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Chondral and Osteochondral Injuries of the Knee

- See: Knee Joint Menu

- Discussion:
- articular cartilage injury and potential for repair;
- rotational forces in direct trauma is the most common cause of injury to the articular cartilage;
- in adults, the tidemark zone is the weak link between the overlying cartilage and subchondral
bone and therefore shearing injuries most often produce a chondral injury rather than an
osteochondral injury;
- injury is mostly in wt bearing regions of articular cartilage, and usually in medial compartment
(4 times more common that lateral injuries);
- classification
- pediatric OCD: steochondritis dessicans
- natural history:
- references:
- Isolated Full Thickness Chondral Injuries. Prevalance and Outcome of Treatment. A Study of 5233 Knee Arthroscopies.
- Articular cartilage defects: study of 25,124 knee arthroscopies
- Articular cartilage lesions in 993 consecutive knee arthroscopies

Osteochondral defects (OCDs) of the knee are a relatively common problem and can be challenging to treat. Articular cartilage is avascular and consequently has limited regenerative potential. The avascularity is speculated to limit progenitor cell infiltration, which is necessary for cartilage regeneration. Adequate treatment of OCDs is essential to prevent progressive tissue loss and ultimately degenerative joint disease.

Traditional methods of treatment such as microfracture or mosaicplasty are generally reserved for smaller defects (i.e. < 2 cm2) and result in fibrocartilage formation, which has inferior biomechanical and biochemical properties to hyaline cartilage and over time undergoes degeneration.

The use of a cellular repair (autologous chondrocyte implantation) is not new but recently became a NICE (National Institute for Clinical Excellence) recommended procedure in the UK. It involves two stages and laboratory culture of harvested chondrocyte cells.

This ‘stem cell harvest and transplant’ technique uses chondrocyte precursor cells (mesenchymal stem cells) harvested from the pelvis and has the advantage of being performed in a single stage; it is also cheaper than ACI. We have performed this at our institution for over 4 years and have demonstrated significant improvements in Cincinatti scores at two years. The three year graft survival is 96.3%. Poorer results are found in older patients and those who have had previous surgery.

Rehabilitation is crucial and return to sports is not expected before the six month mark.

The ‘Syngenit surgical’ kit is produced by Synergy Medical Technologies, UK. It comes sterile packed in one box and is based on a similar technique published by Buda et al at the Rizzolli Institute (Buda et al. J Bone Joint Surg Am 2010;92 [Suppl. 2]:2–11). They successfully used a hyaluronic acid membrance and 2mls of concentrated bone marrow aspirate for knee articular cartilage repair.

Readers will also find of interest the following related OrthOracle techniques:

Knee arthroscopy and microfracture of osteochondral defect

Osteochondral grafting of the talus (OATS procedure)

Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.

In the USA contact: https://www.fda.gov/medical-devices/products-and-medical-procedures

In the UK contact:  https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency

In the EU contact: https://www.ema.europa.eu/en/human-regulatory/overview/medical-devices 

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- Exam:
- symptoms of intermittent locking, recurrent effusions, crepitus, and persistant pain may all be associated with chondral injuries;
- however, similar symptoms are found in extensor mech injuries; and meniscal injuries
- with knee flexion, the anterior and central face of the medial femoral can be palpated (as opposed to the posteromedial joint
line which indicates a meniscal tear);
- w/ a dashboard type injury, consider PCL tear;

- Radiographs:
      - The accuracy of magnetic resonance imaging scanning and its influence on management decisions in knee surgery.
      - Sensitivity of routine 1.0-Tesla magnetic resonance imaging versus arthroscopy as gold standard in fresh traumatic chondral lesions of the knee in young adults.
- Diagnosis of chondral lesions of the knee joint: can MRI replace arthroscopy? A prospective study
- Evaluation of cartilage defects in the knee: validity of clinical, magnetic-resonance-imaging and radiological findings compared with arthroscopy

- Non Operative Treatment:
- articular steroid injection
- anti-inflammatories
- valgus unloading knee brace;

- Surgical Treatment Options:
    - debridement of chondral defects and microfracture
- mosaicplasty and cartilage transplants for chrondral injuries:
enhanced microfracture with autolgous hamstring resurfacing;
- role of allografts in repairing chondral defects: (see allografts);
- growth factors: (see BMP)
- as noted by Sellers, et al (1997), treatment with rhBMP-2 significantly accelerated formation of new subchondral bone and
improve the microscopic appearance of overlying articular cartilage;
- technical involved insertion of a BMP laden collagen sponge into a chondral defect;
- disadvantages: there may be a lack of integration of the repair tissue with the normal adjacent cartilage;
- references:
- The repair of osteochondral defects using an exogenous fibrin clot. An experimental study in dogs.
- The effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) on the healing of full-thickness defects of articular cartilage. (see osteoarthritis)


Management of Articular Cartilage Injuries in the Knee (power point slide show)

Isolated chondral fractures of the knee.

The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in the rabbit.

Mesenchymal cell-based repair of large, full-thickness defects of articular cartilage.

Restoration of injured or degenerated articular cartilage.

Spontaneous repair of superficial defects in articular cartilage in a fetal lamb model.

Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial.

An Analysis of the Quality of Cartilage Repair Studies.

Analysis of Stored Osteochondral Allografts at the Time of Surgical Implantation.

Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study.

Alternatives to Total Knee Replacement:    Autologous Hamstring Resurfacing Arthroplasty