- Discussion:
- these injuries are distinct from
degenerative arthritic lesions and management of these lesions should remain distinct as well;
- theory is that penetration of subchondral bone causes bleeding from underlying vessels which allows clot formation in the cartilaginous defect and
subsequent formation of fibrocartilage;
- some argue that subchondral drilling may be preferable to abrasion arthroplasty;
- for smaller chondral/osteochondral lesions, most authors recommend debridement and either abrasion arthroplasty or microfracture technique;
-
thermal chondroplasty:
- involves simple debridement of chondral surface inorder to achieve a smooth stable surface;
- in the report by Ryland B. Edwards et al, the authors compared the effects of treatment with bipolar and monopolar radiofrequency energy
on 30 OCD sections harvested from 22 patients with spontaneously occurring chondromalacia who were undergoing knee arthroplasty;
- significant chondrocyte death, as determined by cell viability staining with confocal laser microscopy, was observed with each group;
- bipolar devices produced significantly greater depths of chondrocyte death than did the monopolar device;
- bipolar caused cell death to subchondral bone more often (13 of 20 specimens) than did monopolar (0 of 10 specimens);
- authors recomend caution when treating fibrillated cartilage with radiofrequency energy, particularly with the bipolar devices tested;
- references:
- Thermal Chondroplasty of Chondromalacic Human Cartilage. An Ex Vivo Comparison of Bipolar and Monopolar Radiofrequency Devices
Ryland B. Edwards, III et al. The American Journal of Sports Medicine 30:90-97 (2002)
-
Is there a role for radiofrequency-based ablation in the treatment of chondral lesions?
-
Arthroscopic Evaluation of Radiofrequency Chondroplasty of the Knee
-
abrasion arthroplasty:
- alternatively, LL Johnson MD, 1991, has demonstrated that during and following arthroscopic surgery, blood clot generated during the case
attaches to the surgically incised surfaces (including debrided chondral defects) and further, he demonstrated that this clot does not
dislodge w/ passive flexion and extension of the knee;
- w/ this evidence, it may not be necessary to drill the chondral defect, since the majority of blood clot is formed from synovial bleeding;
- further, these observations imply that patients should be kept non wt bearing during the initial postoperative phase,
inorder to avoid clot dislodgement;
- references:
- Arthroscopic Abrasion Arthroplasty Historical and Pathological Perspective: Present Status; LL Johnson MD Arthroscopy: Vol 2(1): 54-69. 1986.
- Potential for regeneration of articular cartilage in defects created by chondral shaving and subchondral abrasion. JBJS Vol 73-A. 1991. p 1301-1315.
-
microfracture:
- an arthroscopic awl is used to make multiple perforations (microfractures) in the subchondral bone;
- bone is perforated every 4-5 mm to a depth of 3-4 mm
- theory behind this type of technique is that simple abrasion arthroplasty may not allow a sustained reparative response (no more than 2 weeks of healing)
where as the micro-fracture technique (which penetrates the subchondral bone) allows a better and more sustained healing process;
- patients are kept non wt bearing for 6-8 weeks.
- references:
- The surgical treatment of knee injuries in skiers. Steadmand JR and Strereet WI. Med Sci Sports Exerc. Vol 27 1995. p 328.
- Treatment of articular cartilage defects in athletes: An analysis of functional outcome and lesion appearance. Orthopedics July 1998. Vol 21. 1998. p 761.
-
Early events in cartilage repair after subchondral bone microfracture.
-
Chondral Defect Repair After the Microfracture Procedure. A Nonhuman Primate Model.
-
Chondral Defect Repair After the Microfracture Procedure. A Nonhuman Primate Model.
-
The Microfracture Technique for the Treatment of Articular Cartilage Lesions in the Knee.
-
A Randomized Trial Comparing Autologous Chondrocyte Implantation with Microfracture. Findings at Five Years
- spongialization:
- refers to the full thickness debridement of the chondral defect, down to cancellous bone;
- the theory behind this concept is that the debridement needs to reach below the tidemark layer inorder to reach a well vasculized surface
which contains pleuropotential stem cells (that can subsequently grow into fibrocartilage).
- empirically, it has been observed that this deep debridement is associated w/ prolonged postoperative pain, slow recovery, and joint fibrosis;
- arthroscopy of the degenerative knee
Isolated chondral fractures of the knee. (from Bauer and Jackson: J. Arthoscopic and Related Surgery, 1988)
Characteristics of the Immediate Postoperative Blood Clot Formation in the Knee Joint.
LL Johnson MD Arthroscopy: The Journal of Arthroscopic and Related Surgery. Vol 7(1), 1991. p 14-23.
The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage: An experimental investigation in the rabbit.
Salter RB, Simmonds DF, Malcolm BW, et al: J Bone Joint Surg 1980;62A:1232.
Isolated chondral fractures of the knee.
Mesenchymal Cell Based Repair of Large Full Thickness Defects in Articluar Cartilage. S Wakitani. JBJS Vol 76-A. 1994. p 579-592.
Restoration of injured or degenerated articular cartilage. JA Buckwalter et al. J. Am. Acad of Orthopaedic Surgeons. 1994. 192-201.
Osseous injury associated with acute tears of the anterior cruciate ligaments. KP Speer. et al. Am J. Sports Med. Vol 20. 1992. p 382-389.
Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short term sequelae evaluated with MR imaging.
AD Vellet et al. Radiology Vol 178. 1991. p 271-276.
Spontaneous repair of superficial defects in articular cartilage in a fetal lamb model. RS Namba MD et al. JBJS. Vol 80-A. No 1. Jan 1988.
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