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Knee-Chondral-Injuries -Clinical-Treatment-Strategies-And-Experimental-Models.Pdf Injury, Int. J. Care Injured 43 (2012) 694–705 Contents lists available at ScienceDirect Injury jo urnal homepage: www.elsevier.com/locate/injury Review Knee chondral injuries: Clinical treatment strategies and experimental models a b, Javier Vaquero , Francisco Forriol * a Hospital Gregorio Maran˜on, Orthopaedic Surgery Department, Madrid, Spain b University CEU, School of Medicine, Department of Orthopaedic Surgery, Campus Monteprincipe, 28668 Boadilla del Monte, Madrid, Spain A R T I C L E I N F O A B S T R A C T Article history: Articular cartilage has a very limited capacity to repair and as such premature joint degeneration is often Accepted 15 June 2011 the end point of articular injuries. Patients with chondral injury have asymptomatic periods followed by others in which discomfort or pain is bearable. The repair of focal cartilage injuries requires a precise Keywords: diagnosis, a completed knee evaluation to give the correct indication for surgery proportional to the Cartilage damage and adapted to each patient. Many of the surgical techniques currently performed involve Biotechnology biotechnology. The future of cartilage repair should be based on an accurate diagnosis using new MRI Chondrocyte transplantation techniques. Clinical studies would allow us to establish the correct indications and surgical techniques Microfracture implanting biocompatible and biodegradable matrices with or without stem cells and growth factors. Osteochondral Arthroscopic techniques with the design of new instruments can facilitate repair of patella and tibial plateau lesions. ß 2011 Elsevier Ltd. All rights reserved. Contents Introduction . 694 Indications for treatment . 695 Systematic evaluation of surgical techniques . 696 Repair techniques . 696 Arthroscopic debridement . 696 Stimulation of the bone marrow . 696 Clinical evaluation of microfractures . 697 Substitution techniques. 698 Autologous osteochondral grafts (mosaicplasty) . 698 Clinical evaluation of mosaicplasty . 698 Osteochondral allografts. 699 Synthetic plugs . 699 Regeneration techniques (ACI/MACI) . 699 Clinical evaluation of ACI and MACI . 699 Experimental studies on cartilage repair . 700 Experimental studies using microfractures . 701 Experimental studies using different scaffolds . 701 Experimental studies in osteochondral defects . 701 Experimental studies using ACI. 702 Experimental studies with growth factors in cartilage . 702 Experimental studies of cartilage gene therapy . 702 Future directions . 703 References . 703 Introduction Joint cartilage is extremely vulnerable to injury, and has a very limited capacity to repair by fibrocartilage. Usually the end point of * Corresponding author. Tel.: +34 619214066. E-mail address: [email protected] (F. Forriol). articular injuries is premature joint degeneration. Injuries to the 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.06.033 J. Vaquero, F. Forriol / Injury, Int. J. Care Injured 43 (2012) 694–705 695 joint cartilage involve loss of macromolecules, rupture of Indications for treatment cartilaginous matrix, and finally rupture of the bone matrix; these represent three stages along the same process, which should be Lesion size, activity level and patient age are the factors that are 1 borne in mind when treatment is being considered. Patients with generally taken into account to determine the technique for chondral injury have asymptomatic periods followed by others in repairing the cartilage. Various treatment protocols have been which discomfort or pain is bearable. However, there are no long- proposed. One of the best known and most widely used algorithms term follow-up studies which compare the results of treatment is based on the size of the injury and the amount of activity carried 9 with the natural history of the process. It is also not known how out by the patient. However, no relationship has been established long the repaired tissue lasts, or what the cost–benefit ratio is. between the size of the injury and clinical progress after 10–12 Many of the operations performed at present involving biotech- treatment. The patient’s activity should have an influence 13 nology are associated with high cost and high morbidity, and have on the result, and as such improvements in terms of function 2 not been shown to offer better long-term results. should be greater in active patients than in sedentary ones. Other 3 Aroen etal. analysed 1005knee arthroscopies performed in three factors for consideration include age, time over which the hospitals over a 6-month period. The preoperative radiographs condition has developed, and the site and depth of the injury. showed joints with signs of degeneration in 13% of cases, chondral Age could be related to the degenerative process around the injury, pathology of varioustypesin66%ofcasesandachondraldefectin20% or could be a factor, which has a negative impact on the joint 14 of the knees, whilst injuries of International Cartilage Research itself. The younger the patients are, the better the results tend to 4 2,13,16,17 Society (ICRS) classification grades3and4werepresentin11%.Ofall be; the best results are obtained in patients aged under 30. 2 the knees, 6% had injuries greater than 2 cm in size. In another study, A relation also has been observed between the result and the time 5 Curl et al. reviewed 31,000 knee arthroscopies and found chondral each patient has to wait from the onset of symptoms until 10,18 injuries in 63% of patients, whilst 5% of patients aged under 40 had an surgery. These findings could be related to cell and tissue 6 Outerbridge score of IV in the inner femoral condyle. Hjelle et al. ageing, which is linked to the regenerative response. conducted aprospective review of 1000 arthroscopies,and noted that Some secondary factors should also not be ignored, such as the 2 61% of the patients had cartilage injury measuring 2 cm on average. integrity of the joint, that is, the state of the menisci or the 7 Widuchowski et al. analysed retrospectively 25,124 arthroscopies ligaments, the weight of the patient and the alignment of the lower 9 and found chondral injuries in 60% of patients; which were classified limb. According to Cole et al., the two factors which influence the as chondral or osteochondral injuries in 68%, osteoarthritis in 29%, result of ACI (autologous chondrocyte implant) are age and worker osteochondritis dissecans in 2% and other types in 1%. Of these, 30% compensation injuries. However, poor alignment of the lower limb, were isolated injuries and the others were associated with damage to the state of the menisci, the degree of articular stability and the other structures. The most frequent sites being affected were the body mass index are also important. A body mass index of <30 is 7 19 patellar surface and the medial femoral condyle. associated with better results. One further aspect is the site of the The majority of studies of joint cartilage injury and repair have injury, since injury to the patella is not the same as injury to the been conducted in adults, but in reality, a small number of cases of tibial plateau or the femoral condyles. The location of injuries articular injuries do occur in children and adolescents, particularly treated with ACI has a clear bearing on the clinical results; lesions those involved in competitive sports. The articular cartilage to the medial femoral condyle are generally found to have better 10 injuries in adolescents are usually quite readily categorised as results than those to the lateral condyle three years after surgery ; 8 either acute traumatic injury or as osteochondritis dissecans. The this was also observed in a retrospective study, in which the articular cartilage of the child is structurally similar to the physis, clinical result in cases of injuries in the femoral condyles treated with zones of provisional calcification. A high proportion of these with microfractures was better than when the injuries were 8 20 injuries go undiagnosed initially, resulting in a chondral defect. located in the patella or tibial plateau (Fig. 1). Fig. 1. Algorithm for chondral and osteochondral knee injuries related with size and patient activity. 696 J. Vaquero, F. Forriol / Injury, Int. J. Care Injured 43 (2012) 694–705 Table 1 Prospective studies comparing different techniques of treatment of full thickness focal articular cartilage defects. Authors, citation, year N cases Evidence level Results Comments Follow-up 45 Bentley et al. 2003 58 ACI Level I Higher Cincinnati score with ACI. Only Arthrotomy 42 OAT differences in medial femoral condyle Superior histologic results (ICRS) at 19 months lesions 1 year in ACI 46 Horas et al. , 2003 20 ACI Level II Similar results with Tegner or Meyers Arthrotomy and multiple sizes plugs 20 OAT scores. Significant higher Lysholm score Mainly fibrocartilage in ACI group 2 years in mosaicplasty 13 Knutsen et al. , 2004 40 MFx Level I Significantly better SF-36 in Micro-Fx. Higher percentage of hyaline-like 40 ACI No differences in Lysholm or VAS scales tissue in ACI 2 years 15 Gudas et al. , 2005 29 MFx Level I 96% good and excellent results (HSS and Athletes 28 OAT ICRS) in OAT and 52% in MFx Younger patients better results 3 years 65 Bartlett et al. , 2005 44 ACI Level I Similar Cincinnati score Similar ICRS score in biopsies 47 MACI 1 year 25 Barber and Iwasko , 2006 30 mechanical shaving Level II Both groups improved in Tegner, No necrosis developed 30 monopolar Cincinnati, IKDC and Vas scales. radiofrequency probe No difference between groups 2 years 71 Knutsen et al. , 2007 40 MFx Level I No significant difference Younger patients did better 40 ACI No correlation between clinical and 30% early signs of OA 5 years histological outcomes 14 Saris et al. , 2008 61 MFx Level I Similar KOOS scores but less pain in ACI Better histological results in ACI À57 ACI+ 18 months 18 Saris et al. , 2009 61 MFx Level I Significantly better KOOS results Time to treatment correlates with 57 ACI+ better results 3 years 52 Gudas et al.
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