Surgical Management of Cartilage Defects in Athletes

Surgical management

Intuitively, one understands that a lesion of any size in the smooth surface of the articular cartilage can lead to perturbations in the normal mechanical functioning of the cartilage cap. Increased pressures are concentrated on the cartilage surrounding the lesion, normal matrix interactions become interrupted, and ultimately, an increase in the rate of cartilage deterioration and osteoarthritis can ensue. Once the determination has been made of articular cartilage damage, and the lesion

Irrigation, debridement, abrasion chondroplasty

Several studies have noted that patients that undergo arthroscopic lavage of an injured joint demonstrate an improvement in symptoms [8], [9]. It must be noted that a few studies have reported an inherent placebo effect by the procedure of arthroscopic lavage when used in the treatment of osteoarthritis [10], [11]. These studies should not be taken to infer that arthroscopic lavage in an acutely injured joint relies on a similar placebo effect as may be seen in the chronic process of

Marrow stimulation techniques (microfracture)

This technique relies on the infiltration of pleuripotent mesenchymal stem cells to provide a type of restorative cartilage growth into a cartilage defect. The technique has been used in the various patient groups including most significantly, the highly trained and conditioned athletic population. The technique as described by Steadman et al involves the use of specially designed sharp awls used arthroscopically to make multiple perforations, or microfractures, into the subchondral bone in a

Radiofrequency ablation/debridement

This treatment modality is based on the observations that cartilage defects that do not penetrate completely through the articular surface down to the subchondral bone show little ability to repair itself without intervention. These lesions often continue to propagate down to the subchondral bone through delamination, fragmentation, and fibrillation. Rather than use knives, biters, curettes, or rotary shavers to remove loose and irregular articular cartilage, several authors have employed the

Periosteal grafting

This technique uses transplantation of the periosteum with its rich cellular components into a cartilaginous defect. These cells in the periosteal matrix include pleuripotent-undifferentiated cells that have the potential to form cartilage. When placed in the appropriate avascular environment with the appropriate mechanical stimulus, these cells grow and developed into various forms of cartilage. O'Driscoll has pointed out the numerous technical considerations when using this technique. The

Autologous chondrocyte implantation

The treatment of cartilage defects in the knee with the transplantation of autologous chondrocytes was first reported in a 1994 study by Brittberg et al [27]. This technique involves the harvesting of cartilage cells from an uninvolved area of the joint in an initial arthroscopic procedure. The cells are then grown and multiplied in culture medium in the laboratory for several weeks multiplying the cells 10- to 20-fold. These cultured cells are then reimplanted into the cartilage defect

Osteochondral autografts (oats, mosaicplasty)

The successful treatment of articular cartilage lesions using the transplantation of one or more autologous osteochondral plugs (mosaicplasty) has been demonstrated by several authors [33], [34]. This technique involves removing small osteochondral plugs from the periphery of the patellofemoral joint, or along the margins of the intercondylar notch, and transplanting them into areas of articular cartilage defect in the weight bearing areas of the joint. This construct allows the maintenance of

Osteochondral allografts

Osteochondral allografts are useful in treating cartilage injuries that are of larger size, or where there has been more extensive disruption of the subchondral bone. It is often used as a salvage procedure when other therapies have been attempted and failed, and can be useful after high-energy trauma and fractures. Several biologic factors of osteochondral grafts are responsible for their success in cartilage transplantation. The grafts are composite grafts of living chondrocytes and bone as

Comparative studies

There has been a pronounced dearth of randomized controlled comparative studies regarding the treatment of articular cartilage defects in the orthopaedic literature. Many of the recently developed treatment options and techniques are relatively new with few published studies. There are also few studies with sufficient numbers of patients to allow comparisons of the various treatments, and draw conclusions about the significance of observed differences in outcomes. As these studies emerge, they

Summary

There has been tremendous discussion attempting to determine what constitutes the appropriate treatment for this challenging clinical problem. Several authors have presented various opinions for pleasantly plausible repair algorithms [5], [7], [44], [45], [46], [47]. Rather than recapitulate their work, it is helpful to consider restorative and reparative options in general terms of their possible judicious applications.

Any potential procedure must be carefully analyzed for appropriateness, and