesting enough plugs to fill this defect may lead to significant donor site morbidity. Chondroplasty and abrasion arthroplasty are not good solutions to this chondral defect in a young symptomatic patient. Autologous chondrocyte implantation (ACI) would also be a correct response, but it was not listed.

Bert discusses the science, histology, history, and clinical results of abrasion arthroplasty for treatment of osteoarthritis of the knee.

Alford et al. review the indications for treatment of chondral defects and describe the various treatment options. In addition, they discuss clinical scenarios regarding comorbid conditions including ligament instability, meniscal deficiency, and malalignment by developing a treatment algorithm (Illustration A).

Illustrations: A

REFERENCES:

1. Bert, JM. Abrasion arthroplasty. Operative techniques in orthopaedic surgery. 2001. Volume 11, Issue 2, Pages 90-95 (Note: this journal article is not available via pubmed)

2. Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005 Mar;33(3):443-60. Review. PMID:15716263 (Link to Abstract)

3. Garrick JG (Ed). Orthopaedic Knowledge Update: Sports Medicine. American Academy of Orthopaedic Surgery. Rosemont, IL. 2004, PP 223-232

Question Authors:

Patrick O'Donnell MD/PhD, Patrick McCulloch MD, Eric Shirley MD, Mark Miller MD,

Please Rate Educational Value!

3.0

Average 3.0 of 17 Ratings

TAG

(OBQ06.186) All of the following are acceptable scenarios for the use of autologous chondrocyte implantation (ACI) in the patellofemoral joint EXCEPT: Topic

Review Topic

1. Grade 4 lesion of the medial femoral condyle
2. Grade 4 lesion of the trochlea
3. Joint space narrowing on Merchant view
4. Varus mechanical axis on standing full length radiograph
5. Concomitant anteromedial tibial tubercle transfer osteotomy (Fulkerson's)

PREFERRED RESPONSE ▶

DISCUSSION: Joint space narrowing on a merchant view is a contraindication for autologous chondrocyte implantation for patellofemoral arthritis.

Saleh et al states ACI relies on intact, full-thickness cartilage margins to maintain the joint space so that the growing cartilage repair tissue may fill the defect. Cartilage loss seen with diffuse arthritis is not amenable to ACI. It is critical that there is a preserved patellofemoral joint space as seen on a Merchant or skyline view. The article states that ACI can be used for grade 3 or 4 defects on the patella or trochlea. Concomitant realigment procedures of the patellofemoral joint (such as lateral release, medial tubercle transfer, or anteromedial tubercle transfer) and the tibiofemoral joint (high tibial osteotomy) are indicated in the presence of mechanical malalignment.

The article by Peterson et al followed 94 patients for 2-9 years and found graft failure in only seven patients. Histologic analysis of 37 "second-look" arthroscopy biopsy specimens showed a correlation between hyaline-like tissue and good to excellent clinical results.

NOTICE: ACI is not FDA approved for use on the patella and the use of ACI "off-label" should be discussed with patients preoperatively.

REFERENCES:

1. Saleh KJ, Arendt EA, Eldridge J, Fulkerson JP, Minas T, Mulhall KJ. Symposium. Operative treatment of patellofemoral arthritis. J Bone Joint Surg Am. 2005 Mar;87(3):659-71. PMID:15741637 (Link to Abstract)

2. Peterson L, Minas T, Brittberg M, Nilsson A, Sjögren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000 May;(374):212-34. PMID:10818982 (Link to Abstract)

3. http://www.fda.gov/downloads/BiologicsBloodVaccines/CellularGeneTherapyProducts/ApprovedProducts/UCM109339.pdf

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, John Badylak MD, Mark Miller MD,

Please Rate Educational Value!

2.0

Average 2.0 of 24 Ratings

Cases

	AVN with collapse of medial and lateral condyles bilaterally (C1039) Anatomy - - Articular Cartilage Defects of Knee HPI - 17yo F bilateral knee AVN. Pain and swelling limiting activities. MRIs of both k... What surgery would you reccomend for this young girl?	4/6/2011 3 responses
	MFC cartilage defect (C1077) Sports - - Articular Cartilage Defects of Knee HPI - Former elite marathon runner has been unable to exercise for a year. She was dia... What do you think of this treatment strategy for an active patient with a c...	10/20/2011 49 responses
	Large Cartilage Defect to Medial Patellar Facet in 17 yo Athlete (C1281) Sports - Treatment Consult - Articular Cartilage Defects of Knee HPI - Highly competitive high school football player presents with knee pain after suf... How would you treat this patient?	10/2/2012 125 responses

See More Cases

Videos

	Autologous Chondrocyte Implantation Sports - Educational Presentation - Articular Cartilage Defects of Knee Case example of Carticel cartilage restoration of the knee.	4/21/2013 36 views 5
	Minced Juvenile Allograft Cartilage Implantation for Patellar Defect - Dr. David Diduch Sports - Surgical Techniques - Articular Cartilage Defects of Knee This video demonstrates a Minced Juvenile Allograft Cartilage Implantation (DeNo...	10/11/2012 122 views 5

See More Videos

Groups

Cartilage Repair Study Group

Sports - Techniques

10/28/2011

261 responses

See More Groups

Evidence & References Show References

Level of Evidence 4 (Case Series)

Pascual-Garrido C, Slabaugh MA, L'Heureux DR, Friel NA, Cole BJ. Recommendations and treatment outcomes for patellofemoral articular cartilage defects with autologous chondrocyte implantation: prospective evaluation at average 4-year follow-up. Am J Sports Med. 2009 Nov;37 Suppl 1:33S-41S. Epub 2009 Oct 27. PMID: 19861699 (Link to Abstract)
Paulos L, Swanson SC, Stoddard GJ, Barber-Westin S. Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med. 2009 Jul;37(7):1288-300. Epub 2009 Jun 2. PMID:19491333 (Link to Abstract)
Peterson L, Minas T, Brittberg M, Nilsson A, Sjögren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000 May;(374):212-34. PMID:10818982 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Buckwalter JA, Mankin HJ: Articular cartilage: Degeneration and osteoarthritis, repair, regeneration, and transplantation. Instr Course Lect 1998;47:487-504
Bert, JM. Abrasion arthroplasty. Operative techniques in orthopaedic surgery. 2001. Volume 11, Issue 2, Pages 90-95 (Note: this journal article is not available via pubmed)
Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005 Mar;33(3):443-60. Review. PMID:15716263 (Link to Abstract)
Saleh KJ, Arendt EA, Eldridge J, Fulkerson JP, Minas T, Mulhall KJ. Symposium. Operative treatment of patellofemoral arthritis. J Bone Joint Surg Am. 2005 Mar;87(3):659-71. PMID:15741637 (Link to Abstract)
http://www.fda.gov/downloads/BiologicsBloodVaccines/CellularGeneTherapyProducts/ApprovedProducts/UCM109339.pdf

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 471-488
Tyler TF, Johnson C, Jenkins WL. Rehabilitation following osteochondral injury to the knee.nee. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:257-262.
Garrick JG (Ed). Orthopaedic Knowledge Update: Sports Medicine. American Academy of Orthopaedic Surgery. Rosemont, IL. 2004, PP 223-232

Undefined

Whiteside RA, Bryant JT, Jakob RP, Mainil-Varlet P, Wyss UP. Short-term load bearing capacity of osteochondral autografts implanted by the mosaicplasty technique: an in vitro porcine model. J Biomech. 2003 Aug;36(8):1203-8. PMID:12831747 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Articular Cartilage Defects of Knee

Qbank (4 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Related Videos

Question Comments

Cases

Videos

Groups

Evidence & References Show References

Topic Comments