forms of cartilage Articular cartilage is one of five forms of cartilage hyaline or articular cartilage fibroelastic cartilage (meniscus) fibrocartilage (at tendon and ligament insertion into bone) elastic cartilage (trachea) physeal cartilage (growth plate) Articular (hyaline) Cartilage Components Function decreases friction and distributes loads cartilage exhibits stress-shielding of the solid matrix components due to its high water content, the incompressibility of water, and the structural organization of the proteoglycan and collagen molecules Composition includes extracellular matrix (water, collagen, proteoglycans) 90% type II collagen cells (chondrocytes) % by weight water > collagen > proteoglycan > noncollagenous protein > cells Extracellular matrix water makes up 65% to 80% of mass of the cartilage accounts for 80% of the weight near the surface 65% at the deep zone water content decreases with normal aging increases with osteoarthritis increased water content leads to increased permeability decreased strength decreased Young Modulus of elasticity collagen makes up 10 to 20% of total cartilage mass type II collagen accounting for 90% to 95% of the total collagen content. functions to provide cartilagenous framework and tensile strength small amounts of types V, VI, IX, X, and XI collagen are also present proteoglycans make up 10 to 15% of cartilage function to provide compressive strength and attract water aggrecan is most responsible for hydrophilic behavior produced by chondrocytes proteoglycans composed of GAG subunits chondroitin sulfate keratin sulfate noncollagenous protein Cells chondrocytes produce collagen, proteoglycans, and enzymes derive from chondroblasts that are trapped in lacunae and become chondrocytes chondrocyte metabolism responds to both mechanical (mechanical load, hydrostatic pressure change) and chemical stimuli (growth factors, cytokines) immature articular cartilage has stem cells (mature articular cartilage does not) Layers of Articular Cartilage Normal articular cartilage is composed of three zones and the tidemark zones based on the shape of the chondrocytes and the orientation of the type II collagen. Zones of Articular Cartilage Superficial zone (tangential zone) Type II collagen orientation is parallel to joint Has flattened chondrocytes, condensed collagen fibers, and sparse proteoglycans Has the highest concentration of collagen and lowest concentration of proteoglycans Only zone where articular cartilage progenitor cells have been found Intermediate zone Type II collagen has an oblique or random organization Is the thickest layer with round chondrocytes, and abundant proteoglycan content Deep layer (basal layer) Type II collagen is perpendicular to joint and crosses tidemark Has the highest concentration of proteoglycans Round chondrocytes arranged in columns Tidemark Is deep to the basal layer and separates the true articular cartilage from the deeper cartilage that is a remnant of the cartilage anlage, which participated in endochondral ossification during longitudinal growth in childhood. The tidemark divides - the superficial, uncalcified cartilage from the deeper, calcified cartilage - division between nutritional sources for the chondrocytes The tidemark is found only in joints Most prominently in the adult and nongrowing joint Subchondral Bone Growth Factors PDGF thought to be involved with healing of articular cartilage lacerations effects extrapolated from PRP (which contains it) no adverse effects in normal joints TGF-B stimulates proteoglycan and ECM synthesis decreases catabolic activity of IL-1 and MMPs causes synovial proliferation and fibrosis induces osteophyte formation b-FGF (Basic Fibroblastic Growth Factor) stimulates DNA synthesis in articular chondrocytes IGF-1 (Insulin growth factor -1) stimulates DNA and cartilage matrix synthesis in adult articular cartilage stimulates ECM synthesis decreaes synovial thickening and chronic synovial inflammation additive when combined with TGF-b Nourishment and Metabolism Cartilage is avascular Nourished by synovial fluid at the surface subchondral bone at the base Relies on glycolysis for ATP production Mechanical Stress Response Physiologic stress stimulates matrix synthesis and inhibits chondrolysis cyclic stress (1-5 MPa) moderate frequency (0.1-1 Hz) low rates (<1000 MPa/s) Excess stress suppresses matrix synthesis and promotes chondrolysis excess stress (>5 MPa) static load (<0.01 Hz) high rates (>1000 MPa/s) Cellular responses primary cilia act as a mechanosensory organ on chondrocytes and osteoblasts transduction of mechanical signals involves integrins Repetitive loading moderate running increases cartilage thickness and proteoglycan content strenuous loading leads to cartilage thinning and proteoglycan loss immobilization leads to cartilage thinning, softening and proteoglycan loss Wear Mechanics Forms of lubrication elastohydrodynamic main mechanism during dynamic joint function elastic deformation of articular surfaces thin films of lubricant separate the surfaces a fully congruent joint will not allow a fluid film to form boundary (slippery surfaces) bearing surface is non-deformable lubricant only partially separates surfaces superficial zone proteins have a role in this lubrication mechanism boosted (fluid entrapment) concentration of lubricating fluid in pools trapped by regions of bearing surfaces that are making contact hydrodynamic fluid separates surfaces when one surface is sliding on the other weeping fluid shifts out of articular cartilage in response to load surfaces separated by hydrostatic pressure Mechanisms of wear adhesion abrasion transfer fatigue third body Aging in Articular Cartilage With age changes in articular cartilage include increases in chondrocytes size protein content stiffness (passive glycation leads to increased stiffness of collagen) increase in ratio of proteoglycan keratin sulfate to chondroitin sulfate decrease in absolute number of cells (becomes hypocellular, despite the fact that individual chondrocytes are increasing in size) water content (differentiates from osteoarthritis where water content actually increases) solubility proteoglycan size elasticity Advanced glycosylation end-products (AGEs) from spontaneous nonenzymatic glycation of proteins when sugars (glucose, fructose, ribose) react with lysine or arginine residues because of the low turnover, articular cartilage is susceptible to AGEs accumulation. accumulation of AGEs has been thought to play a role in the development of OA of the knee and ankle. effects of AGEs formation modification of type II collagen by cross-linking of collagen molecules increasing stiffness and brittleness increasing susceptibility to fatigue failure Aging vs. Osteoarthritis effect on Articular Cartilage Aging Osteoarthritis Water Decreased Increased Modulus/stiffness Increased (less elastic) Decreased (more elastic) Chondrocytes Fewer but increased size Cells cluster (late stage) Glycosaminoglycans Increased keratan sulfate:chondroitin 4 sulfate ratio, constant chondroitin 6 sulfate Increased chondroitin 4 sulfate:keratan sulfate ratio Proteoglycans Increased decorin, decreased proteoglycan size Proteoglycans unbound from hyaluronate Collagen Increased collagen crosslinking/brittleness Collagen disorganized (increased collagenase) Advanced Glycosylation End products (AGE) Increased Accumulation of AGE thought to lead to OA knee and ankle Injury Following an intra-articular fracture, in addition to mechanical disruption and cartilage necrosis, the following inflammatory cytokines are released, contributing to articular damage and the eventual development of post-traumatic arthritis:IL-1β, TNF-α, nitric oxide, matrix metalloproteinases, aggrecans, and damage associated molecular patterns. Healing in Articular Cartilage Deep lacerations (through tidemark) leads to fibrocartilage healing occurs when laceration travels through tidemark and penetrates subchondral bone fibrocartilage produced by undifferentiated marrow mesenchymal stem cells a healing response is initiated with hematoma, stem cell migration, and vascular ingrowth. This response produces type I collagen and resultant fibrocartilage rather than desired hyaline cartilage as produced by chondrocytes. This repair cartilage has diminished resiliency, stiffness, poor wear characteristics, and the predilection for arthritis. Superficial laceration (not through tidemark) leads to chondrocytes proliferation but no healing takes place because of avascular nature of cartilage Clinical Conditions Articular Defects of the Knee (Adults) Osteocondritis dissecans
QUESTIONS 1 of 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Previous Next (SBQ18BS.2) A 32-year-old male sustains the injury shown in Figure A. He undergoes surgical fixation with subsequent removal of hardware. He does well for 10 years and then presents to your office with increasing left knee stiffness and pain for the last 6 months. He reports no constitutional symptoms or recent trauma. His physical exam is notable for well-healed incisions, a mild effusion, no ligamentous instability, and 5-100 degrees of range of motion. An XR is obtained and shown in Figure B. Which of the following correctly lists the cytokines produced following the initial injury that may contribute to the findings shown in Figure B and the patient's current symptoms? QID: 211123 FIGURES: A B Type & Select Correct Answer 1 IL-1ß, TNF-a, nitric oxide, matrix metalloproteinases, aggrecans, damage-associated molecular patterns 76% (1356/1773) 2 FGF4, BMP6, nitric oxide, matrix metalloproteinases, basic FGF, VEGF 8% (141/1773) 3 IL-8, BMP2, TNF-a, damage-associated molecular patterns, aggrecans, BMP5 8% (140/1773) 4 VEGF, M-CSF, IL-1ß, BMP2, BMP6, nitric oxide 4% (75/1773) 5 BMP5, basic FGF, nitric oxide, aggrecans, TNF-a, IL-1ß 3% (54/1773) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.100) A 32-year-old runner sustains a trimalleolar left ankle fracture. She undergoes open reduction and internal fixation and is kept non-weightbearing after surgery. At 2 months, what changes will occur in the articular cartilage of both her knees as a result of her current weightbearing regimen? QID: 4735 Type & Select Correct Answer 1 Cartilage thickening in the left (ipsilateral) knee and no change in cartilage thickness in the right (contralateral) knee 10% (399/4100) 2 Cartilage thinning in both knees 6% (262/4100) 3 Cartilage thinning in the left (ipsilateral) knee and no change in cartilage thickness in the right (contralateral) knee 50% (2058/4100) 4 Cartilage thinning in the left (ipsilateral) knee and increased cartilage thickness in the right (contralateral) knee 32% (1298/4100) 5 Increased cartilage thickness in both knees 0% (19/4100) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE13BS.51) What proteinaceous compound binds to hyaluronic acid to function as an effective boundary molecular layer in articular cartilage? QID: 8288 Type & Select Correct Answer 1 Lubricin 38% (156/411) 2 Vitronectin 4% (15/411) 3 Aggrecan 32% (132/411) 4 Chondroitin sulfate 25% (103/411) N/A Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.203) Which of the following best describes the appearance of chondrocytes and orientation of collagen fibrils in the superficial zone of articular cartilage? QID: 4563 Type & Select Correct Answer 1 Round chondrocytes oriented parallel with the tidemark and collagen fibrils oriented perpendicular to the tidemark 6% (242/4068) 2 Round chondrocytes oriented parallel with the tidemark and collagen fibrils oriented parallel to the tidemark 7% (272/4068) 3 Flattened chondrocytes oriented parallel with the tidemark and collagen fibrils oriented perpendicular to the tidemark 22% (900/4068) 4 Flattened chondrocytes oriented perpendicular with the tidemark and collagen fibrils oriented perpendicular to the tidemark 9% (347/4068) 5 Flattened chondrocytes oriented parallel with the tidemark and collagen fibrils oriented parallel to the tidemark 55% (2252/4068) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ12.93) Which of the following contributes most to the ability of hyaline cartilage to attract water? QID: 4453 Type & Select Correct Answer 1 Aggrecan 88% (3914/4456) 2 Biglycan 6% (289/4456) 3 Decorin 2% (94/4456) 4 Fibromodulin 2% (75/4456) 5 Osteocalcin 1% (54/4456) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ11.163) Figure A displays a schematic of the zones of articular hyaline cartilage. Which of the following zones has been shown to contain articular cartilage progenitor cells? QID: 3586 FIGURES: A Type & Select Correct Answer 1 A 30% (887/2939) 2 B 14% (422/2939) 3 C 31% (897/2939) 4 D 6% (174/2939) 5 E 19% (547/2939) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.67) What part of the articular cartilage has the highest concentration of proteoglycans and the lowest concentration of water? QID: 453 Type & Select Correct Answer 1 Superficial 18% (515/2838) 2 Transitional 7% (198/2838) 3 Deep 57% (1604/2838) 4 Tidemark 8% (218/2838) 5 Calcified cartilage 10% (290/2838) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07HK.93) Which of the following substances makes up the majority by weight of the extracellular matrix for articular cartilage? QID: 6053 Type & Select Correct Answer 1 Keratin sulfate 1% (4/531) 2 Collagen type II 15% (81/531) 3 Water 78% (414/531) 4 Protein 2% (8/531) 5 Chondroitin sulfate 4% (19/531) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ06.210) Which of the following features of metal-on-metal total hip arthroplasty does not allow for improved fluid film lubrication between the components? QID: 221 Type & Select Correct Answer 1 Larger femoral head 11% (411/3732) 2 Slight clearance of fit between the acetabular cup and the femoral head 16% (613/3732) 3 Minimal surface roughness of the femoral head 3% (101/3732) 4 Complete congruence of fit between the acetabular cup and the femoral head 67% (2516/3732) 5 Minimal surface roughness of the acetabular cup 2% (78/3732) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ04.3) Which of the following statements regarding articular cartilage is TRUE? QID: 114 Type & Select Correct Answer 1 Cartilage is an isotropic material 10% (104/1034) 2 Most of the water in articular cartilage exists in the deep layer next to the calcified cartilage 19% (194/1034) 3 Cartilage only heals if the injury does not pass through the tidemark 16% (167/1034) 4 Calcified cartilage is the only place that type IV collagen is found 6% (57/1034) 5 Cartilage exhibits stress shielding of the solid matrix components 49% (505/1034) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ04.20) A 28-year-old marathon runner has a knee MRI done to evaluate medial sided knee pain. No meniscus tear is identified, but the articular cartilage of the femoral condyles is noted to be twice as thick as normal values. What is the most likely cause of this finding? QID: 131 Type & Select Correct Answer 1 Osteoarthritis 2% (23/934) 2 Undiagnosed osteopetrosis 0% (3/934) 3 Synovial cytokine sensitization due to excess running 11% (102/934) 4 Extra-articular hydrostatic pressure changes 4% (38/934) 5 Chondrocyte modulation via mechanotransduction 82% (765/934) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ04.78) Which of the following biochemical changes are common to both aging cartilage and osteoarthritic (OA) cartilage? QID: 1183 Type & Select Correct Answer 1 Increased water content 10% (294/3060) 2 Decreased collagen content and decreased modulus of elasticity 28% (849/3060) 3 Decreased proteoglycan content 56% (1705/3060) 4 Increased chondroitin sulfate concentration 3% (84/3060) 5 Decreased keratin sulfate concentration 4% (116/3060) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
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