science

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Chondral lesions in adults

• Abdelsamie Halawa MD
• Banha faculty of medicine
• 2015

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Introduction

• Articular cartilage covers the articulating
  surfaces within joints
• functions include load transmission,
  lubrication, joint congruity
• Cartilage injuries have limited spontaneous
  healing
• may progress to arthritis

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Anatomy
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Presentation

• Symptoms
• localized pain, effusion, mechanical symptoms
• Physical exam
• joint effusion, focal tenderness

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Imaging

• Radiographs
• used to rule out arthritis, bony defects, and
  check alignment
• weight bearing 45 deg PA most sensitive for early
  joint space narrowing 
• merchant view for patello-femoral joint 
• double limb standing long films to check
  alignment 
• MRI
• most sensitive for evaluating focal defects
• Fat-suppressed T2, proton density, T2 fast
  spin-echo (FSE) offer improved sensitivity and
  specificity over standard sequences
• dGEMRIC (delayed gadolinium-enhanced MRI for
  cartilage) and T2-mapping are evolving techniques
  to evaluate cartilage defects and repair 
• CT scan
• better evaluation of bone loss
• used to measure TT-TG when evaluating the
  patello-femoral joint

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TT-TG measurement
(1) line tangent to the posterior epicondyle
(red), (2) perpendicular line through deepest
point of the trochlea (blue), (3) line parallel
to the trochlea line through the most anterior
portion of the tibial tuberosity (green) TT-TG
measurement is distance btwn blue green lines. 
ABNORMAL if gt 20 mm ? shows valgus component of
extensor mechanism of knee associated with
patellar instability trochlear dysplasia 
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dGEMRIC (delayed gadolinium-enhanced MRI for
cartilage)  
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Outerbridge Arthroscopic Grading System

• Grade O? Normal cartilageGrade I? Softening
  and swellingGrade II? Partial thickness defect,
  fissures lt 1.5cm diameter
• Grade III? Fissures down to subchondral bone,
  diameter gt 1.5cm
• Grade IV? Exposed subchondral bone

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ICRS (International Cartilage Repair Society)
Grading System

• Grade 0 ? Normal cartilageGrade 1 ? Nearly
  normal (superficial lesions)Grade 2 ? Abnormal
  (lesions extend lt 50 of cartilage depth)
• Grade 3 ? Severely abnormal (gt50 of
  cartilage depth)
• Grade 4 ? Severely abnormal (through the
  subchondral bone)

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Treatment

• Non-operative
• rest, NSAIDs, bracing
• indications
• first line of treatment when symptoms are mild
• corticosteroid injections, hyaluronic acid,
  glucosamine
• indications
• controversial 
• may provide symptomatic relief but healing of
  defect in unlikely

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• Operative
• debridement/chondroplasty vs. reconstruction
  techniques 
• indications
• failure of non-operative management 
• technique
• treatment is individualized, there is no one best
  technique for all defects
• decision-making algorithm is based on several
  factors
• patient factors
• age
• skeletal maturity
• low vs. high demand activities
• ability to tolerate extended rehabilitation
• defect factors
• size of defect
• location
• contained vs. uncontained
• presence or absence of subchondral bone
  involvement

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Surgical Techniques

• Debridement / Chondroplasty
• overview
• goal is to debride loose flaps of cartilage
• may relieve mechanical symptoms from loose
  chondral fragments
• short-term benefit in 50-70 of patients
• benefits 
• include simple arthroscopic procedure, faster
  rehabilitation
• limitations
• problem is exposed subchondral bone or layers of
  injured cartilage
• unknown natural history of progression after
  treatment

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• Fixation of Unstable Fragments
• overview
• need osteochondral fragment with adequate
  subchondral bone
• technique
• debride underlying nonviable tissue
• consider drilling subchondral bone or adding
  local bone graft
• fix with absorbable or nonabsorbable screws or
  devices
• benefits
• best results for unstable osteochondritis
  dissecans (OCD) fragments in patients with open
  physis
• limitations
• lower healing rates in skeletally mature patients
• nonabsorbable fixation (headless screws) should
  be removed at 3-6 months 

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• The optimal treatment for chondral defects is
  debatable.
• The current options are
• distraction,
• debridement,
• Abrasion,
• microfracture,
• antegrade or retrograde drilling,
• Mosaicplasty
• osteochondral autograft transfer system (OATS),
• autologous chondrocyte implantation (ACI),
• matrix-induced autologous chondrocyte
  implantation (MACI),
• autologous matrix-induced chondrogenesis (AMIC),
• allologous stem cell transplantation,
• allograft bone/cartilage transplantation .

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• Marrow Stimulation Techniques 
• overview
• goal is to allow access of marrow elements into
  defect to stimulate the formation of reparative
  tissue
• includes microfracture, abrasion arthroplasty,
  osteochondral drilling
• Microfracture technique 
• defect is prepared with stable vertical walls and
  the calcified cartilage layer is removed
• awls are used to make punctate perforations
  through the subchondral bone 
• protected weight bearing and continuous passive
  motion (CPM) are used while mesenchymal stem
  cells mature into mainly fibrocartilage  
• benefits
• include cost-effectiveness, single-stage,
  arthroscopic
• best results for acute, contained cartilage
  lesions less than 2x2cm
• limitations
• poor results for larger defects
• does not address bone defects

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Abrasion arthroplasty,

• The superficial dead sclerotic layer is abraded
  by the burr in a universal mannar till the tide
  mark
• protected weight bearing and continuous passive
  motion (CPM) are used while mesenchymal stem
  cells mature into mainly fibrocartilage  
• benefits
• include cost-effectiveness, single-stage,
  arthroscopic
• best results for chronic, uni-compartmental OA,
  and when associated with alignment procedures as
  HTO
• limitations
• poor results for many compartmental OA
• Technically demanding , as abrasion beyond the
  tide mark will lead to pain

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Abrasion arthroplasty
The abrasion arthrplasty is a combined procedure
many actions inside the knee 1- Partial
synovectomy 2- Partial menisectomy 3- Loose body
removal and osteophyts of mechanical block 4-
Abrasion
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Osteochondral drilling
The surgery was developed in the late 1980s and
early 1990s by Dr. Richard Steadman of the
Steadman-Hawkins clinic in Vail, Colorado
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• Osteochondral autograft / Mosaicplasty
• overview
• goal is to replace a cartilage defect in a high
  weight bearing area with normal autologous
  cartilage and bone plug(s) from a lower weight
  bearing area
• chondrocytes remain viable, bone graft is
  incorporated into subchondral bone and overlying
  cartilage layer heals. 
• technique
• a recipient socket is drilled at the site of the
  defect
• a single or multiple small cylinders of normal
  articular cartilage with underlying bone are
  cored out from lesser weight bearing areas
  (periphery of trochlea or notch)
• plugs are then press-fit into the defect
• limitations
• size constraints and donor site morbidity limit
  usage of this technique
• matching the size and radius of curvature of
  cartilage defect is difficult
• fixation strength of graft initially decreases
  with initial healing response
• weight bearing should be delayed 3 months 
• benefits 
• include autologous tissue, cost-effectiveness,
  single-stage, may be performed arthroscopically

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• Osteochondral allograft transplantation 
  System(OATS Mega OATS)
• overview 
• goal is to replace cartilage defect with live
  chondrocytes in mature matrix along with
  underlying bone
• fresh, refrigerated grafts are used which retain
  chondrocyte viability
• may be performed as a bulk graft (fixed with
  screws) or shell (dowels) grafts
• technique
• match the size and radius of curvature of
  articular cartilage with donor tissue
• a recipient socket is drilled at the site of the
  defect 
• an osteochondral dowel of the appropriate size is
  cored out of the donor 
• the dowel is press-fit into place
• benefits 
• include ability to address larger defects, can
  correct significant bone loss, useful in revision
  of other techniques
• limitations
• limited availability and high cost of donor
  tissue
• live allograft tissue carries potential risk of
  infection

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• Autologous chondrocyte implantation (ACI) 
• overview
• cell therapy with goal of forming autologous
  "hyaline-like" cartilage
• technique 
• arthroscopic harvest of cartilage from a lesser
  weight bearing area
• in the lab, chondrocytes are released from matrix
  and are expanded in culture
• defect is prepared and chondrocytes are then
  injected under a periosteal patch sewn over the
  defect during a second surgery
• benefits 
• may provide better histologic tissue than marrow
  stimulation
• long term results comparable to microfracture in
  most series
• include regeneration of autologous tissue, can
  address larger defects
• limitations 
• must have full-thickness cartilage margins around
  the defect
• open surgery
• 2-stage procedure
• prolonged protection necessary to allow for
  maturation

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• Matrix-associated autologous chondrocyte
  implantation
• overview
• example is "MACI" 
• cells are cultured and embedded in a matrix or
  scaffold
• matrix is secured with fibrin glue or sutures
• benefits
• include ability to perform without suturing, may
  be performed arthroscopically
• limitations
• 2-stage procedure
• in worldwide use/evaluation- not available in the
  USA

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Matrix-associated stem cell transplantation (MAST)
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• (a and b) Chondro-Guide1 matrix (Geistlich,
  Baden-Baden, Germany). This matrix contains
  collagen I and III. The matrix has two layers
  (bilayer). The superficial layer is water proof
  (a and b, top). The deep layer is porous (b,
  bottom). Different sizes are available.

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• Patellar cartilage unloading procedures
• Maquet (tibia tubercle anteriorization)
• indicated only for distal pole lesions
• only elevate 1 cm or else risk of skin necrosis
• contraindications
• superior patellar arthrosis (scope before you
  perform the surgery)
• Fulkerson alignment surgery (tibia tubercle
  anteriorization and medialization   
• indications (controversial)
• lateral and distal pole lesions 
• increased Q angle
• contraindications
• superior medial patellar arthrosis (scope before
  you perform the surgery) 
• skeletal immaturity

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Thank You