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Knee chondral and osteochondral injuries

Introduction

The articular cartilage is a layer of soft and smooth tissue that covers the articulating surfaces of two bones (figure 1). Articular cartilage contributes to smooth joint motion and load transmission and absorption.

 
Εικόνα 1. Αρθροσκοπική εικόνα αρθρικού χόνδρου γόνατος.
Figure 1. Knee articular cartilage.
Figure 1. Knee articular cartilage.
 

 

Articular cartilage lesions are very difficult to treat because of the absence of blood supply. Hippocrates (ancient Greek physician) was the first to notice that articular cartilage injuries coud not heal. As a result, failure to properly treat chondral and osteochondral injuries may lead to gradual extension of the lesion and eventually to osteoarthritis.

Articular cartilage injury may be acute or chronic and result from direct or shearing forces that cause partial or complete chondral defect (figure 2).

 
Εικόνα 2. Αρθροσκοπική εικόνα οστεοχόνδρινης βλάβης.
Figure 2. Knee articular cartilage lesion.
Figure 2. Knee articular cartilage lesion.
 

In some cases the defect may contain a portion of the subchondral bone resulting in osteochondral lesion (figure 3). Osteochondral lesions may be the result of non-traumatic causes such as osteochondritis dissecans and osteonecrosis

 
Εικόνα 3. Αρθροσκοπική εικόνα οστεοχόνδρινης βλάβης έσω μηριαίου κονδύλου (Διαχωριστική Οστεοχονδρίτιδα)
Figure 3. Knee osteochondral lesion (Osteochondritis Dissecans).
Figure 3. Knee osteochondral lesion (Osteochondritis Dissecans).
 

Treatment

Conservative treatment is usually the first choice of treatment and consists of:

  • Reduction of the loads transmitted through the chondral injury. This goal could be accomplished simply by using crutches or reducing the level of activity.
  • Painkillers and anti-inflammatory drags.
  • Physiotherapy.
  • Rehabilitaion regimen aiming at full range of motion, muscle strengthening and proprioception
  • Disease-modifying medication such as chondroitin sulfate and glucosamine. The administration should becarried on for 3-6 months.Nevertheless, there is no proof that these drugs enhance the healing process.
  • Finally, hyalouronic acid injections, growth factors from platelet rich plasma (PRP) and mesenchymal stem cells (MSCs) could be used in order to enhance the healing process.

If these measures are not effective, microfracture (video 1), autologous osteochondral transplantation (figures 4 and 5) or sytthetic implants (video 2) may be needed. All artcular cartilage repair technques are described in this chapter

 

Εικόνα 4. Εικόνες αρθροσκοπικής και mini-open τεχνικής mosaicplsty.
Figure 4. Arthroscopic view of mosaicplasty.
Figure 4. Arthroscopic view of mosaicplasty.
Εικόνα 4. Εικόνες αρθροσκοπικής και mini-open τεχνικής mosaicplsty.
Figure 5. Mini-open mosaicplasty technique.
Figure 5. Mini-open mosaicplasty technique.
 

Lastly, it should be kept in mind that predisposing factors such as joint instability and mechanical axis malalignment (figure 6) should be concomitantly corrected. Without addressing these factors, no treatment is effective.

 
Εικόνα 5.Ακτινολογικός έλεγχος μηχανικού άξονα γόνατος πριν και μετά από οστεοτομία βλαισοποίησης γόνατος.
Figure 6. Mechanical axis before and after HTO.
Figure 6. Mechanical axis before and after HTO.
 

Video 1. Knee osteochondral lesion treated with microfracture technique.

Video 2. Knee osteochondral lesion treated with synthetic implants.