Cartilage Lesion - How i Do it

Paulo Ribeiro de Oliveira
Coordenador da Unidade Funcional do Joelho
Hospital de São João - Porto / F. Medicina do Porto
Cartilage Lesion– what can we do ?
Our Point of View !

Cartilage
Tissue that lines the diarthrodial joints, with:
1. Low friction surface
2. Avascular
3. Permeable (water and nutrients)
4. Flexible wear resistant
5. Elasticity
6. Resistance to compressive forces
7. Ability to minimize peak loads transmitted to
the subchondral bone
8. Little regenerative capacity

Constitution :
1. Collagen fibers type II and type IX
(strength and stress resistance)
2. Water 70 - 80%
3. Proteinoglicans or hydrophilic molecules
"aggrecan" (20 to 40% dry weight)
(elasticity and deformability)
4. Chondrocytes (10% dry weight)
5. Other collagens type V, VI, XI small
amounts
Cartilage

1. Microlesion of cells and matrix with no visible damage to
the cartilage
2. Macrolesion
3. Fractures of articular cartilage and subchondral bone
(osteochondral fractures)
Cartilage

Outerbridge classification:
Grade 0 - Normal cartilage
Grade 1 - Cartilage softened and swollen
Grade 2 - Cracking not reaching the
subchondral bone; less than 1.5 cm
Grade 3 - Cracking reaching the subchondral
bone without exposure; greater than 1.5 cm
Grade 4 - subchondral bone exposure of any
diameter
Cartilage
ICRS Classification:
Normal: grade 0
Almost normal:
Grade 1a- superficial lesions / softening
Grade 1b - 1a and / or fissures or surface cracks
Abnormal:
Grade 2 - length < 50% thickness
Serious injury:
Grade 3 a – extension > 50%
Grade 3 b - to the calcified layer
Grade 3 c - to the surface of the subchondral
bone (without entering)
Grade 3 d - includes blisters
Very serious injury:
Grade 4 a - penetration of the subchondral bone
but not the full diameter of the defect
Grade 4b - penetration across the diameter of the
defect
Several classifications : Outerbridge, ICRS etc

The primary factor in the development of a cartilage lesion is
undoubtedly the relationship between the size of the lesion and the
load surface, being adversely affected by:
Obesity
Age
Axial misalignment
Family history of osteoarthritis
Overload activities
Cartilage

Cartilage
Treatment
• Individual
• Effective complaints
• Patient expectations
• Age (physiological)
• IMC
• Symptomatology (mechanical pain,
inflammatory or mixed)
• Occupation
• Ability to understand the detailed objectives
and commitment to accept
• Defect
• Localization
• Number of defects
• Size
• Depth
• Defect geometry
• The underlying subchondral space rating
• Lesion contained or not
• Axial deviations
• Instability associated
• Associated injuries (meniscal)
All treatment should be individualized on the basis of these parameters

Conservative treatment
Drugs - NSAIDs
Infiltration - corticosteroids, viscosupplementation, collagen ???
Orthoses
Exercise, weight loss
Activity modification
Cartilage

Microfractures
Microfratures and augmentation
Autologous osteochondral graft
Osteochondral allograft
Matrix autologous chondrocyte implantation
Cartilage
Treatment

Microfractures
❖ Serve to facilitate the repair process with surface repopulation with undifferentiated
mesenchymal cells
❖ Complete filling of the lesion with a stable clot
❖ Overcorrection of axial misalignments
❖ Role of BMP, PGF etc...
Cartilage
Treatment

Cartilage
Treatment

A recent systematic review of twenty-eight studies with >3000 patients found that knee function was consistently improved in
the first twenty-four months after microfracture in the patients studied. After two years, knee function scores remained above
preoperative levels but declined; only 67% to 85% of patients continued to report improvement in the two to five-year time
frame.
It was also noted that shortcomings of the microfracture technique included limited production of hyaline cartilage,
unpredictable repair cartilage volume, and higher failure rates for cell transplantation surgery following failed prior microfracture
compared with patients in whom similar cellular treatments were used as first-line options.
Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-
based systematic analysis. Am J Sports Med. 2009 Oct;37(10):2053-63.
There is growing evidence that modification or augmentation of microfracture may improve the quality of the repair tissue
formed and ultimately the clinical outcome for patients.
At the present time, it is believed that marrow stimulation techniques are best reserved as a first-line option for isolated defects
of <2.5 cm2 on the femoral condyles. Biologic augmentation techniques may broaden these indications and improve longterm
outcomes.
Strauss EJ, Barker JU, Kercher JS, Cole BJ, Mithoefer K. Augmentation strategies following the microfracture technique for repair of focal chondral
defects. Cartilage. 2010 Mar;1(2):145-52. 
Cartilage
Microfrature and augmentation

Axial deviations correction
To correct the axial misalignment for a better distribution
of the axial compressive forces
Studies have shown the appearance, after osteotomy, of
fibrocartilage in the medial compartment (Bergenudd H et
al)
This symptons improvement deteriorates with the time
course (Coventry MB et al)
The axial correction should never be by default and should
be performed if necessary in conjunction with
reconstruction techniques
Cartilage
Treatment

Autologous osteochondral graft
It consists in the transplant of osteochondral grafts from a non load zone to
vital areas of the articular surface
Outerbridge HK et al. and Hangody et al. confirmed the validity of this
technique for limited defects correction, highlighting the potential morbidity of
the donor area and the difficult technique of fixation of the graft
Important: early mobilization , without load up to 6-8 weeks
Cartilage
Treatment

Create a sufficiently smooth and sliding
surface of hyaline cartilage or similar
Enabling the delay of joint degeneration
Cartilage
Treatment
Autologous
osteochondral graft

INDICATIONS
Chondral or osteochondral focal lesions on loading surfaces of the joints
Can be used in astragalus, head of the femur, knee, etc.
Usually below the age of 50
Defects of 1 - 4 cm2
Treatement of associated pathologies: meniscal or ligamentous injuries,
axial deviations correction
Patient compliance to the protocol
Cartilage

Absolute:
Neoplasia, infection, rheumatoid arthritis and
similar pathologies
Absence of a compatible donor zone
〉50 years
Defect 〉8 cm2
Defect deeper than 10mm
Noncompliant patient
Relative:
40 - 50 years
Defect size 4 - 8 cm2
Moderate degenerative changes
Cartilagem
CONTRAINDICATIONS

TÉCNICA
Arthroscopic
Technically demanding
Miniarthrotomy
Best alternative for
inexperienced
Cartilagem
Tratamento

Pure chondral lesions - the cylinder should be 15 mm
Osteochondral lesions - the cylinder should be 25 mm
Cartilage
Treatment

Cartilagem
Tratamento

Cylinder perpendicular to articular surface
Avoid the cylinder sinking; 1 - 2 mm above the adjacent
surface
No load for 3 - 5 weeks
Cartilage
Treatment

MOSAICPLASTY – RMN 1 YEAR

Bobic ( 1996)
Mosaicplasty in 12 patients with ACL injury: with good or excellent results in 10/12 cases
Wang ( 2002)
Mosaicplasty in 16 patients with 2 to 4 years of follow-up: 80% good or excellent results
Sharp et al ( 2005)
Combined chondrocyte transplantation and mosaicplasty with follow up of 3 years in 13 patients with large lesions:
excellent results in 10/13 patients
Hangody, L. et al. JBJS . Am. 85:25-32, 2003
10 years of follow - up of 831 patients with mosaicplasty: excellent results in 92% in the femoral condyle, 87% in tibial
plate, 79% in patella or trochlear region and 94% in astragalus
Cartilagem
Mosaicplasty
Effect of Impact on Chondrocyte Viability During Insertion of
Human Osteochondral Grafts
BY BORIS H. BORAZJANI et al
Investigation performed at University of California-San Diego, La Jolla, California
Conclusions: Impact insertion of osteochondral grafts generates damaging loads that cause
chondrocyte death, particularly in the superficial zone, mainly as a result of apoptosis mediated by
the activation of caspases.
Clinical Relevance: Chondrocyte death that occurs during impact insertion of osteochondral grafts may lead to compromised
function. Understanding the mechanisms and consequences of such impact loading may provide insights into potential
therapeutic interventions, or lead to changes in the insertion technique, to decrease the cell injury associated with impact
loading.
In conclusion : Osteochondral autograft transfer is
recommended for smaller lesions, lesions in high-
demand athletes, and lesions with associated bone
loss, while microfracture is suited for medium-size
defects with little or no bone loss in lower- demand
patients and they should therefore be reserved for
revision situations.

Use of cadaver tissue to correct larger defects
Restrictions
Size
Height
Default location
Are factors that influence the adaptation of the graft to the
recipient
Advantages
Ability to fill large defects
Absence of donor morbidity
Cartilage
Treatment

Restrictions
Obtainment difficulties
Rejection
Difficulty in graft incorporation
Diseases transmission
Potential high cost
Technical difficulty in graft conditioning
Cartilage
Treatment

Graft types
Allograft in culture medium - 91% viability of chondrocytes
after 14 days (Ball, ST et al.).
Cryopreserved allograft - feasibility 77% of chondrocytes to
one year (animal study) deterioration with time (Gole et al.)
Allograft "Fresh Frozen" - The process of freezing at - 80 °
destroys the viability of chondrocytes in all graft (Enneking,
WF et al.)
Cartilage
Treatment
Most authors concluded that the survival is directly related to the
number of viable cells
Transplantation of Osteochondral Allografts After Cold Storage
BY THEODORE MALININ, MD, H. THOMAS TEMPLE, MD, AND BILL E.
BUCK, MD
Investigation performed at the Department of Orthopaedics and Rehabilitation,
University of Miami School of Medicine, Miami, and the Mannheimer Foundation, Homestead, Florida
Conclusions: Time-dependent loss of chondrocytes in articular cartilage
stored at hypothermia, especially in specimens stored for longer than fifteen
to twenty days, was observed in this study. Cartilage allografts transplanted
into nonhuman primates after twenty-one days of storage underwent more
severe degenerative changes than allografts that had been stored for less
than twenty-one days. These findings suggest caution when transplanting
cartilage stored at hypothermia for over twenty days.
Clinical Relevance: Surgeons who perform fresh osteochondral allograft transplantation should be cognizant of the time-
dependent changes associated with cold storage of these grafts. Full-thickness articular cartilage defects usually do not heal,
presumably because of the limited regeneration capacity of the tissue. The treatment of patients with articular cartilage lesions
is a challenge to orthopaedic surgeons. The problem is magnified by the high frequency of cartilage injury in the knees of
young people and the relatively poor results of arthroplasty in young, active individuals. The results of treating cartilage
defects have been largely disappointing. Shaving, burring, or drilling of these lesions does not predictably result in cartilage
regeneration in humans or in experimental animals. Other treatments have yielded varying outcomes, and each has its
inherent limitations and advantages.

Cartilage
Treatment
❖ Harvesting cartilage tissue from the host with chondrocytes, 14 - 21 days
of growth and redeploy them in joint surface defects (Wakitani S, et al)
❖ Autologous chondrocytes implantation in cartilage defects can be
effectively and reproducibly. We must pay attention to the possibility of the
carrier agents if used may trigger synovial reactions (Brittberg, M et al)
Matrix-assisted autologous
chondrocyte implantation

Advantages of the 3rd generation technique
The matrix with chondrocytes is subjected to mechanical stimulation, with
hydrostatic pressure to chondrocytes for a minimum of seven days which
will increase the production of collagen type II, aggrecan and other normal
components of hyaline cartilage
Easy application and adaptation to different sizes and shapes of defects
Cartilage
Treatment

Cartilage
Treatament

Cathal J. Moran, MD, FRCS(Orth), Cecilia Pascual-Garrido, MD, Susan Chubinskaya, PhD, Hollis G. Potter, PhD, Russell F. Warren, MD, Brian J. Cole,
MD, MBA, and Scott A. Rodeo, MD
Investigation performed at the Hospital for Special Surgery, New York, NY, and Rush University Medical Center, Chicago, Illinois
Cartilage

Condylar injury
Axial deformity
AP instability
Meniscal injury
Lesion size
« 2-3cm
Microfractures ++
OATS ++
» 2-3 cm
Inactive
Microfractures +-
OATS +-
OCA ++
MACI ++
Active
OCA ++
MACI ++
Cartilage
Treatment- How I Do It

Patellofemoral injury
Misalignment of the knee
extensor apparatus
Lesion size
« a 2-3cm
Inactive
Microfractures ++
MACI/AMPF +-
Active
ACI/AMPF ++
OATS/AMPF +-
OCA/AMPF +-
» a 2-3 cm
Inactive
Microfractures ++
MACI / AMPF +-
Active
OCA/AMPF ++
MACI/AMPF ++
Cartilage
Treatment- How I Do It

Thank´s

Cartilage Lesion - How i Do it

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