Cartilage injuries most commonly occur in the knee joints and can affect both young and elderly populations through traumatic or degenerative means. Treatment depends on the severity and location of the injury. For partial thickness injuries, arthroscopic debridement can provide short-term relief. For full thickness injuries, options include stimulating intrinsic healing by microfracture, altering joint loads through osteotomy, transferring autologous tissue through mosaicplasty or chondrocyte implantation, or using allografts. Future approaches may involve gene therapy to enhance the repair process.

1. CARTILAGE
INJURIES
PRESENTER- Dr.
RAGHAVENDRA
.

2. INTRODUCTION
 Most common in knee joints.
 Occur in both young and elderly populations.
 ETIOLOGY- 1. traumatic.
2. degenerative.

3. COMPOSITION AND STRUCTURE
CARTILAGE
MATRIX
WATER(80%)
COLLAGEN
PROTEOGLYCANS
GLYCOPROTEINS
CELLS
CHONDROCYTES

4.  CHONDROCYTES- play role in synthesis,
maintenance, degradation.
 Mechanical properties of cartilage is due to biphasic
nature of cartilage.

5. Classifications
 Based on severity-

6. classification
ICRS, International
Cartilage Repair Society
Bauer and Jackson classification

7. RESPONSE TO INJURY
INJURY TO CARTILAGE
CHONDROCYTES DEGENERATION
WITH MATRIX DESTRUCTION
NO HAEMATOMA
NO FIBRIN
NO INFLAMMATION
NO UNDIFFENTIATED CELL SUPPLY

8. Remaining viable
chondrocytes
profilerate
Incomplete and
short lived
response

9. Symptoms and signs
Symptoms-
 pain ( most common and increases with weight
bearing).
 Swelling
 Mechanical symptoms.

10. SIGNS-
1. Tenderness.
2. Effusion.
3. Fat globules on aspiration may suggest chondral
injury or osteochondral fracture.

11. Investigations
 X rays –
 MRI- cartilage sensitive MRI or fast spin echo
sequence MRI.
 Most accurate- diagnostic arthroscopy.

12. TREATMENT
 Consider lesion location, size, and depth, associated
instability, malalignment , age, and activity level of
patient.
 Broadly divided in 1. partial thickness injury.
2. full thickness injury.

13. CONSERVATIVE-
 Decreasing the load on the joint( lose weight).
 Alter activities.
 Strengthen the muscles across the joint .
 Orthoses or braces also are beneficial.
 Analgesics and antiinflammatory medications.

14. OPERATIVE TREATMENT
Operative treatment generally is indicated if nonoperative
methods fail to relieve pain and mechanical symptoms.
The choice of procedure is based primarily on the
size of the lesion and the activity demands of the
patient.

15. Partial thickness injury
 Remain stable for long duration.
 It is important to distinguish symptomatic lesions
from those that are incidental findings.
 Correlate symptoms and findings.
 Treat only those areas that have large articular flaps
and impending loose bodies.

16. Arthroscopic debridement
 For patients with minimal symptoms and small
lesions (<2 cm) in areas of limited weight bearing,
arthroscopic débridement to remove loose flaps
or edges that impinge in the joint can provide
short-term relief .

17. Arthroscopic debridement
When debriding a lesion, rotate the cutting surface of the
arthroscopic debrider blade 90°, and use only the blade edge
in a tangential fashion to resect articular flaps.

18.  The goal of arthroscopic débridement and lavage
is to reduce the inflammation and mechanical
irritation within the joint.

19. FULL THICKNESS INJURIES
 These techniques began with open debridement,
spongialization, and osteotomy; evolved into
arthroscopic debridement, abrasion arthroplasty, and
microfracture; and now include autogenous
osteoarticular mosaicplasty, autogenous chondrocyte
implantation, and allograft replacement

20. FOUR BASIC TECHNIQUES
 (A) STIMULATION OF INTRINSIC HEALING
POTENTIAL
 (B) ALTERATION OF LOADS
 (C) TRANSFER OF AUTOGENOUS TISSUE AND
CELLS
 (D) TRANSFER OF ALLOGRAFT TISSUE

22. Stimulation of Intrinsic Healing
Potential
Debridement with drilling, abrasion arthroplasty, and microfracture all share the
basic principles of removing loose debris and degenerative cartilage, and
penetrating the subchondral bone to produce bleeding.

23. With subchondral bone penetration, a pluripotential stem cell
line is released and, in the proper environment, can differentiate
into a chondrogenic cell line .

24.  It is important to understand that subchondral
penetration does not produce normal articular
cartilage, instead it produces fibrocartilage with a
high concentration of type I collagen.

25.  Gill et al. listed five factors that affect the quality
of the cartilaginous repair tissue after
microfracture of a chondral defect-
 (1) during débridement, the calcified cartilage
layer must be removed, but the abrasion of the
subchondral bone must be avoided.
 (2) a 1- to 2-mm bridge of bone must be left
between penetrations to allow connective tissue to
fill the defect and adhere to the base of the defect.
 (3) joint function must be maintained after
surgery by the use of early continuous passive
motion.

26.  (4) protected weight bearing must be strictly
enforced, depending on the location of the lesion
 (5) any significant abnormality in the mechanical
axis must be corrected in conjunction with the
microfracture procedure

27. Alteration of Loads
 Its underlying principle is to shift a force concentration
overload away from a damaged joint surface.
 Insall et al. reported good and excellent results from
proximal tibial osteotomy in 85% of patients at 5 years
but noted only 37% excellent results after 9 years.

28. Autogenous Tissue Grafting
 Transfer normal articular cartilage into a damaged
area.
1: Preparation of recipient site
2: Harvest of the grafts
3,4: Preparation for the plug grafts
5: Insertion of the plugs
6: Completed mosaicplasty.

29.  Osteochondral
autografts can be
transplanted into
damaged areas (2 cm
to 3.5cms) from areas
of less weight bearing
on the femoral
condyle.

30. ADVANTAGES-
 NO RISK OF DISEASE TRANSMISSION
 NO PROBLEM WITH TISSUE REJECTION
 A HIGH RATE OF UNION
 CHONDROCYTE VIABILITY IS MAINTAINED WITH
FRESH AUTOGENOUS GRAFTS

31.  Disadvantages-
 supply of expendable autogenous osteoarticular grafts
is limited.
 donor site morbidity is a major concern.

32. Periosteal and Perichondrial
Grafting
 The principle behind these procedures is to provide a
new source of chondrogenic cells to repair the defect.

33. Autologous Chondrocyte
Implantation

35. Peterson autologous chondrocyte
implantation “sandwich”
technique
“Sandwich” technique of autogenous
chondrocyte implantation uses layers of
transplanted bone, periosteal flap,
chondrocytes, and periosteal flap

36.  A disadvantage of autologous chondrocyte
implantation is the prolonged postoperative
rehabilitation that requires strict compliance of
the patient with weight bearing and activity
restrictions.

37. FUTURE APPROACHES
 Repair process at the cellular and molecular levels
by the transfer of new genetic information to cells
that contribute to the healing process by gene
therapy.