Cartilage Injury of the Knee

Cover
Preface
Contents
1: Articular Cartilage: Functional Biomechanics
1.1 Introduction
1.2 The Relationship Between Structure and Biomechanical Properties
1.2.1 Collagens
1.2.2 Proteoglycans and Glycosaminoglycans
1.2.3 Chondrocytes
1.2.4 Water
1.2.5 Zones
1.3 Biomechanical Properties
1.3.1 General Concepts
1.3.2 Mechanical Behavior of the Articular Cartilage
1.3.3 Behavior in Compression, Tension, and Shear
References
2: Biomarkers in Articular Cartilage Injury and Osteoarthritis
2.1 Introduction
2.2 Biomarkers in Cartilage Damage
2.3 Radiological Biomarkers in Cartilage Damage and Repair
2.4 Systemic and Local Biomarkers of Cartilage Damage
2.4.1 Collagen Biomarkers in Urine
2.4.2 Collagen Degradation Biomarkers in Serum
2.4.3 Collagen Synthesis Biomarkers in Serum
2.4.4 Local Biomarkers of Cartilage Damage
2.5 Biomarkers in Cartilage Repair
2.5.1 Immunohistochemistry
2.5.2 Cell Morphology
2.5.3 Biochemical Analysis
2.5.4 Cell Surface Markers
2.5.5 Chondrogenic Gene Markers
2.6 Biomarkers in Early Osteoarthritis
2.6.1 Matrix-Degrading Enzymes
2.6.2 Matrix Molecules
2.6.3 Regulatory Molecules
2.6.4 Other Molecules
2.6.5 Biomarker Panels
2.7 Summary
References
3: How Do We Best Measure Outcomes Following Cartilage Repair Surgery?
3.1 Introduction
3.2 Objective vs. Subjective Measures
3.3 Best Objective Measures
3.4 Best Subjective Measures
3.5 Future Opportunities
References
4: Quantitative Magnetic Resonance Imaging of Articular Cartilage Structure and Biology
4.1 Introduction
4.2 Overview: Normal Cartilage Structure and Biology
4.2.1 Trilaminar Appearance by Magnetic Resonance Imaging
4.3 Quantitative Magnetic Resonance Imaging Strategies to Noninvasively Assess and Monitor Cartilage Structure and Biology
4.3.1 Semiquantitative Assessments of Cartilage Morphology
4.4 Cartilage Morphometry
4.4.1 Quantitative Assessments of Cartilage: Compositional MRI
4.4.1.1 T2
4.4.1.2 Ultrashort Echo Time (UTE)
4.4.1.3 dGEMRIC
4.4.1.4 T1ρ
4.4.2 Limitations of Morphologic and Compositional Cartilage MRI
4.4.3 Summary
References
5: MRI in Knee Cartilage Injury and Posttreatment MRI Assessment of Cartilage Repair
5.1 Morphological MRI
5.1.1 Microfracturing (MFX)
5.1.2 Osteochondral Auto- and Allograft (OAT and AOT)
5.1.3 Autologous Chondrocyte Implantation (ACI) and Matrix-Associated Chondrocyte Implantation (MACI)
5.1.4 Successful Cartilage Repair
5.1.5 Bony Defects
5.2 T2/T2* Mapping in the Injured Knee
5.2.1 T2 and T2* Mapping
5.2.1.1 Technical Considerations
5.2.1.2 Cartilage Injury
5.2.1.3 Cartilage Repair
5.3 gagCEST
5.3.1 MRI of Cartilage Lesions and Repair: gagCEST
5.4 Sodium (23Na) MRI
5.4.1 Biochemical Investigations of Cartilage Tissue Using Sodium MRI
5.4.2 23Na-MRI for Different Cartilage Repair Technique Evaluations
References
6: Assessment of Patient, Joint, Cartilage Injury Characteristics
6.1 Assessment of the Patient
6.1.1 Clinical History
6.1.2 Special Populations
6.1.3 Medical Comorbidities and Family History
6.2 Assessment of the Joint
6.2.1 Physical Examination
6.2.2 Examination of the Knee Joint
6.2.3 Tibiofemoral Articulation
6.2.4 Patellofemoral Articulation
6.2.5 Radiographic Evaluation of Joint Alignment and Integrity
6.2.6 Supplemental Radiographs
6.2.7 Supplemental CT Scans
6.3 Assessment of Cartilage Injury
6.4 Conclusions
References
7: Nonoperative Management Options for Symptomatic Cartilage Lesions
7.1 Introduction
7.2 Clinical Evaluation and Classification
7.3 Indications for Nonoperative Management
7.4 Chondroprotection, Chondrofacilitation, and Resurfacing: A Framework for Management
7.5 Chondroprotection
7.5.1 Weight Loss
7.5.2 Supplements
7.5.3 Estrogen
7.5.4 Steroid
7.5.5 Future Directions in Chondroprotection
7.6 Chondrofacilitation
7.6.1 Hyaluronic Acid
7.6.2 Platelet-Rich Plasma
7.6.3 Bone Marrow Aspirate Concentrate
7.6.4 Cellular Based Therapies
7.6.5 Osseous Involvement
7.6.6 Future Directions in Chondrofacilitation
7.7 Treatment Algorithm
7.8 Summary and Conclusion
References
8: The Role of Osteotomy in the Patellofemoral Joint with Cartilage Surgery
8.1 Introduction
8.2 Biomechanical Rationale
8.3 Clinical Outcomes
8.3.1 Tibial Tubercle Osteotomy with Palliative or Reparative Chondral Procedures
8.4 Tibial Tubercle Osteotomy with Restorative Chondral Procedures
8.4.1 Autologous Chondrocyte Implantation
8.4.2 Particulate Juvenile Allograft Cartilage
8.5 Tibial Tubercle Osteotomy with Reconstructive Chondral Procedures
8.6 Complications of Tibial Tubercle Osteotomy
8.7 Preoperative Planning: When to Add a Tibial Tubercle Osteotomy
8.7.1 Clinical Assessment
8.7.2 Radiographic Assessment
8.7.3 Arthroscopic Assessment
8.8 Senior Author’s Current Practice
8.9 Conclusions
References
9: Osteotomy for the Varus Knee in Cartilage Surgery
9.1 Introduction
9.2 Rationale for Unloading Osteotomies in Cartilage Surgery
9.2.1 Relevance of Varus Malalignment in the Development and Progression of Cartilage Defects
9.2.2 Relevance of Varus Malalignment and Corrective Osteotomies in Cartilage Surgery
9.2.3 Outcomes After Combined Valgus Osteotomy and Cartilage Repair Procedures
9.3 Technical Approach
9.3.1 Preoperative Diagnostic and Patient Selection
9.3.2 Principles of the Surgical Technique and Rehabilitation
9.3.3 Case Presentation (Figs. 9.3 and 9.4)
9.4 Conclusions
References
10: Osteotomy for the Valgus Knee in Cartilage Surgery
10.1 Introduction
10.2 Indications and Contraindications
10.3 Assessment
10.4 Surgical Options
10.4.1 Distal Femoral Osteotomy
10.4.2 Proximal Tibial Osteotomy
10.5 Operative Techniques
10.5.1 Distal Femoral Medial Closing-Wedge Osteotomy
10.5.2 Distal Femoral Lateral Opening-Wedge Osteotomy
10.5.3 Proximal Tibial Medial Closing-Wedge Osteotomy
10.5.4 Proximal Tibial Lateral Opening-Wedge Osteotomy
10.6 Post-operative Care
10.7 Complications
10.8 Conclusions
References
11: Role of the Meniscus in Cartilage Injury: Basic Science
11.1 Introduction
11.2 Anatomy
11.3 Embryology
11.3.1 Congenital Malformations of the Meniscus
11.4 Microstructure
11.4.1 Histology
11.4.2 Response to Injury
11.4.3 Stages of Healing
11.5 Biomechanical Properties
11.5.1 Motion and Stability
11.6 Conclusion
References
12: Concomitant Meniscus Repair for Cartilage Treatment
12.1 Importance of Meniscal Repair
12.2 Assessment of Tear Repairability
12.2.1 Tear Factors
12.2.1.1 Tear Location
12.2.1.2 Tear Orientation
12.2.1.3 Tear Length
12.2.1.4 Age of Tear
12.2.2 Patient Factors
12.2.2.1 Age, BMI, Sex
12.2.3 Indications for Repair
12.3 Which Repair Technique to Use When
12.3.1 Radial Tears
12.3.2 Vertical and Bucket Handle Tears
12.3.3 Horizontal Tears
12.4 Partial Meniscus Restoration
12.5 Biologic Augmentation
12.5.1 Synovial Abrasion/Trephination
12.5.2 Marrow Stimulation and Stem Cells
12.5.3 Fibrin Clot
12.5.4 Platelet-Rich Plasma
12.5.5 Growth Factor
12.6 Rehabilitation
References
13: Meniscus Root Tear and Its Treatment
13.1 Meniscus Root Tear Introduction
13.1.1 Anterior Roots
13.1.2 Posterior Roots
13.1.3 Articular Cartilage
13.2 Clinical Presentation and Diagnosis of Root Tears
13.3 Imaging
13.4 Root Tear Classification and Meniscal Extrusion
13.5 Natural History
13.5.1 Subchondral Insufficiency Fractures of the Knee (SIFK)
13.5.2 Articular Cartilage Damage
13.6 Clinical Outcomes
13.7 Repair Options
13.7.1 Transtibial Pull-Through Repair
13.7.2 Suture Anchor Repair
13.8 Author’s Preferred Operative Technique: Transtibial Pull-Through
13.9 Postoperative Care
13.10 Controversies
References
14: Cartilage Debridement of Symptomatic Lesions
14.1 Introduction to Cartilage Debridement
14.1.1 Epidemiology and Demographics
14.1.2 Conservative Management
14.1.3 Surgical Debridement
14.2 General Evaluation
14.2.1 Patient Characteristics
14.2.1.1 Establishing Desired Activity Level
14.2.1.2 Level of Osteoarthritis at the Time of Surgery
14.2.1.3 Status of the Meniscus
14.2.1.4 Pain and Mobility
14.2.2 Lesion Characteristics and Classification
14.2.2.1 Anatomic Location
14.2.2.2 Size
14.2.2.3 Depth
14.2.2.4 Subchondral Bone Involvement
14.3 Treatment
14.3.1 Surgical Techniques
14.3.1.1 Mechanical Debridement
14.3.1.2 Radiofrequency Debridement
Thermal Radiofrequency
Nonthermal Radiofrequency
14.3.1.3 Quality of Cartilage in a Defect
14.3.1.4 Concomitant Procedures
14.3.2 Clinical Outcomes and Follow-Up
14.3.2.1 Evolution of Osteochondral Lesion After Debridement
14.3.2.2 Rehabilitation
14.4 Summary and Conclusions
References
15: Management of Osteochondritis Dissecans of the Knee
15.1 Introduction
15.2 Natural History
15.3 Reparative Management
15.3.1 Drilling
15.3.2 Internal Fixation
15.4 Restorative Management
15.4.1 Osteochondral Grafts
15.4.2 Cell-Based Therapy
References
16: Managing Concomitant Cartilage Injury with ACL Tears
16.1 ACL Anatomy and Biomechanics
16.1.1 Functional Biomechanics of the ACL
16.1.2 The Menisci
16.2 ACL Injuries
16.2.1 General
16.2.2 Injury Patterns and Mechanisms
16.2.3 Overview of Treatment Options
16.3 Concomitant Injuries
16.3.1 Introduction
16.3.2 Influence of Isolated ACL Tear on the Articular Cartilage
16.3.3 The Influence of Concomitant ACL and Meniscal Tears on the Articular Cartilage
16.3.4 Injuries Associated with Hyperlaxity and Instability
16.4 Treatment
16.4.1 Introduction
16.4.2 ACLR Techniques
16.4.3 Bone Bruising
16.4.4 Principles of Combined Injury Treatment
16.5 Rehabilitation
16.6 Conclusions
References
17: Marrow Stimulation: Microfracture, Drilling, and Abrasion
17.1 Introduction
17.2 Indications
17.3 Contraindications
17.4 Technique
17.5 Postoperative Care
17.6 Outcomes
References
18: Microfracture Augmentation Options for Cartilage Repair
18.1 Introduction
18.2 Autologous Matrix-Induced Chondrogenesis (AMIC)
18.2.1 Indications
18.2.2 Technique
18.2.3 Outcomes of AMIC
18.2.4 Limitations of AMIC
18.3 Novel Scaffold Adjuvants
18.3.1 ChonDux
18.3.2 Chondrotissue
18.3.3 GelrinC
18.3.4 BST CarGel
18.3.5 ArtiFilm ECM
18.3.6 Limitations of Novel Scaffolds
18.4 BioCartilage
18.5 Biologic Augmentation
18.5.1 Bone Marrow Aspirate Concentrate
18.5.2 Platelet-Rich Plasma
18.5.3 Adipose-Derived Injections
18.5.4 Amniotic Suspension Allograft Injections
18.5.5 Other Promising Injectable Augmentation Modalities
18.6 Conclusion
References
19: Cell-Based Cartilage Repair
19.1 Introduction
19.2 Intrinsic Repairs
19.2.1 Bone Marrow-Derived Repair Cells
19.3 Synovial and Adipose Cells
19.3.1 Synovial Derived MSCs
19.3.2 Adipose Tissue-Derived MSCs
19.3.3 Adipose Tissue-Derived Stromal Vascular Fraction Cells
19.3.4 Umbilical Cord Blood-Derived MSCs
19.3.5 Menstrual Blood-Derived MSCs
19.3.6 Muscle-Derived Stem Cells
19.3.7 Peripheral Blood Progenitor Cells
19.4 Autologous Chondrocytes
19.4.1 Autologous Chondrocytes (In Vitro Expanded)
19.4.2 Directly Isolated Autologous Chondrocytes
19.4.3 Autologous Chondrons
19.4.4 Allogeneic Chondrocytes (In Vitro Expanded)
19.4.5 Nasal, Auricular, and Costal Chondrocytes
19.4.6 Xenogeneic Chondrocytes
19.4.7 Autologous Cartilage Fragments
19.4.8 Allogeneic Cartilage Fragments
19.4.9 IPS-Cells and Embryonic Cells
19.5 Summary
References
20: Role of MSCs in Symptomatic Cartilage Defects
20.1 Introduction
20.2 Mesenchymal Stem Cells
20.2.1 Sources
20.2.2 Mechanisms of Action
20.2.3 Methods of Delivery
20.3 Clinical Results of MSC Therapies
20.4 Scaffold-Based Stem Cell Delivery Methods
20.5 Scaffold-Free Methods
20.6 Conclusion
References
21: Scaffolds for Cartilage Repair
21.1 Introduction
21.1.1 Cellulated Scaffold
21.1.2 Cell-Free Scaffold
21.2 Physical Properties of Scaffolds
21.3 Surgical Indication
21.4 Rehabilitation Protocol
21.5 Cell-Free Scaffolds Available in Clinical Practice
21.5.1 MaioRegen® (Fin-Ceramica S.p.A., Faenza, Italy)
21.5.2 Agili-C™ (Cartiheal (2009) Ltd., Israel)
21.5.3 AMIC® Chondro-Gide® (Geistlich)
21.6 Clinical Results
21.6.1 MaioRegen® Clinical Results
21.6.2 AMIC® Chondro-Gide® (Geistlich) Clinical Results
21.6.3 Agili-C™ (Cartiheal (2009) Ltd., Israel) Clinical Results
References
22: Osteochondral Autograft for Treatment of Small Cartilage Injuries
22.1 Introduction
22.2 Surgical Technique
22.3 Surgical Indications
22.4 Clinical Outcomes
22.4.1 Randomized Controlled Trials
22.4.2 Cost-Effectiveness
22.4.3 Return-to-Sport
22.4.4 Contrasting Findings
22.4.5 Complications
22.5 Basic Science Studies
22.6 Conclusion
References
23: Osteochondral Allograft Transplantation
23.1 Introduction
23.2 History
23.3 Immunology
23.4 Allograft Recovery, Processing, and Storage
23.5 Indications
23.6 Contraindications
23.7 Preoperative Planning
23.8 Surgical Techniques
23.8.1 Press-Fit Plug Technique
23.8.2 Press-Fit Plug Technique Postoperative Management
23.8.3 Shell Technique
23.8.4 Shell Technique Postoperative Management
23.9 Outcomes of Fresh Osteochondral Allograft Transplantation
23.9.1 Factors Affecting Outcome
23.9.1.1 Age
23.9.1.2 Location
23.9.1.3 Diagnosis
23.9.1.4 Size
23.9.1.5 Storage Time
23.10 Return to Sport
23.11 Complications
23.12 Summary
References
24: Emerging Cartilage Repair Options
24.1 Introduction
24.2 Key Concepts
24.2.1 Platelet-Rich Plasma for Cartilage Treatment
24.2.2 Autologous Chondrocyte Implantation
24.2.3 Stem/Stromal Cell-Based Therapeutics
24.2.4 Single-Stage Auto/Allo Cartilage Repair
24.3 Conclusions
References
25: One-Step Chondral and Subchondral Lesion Treatment with MSCs
25.1 Introduction
25.2 One Step Treatments for Chondral and Osteochondral Injuries
25.2.1 HA-BMAC
25.2.2 Indications
25.2.3 The Procedure
25.3 One-Step Treatment for Subchondral Bone Lesions
25.3.1 Osteo-Core-Plasty
25.4 Postoperative Rehabilitation
25.4.1 Immediate Postoperative Protocol at the Hospital
25.4.2 Postoperative Rehabilitation Protocol
25.4.2.1 Proliferative/ Protective Phase (0–6 Weeks)
25.4.2.2 Transition Phase (6–12 Weeks)
25.4.2.3 Maturation Phase (12–24 Weeks)
25.4.2.4 Functional Recovery Phase (24–52 Weeks)
25.5 Conclusions
References
26: Cartilage Restoration and Stabilization Strategies for the Patellofemoral Joint
26.1 Introduction
26.2 History and Physical Exam
26.3 Imaging
26.4 Treatment Indications
26.5 Non-operative Management
26.6 Surgical Management of Cartilage Defects
26.7 Patellar Dislocation: Osteochondral Fracture and Chondral Shear Injuries
26.8 Debridement/Chondroplasty
26.9 Microfracture
26.10 Osteochondral Autograft Transfer (OAT)
26.11 Osteochondral Allograft
26.12 Autologous Chondrocyte Implantation
26.13 Particulated Juvenile Allograft Cartilage
26.14 Perforated Allograft Cartilage
26.15 Choosing an Appropriate Cartilage Repair Therapy
26.16 Associated Procedures and Patellofemoral Cartilage Restoration
26.16.1 Tibial Tubercle Osteotomy
26.16.2 Soft Tissue Procedures
26.17 Rehabilitation
26.18 Complications
26.19 Conclusion
References
27: Rehabilitation and Decision for Return to Play Following Cartilage Restoration Surgery
27.1 Introduction
27.2 Principles of Rehabilitation Following Cartilage Restoration
27.3 Return-to-Play Vision
27.4 Return-to-Play Protocol and Decision
27.4.1 First Stage (Early Rehabilitation)
27.4.2 Second Stage (Early Rehabilitation)
27.4.3 Third Stage (Mid Rehabilitation)
27.4.4 Fourth Stage (Mid-to-Late Rehabilitation)
27.4.5 Fifth Stage (Late Rehabilitation)
27.5 Conclusions
References
28: Return to Sport Following Cartilage Treatment: Where Is the Evidence?
28.1 Introduction
28.2 Return-to-Sport
28.2.1 Marrow Stimulation Techniques (Microfracture, Microdrilling)
28.2.2 Cell-Based Cartilage Repair Techniques (ACI/MACI)
28.2.3 Osteochondral Autograft Transfer (OAT)/Mosaicplasty
28.2.4 Osteochondral Allograft Implantation (OCA)
28.3 Effect of Different Rehabilitation Programs on Return to Sport
28.4 Key Points in Reviewing Return-to-Sport Evidence
28.5 Summary
References