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Articular cartilage injury
- 2. HISTORY “Cartilago” (Latin), “Chondros” (Greek) First recognized in the 4th century Aristotle
- 3. HISTORY “Ulcerated cartilage is a troublesome thing, once destroyed it never heals” William Hunter, 1743
- 4. ANATOMY Hyaline cartilage Avascular, aneural & alymphatic
- 5. ANATOMY Components Extracellular Matrix (ECM) Collagen Proteoglycan Water Cellular Chondrocyte
- 6. ANATOMY 4 distinct histological zones Superficial Middle Deep Calcified cartilage Tide mark
- 7. INCIDENCE 63% in 31 000 arthroscopic knee procedures 66% in 993 arthroscopic knee procedures. 11% was localized full thickness which required repair Curl W. W. (1997). Cartilage injuries: a review of 31,516 knee arthroscopies Arthroscopy Årøen A. (2004). Articular cartilage lesions in 993 consecutive knee arthroscopies. The American Journal of Sports Medicine
- 8. CAUSES Trauma Chronic degeneration Subchondral bone abnormality (e.g. OCD) Tumor
- 9. INJURY TYPES Type 1 injury Type 2 injury Type 3 injury Spindler K.P. (2002). Soft tissue physiology and repair. In Kenneth J. & Koval M.D.. Orthopaedic Update Knowledge 7. AAOS
- 10. HEALING Fibrin clot formation Mesenchymal stem cell migration Vascular ingrowth All leading to fibrocartilage (type I collagen) formation
- 11. HEALING Normal Healed with fibrocartilage Fragmentatio n of fibrocartilage Shantz J.S. (2014). Bone and cartilage healing
- 12. CLASSIFICATION
- 13. CLASSIFICATION 1. Outerbridge 2. International Cartilage Repair Society (ICRS)
- 25. Sharifi A.M. et al (2016). Articular cartilage- injury, healing and regeneration. Current Orthopaedic Practice.
- 26. OPERATIVE AIMS 1. Lessen symptoms 2. Improve joint congruence 3. Prevent additional cartilage deterioration Özmeriç A. (2014). Treatment for cartilage injuries of the knee with new treatment algorithm, World Journal of Orthopaedics.
- 27. OPERATIVE STRATEGIES 1. Palliative 2. Reparative 3. Restorative Vaishya R. (2016). The journey of articular cartilage repair, J Clin Orthop Trauma.
- 28. OPERATIVE STRATEGIES 1. Palliative – E.g. debridement & lavage 2. Reparative 3. Restorative Vaishya R. (2016). The journey of articular cartilage repair, J Clin Orthop Trauma.
- 29. DEBRIDEMENT & LAVAGE Include: Articular trimming Removal loose bodies Synovectomy Mechanical & thermal devices
- 30. DEBRIDEMENT & LAVAGE Also reduce concentration of degradative enzymes & inflammatory cytokines Relieve pain in short term
- 31. OPERATIVE STRATEGIES 1. Palliative 2. Reparative – E.g. Marrow stimulating techniques (subchondral drilling, abrasion chondroplasty, microfracture, AMIM) 3. Restorative Vaishya R. (2016). The journey of articular cartilage repair, J Clin Orthop Trauma.
- 32. MARROW STIMULATING TECHNIQUE A technique to penetrate subchondral bone & allow communication with the marrow cavity Pridie (1959)- open technique Johnson (1986) - arthroscopic 3 types: 1. Subchondral drilling 2. Abrasion chondroplasty 3. Microfracture (Steadman, 1994)
- 33. SUBCHONDRAL DRILLING • Multiple holes drilled in subchondral bone • Poor access, risk thermal necrosis and long term efficacy is questionable
- 34. ABRASION CHONDROPLASTY • Use motorized burr • Aim to remove 1- 3mm subchondral bone • Risk of thermal necrosis and more destructive
- 35. MICROFRACTURE • Unstable cartilage removed to create a well-contained defect area • Subchondral plate completely exposed
- 36. MICROFRACTURE • Awl is used to create multiple fracture holes • Post op – early mobilization with CPM & protected weightbearing
- 37. ACELLULAR MATRIC INDUCED MICROFRACTURE (AMIM) Use scaffold to augment microfracture Stabilize fibrin clot Optimum environment for mesenchymal cells to migrate & differentiate AMIM using BST CarGel (a chitosan based scaffold extracted from shrimp exoskeleton)
- 38. OPERATIVE STRATEGIES 1. Palliative 2. Reparative 3. Restorative – E.g. AOT (mosaicplasty), OAT, ACI Vaishya R. (2016). The journey of articular cartilage repair, J Clin Orthop Trauma.
- 39. AUTOLOGOUS OSTEOCHONDRAL TRANSPLANTATION (AOT) Restoration procedure aim to produce true hyaline cartilage Single large bone plug or multiple small plugs Multiple small plugs = Mosaicplasty (Hangody 1991)
- 40. MOSAICPLASTY • Chondral defect prepared – multiple cylindrical holes with perpendicular vertical edges of normal cartilage around • Ostechondral plugs harvested from low weight bearing area
- 41. MOSAICPLASTY • Osteochondral plugs used to fill chondral defect in a ‘mosaic’ pattern
- 43. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) First described by Brittberg (1994) 3 generations: 1st gen – Periosteum patch (PACI) 2nd gen – Collagen cover (CACI) 3rd gen – Matrix induced (MACI) 2-stage procedure
- 44. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) Brittberg M. (1994). Treatment of deep cartilage defect in knee with ACI, The New England Journal of Medicine
- 45. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) Brittberg M. (1994). Treatment of deep cartilage defect in knee with ACI, The New England Journal of Medicine 1st stage: 1. Arthroscopic evaluation 2. Cartilage biopsy
- 46. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) Brittberg M. (1994). Treatment of deep cartilage defect in knee with ACI, The New England Journal of Medicine 2nd stage: Done after 6/52 1. Defect debridement 2. Periosteal flap harvesting & grafting 3. Implantation of cells
- 47. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) PACI CACI MACI
- 49. MATRIX-INDUCED AUTOLOGOUS CHONDROCYTE IMPLANTATION (MACI) CaReS Novocart 3D NeoCart Vericel
- 50. AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) A large ‘kissing lesion’ chondral injury of lateral compartment of knee, treated with ACI
- 51. OUTCOMES OF ACI Cartilage repair in adolescent knees using ACI provide success across different clinical outcomes measures No significant difference between MST, AOT & ACI in improving function and pain at intermediate term follow up DiBartola A.C. (2016). Clinical Outcomes After ACI in Adolescents' Knees: A Systematic Review Arthroscopy. Mundi R. (2016). Cartilage Restoration of the Knee: A Systematic Review and Meta-analysis of Level 1 Studies. The American Journal of Sport Med.
- 52. ALGORITHM At present, no world-wide accepted method for managing cartilage injury No one procedure is best for all types of defect
- 53. ALGORITHM Özmeriç A. (2014). Treatment for cartilage injuries of the knee with new treatment algorithm, World Journal of Orthopaedics.
- 54. TAKE HOME MESSAGES Only injury beyond tidemark will initiate healing process Articular cartilage is hyaline cartilage, but healed with fibrocartilage CPM and early controlled weight bearing are mandatory for post op rehabilitation
Editor's Notes
- The recognition of cartilage as a vital tissue of the body has been there for ages. Aristotle was the first scientist to mention it vaguely in the fourth century BC.1
- William Hunter (23 May 1718 – 30 March 1783) was a Scottish anatomist & physician. He was a leading teacher of anatomy, and the outstanding obstetrician of his day. To orthopaedic surgeons he is famous for his studies on bone and cartilage In a famous quote the renowned anatomy surgeon, John Hunter (1743) stated: ‘‘Cartilage injury is a troublesome thing and once injured is seldom repaired.’’ Unfortunately, this remained a general assumption of thinking about cartilage repair for the next 200 years! Since the 1980s, there has been a sudden interest and flurry of cartilage research. Several concepts developed during this period laid the foundation for technologies in current use today
- Gliding surfaces of synovial joint are covered with a specialized type of hyaline cartilage, called ‘articular cartilage -Provide a low friction gliding surface -Act as shock absorber -Minimize peak pressure on subchondral bone Chondrocytes receive their nutrition by diffusion through the matrix from synovial fluid
- Water 65-80% -Allows load-dependent deformation of the cartilage -In osteoarthritis, water content becomes more than 90% due to increased permeability and disruption of the matrix. This leads to decreased modulus of elasticity and thus reduction in load bearing capability of the articular cartilage. Collagen 10-20% -Tensile strength -Type II 95% Proteoglycan 10-20% -Compressive strength -Maintain fluid & electrolyte balance -Subunit called GAG (chondroitin sulphate & keratin sulphate), linked to hyaluronic acid Chondrocyte 5% -Synthesize matrix components -Regulate matrix metabolism
- Superficial -Flattened ellipsoid cells & lie parallel to the joint surface -Chondrocytes in this zone synthesize high concentration of collagen and low concentration of proteoglycans Middle -Collagen randomly arranged Deep -Cells arranged perpendicular to surface -Largest collagen fibre diameter -Highest concentration PG Calcified cartilage -Anchor AC to subchondral bone -Mainly type X collagen The tidemark is a thin basophilic line seen at light microscopy sections of decalcified articular cartilage that corresponds to the boundary between the calcified and uncalcified cartilage
- The main presenting symptoms of AC injury are pain and mechanical symptoms, such as locking or catching.
- Osteochondritis dissecans, which is caused by blood deprivation in the subchondral bone that leads to avascular necrosis and bone resorption will leave the articular cartilage prone to damage. Cracks may form in the articular cartilage and subchondral bone, resulting in fragmentation of both cartilage and bone, and free movement of these osteochondral fragments within the joint space cause pain and further damage.44 Tumors made up of cartilage tissue, either benign (chondroma) or malignant chondrosarcoma)
- Injuries to the articular surface can be divided into acute and subacute (gradual). Acute injury types include blunt trauma, shear, and thermal (including electrocautery as well as laser). Subacute or gradual types occur as a result of mechanical overload secondary to meniscal loss and/or ligamentous instability, aging, and potentially exercise. Mechanical trauma (blunt, twisting, or impact loading) to the articular cartilage leads to three basic types of tissue damage. Type 1 is the destruction or alteration of the macromolecule framework (that is, loss of matrix or macromolecules, or cell injury without evidence of disruption). Type 2 is the disruption of the articular cartilage alone (chondral fractures or fissuring). Type 3 is disruption of the articular cartilage with penetration into the subchondral bone (for example, an osteochondral fracture). The healing potentials of these lesions are significantly different because the articular cartilage is avascular. Because types 1 and 2 do not penetrate the subchondral bone, there exists an extremely poor to nonexistent potential for healing because an inflammatory component is not elicited and the chondrocytes have limited ability to initiate a repair process. In contrast, type 3 injuries produce an inflammatory response with a fibrin clot and exposure of mesenchymal undifferentiated cells that populate this fibrin clot and produce a reparative tissue. However, this tissue consists primarily of type I collagen and does not have the biomechanical properties of normal articular cartilage. This fibrocartilage is prone to early degenerative changes.
- A typical tissue response to injury follows a cascade of necrosis, inflammation, repair, and scar formation Without a robust inflammatory response and proper tissue circulation, MSCs differentiate into endothelial cells and fibroblasts
- A: Normal rabbit articular cartilage showing the homogeneous extracellular matrix. The chondrocytes near the articular surface are relatively small and flattened, in which those in the middle and deeper zones of the articular cartilage have a more spherical shape. B: Well-formed fibrocartilaginous repair cartilage. Notice that the extracellular matrix is more fibrillar and the chondrocytes do not show the same organization as normal articular cartilage. Nonetheless, this repair cartilage does fill the defect in the articular surface. In most instances after osteochondral injury, this type of tissue forms within 6 to 8 weeks C: Photomicrograph showing fibrillation and fragmentation of fibrocartilaginous repair tissue. Because fibrocartilaginous repair tissue lacks the mechanical properties of normal articular cartilage, it often degenerates over time
- Although cartilage lesions had been directly examined and described as far back as the early 20th century, the etiology of chondromalacia of the patella was not well understood when Outerbridge published his first paper on the subject in 1961 [15]. In this initial study, he evaluated the cartilage of the patella during 196 medial meniscectomies to better understand how chondromalacia progressed and which areas of the patella were primarily affected. He found that chondromalacia was most common on the medial facet as a result of constant friction with a rim on the upper border of the medial femoral condyle. He also noted the incidence of chondromalacia of the patella to be approximately 50% in patients who underwent open medial meniscectomy, even in the absence of symptoms. To better understand the etiology of chondromalacia of the patella, Outerbridge developed his classification system describing varying severity of cartilage lesions by direct visualization, which he continued to use in his subsequent papers [15-17]. Since the introduction of Outerbridge’s classification system originally designed for chondromalacia of the patella, it has been adapted to include the entire knee in 1989 and other joints since then Chondromalacia can be divided into 4 grades by MRI, typically using fat saturated proton density sequences. This grading system is the modified Outerbridge grading system, which was devised for arthroscopy initially for assessment of chondromalacia patella, but then modified and extended for all chondral surfaces
- Axial image acquired with multiple-echo data image combination sequence shows grade 1 cartilage lesion. There is a focal area of chondral softening revealed as an area of focal hyperintensity (arrow) within the articular cartilage
- Axial 2D fat-saturated PD-weighted fast spin-echo image of knee joint in a 47 year old man shows arthroscopically confirmed superficial cartilage fibrillation (arrows) categorized as grade 2 cartilage lesion
- Axial fast spin-echo PD FS image in 39 year old man reveals a wide area of full-thickness chondromalacia (arrow) involving the median ridge and the medial patellar facet categorized as grade 3 lesion (fissuring of cartilage to level of subchondral bone) in the posterior aspect of the patella. The subchondral bone is not exposed, which discriminates this lesion from a grade 4 lesion 46 year old male volunteer with knee pain. Sagittal images of knee joint show superficial cartilage fissure (long arrow) within medial femoral condyle. Note that superficial cartilage lesion is more conspicuous on SPGR image. This is classically termed as ‘crab meat’ appearance. Additionally, small amount of marrow edema (short arrow) is also appreciable. According to Modified Outerbridge classification, crab meat appearance is categorized as grade 3 chondral lesions
- Axial FS PD-weighted sequence (TR/TE, 884/26; flip angle, 30°) image of knee joint shows grade 4 chondromalacia (yellow arrow) of articular cartilage in median patellar ridge and lateral patellar facet. The remainder of articular cartilage is irregularly thinned out. There is a moderate amount of edema of marrow in subchondral aspect (white arrow). (B) Coronal FS PD weighted images of an adult patient. There is a large osteochondral lesion involving weight-bearing surface of medial tibial condyle. There is a moderate depression of this osteochondral lesion (arrow) with moderate surrounding marrow edema
- Cartilage healing requires mechanical stimulation. Immobilization worsen
- Repair refers to the restoration of a damaged articular surface with a neo-cartilage tissue, which resembles to the native cartilage, but does not necessarily duplicate its structure, composition and function. Regeneration refers to the formation of tissue, indistinguishable from the native articular cartilage.
- Repair refers to the restoration of a damaged articular surface with a neo-cartilage tissue, which resembles to the native cartilage, but does not necessarily duplicate its structure, composition and function. Regeneration refers to the formation of tissue, indistinguishable from the native articular cartilage.
- It was a broad term, which included articular trimming, meniscectomy, removal of osteophytes and loose bodies, articular abrasions and even synovectomy
- Repair refers to the restoration of a damaged articular surface with a neo-cartilage tissue, which resembles to the native cartilage, but does not necessarily duplicate its structure, composition and function. Regeneration refers to the formation of tissue, indistinguishable from the native articular cartilage.
- This technique involves debridement of the articular defect circumferentially using a motorized burr to remove 1-3 mm of subchondral bone[23]. However, excessive trauma to the underlying bone and thermal necrosis can be potentially more destructive than helpful. Therefore this technique is not used in current practice[
- In this procedure, all the unstable cartilage is removed to create a stable well-contained defect surrounded by normal cartilage, with a complete exposure of the subchondral plate. The success of this procedure lies in creating stable perpendicular edges of healthy cartilage around the defect.
- An arthroscopic awl is then used to create iatrogenic but controlled multiple fracture holes penetrating the subchondral plate of bone, 3–4 mm apart. Importantly, the integrity of the subchondral bone plate has to be maintained. The defect gets filled in with a so-called ‘super clot’, an optimal environment for pluripotent marrow cells to differentiate into a stable repair tissue. Early mobilization with continuous passive motion, followed by strictly protected weightbearing programme, is mainstay in the success of the outcome following microfracture therapy.
- Adjunt to microfracture procedure
- Repair refers to the restoration of a damaged articular surface with a neo-cartilage tissue, which resembles to the native cartilage, but does not necessarily duplicate its structure, composition and function. Regeneration refers to the formation of tissue, indistinguishable from the native articular cartilage.
- Can be done open, mini open or arthroscopically In this technique,cylindrical osteochondral plugs are harvested from a low-weight-bearing areas within the knee joint. The chondral defect is prepared, with perpendicular vertical edges of normal cartilage around. The osteochondral plugs are used to fill the chondral defect to create a ‘mosaic’ pattern hence called as mosaicplasty. Various sizes of the plugs are used to get maximum fill of the defect. The gaps between the plugs get filled in by fibrocartilage
- In this technique,cylindrical osteochondral plugs are harvested from a low-weight-bearing areas within the knee joint. The chondral defect is prepared, with perpendicular vertical edges of normal cartilage around. The osteochondral plugs are used to fill the chondral defect to create a ‘mosaic’ pattern hence called as mosaicplasty. Various sizes of the plugs are used to get maximum fill of the defect. The gaps between the plugs get filled in by fibrocartilage
- Chondrocytes require mechanical load to stimulate the production of ECM and remain in a chondrogenic phenotype