Surgical options for early arthritis in young persons and athletes: the role of meniscus transplants, microfracture, Osteoarticular Transplants (OATs), Autologous Chondrocyte Implantation (ACI) and osteotomy

Edited By: Christopher J. Wahl, M.D., Suzanne L. Slaney, PA-C, ATC, MMS
Last updated Friday, June 30, 2006

Figure 5. X-Ray (A) and operative (B) views of a traumatic cartilage defect (osteochondral defect). A. While cartilage cannot be visualized on X-ray, a defect was suspected because of the displaced flake of bone (red arrow) that was avulsed with the cartilage fragment. B. At operation, the large region of the femur where the cartilage was torn away is clearly evident (black arrow). The cartilage was repaired and healed uneventfully.

Figure 6. Xray (A) and MRI (B) views of a focal OCD (Osteochondritis Dessicans) lesion. The red arrows indicate the region of bone that has no blood supply and has died. The blue arrow demonstrates intact articular cartilage overlying the region of dead bone. If treated early, the underlying bone can frequently be saved before the cartilage over the bone detaches or dies.

Figure 7. Arthroscopic views of a tear of the medial meniscus. A. A “flap” tear of the back edge of the meniscus is clearly visible. The patient experienced locking of the knee when the flap would enter the joint. B. The torn fragment has been removed and the meniscus reshaped and contoured to look and function more normally.

Figure 8. A medial meniscus repair. A. Note the rim of the meniscus (probe), torn away from the joint capsule. In this patient, torn fibers of the medial collateral ligament (MCL) are also visible in the joint. B, C, D. Specialized instruments allow the placement of sutures to secure the meniscus, which helps it heal.

Figure 9. Meniscal transplant. A. Lateral knee compartment with articular cartilage loss of the tibia (T) that can occur from an insufficient meniscus. B. Lateral compartment with degenerative meniscus (DM) between the femur (F) and tibia (T), which both show reactive arthritis. C. Dovetail “socket” prepared on the tibia (T) to accept a donor meniscus. D. Donor meniscus (M) attached to its native bone (B). E. Donor meniscus (M) and bone attachment (B) in place.

Figure 10a. The microfracture technique. Closckwise from top. A region of cartilage loss is cleared of loose, dead fragments. Special instruments are used to perforate the bone to the marrow space beneath it. The perforations (called “microfractures”) allow blood and healing cells in the bone marrow to fill the defect.

Figure 10b. The microfracture technique (cont’d). (Clockwise from top) A flap of loose cartilage caused locking in this patient’s knee. The flap was removed and a microfracture performed to bleeding bone. Six months after the procedure, the lesion has filled with fibrocartilage. The patient is symptom-free.

Figure 11a. The osteoarticular transplant (OATs) procedure. A. A region of damaged cartilage is evident on the femur (circled region). B. The lesion and any abnormal surrounding cartilage are removed, leaving a recipient site of normal bone and cartilage (C). A size-matched, donor allograft femur with healthy cartilage and bone is used to obtain a donor “plug” of bone and cartilage (inset).

Figure 11b. The osteoarticular transplant (OATs) procedure (cont’d). Counterclockwise from top left. The harvested donor “plug” is made to exactly fit the size and contour of the damaged recipient region. It is inserted flush with the surrounding normal cartilage. Over 6 to 12 weeks, the graft will heal to the patient’s underlying bone.

Figure 12. Technique for autologous chondrocyte implantation (ACI). A defect is prepared so that it is surrounded by normal, healthy cartilage. A small flap of soft tissue (periosteum) is removed from the tibia to be used as a cover flap. This periosteum is sewn over the defect, and treated with a sealant (fibrin) to avoid leakage of injected cells. Cartilage precursor cells harvested at a previous surgery and grown for 6 weeks (called "chondrocytes") are injected beneath the flap.

Figure 13. Alternatives for osteotomy procedures. A. The “closing wedge” osteotomy removes a small wedge of bone such that the alignment of the joint is corrected. In this image, a “bow-legged” knee has been converted to a normal alignment. (Courtesy Knee Guru.com) B. Our preferred alternative is an “opening wedge” osteotomy, in which a cut is made in the bone, grafted with bone, and fixed in place. The “opening wedge” does not decrease leg length, as a closing wedge does.

Review of the condition

What are some general characteristics of arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.? What are its usual manifestations?

The loss of the articular cartilage in the knee is called arthritis by definition. The most common complaint is pain.  This initially manifests as pain with certain activities or long days, but can progress to pain even at rest or prevent comfortable sleep.  Frequently, patients will complain of swelling or have a “full” feeling after activities.  If fragments of torn cartilage or the meniscus become trapped in the joint, a patient will experience sudden, sharp pains or locking of the joint.  If the arthritis has been present for a long time, changes in the alignment of the joint (e.g. “bow-legs” or “knock-knees”) may begin to develop.

The changes or pain may develop gradually over time, or can be the result of a traumatic injury, such as a fall or athletic injury.

What are the different types of arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.?

Cartilage is the term used to describe two different structures in the knee: the articular cartilage (a smooth gliding surface covering the end of the bone—analogous to the Teflon™ in a non-stick frying pan) and meniscal cartilages (C-shaped “bumpers” between the bone ends that help to make the bones conform and absorb shock).  Either or both of these “cartilages” can be damaged, and frequently when one is damaged the other is injured as a result. (Figure 1)

In traumatic injuries to the articular cartilages, the cartilage may shear off the end of the bone, sometimes taking a bony fragment with it. (Figure 5)  If diagnosed early, these “osteochondral cartilage defects” can frequently be repaired surgically and will heal.  These injuries are very different from OCD lesions described below, as the remaining bone beneath the cartilage is healthy.  These cartilage lesions can be small (focal) or large (global).  With osteochondral defects, the treatment plan is to repair the defect if possible, or replace the small region of affected cartilage with a substitute.

Occasionally, the bone beneath a region of cartilage may lose its blood supply and die. (This can occur even without a traumatic injury to the knee).  Because the articular cartilage receives its nourishment predominantly from the underlying bone, the cartilage may then also die and can fragment.  These lesions are called “osteochondritis dissecans”  (OCD) lesions. (Figure 6)  To repair these lesions, the cartilage AND underlying bone must be considered.  OCD lesions can be small (focal) or large (global).  A similar condition is “avascular necrosis” (AVN).  For these conditions, the treatment plan revolves around restoring a normal joint contour and replacing the damaged or dead cartilage and bone with a substitute.

“Degenerative” lesions, are those that occur gradually. While they occasionally result from traumatic injury, they are more commonly related to subtle problems with joint alignment or long-term overuse of the joint.  Most degenerative cartilage lesions are global lesions that involve a large portion of the weight-bearing region of the joint.  When these lesions are large, the treatment may involve re-aligning the joint to shift stress away from the damaged cartilage, which slows the progression of the arthritis and decreases pain.

What else might be confused with or similar to arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.? How can these be distinguished from the condition?

Cartilage-restoration procedures (debridement, microfracture, OATs, ACI) are rarely indicated in a joint that suffers from moderate or severe degenerative osteoarthritis. Most persons with global arthritis or severe breakdown of the cartilage have developed changes in the joint that cannot be addressed by the restoration of small regions of cartilage.  When both sides of the joint are involved (e.g. the “top” and “bottom” of the knee), the lesions are termed “bipolar.”  The results of restoration procedures in these cases are less favorable, so the procedure is rarely performed.

Small tears of the meniscus can be trimmed (debrided). (Figure 7)  As long as the removed portion is relatively small, the improvement in symptoms is remarkable and the long-term drawbacks are minimal.  Some larger meniscus tears are repairable. (Figure 8) If at all possible, meniscus repair is preferable to removal, particularly in younger patients.  When the damage to the meniscus is extensive or irreparable, a person may wish to consider meniscal transplantation. (Figure 9)

Tears of the ligaments (ACL, PCL, LCL, MCL) are also common and may cause a sense of “locking” or “instability” of the joint.  While these can occur alongside cartilage injuries, their treatment is totally different.

How common is arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee. (statistics, demographics, risk factors)?

How is arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee. diagnosed? What tests or exams may be used?

The diagnosis of cartilage defects (osteochondral injuries, OCD lesions, AVN, etc.) and mensical lesions can be made in several ways.

2.  X-rays may identify a region of dead bone, abnormal contours in the joint surface, a displaced bone fragment (with cartilage attached), or abnormal alignments of the joint.

3.  An MRI with an MRI arthrogram (MRI after an injection of contrast dye into the joint) will reveal:

• whether there are ligament injuries in the joint (e.g. ACL or PCL)
• the condition of the meniscal cartilage
• the presence of bony injury, devitalization, or death
• the precise location, size, and nature of the injury to articular cartilage

Can medications help arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.?

Some medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), will frequently help to ease pain or symptoms related to the injured joint.  Narcotics are not used to treat these conditions.

Over-the-counter supplements like Chondroitin Sulfate and Glucosamine can be helpful in alleviating the pain and swelling due to cartilage injuries or arthritis.  These must be taken for 2 to 3 weeks before any benefit will be evident. 

Can exercises help arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.?

In rare cases or in sedentary individuals, there may be a role for non-operative treatment and rehabilitation. In general, this involves modifying activities to avoid the things that cause discomfort or swelling.  A guided rehabilitation program can strengthen the muscles around the knee and can frequently alleviate discomfort.  Occasionally, orthotics (shoe inserts) can be custom made and fitted to “unload” the region of the joint that is injured.  Specialized knee braces may also help “unload” the injured region, but are somewhat difficult to wear all the time and some patients find them uncomfortable.  In general, these therapies may help with the symptoms of the cartilage injury, but will not actually fix the damaged tissues.

Specifically, how is arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee. improved by microfracture, meniscal transplantation, osteoarticular allograft/autograft transplants (oats), autologous chondrocyte implantation (aci) and ostotomy for arthritis in the athlete.?

BENEFITS OF SURGICAL CARTILAGE RESTORATION OR MENISCAL TRANSPLANTATION

• alleviate pain and swelling
• restore function and return to activity
  
• prevent further deterioration of the joint surfaces

The treatments can be used individually or in conjunction to achieve these goals. In particular the procedures have different goals:

• Arthroscopic debridement removes torn, injured, or loose fragments of the meniscus or cartilage to stop the mechanical symptoms of locking, catching, or grinding (Figure 7)
• Microfracture is used to stimulate a “patch” over a damaged region of cartilage when there is healthy bone with a regular contour beneath it. The technique, also called “marrow stimulation,” takes advantage of the body’s healing response to encourage new fibrocartilage to fill a cartilage defect.  This is analogous to filling a pothole in the road with tar and gravel—the tissue is a “substitute” for cartilage, but is not completely normal cartilage. (Figure 10a, 10b)
• Osteoarticular Transplants (OATs) replace the damaged cartilage and underlying bone with cylinders of bone and cartilage that are taken from elsewhere in the patient’s body (autograft) or from a donated knee (allograft). The potential advantage of these procedures is that the cartilage replaced is essentially normal and maintains the typical architecture of cartilage, the cartilage/bone interface, and bone. (Figure 11a, 11b)
• Autologous Chondrocyte Implantation (ACI) is a technique in which a patient’s cartilage is “grown” in a lab to create the precursor cells to cartilage—analogous to articular cartilage “seeds.” The precursor cells are then inserted into the injured region in an attempt to grow a new surface.  The normal architecture of cartilage is not restored with this technique. (Figure 12)
• Osteotomy procedures are designed to carefully cut and re-align the bones to correct the abnormal forces that act across a joint. These procedures are frequently performed in addition to the previously mentioned re-alignment procedures, because restoring cartilage in a mal-aligned joint is futile. (Figure 13)
• Meniscal transplantation replaces the absent or irreparable meniscus with a donor (allograft) meniscus. The donated meniscus is a reasonably good substitute in terms of function and protection, but will not last as long as a normal meniscus. (Figure 9)

Surgery for Arthritis, osteochondral defects (OCD lesions), meniscus transplantation and cartilage loss in the knee. at the University of Washington

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