Cartilage injuries have limited healing potential due to lack of blood supply. Management involves conservative or surgical options depending on severity. Conservative options include rest, bracing and medications. Surgical options include debridement for partial tears or stimulation of healing for full thickness tears using microfracture, drilling or abrasion. Larger defects may be treated with osteochondral transplantation or cell-based therapies like ACI which harvest and grow the patient's own cartilage cells. Proper rehabilitation is important for all treatments to promote healing and prevent further damage.

1. MANGEMENT
OFCARTILAGE
INJURIES.

2. INTRODUCTION
Cartilage is derived (embryologically) from
mesenchyme.
. Chondroblasts produce the intercellular
matrix as well as the collagen fibres.
Chondroblasts that become imprisoned within
this matrix become chondrocytes.
The articular surface of most synovial joints are
lined by hyaline cartilage

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

4. Relatively acellular. Type 2 collagen
No vascular, neural or lymphatic supply
Has little capacity to heal after injury.
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Wear resistant
Low friction
Lubricated surface
Slightly compressible and elastic
Hyaline cartilage

5. StructureofCartilage
drbagaria.com

6. Classifications –
MODIFIEDOUTERBRIDGECLASSIFICATION

7. RESPONSETOINJURY
INJURYTO CARTILAGE
CHONDROCYTES DEGENERATION
WITH MATRIX DESTRUCTION
NO HAEMATOMA
NO FIBRIN
NO INFLAMMATION
NO UNDIFFENTIATED CELLSUPPLY

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
Xrays –
MRI- cartilage sensitive MRI or fast spin echo
sequence MRI.
Most accurate- Diagnostic Arthroscopy.

12. TREATMENT

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 anti-inflammatorymedications.

14. OPERATIVE TREATMENT
Indicated if nonoperative methods fail to relieve pain and
mechanical symptoms.
• Partial thickness
• Full thickness
• Size of the lesion
• Activity demands of the patient.

15. PARTIAL THICKNESS INJURY
Important to distinguish symptomatic lesions
from those that are incidental findings.
Treat only those areas that have large articular flaps
and impending loosebodies.

16. Arthroscopic debridement
and lavage
INDICATIONS
Minimal symptoms and small lesions (<2 cm) in
areas of limited weight bearing
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. Cartilage degeneration progresses
Leads to early OA
DRAWBACK

20. FULLTHICKNESSINJURIES

21. FOURBASICTECHNIQUES
1. STIMULATION OF INTRINSIC HEALING
POTENTIAL
2. ALTERATION OF LOADS
3. TRANSFER OF AUTOGENOUS TISSUE AND
CELLS
4. TRANSFER OF ALLOGRAFT TISSUE

22. 1. STIMULATION OF INTRINSIC
HEALING POTENTIAL
• DEBRIDEMENT WITH DRILLING
• ABRASION ARTHROPLASTY
• 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, can differentiate into a chondrogenic cell line .

25. Cell source: Autologous bone marrow constituents
Scaffold: none
(i) 1 stage
(ii) Open procedure
(iii) 2- to 2.5-mm drill holes to access bone marrow
(iv) Inconsistent results
(v) Long recovery
(vi) High complication rate

26. ABRASION
CHONDROPLASTY
✤ Abrading subchondral bone superficially
✤ Intraosseous space opens up with vessels and
mesenchyme
✤ Stimulates reparative process.

27. ABRASIONCHONDROPLASTY

28. Abrasion Chondroplasty

29. Cell source: autologous bone marrow constituents
Scaffold: none
(i) 1 stage
(ii) Arthroscopic procedure
(iii) Irreproducible, unreliable
(iv) Loss of underlying subchondral mechanical support

30. MICROFRACTURE
Strengths:
Arthroscopic
Relatively simple procedure
Limitations:
• Creates fibro-cartilage /poor
wear characteristics
• More effective on smaller
defects
• 6-8 weeks non-weight- bearing
and CPM required to optimize
results

31. Cell source: autologous bone
marrow constituents
Scaffold: none
(i) 1 stage
(ii) Arthroscopic procedure
(iii) 0.5- to 1-mm holes
(iv) Less impact on
biomechanics of underlying
subchondral bone

35. Subchondral penetration does not produce
normal articular cartilage, instead it produces
fibrocartilage with a high concentration of type I
collagen.

36. Gill et al. listed five factors that affect the quality of the
cartilaginous repair tissue after microfracture
(1) The calcified cartilage layer must be
removed, but the abrasion of the subchondral
bone must be avoided.
(2) 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) Early continuous passive motion.

37. (4) Protected weight bearing must be strictly
enforced, depending on the location of the lesion
(5) The mechanical axis must be corrected in
conjunction with the microfracture procedure

38. 2. ALTERATION OF LOADS
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
Only 37% excellent results after 9 years.

39. 3. OSTEOCHONDRAL
TRANSPLANTATION
✤ Could be Allo or auto
✤ Commomest auto: Mosaicplaty ( S & N); OATS ( Arthrex)
✤ Good for Intermediate defects upto 5 sq cm
Transfer of normal articular cartilage into a damaged area.

40. OATS Indications: the “ideal” chondral lesion is
relatively small, full-thickness defect (10 to 15 mm in
diameter
Osteochondral Autograft Transplantation (OATS)

41. OATS/Mosaicplasty Contraindications
• Large and deep
osteochondral defects
• Arthritic, degenerative lesions
• Lesions with areas of
unstable, semidetached
surrounding cartilage
• Angular deformities
• Untreated instability
• Major meniscal deficiency

42. TECHNIQUE
✤ Harvesting from NWB areas
✤ Cylindrical osteochondral grafts
✤ Transferred to defect

43. OATS donor sites
• Above the sulcus terminals:
good concavity match to the
MFC
• Lateral Intercondylar notch:
same as notchplasty and
roofplasty area

49. • A study done by K Burns (SLC, University of
Utah) demonstrates that positioning the graft
flush or slightly proud approximates normal
articular pressures most closely …
• … and that placing the graft even 1 mm
recessed was no different than having a
defect in terms of articular contact
pressure.
• This study emphasizes the importance of
obtaining congruity between the transplanted
cartilage surface and the surrounding,
recipient articular cartilage.
Correct OATS Surgical Technique

50. OAT MFC recipient site, a year after implantation

51. OAT Problems
• Problems with large defects: limited availability
of autologous grafts
• Technical (spatial) problems with harvesting and
positioning of multiple, relatively long grafts,
needed to cover a large and deep defect.
• Multiple graft transfer - high incidence of
intra-operative complications and poor
outcomes.
• A potential for significant donor-site problem
with multiple graft harvesting, including
chondral degeneration, local AVN and condylar
fractures.

52. Trochlear OATS

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

54. DISADVANTAGES-
Supply of expendable autogenous osteoarticular grafts is
limited.
Donor site morbidity is a major concern.
Overtime larger lesions fail

55. 4. ACI – AUTOLOGOUS
CHONDROCYTE IMPLANTATION

56. Indications for ACI
• Symptomatic full-thickness chondral injury of
the femoral articular surface (femoral weight-
bearing condyles and sulcus or trochlea) in a
physiologically young (<45 years) patient
who is compliant with the rehabilitation
protocol
• osteochondritis dissecans (OCD)

57. • First clinical trial by Brittberg et al in 1994
• Arthroscopic biopsy is taken from intercondylar notch area
• Cells are multiplied 10-15 times in the lab
• At Second surgery , periosteum is harvested from proximal
tibia
• Sutured to the defect edges and cells injected under the
periosteum
FIRST GENERATION ACI

58. AUTOLOGOUS CHONDROCYTE
IMPLANTATION

60. 1
▪ Strengths:
▫ Can produce hyaline-like cartilage
▫ Not limited by defect size
▫ Most commonly used for moderate-to-large defects in
patients who have failed previous interventions
articular cartilage
Autologous Chondrocyte Implantation :
ACI – 1st gen

61. ▪ Limitations:
• Insufficient mechanical stability
• Uncertain distribution of cells within the defect
• Periosteal hypertrophy
• Open/More invasive
• 2 stage procedure/ expensive
• Longer recovery period

63. ● Autogenous /Allogenic cells
● Chondroinductive &
chondroconductive 3d matrix
● Fibrin glue to fix patch
● Technical ease
51
2nd Generation Cell
Based- MACI

65. MACI® - autologous cultured chondrocytes on porcine
collagen membrane

67. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agraseno
1
r
1
tho.com

68. Contraindications
• Pregnant or breast feeding.
• Patients younger than 18 or over 55 years of age
• Allergic to antibiotics such as gentamicin, or materials that come from cow,
pig, or ox
• Severe osteoarthritis of the knee, other severe inflammatory conditions,
• Infections

69. 3rd GENERATION – CELL GELL IMPLANTATION
• Biopsy and culture done
• Mix cell with hydrogel
• Hydrogel contains cells and growth factors necessary for
integration of new cells in damaged tissue
• Administered in Single use container and flows into the
conformity
• Degrades slowly to allow stable tissue regeneration

76. Rehabilitation goals
●Aggressive ROM exercises to enhance
chondrocyte regeneration and decrease the
likelihood of intraarticular adhesions
●Touch-weight bearing for 6 wks and full by 12 weeks
to prevent overload and central degeneration or
delamination of a weight bearing graft
● Isometric exercises to regain muscle tone and prevent
atrophy

78. PETERSONS SANDWICH TECHNIQUE
• For osteochondral defects of more than 8 to
10 mm in depth, bone grafting is
recommended.
• The bone graft may be performed at the time
of biopsy and the implantation may be
delayed to allow for bone graft consolidation.

79. Bone defect is filled with bone graft, periosteum is
sutured on top of the bone graft at the level of the
subchondral bone plate, a second layer of periosteum is
placed over the cartilage defect, and the chondrocytes are
then placed between the layers of periosteum.