Introduction Spectrum of disease entities from single, focal defects to advanced degenerative disease of articular (hyaline) cartilage Epidemiology incidence 5-10% of people > 40 years old have high grade chondral lesions location chronic ACL tear anterior aspect of lateral femoral chondyle and posterolateral tibial plateau osteochondritis dissecans 70% of lesions found in posterolateral aspect of medial femoral condyle Pathophysiology mechanism of injury acute trauma or chronic repetitive overload impaction resulting in cartilage softening; fissuring; flap tears; or delamination the cause of OCD is unknown pathomechanics impaction forces greater than 24 MPa will disrupt normal cartilage cellular biology cartilage injuries have limited spontaneous healing and propensity to worsen over time Anatomy See Articular Cartilage Basic Science Classification Outerbridge Arthroscopic Grading System Grade 0 Normal cartilage Grade I Softening and swelling Grade II Superficial fissures Grade III Deep fissures, without exposed bone 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 History commonly present with history of precipitating trauma some defects found incidentally on MRI or arthroscopy Symptoms asymptomatic vs. localized knee pain may complain of effusion, motion deficits, mechanical symptoms (e.g., catching, instability) Physical exam inspection look for background factors that predispose to the formation of articular defects joint laxity malalignment compartment overload motion assess range of motion, ligamentous stability, gait Imaging Radiographs indications used to rule out arthritis, bony defects, and check alignment recommended views standing AP, lateral, merchant views optional views semiflexed 45 deg PA views most sensitive for early joint space narrowing long-leg alignment views determine the mechanical axis CT scan indications better evaluation of bone loss findings used to measure TT-TG when evaluating the patello-femoral joint MRI indication most sensitive for evaluating focal defects views 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 Studies Laboratory may be used to rule out inflammatory disease Treatment Nonoperative rest, NSAIDs, physiotherapy, weight loss indications first line of treatment when symptoms are mild viscosupplementatoin, corticosteroid injections, unloader brace indications controversial may provide symptomatic relief but healing of defect is unlikely Operative debridement/chondroplasty vs. reconstruction techniques indications failure of nonoperative management acute osteochondral fractures resulting in full-thickness loss of cartilage 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 basic algorithm (may vary depending on published data) femoral condyle defect correct malaligment, ligament instability, meniscal deficiency measure size < 4 cm2 = microfracture or osteochondral autograft transfer (pallative if older/low demand) > 4 cm2 = osteochondral allograft transplantation or autologous chondrocyte implantation patellofemoral defect address patellofemoral maltracking and malalignment measure size < 4 cm2 = microfracture or osteochondral autograft transfer > 4 cm2 = autologous chondrocyte implantation (microfracture if older/low demand) Surgical Techniques Debridement / Chondroplasty overview goal is to debride loose flaps of cartilage removal of loose chondral fragments may relieve mechanical symptoms 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 chondroplasty, osteochondral drilling microfracture technique defect is prepared with stable vertical walls and the calcified cartilage layer is removed aggressive debridement with removal of subchondral plate may lead to osseous overgrowth awls are used to make multiple perforations through the subchondral bone 3 - 4 mm apart 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 2 cm x 2cm limitations poor results for larger defects >2 cm x 2cm does not address bone defects requires limitation of weight bearing for 6 - 8 weeks 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 chondrocytes remain viable, bone graft is incorporated into subchondral bone and overlying cartilage layer heals. 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 only FDA approved cell therapy for cartilage in the USA include ability to perform without suturing, may be performed arthroscopically limitations 2-stage procedure Expense
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Microfracture of the Knee Orthobullets Team Knee & Sports - Osteonecrosis of the Knee Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Osteochondral Plug Allograft Transfer of the Knee Orthobullets Team Knee & Sports - Articular Cartilage Defects of Knee
QUESTIONS 1 of 12 1 2 3 4 5 6 7 8 9 10 11 12 Previous Next (SBQ16SM.18) A 30-year-old active-duty woman presents to your clinic with right knee pain and without any history of trauma. She is an avid runner and is part of the Army 10-miler team. Her pain is located directly over her medial femoral condyle (MFC). Additionally, she describes intermittent episodes of an inability to fully extend her knee. Her clinical mechanical alignment, patellar tracking, meniscal examination, and ligamentous examination are all equivocal on physical examination. Your diagnostic imaging workup with pertinent findings is represented in Figures A through E. You perform a diagnostic arthroscopy to confirm that the pathology is isolated to the medial compartment and you note that there is not any evidence of ligamentous or meniscal pathology. Based on your findings which definitive surgical options would you recommend to the patient? Tested Concept QID: 211304 FIGURES: A B C D E Type & Select Correct Answer 1 Proximal tibia valgus osteotomy, microfracture to the MFC, and removal of loose osteochondral bodies 7% (95/1359) 2 Distal femur varus osteotomy and autologous chondrocyte implantation to the MFC 1% (18/1359) 3 Osteochondral autograft transplantation to the MFC 19% (253/1359) 4 Removal of loose osteochondral bodies and osteochondral allograft transplantation to the MFC 68% (930/1359) 5 Patellofemoral realignment osteotomy, removal of loose osteochondral bodies, and autologous chondrocyte implantation to the MFC 3% (46/1359) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (SBQ16SM.7) Figures A-C are the arthroscopic, radiographic and MRI images of a 34-year-old male who has had knee pain for the past 11 months. He has failed conservative and arthroscopic management under the care of another physician. He comes to you for a second opinion. The decision is made to proceed with osteochondral allograft transplantation to the medial femoral condyle. All of the following are contraindications for this surgery except: Tested Concept QID: 211183 FIGURES: A B C Type & Select Correct Answer 1 Osteochondral defect measuring > 2 cm2 76% (1045/1369) 2 Uncorrectable limb malalignment 4% (49/1369) 3 Ligamentous instability of the knee 5% (62/1369) 4 Meniscal insufficiency 10% (138/1369) 5 Multi-compartmental arthrosis 5% (67/1369) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.99) A 35-year-old man presents with mechanical knee pain after a fall. An arthroscopic picture taken during diagnostic arthroscopy is shown in Figure A. His surgeon considers treatment with Technique B and Technique C, which are shown in Figures B and C, respectively. Which of the following statement is true with respect to Technique B and C? Tested Concept QID: 4734 FIGURES: A B C Type & Select Correct Answer 1 A diminished immune response to transplanted chondrocytes is seen in Technique C because the dense cartilage matrix acts as a barrier that limits antigen exposure. 5% (320/6293) 2 In Technique C, healing is initiated by mesenchymal stem cell migration from subchondral bone. In Technique B, healing is initiated by allogeneic chondrocytes reimplanted beneath a periosteal patch. 3% (217/6293) 3 Grafts in Technique C are transferred to an antibiotic solution to kill microorganisms and stored at 4°C until use. 7% (460/6293) 4 A biopsy of the repair site at 3 months will reveal more Type I collagen in Technique B than in Technique C. 72% (4537/6293) 5 Technique C is a 2-stage procedure. Technique B is a single-stage procedure. 11% (688/6293) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ13.152) A 25-year-old patient undergoes the procedure seen in Figure A. Which of the following statements best describes the incorporation of the graft and biopsy results of the graft at one year? Tested Concept QID: 4787 FIGURES: A Type & Select Correct Answer 1 The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type I collagen. 12% (655/5456) 2 The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type II collagen. 59% (3206/5456) 3 The transplanted chondrocytes are nonviable and cartilage is used as a scaffold for growth of new articular cartilage. Biopsy shows type II collagen. 6% (348/5456) 4 The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Biopsy shows type I collagen. 9% (468/5456) 5 The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Biopsy shows mixture of type I and II collagen. 13% (711/5456) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ13.203) What type of tissue is formed by the activation of marrow mesenchymal cells following subchondral drilling of an 8x7 mm osteochondral defect? Tested Concept QID: 4838 Type & Select Correct Answer 1 Elastic cartilage 0% (10/5461) 2 Fibrocartilage 96% (5238/5461) 3 Hyaline cartilage 1% (77/5461) 4 Trabecular bone 1% (48/5461) 5 Hypertrophic chondrocytes 1% (64/5461) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (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? Tested Concept QID: 3424 Type & Select Correct Answer 1 Anterior (Maquet) tibial tubercle osteotomy 4% (192/4663) 2 Anteromedial (Fulkerson) tibial tubercle osteotomy 75% (3486/4663) 3 Anterolateral tibial tubercle osteotomy 10% (461/4663) 4 Medial opening wedge high tibial osteotomy 6% (298/4663) 5 Lateral closing wedge high tibial osteotomy 4% (194/4663) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ10.257) Following a medial femoral condyle osteochondral autograft mosaicplasty, which of the following statements best describes the fixation of the graft? Tested Concept QID: 3353 Type & Select Correct Answer 1 Graft fixation strength increases linearly with time until subchondral union at 3 months 6% (118/1889) 2 Graft fixation strength initially decreases during the early healing phase, and then increases with subchondral bone healing 85% (1600/1889) 3 Graft fixation strength does not change during the first 3 months following surgery 2% (30/1889) 4 Graft fixation strength is enhanced by early weight bearing 3% (56/1889) 5 Graft fixation strength initially increases over the first 6 weeks, then recedes with bony remodeling 4% (76/1889) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 25 x 25mm after debridement. What surgical treatment would you recommend? Tested Concept QID: 480 FIGURES: A Type & Select Correct Answer 1 Osteochondral autograft with 1-2 plugs 26% (290/1109) 2 Osteochondral allograft 58% (641/1109) 3 Microfracture 13% (148/1109) 4 Unicompartment arthoplasty 1% (14/1109) 5 Abrasion arthroplasty 0% (4/1109) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (SBQ07SM.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? Tested Concept QID: 1417 FIGURES: A Type & Select Correct Answer 1 Fibrocartilage 93% (1298/1399) 2 Fibrous tissue 3% (36/1399) 3 Elastofibroma 0% (2/1399) 4 Hyaline cartilage 3% (43/1399) 5 Chondromalacia 1% (9/1399) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ06.186) All of the following are acceptable scenarios for the use of autologous chondrocyte implantation (ACI) in the patellofemoral joint EXCEPT: Tested Concept QID: 372 Type & Select Correct Answer 1 Grade 4 lesion of the medial femoral condyle 10% (268/2627) 2 Grade 4 lesion of the trochlea 6% (148/2627) 3 Joint space narrowing on Merchant view 57% (1488/2627) 4 Varus mechanical axis on standing full length radiograph 23% (601/2627) 5 Concomitant anteromedial tibial tubercle transfer osteotomy (Fulkerson's) 4% (111/2627) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept
All Videos (73) Podcasts (4) Login to View Community Videos Login to View Community Videos ISTA: New Early-Career Webinar Series 2020 A Machine Learning Approach for Measuring Articular Cartilage Damage in the Knee - Maria Kristina Bartolo Knee & Sports - Articular Cartilage Defects of Knee 2/25/2021 26 views 0.0 (0) 2019 Orthopaedic Summit Evolving Techniques Fresh Osteochondral Allografts: Don't Waste Your Time With Other Things - Forget About Cell-Based Therapy - Thomas DeBerardino, MD Thomas DeBerardino Knee & Sports - Articular Cartilage Defects of Knee 12/3/2020 250 views 4.0 (1) 2019 Orthopaedic Summit Evolving Techniques Cryopreserved, Flexible Allografts: Don't Give Up On Them - Seth Sherman, MD Seth Sherman Knee & Sports - Articular Cartilage Defects of Knee 12/3/2020 228 views 4.0 (1) Knee & Sports⎪Articular Cartilage Defects of Knee Orthobullets Team Knee & Sports - Articular Cartilage Defects of Knee Listen Now 13:37 min 11/18/2019 385 plays 5.0 (2) Question Session⎪Articular Cartilage & Articular Cartilage Defects of Knee Orthobullets Team Knee & Sports - Articular Cartilage Defects of Knee Listen Now 37:19 min 11/18/2019 51 plays 0.0 (0) Question Session⎜Articular Cartilage Defects of Knee & Distal Biceps Avulsions Orthobullets Team Knee & Sports - Articular Cartilage Defects of Knee Listen Now 21:32 min 11/11/2019 19 plays 0.0 (0) Sports ⎜ Articular Cartilage Defects of the Knee (ft. Dr. Mark Pagnano) Team Orthobullets (AF) Knee & Sports - Articular Cartilage Defects of Knee Listen Now 13:13 min 10/18/2019 34 plays 3.0 (1) See More See Less
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