Chondral injures present an unique exceptional challenge to the treating physician in view of the poor natural healing capacity of the articular cartilage cells

Articular cartilage is avascular and therefore has a limited repair capacity. The function of the articular cartilage is to allow lubricated low friction gliding movements of joints and to cushion the loading across the joint. Articular cartilage is made up of dense Type II collagen, a proteoglycan matrix and chondrocytes fixed within the matrix. The fluid contained as hydrostatic pressure within the homeostasis within the extracellular matrix of articular cartilage. This maintains the mechanical integrity of the articular cartilage to withstand the compressive loads across a joint and allow gliding and sliding movement..

Articular Cartilage Treatment Options

Arthroscopic Debridement (Chondroplasty):.

Marrow Stimulation (Microfracture): Osteochondral Transfer (Mosiacplasty) and OsteochondralAllografts:

Cell-Based Cartilage Repair Techniques
*Autologous Chondrocyte Implantation (ACT)/Matrix Autologous Chondrocyte Implantation (MACI):
ACI/MACI is suitable for athletes 20-50 years old with an isolated femoral condyle defect greater then 2-4 cm, less than 3-6mm deep.

Neocartilage Implantation
Neocartilage implantation involves sophisticated tissue engineering technology. The chondrocytes are harvested in a similar way to ACI, the cells are then expanded in a 2-D culture and seeded in a bovine collagen gel/sponge construct.

Each knee has two menisci. They are commonly called “the cartilages”, although this is not strictly accurate. There is one on the medial (inner) side of the knee and one on the lateral (outer) side of the knee. They are C or crescent-shaped and serve to cup the femur as it sits on the tibia to improve the congruity of the joint. The main role of the meniscus is to spread the load being put through the two joint surfaces, thereby protecting the joint surface cartilage. In some ways they act as shock absorbers of the knee. They are made up of a tough gristly material called fibrocartilage.. A torn meniscus causes pain, swelling and stiffness. You also might have trouble extending your knee fully.

Conservative treatment to heal on its own.

Surgery; Menisci Repair or Menisectomy

The Anterior Cruciate Ligament (ACL) is the main stabilizer in the knee. It prevents anterior movement of the tibia during twisting of the knee or landing from a jump. The injury is usually associated with immediate pain and swelling in the knee associated with instability or giving way. The initial pain and swelling may settle over a number of weeks but often a degree of instability on twisting or recurrent swelling is present. The ligament does not heal or repair itself and the symptoms are usually prolonged unless the patient wishes to restrict their activities and/or to use an immobilizing knee brace. If appropriate treatment is not undertaken then continuing symptoms, limitations in sports and progressive degenerative changes often result. Therefore surgical reconstruction of the ligament is often necessary and commonly recommended in order to allow patients to resume their pre-injury level of activities.

The posterior cruciate ligament is considerably thicker and stronger than the ACL and is also made up of two bundles of fibres. These pass forwards from the back (posterior) to the front (anterior) of the knee. It is attached at its lower end to quite a broad area of the back of the upper tibia. This is its posterior attachment. From there it leads upwards and forwards ending up attached to the inner part of the medial femoral condyle which forms its anterior attachment. The two bundles of fibres are also aligned so that one band becomes tight in rather more flexion and the other band becomes tight in more extended positions of the knee. Like the ACL the PCL contributes to stabilisation of knee movements so that the joint surfaces of the tibia remain properly aligned to the femur in all stages of knee bend. Without it the tibia becomes unstable in relation to the femur and tends to slide backwards under load.
The medial collateral ligament is on the inner (medial) side of the knee. It is quite a wide ligament that passes from the medial aspect of the upper tibia at a point 4 to 5 cm below the knee. From there it passes upwards to join the medial femoral condyle quite far around the side of the condyle. It also has two bands. The superficial layer which is heavier and broader and a deep layer which is much thinner and which attached to the medial meniscus. The MCL controls sideways movements of the knee and without it the knee tends to give way on the inner side that is the knee goes into a valgus (knock knee) alignment under certain types of loading.
Posterior cruciate ligament and postero-lateral corner (PLC) tears occur in association with other ligament injuries around the year, most notably ACL tears. When this occurs it often leads to quite major instability which requires surgical intervention.Fortunately these complex multi-ligament injuries are relatively uncommon. When they do occur they are quite difficult to reconstruct surgically and surgery is best performed by a surgeon with a special interest in this type of ligament surgery.Lateral collateral ligament – LCLThe lateral collateral ligament is on outer (lateral) side of the knee and is sometimes called the fibular collateral ligament.. It is attached at its lower end to the head of the fibula and at its upper end to the lateral femoral condyle slightly towards the back of the condyle. The LCL controls sideways movements of the knee and without it the knee tends to give way on the lateral side, that is, the knee goes into a varus (bow leg) alignment under certain types of loading. It also contributes to the posterolateral corner.Postero-lateral corner – PLCThe structures of the posterolateral corner jointly act as a check ligament to control movement of the lateral side of the knee joint. Another name for these structures is the posterolateral complex reflecting the fact that there are a number of structures that contribute to it. The three main structures involved are the LCL, the popliteus tendon, and the popliteofibular ligament. The bony shape of the lateral side of the knee makes it inherently more unstable than the medial side and additional stability is provided by the PLC to control sideways movement, and a combination of external rotation and backwards movement of the outer side of the upper tibia. Without the PLC, the knee tend s to be rotationally unstable, that is there is an excessive twisting movement of the tibia under certain types of load.

A total knee replacement replaces the surfaces of the knee with plastic and metal components. The femoral replacement is a smooth metal component which fits snugly over the end of the bone. The tibial replacement is in two parts, a metal base plate sitting on the bone and a plastic insert which sits between the metal base on the tibial and the femoral component. If necessary the patella surface (under the knee cap) is replaced with a plastic button which glides over the metal surface of the femoral replacement. However, the patella is occasionally satisfactory and may not require replacement.

The components are usually cemented to the bones in order to secure fixation. In certain circumstances special components may be “press fitted” to the bones without the additional use of cement.

Patellar dislocation is an injury of the knee, typically caused by a direct blow or a sudden twist of the leg. It occurs when the patella (kneecap) slips out of its normal position in the trochlea groove, and generally causes intense pain with swelling of the knee Arthroscopic surrgery may be used to repair damage.

Knee osteotomy is used when patients have early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting weight off of the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in arthritic knee.

High Tibial osteotomy can realign the knee, taking pressure off the damaged side. A procedure known as a high tibial osteotomy wedges open the upper shin bone (tibia) to reconfigure the knee joint. The weight-bearing part of the knee is shifted from degenerative or worn tissue onto healthier tissue.

A high tibial osteotomy is generally considered a method of prolonging the time before a knee replacement is necessary because the benefits typically fade after eight to ten years. This procedure is typically reserved for younger patients with pain resulting from instability and malalignment. An osteotomy may also be performed in conjunction with other joint preservation procedures in order to allow for cartilage repair tissue to grow without being subjected to excessive pressure.

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By : Dr. Mohammad Ashfaq Konchwalla

Consultant Orthopaedic & Sports Surgeon

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