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Osteochondral Injury of the Knee ® Volume 2, Part 3 December 2005 ORTHOPAEDIC SPORTS MEDICINE Board Review Manual Osteochondral Injury of the Knee Endorsed by the Association for Hospital www.turner-white.com Medical Education Your vision is our new bottom line. The company long respected for advancing the science of cartilage repair has more to offer than you ever anticipated. An established leader in the development of biomaterials and cell therapies, Genzyme Biosurgery is excited to now be driving the marketing and distribution of Synvisc® (hylan G-F 20). And our pioneering research into novel OA and cartilage repair solutions is destined to redefine the field of orthobiologics. So take a second look at Genzyme Biosurgery. What you see may surprise you. Genzyme Biosurgery 55 Cambridge Parkway Cambridge, MA 02142 GENZYME and SYNVISC are registered 1-800-901-7251 trademarks of Genzyme Corporation. www.genzymebiosurgery.com ® ORTHOPAEDIC SPORTS MEDICINE BOARD REVIEW MANUAL STATEMENT OF EDITORIAL PURPOSE Osteochondral Injury The Hospital Physician Orthopaedic Sports Medi- cine Board Review Manual is a peer-reviewed of the Knee study guide for orthopaedic sports medicine fellows and practicing orthopaedic surgeons. Contributors: Each manual reviews a topic essential to the current practice of orthopaedic sports medi- Jason M. Scopp, MD cine. Director, Cartilage Restoration Center, Peninsula Orthopaedic Associates, PA, Salisbury, MD PUBLISHING STAFF PRESIDENT, GROUP PUBLISHER Bert R. Mandelbaum, MD Bruce M. White Fellowship Director, Santa Monica Orthopaedic EDITORIAL DIRECTOR and Sports Medicine Group, Santa Monica, CA Debra Dreger ASSOCIATE EDITOR Editor: Tricia Faggioli Andrew J. Cosgarea, MD EDITORIAL ASSISTANT Associate Professor, Department of Orthopaedic Surgery, Farrawh Charles Johns Hopkins University School of Medicine, Baltimore, MD EXECUTIVE VICE PRESIDENT Barbara T. White EXECUTIVE DIRECTOR OF OPERATIONS Jean M. Gaul PRODUCTION DIRECTOR Suzanne S. Banish Table of Contents PRODUCTION ASSISTANT Kathryn K. Johnson Introduction. 2 ADVERTISING/PROJECT MANAGER Patricia Payne Castle Anatomy and Biomechanics of Articular Cartilage . 2 SALES & MARKETING MANAGER Deborah D. Chavis Pathophysiology of Articular Cartilage Injury. 2 NOTE FROM THE PUBLISHER: Evaluation . 5 This publication has been developed without involvement of or review by the American Management . 6 Board of Orthopaedic Surgery. References . .11 Endorsed by the Association for Hospital Medical Education Cover Illustration by Photodisc Copyright 2005, Turner White Communications, Inc., Strafford Avenue, Suite 220, Wayne, PA 19087-3391, www.turner-white.com. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or oth- erwise, without the prior written permission of Turner White Communications. The preparation and distribution of this publication are supported by sponsorship subject to written agreements that stipulate and ensure the editorial independence of Turner White Communications. Turner White Communications retains full control over the design and production of all published materials, including selection of appropriate topics and preparation of editorial content. The authors are solely responsible for substantive content. Statements expressed reflect the views of the authors and not necessarily the opinions or policies of Turner White Communications. Turner White Communications accepts no responsibility for statements made by authors and will not be liable for any errors of omission or inac- curacies. Information contained within this publication should not be used as a substitute for clinical judgment. www.turner-white.com Orthopaedic Sports Medicine Volume 2, Part 3 1 ORTHOPAEDIC SPORTS MEDICINE BOARD REVIEW MANUAL Osteochondral Injury of the Knee Jason M. Scopp, MD, and Bert R. Mandelbaum, MD nization.2 Normal articular cartilage is composed of an INTRODUCTION extracellular matrix and chondrocytes. The extracellu- lar matrix consists primarily of water, proteoglycans, Chondral and osteochondral injuries are common and collagens. Type II collagen accounts for 90% to and typically affect a young, athletic population. In a ret- 95% of the total collagen volume, while types V, VI, IX, rospective review of more than 31,000 knee arthros- X, and XI comprise the remaining 5% to 10%.3 Water copies, Curl et al1 reported articular cartilage damage content varies from 65% to 85%, depending on the in 63% of patients, with more than 60% having a grade load status and the presence or absence of degenerative III or grade IV lesion. Failure to recognize these injuries changes. During the early phases of OA, the water con- can result in long-term disability. tent can increase to 90%.3 The stresses created during athletic activity place the The functional organizational unit of articular carti- knee at risk for a range of osteochondral injuries. If lage is composed of 4 layers: the superficial tangential injury occurs, it is imperative to recognize osteochon- zone, the middle zone, the deep zone, and the calcified dral status as being intimately linked with limb align- cartilage. The tidemark lies between the deep zone and ment, meniscal status, and ligamentous status. A defi- the calcified cartilage and represents the transition ciency in one part of this functional unit can have an from uncalcified to calcified cartilage. The subchondral impact on the others and, in the short term, can lead to bone and the calcified cartilage are continuous and are a loss of athletic performance. If articular cartilage loses crucial supportive structures involved in load transmis- the ability to adapt to repetitive stresses, loss of athletic sion. The resilience of the functional load-bearing unit performance may be followed by the development of is essential for durability and smooth joint motion. chondropenia and ultimately osteoarthritis (OA). This manual reviews the functional anatomy of artic- ular cartilage, the pathophysiology of osteochondral in- PATHOPHYSIOLOGY OF ARTICULAR CARTILAGE jury, and the clinical evaluation and management of INJURY athletes with osteochondral injuries of the knee. A clin- ical algorithm is presented as a clinical tool to organize the treatment options for these patients. PROGRESSIVE LOSS OF CHONDRAL INTEGRITY While the natural history of chondral injury of the knee is not well defined, it is apparent that a loss of artic- ANATOMY AND BIOMECHANICS OF ARTICULAR ular integrity through injury, pathologic loading, and CARTILAGE aging can cause degenerative changes over time. These changes begin as a loss of cartilage volume (chondrope- Articular (or hyaline) cartilage is a viscoelastic mate- nia) and function, followed by development of articular rial that allows variable load bearing by the knee during cartilage defects that lead to elevated joint contact pres- daily functional and athletic activities. Stress reduction sures and further joint degradation and, possibly, the to the subchondral bone and minimization of friction eventual development of OA. The continuum of carti- of the articular surface are essential in fulfilling this lage injury can be clinically depicted in a dose-response role. Articular cartilage provides joint surfaces with low- curve (Figure 1). As the athlete competes, a force (dose) friction wear characteristics that are required for repet- is presented to the articular cartilage. If the cartilage is itive motion, allowing the athlete to perform consis- normal, a typical response occurs. However, as chon- tently at the highest levels of activity and performance dropenia and articular cartilage defects develop, the without symptoms elicited from the knee joint. ultrastructural properties of articular cartilage can no The functional characteristics of articular cartilage longer provide an adequate response, leading to symp- depend on its specific structural composition and orga- toms of pain, swelling, and a loss of athletic performance. 2 Hospital Physician Board Review Manual www.turner-white.com Osteochondral Injury of the Knee Cartilage injury 4 ACL/M injury 3 Estrogen deficient Elite Obese Recreational Dose 2 OA 1 Performance Response Figure 1. The loss of cartilage integrity represents a continuum with chondropenia and osteoarthritis (OA) at opposite ends of Figure 2. Full-thickness articular cartilage defect. (Adapted with the spectrum. Clinically, as articular cartilage integrity fails and permission from Scopp JM, Mandelbaum BR. A treatment algo- with each step down the continuum, the athlete finds he or she rithm for the management of articular cartilage defects. Orthop is unable to reach the same levels of performance (response) Clin North Am 2005;36:420.) with the executed activity (dose). ACL = anterior cruciate liga- ment; M = meniscus. A principal challenge for the clinician is the lack of accurate measurement tools to objectively identify chon- dropenia and to assess the pathologic progression of articular cartilage failure. To a limited degree, magnetic resonance imaging (MRI) with T1 fat suppression offers Linear Stellate Flap increased sensitivity for assessing cartilage volume and proteoglycan content.4 Alternative methods, such as mo- lecular markers that sensitively measure cartilage turn- over, may also prove to be effective for detecting osteo- arthritic changes in the joints at an early stage of the disease.5 In addition, these markers may be important for Crater Fibrillation Degrading the development
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