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Treatment of Knee Cartilage Defect in 2010

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Treatment of Knee Cartilage Defect in 2010 Orthopaedics & Traumatology: Surgery & Research (2011) 97, S140—S153 View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Available online at www.sciencedirect.com REVIEW ARTICLE Treatment of knee cartilage defect in 2010 G. Versier a,∗, F. Dubrana b, the French Arthroscopy Society a Service de chirurgie orthopédique, HIA Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France b Service de chirurgie orthopédique, CHU La-Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France Accepted: 16 August 2011 KEYWORDS Summary Treatment of knee cartilage defect, a true challenge, should not only reconstruct Knee; hyaline cartilage on a long-term basis, but also be able to prevent osteoarthritis. Osteochon- Cartilage; dral knee lesions occur in either traumatic lesions or in osteochondritis dissecans (OCD). These Osteochondritis; lesions can involve all the articular surfaces of the knee in its three compartments. In princi- Mosaicplasty; ple, this review article covers symptomatic ICRS grade C or D lesions, depth III and IV, excluding Autologous management of superficial lesions, asymptomatic lesions that are often discovered unexpect- chondrocyte culture; edly, and kissing lesions, which arise prior to or during osteoarthritis. For clarity sake, the Allograft international classifications used are reviewed, for both functional assessment (ICRS and func- tional IKDC for osteochondral fractures, Hughston for osteochondritis) and morphological lesion evaluations (the ICRS macroscopic evaluation for fractures, the Bedouelle or SOFCOT for osteo- chondritis, and MOCART for MRI). The therapeutic armamentarium to treat these lesions is vast, but accessibility varies greatly depending on the country and the legislation in effect. Many comparative studies have been conducted, but they are rarely of high scientific quality; the center effect is nearly constant because patients are often referred to certain centers for an expert opinion. The indications defined herein use algorithms that take into account the size of the cartilage defect and the patient’s functional needs for cases of fracture and the vitality, stability, and size of the fragment for cases of osteochondritis dissecans. Fractures measur- ing less than 2 cm2 are treated with either microfracturing or mosaic osteochondral grafting, between 2 and 4 cm2 with microfractures covered with a membrane or a culture of second- or third-generation chondrocytes, and beyond this size, giant lesions are subject to an excep- tional allografting procedure, harvesting from the posterior condyle, or chondrocyte culture on a 3D matrix to restore volume. Cases of stable osteochondritis dissecans with closed articular cartilage can be simply monitored or treated with perforation in cases of questionable vitality. Cases of open joint cartilage are treated with a PLUS fixation if their vitality is preserved; if not, they are treated comparably to osteochondral fractures, with the type of filling depending on the defect size. © 2011 Elsevier Masson SAS. All rights reserved. ∗ Corresponding author. Tel.: +33 1 43 98 52 33. E-mail address: [email protected] (G. Versier). 1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.otsr.2011.09.007 Treatment of knee cartilage defect in 2010 S141 Introduction Table 1 Hughston Score. Cartilage tissue has mechanical properties that allow move- Excellent 4 Normal sports activity ment of the joint surfaces, by combining absorption of No functional symptom stresses, low friction, and high resistance to wear. Despite Normal clinical examination its mechanical performance, cartilage tissue lacks blood and Good 3 Normal sports activity nerve vessels: the cells are supplied by diffusion through Pain on intense activity the extracellular matrix. This all suggests that in a complex Normal clinical examination mechanical context, the low metabolic activity of cartilage Fair 2 Pain and hydrarthrosis if intense tissue protects it from excessive physical stresses. How- activity ever, vascular paucity results in cartilaginous lesions having Sport normal a low spontaneous repair potential. Development of surgi- Normal clinical examination cal techniques is in full expansion with the major challenge Poor 1 Pain and hydrarthrosis if moderate of hyaline cartilage reconstruction on a bone base, the only activity ◦ long-lasting and viable solution for cartilage lesions. This is Loss of flexion less than 20 the therapeutic challenge for the coming decades. Failure 0 Cessation of sports activity Pain and hydrarthrosis in daily activities Lesion assessment Loss of flexion greater than 20◦ Three factors are used to assess the initial cartilage lesion: the patient’s clinical status and the lesion’s size and type. The indication for management is based on the deteriora- arc described by Robert. Directly visualizing the lesion, tion of the functional status measured by pain and functional arthroscopy can appreciate the depth of the lesion using limitation; these criteria are validated by a number of clin- the ICRS grades: ical scores [1]. The most frequently used functional scores are the International Cartilage Repair Society (ICRS) score, • grade 1: nearly normal (superficial lesions): softening, fib- the International Knee Documentation Committee (IKDC) rillations, lacerations, fissures; functional score, and the Hughston score. The ICRS is a • grade 2: abnormal (less than 50% of cartilage depth); validated score used to evaluate the repair of cartilage • grade 3: severely abnormal (cartilage defects extending lesions, to evaluate the functional status (normal, nearly down to more than 50% of cartilage depth); normal, abnormal, and severely abnormal), to compare the • grade 4: severely abnormal (lesion extending past sub- injured side with the healthy side (as a percentage of the chondral plate, bone exposed). healthy side), to evaluate pain using an analogic pain scale, and to classify the sports level from normal to severely According to the ICRS guidelines, the seat of the lesion abnormal [2]. The functional IKDC has not been specifi- is represented by identifying the location of the cartilage cally validated for cartilage lesions, but it is a frequently involvement on drawings of the articular surfaces: a lateral used score. It evaluates, from 0 to 100, the level of activ- view of the knee, an AP view in perspective of the femur, a ity with no pain, stiffness, effusion, locking, the patient’s superior view of the tibia in perspective, and an inferior view sports activities, and the knee’s optimal functioning. The of the patella in perspective. There are four specific radio- functional IKDC is completed by the physical IKDC, which graphic classifications for osteochondritis lesions in children assesses intra-articular effusion, loss of range of motion, (OCD). Two locate the lesions on the AP and lateral images ligament laxity, joint cracking (crepitus), disease related of the knee: the Cahill and Berg [7],(Fig. 1) and Harding [8], to grafting sites, and hopping on one foot. It is also used (Fig. 2) classifications. The two other classifications evalu- to analyze radiographic images. Each group of clinical and ate the radiological signs of OCD, classifying lesions into four radiographic criteria is classified in grades: normal, nearly pathological stages: the Bedouelle [9] and Hughston et al. normal, abnormal, and severely abnormal. A final grade is classifications [6]. given to the patient corresponding to the lowest grade [3,4]. Bedouelle classification: The Hughston score is more specifically used by pediatric orthopaedic physicians and was designed to assess the treat- • stage 1: clearly incomplete well-defined image (Ia) with ment of osteochondritis lesions in children [5,6]. It classifies more or fewer calcifications within (Ib); patients into five clinical categories from failure to an excel- • stage 2: presence of a nodule (IIa) with more or less shrink- lent clinical result (Table 1). age of the nodule in relation to the condyle (IIb); The lesion size can be measured in different ways. The • stage 3: sleigh-bell aspect; standard radiological work-up can be used to estimate the • stage 4: free fragment in the joint with an empty with an width on the AP view of the knee and the length on the empty bed. lateral knee image. However, the CT arthrogram, MRI, and arthro-MRI provide a more precise appreciation of the width on AP slices and length on sagittal slices; this measurement Hughston et al. classification: makes it possible to calculate the surfaces. Arthroscopy directly measures the size of the lesion using either a probe, • stage 0: osteoarthritis, or impingement of the joint space cylindrical gauges, or the measurement of the lesional greater than 50%; S142 G. Versier, F. Dubrana Figure 1 Diagram: Cahill and Berg classification. Zone 1: medial condyle (internal half). Zone 2: medial condyle (external Figure 2 Diagram: Harding classification. Zone A: in front of half). Zone 3: femoral notch. Zone 4: lateral condyle (internal the Blumensaat line. Zone B: between zone A and C. Zone C: half). Zone 5: lateral condyle (external half). behind the tangential line to the posterior cortex of the femoral diaphysis. • stage 1: condyle irregularities, impingement of the joint space less than 50%; fibrous scar (microfracturing, Pridie drilling, and abrasion), • stage 2: condyle flattening; reconstruction methods contributing mature cartilage to • stage 3: healing zone with defect or sclerosis; the
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