Staging and Comorbidities

ABSTRACT

Articular cartilage lesions of the distal femur and patella are common. To provide an accurate diagnosis of a clinically symptomatic cartilage lesion and subsequent appropriate planning for potential treatment options, a proper staging is required. This includes clinical exam, radiographic imaging as well as arthroscopy. Once the staging is completed, other comorbidities may need to be addressed that may require additional surgical procedures. These can either be planned as staged procedures or concomitantly with a cartilage repair procedure. This article will discuss this staging and evaluation process in depth to serve as a guideline to the orthopaedic surgeon engaged in the treatment of cartilage defects in patients with early posttraumatic osteoarthritis (OA).

KEYWORDS

Cartilage - staging - treatment - diagnosis

REFERENCES

• 1 Hjelle K, Solheim E, Strand T, Muri R, Brittberg M. Articular cartilage defects in 1,000 knee arthroscopies.  Arthroscopy. 2002;  18 (7) 730-734
• 2 Widuchowski W, Lukasik P, Kwiatkowski G et al.. Isolated full thickness chondral injuries. Prevalance and outcome of treatment. A retrospective study of 5233 knee arthroscopies.  Acta Chir Orthop Traumatol Cech. 2008;  75 (5) 382-386
• 3 Curl W W, Krome J, Gordon E S, Rushing J, Smith B P, Poehling G G. Cartilage injuries: a review of 31,516 knee arthroscopies.  Arthroscopy. 1997;  13 (4) 456-460
• 4 Engen CNE, Aroen A. Knee cartilage defect patients enrolled in randomized controlled trials are not representative of patients in orthopaedic practice.  Cartilage. 2010;  1 (4) 312-319
• 5 Widuchowski W, Widuchowski J, Faltus R et al.. Long-term clinical and radiological assessment of untreated severe cartilage damage in the knee: a natural history study.  Scand J Med Sci Sports. 2011;  21 (1) 106-110
• 6 Shelbourne K D, Jari S, Gray T. Outcome of untreated traumatic articular cartilage defects of the knee: a natural history study.  J Bone Joint Surg Am. 2003;  85-A (Suppl 2) 8-16
• 7 Messner K, Maletius W. The long-term prognosis for severe damage to weight-bearing cartilage in the knee: a 14-year clinical and radiographic follow-up in 28 young athletes.  Acta Orthop Scand. 1996;  67 (2) 165-168
• 8 Widuchowski W, Widuchowski J, Trzaska T. Articular cartilage defects: study of 25,124 knee arthroscopies.  Knee. 2007;  14 (3) 177-182
• 9 Mithoefer K, Williams III R J, Warren R F, Wickiewicz T L, Marx R G. High-impact athletics after knee articular cartilage repair: a prospective evaluation of the microfracture technique.  Am J Sports Med. 2006;  34 (9) 1413-1418
• 10 McNickle A G, Provencher M T, Cole B J. Overview of existing cartilage repair technology.  Sports Med Arthrosc. 2008;  16 (4) 196-201
• 11 Minas T, Gomoll A H, Solhpour S, Rosenberger R, Probst C, Bryant T. Autologous chondrocyte implantation for joint preservation in patients with early osteoarthritis.  Clin Orthop Relat Res. 2010;  468 (1) 147-157
• 12 Zaslav K, Cole B, Brewster R STAR Study Principal Investigators et al. A prospective study of autologous chondrocyte implantation in patients with failed prior treatment for articular cartilage defect of the knee: results of the Study of the Treatment of Articular Repair (STAR) clinical trial.  Am J Sports Med. 2009;  37 (1) 42-55
• 13 Rue J P, Yanke A B, Busam M L, McNickle A G, Cole B J. Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up.  Am J Sports Med. 2008;  36 (9) 1770-1778
• 14 Mithoefer K, Williams III R J, Warren R F et al.. The microfracture technique for the treatment of articular cartilage lesions in the knee. A prospective cohort study.  J Bone Joint Surg Am. 2005;  87 (9) 1911-1920
• 15 Mithoefer K, McAdams T, Williams R J, Kreuz P C, Mandelbaum B R. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis.  Am J Sports Med. 2009;  37 (10) 2053-2063
• 16 Adkisson IV H D, Martin J A, Amendola R L et al.. The potential of human allogeneic juvenile chondrocytes for restoration of articular cartilage.  Am J Sports Med. 2010;  38 (7) 1324-1333
• 17 Hambly K, Bobic V, Wondrasch B, Van Assche D, Marlovits S. Autologous chondrocyte implantation postoperative care and rehabilitation: science and practice.  Am J Sports Med. 2006;  34 (6) 1020-1038
• 18 Ebert J R, Robertson W B, Lloyd D G, Zheng M H, Wood D J, Ackland T. Traditional vs accelerated approaches to post-operative rehabilitation following matrix-induced autologous chondrocyte implantation (MACI): comparison of clinical, biomechanical and radiographic outcomes.  Osteoarthritis Cartilage. 2008;  16 (10) 1131-1140
• 19 Hirschmüller A, Baur H, Braun S, Kreuz P C, Südkamp N P, Niemeyer P. Rehabilitation after autologous chondrocyte implantation for isolated cartilage defects of the knee.  Am J Sports Med. 2011;  Epub ahead of print
• 20 Wilson J N. A diagnostic sign in osteochondritis dissecans of the knee.  J Bone Joint Surg Am. 1967;  49 (3) 477-480
• 21 Farr J. Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes.  Clin Orthop Relat Res. 2007;  463 187-194
• 22 Hangody L, Kish G, Kárpáti Z, Udvarhelyi I, Szigeti I, Bély M. Mosaicplasty for the treatment of articular cartilage defects: application in clinical practice.  Orthopedics. 1998;  21 (7) 751-756
• 23 Steadman J R, Ramappa A J, Maxwell R B, Briggs K K. An arthroscopic treatment regimen for osteoarthritis of the knee.  Arthroscopy. 2007;  23 (9) 948-955
• 24 Braun S, Steadman J R, Rodkey W G, Briggs K K. [Microfracture and specific rehabilitation for treating osteoarthritis of the knee. Indications, surgical technique, and rehabilitation protocol].  Z Rheumatol. 2009;  68 (10) 811-818
• 25 Ghodadra N B, Verma N N. Biologic joint reconstruction: alternatives to arthroplasty. In: Cole BGA, ed. 1st ed. Thorofare, NJ: Slack Inc; 2009: 13-22
• 26 Lindahl A, Brittberg M, Peterson L. Cartilage repair with chondrocytes: clinical and cellular aspects.  Novartis Found Symp. 2003;  249 175-186, discussion 186–189, 234–238, 239–241
• 27 Brittberg M, Tallheden T, Sjögren-Jansson B, Lindahl A, Peterson L. Autologous chondrocytes used for articular cartilage repair: an update.  Clin Orthop Relat Res. 2001;  (391, Suppl) S337-S348
• 28 Coventry M B. Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee.  J Bone Joint Surg Am. 1987;  69 (1) 32-38
• 29 Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation.  N Engl J Med. 1994;  331 (14) 889-895
• 30 Gomoll A H, Minas T, Farr J, Cole B J. Treatment of chondral defects in the patellofemoral joint.  J Knee Surg. 2006;  19 (4) 285-295
• 31 Minas T, Bryant T. The role of autologous chondrocyte implantation in the patellofemoral joint.  Clin Orthop Relat Res. 2005;  (436) 30-39
• 32 Henderson I J, Lavigne P. Periosteal autologous chondrocyte implantation for patellar chondral defect in patients with normal and abnormal patellar tracking.  Knee. 2006;  13 (4) 274-279
• 33 Schoettle P B, Zanetti M, Seifert B, Pfirrmann C W, Fucentese S F, Romero J. The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning.  Knee. 2006;  13 (1) 26-31
• 34 Rue J P, Colton A, Zare S M et al.. Trochlear contact pressures after straight anteriorization of the tibial tuberosity.  Am J Sports Med. 2008;  36 (10) 1953-1959
• 35 Allen C R, Wong E K, Livesay G A, Sakane M, Fu F H, Woo S L. Importance of the medial meniscus in the anterior cruciate ligament-deficient knee.  J Orthop Res. 2000;  18 (1) 109-115
• 36 Englund M, Guermazi A, Lohmander L S. The meniscus in knee osteoarthritis.  Rheum Dis Clin North Am. 2009;  35 (3) 579-590
• 37 Baratz M E, Rehak D C, Fu F H, Rudert M J. Peripheral tears of the meniscus. The effect of open versus arthroscopic repair on intraarticular contact stresses in the human knee.  Am J Sports Med. 1988;  16 (1) 1-6
• 38 Baratz M E, Fu F H, Mengato R. Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report.  Am J Sports Med. 1986;  14 (4) 270-275
• 39 Lee S J, Aadalen K J, Malaviya P et al.. Tibiofemoral contact mechanics after serial medial meniscectomies in the human cadaveric knee.  Am J Sports Med. 2006;  34 (8) 1334-1344
• 40 Lohmander L S, Englund P M, Dahl L L, Roos E M. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis.  Am J Sports Med. 2007;  35 (10) 1756-1769
• 41 Gomoll A H, Kang R W, Chen A L, Cole B J. Triad of cartilage restoration for unicompartmental arthritis treatment in young patients: meniscus allograft transplantation, cartilage repair and osteotomy.  J Knee Surg. 2009;  22 (2) 137-141
• 42 Lattermann C, Jakob R P. High tibial osteotomy alone or combined with ligament reconstruction in anterior cruciate ligament-deficient knees.  Knee Surg Sports Traumatol Arthrosc. 1996;  4 (1) 32-38