LARSPETERSON, CHRISTIANERNEST
Introduction
The first physician to recognise the clinical problems associated with carti- lage injuries is reported to be Hippocrates in 400 BC. His pupil Herodicus was supposed to be the first sports medicine doctor treating Olympic athletes.
Trauma or impacts, both occasional and repetitive, can cause damages to the articular cartilage as well as the subchondral bone in a joint. The reparative response to articular cartilage injuries is limited. The cartilage has no vascu- lar supply, so unless the subchondral bone is involved, an injury does not cause bleeding and formation of a blood clot that possibly could fill the car- tilage defect. The chondrocytes are unable to migrate into and populate the defect. Local increase of the synthesis of matrix molecules occurs in the neighbourhood of the defect during the acute phase but ends at about 2 weeks for unknown reason. Untreated acute lesions penetrating the articular cartilage of the knee down to bone will likely progress to early post-traumat- ic osteoarthritis by continued enzymatic degradation activity and mechani- cal wear over time. Osteoarthritis is an irreversible process and may lead to considerable disability for the player. The challenge is not only to restore activities of daily life but also to allow athletes to go back to top-level sports such as football.
Risk for Cartilage Injuries
Articular cartilage injuries are common in football and may be career ending if not treated properly. In acute and chronic injuries to the knee joint treated surgically, more than 40% of patients were found to have articular cartilage injuries down to bone. Noyes et al. found that acute and chronic anterior cru- ciate ligament (ACL) injuries were 40–70% associated with articular cartilage injuries [1, 2.] There are also reports that in 40–50% of cases with meniscus injury also have cartilage damage. Hjelle et al. reported that in 1,000 consec-
utive patients with symptoms requiring arthroscopy, chondral or osteochon- dral lesions of any type were found in 61% [3]. In a study by Drawer and Fuller on retired English professional players, 32% had osteoarthritis [4].
Levy et al. found a higher risk of chondral injuries in highly skilled football players [5]. It is thought that the increased risk of articular cartilage injuries and gonarthrosis in football is due to the high joint stresses associated with repetitive joint impact, rapid acceleration and deceleration, and pivoting as well as contact with other players. ACL and meniscus injuries are often com- bined with articular cartilage injuries where the cartilage injury is the most serious and hardest to treat.
Symptoms and Diagnosis
As cartilage lesions are likely to progress in size and worsening symptoms and may cause an end to the career for the player, it is important to diagnose and treat cartilage lesions at an early stage. Symptoms often associated with articular cartilage lesions are pain and swelling during or after activity, crepi- tations, and catching or locking. To diagnose a cartilage lesion, a thorough clinical examination is needed and includes assessment of ligament instabil- ity, varus-valgus malalignment, and patella maltracking or malalignment. X- rays, computed tomography (CT), and especially magnetic resonance imaging (MRI) are useful tools to diagnose damage to the articular cartilage. The def- inite diagnosis is taken during arthroscopy and probing of the articular sur- faces.
Surgical Treatments
Treating chondral lesions has been a known difficult clinical challenge since Hippocrates. There are today many different treatment options for cartilage lesions, such as débridement, coblation, drilling, abrasion, microfracturing, osteochondral transplantation as in mosaic plasty, and autologous chondro- cyte transplantation.
Arthroscopic débridement of loose flaps and rugged surfaces gives short- term relieve of symptoms and may delay or stop further deterioration of a cartilage surface. Coblation (vaporisation) may be used with caution and strictly according to instructions. Drilling, abrasion, and micro-fracturing are all treatments that penetrate the subchondral bone plate into the bone mar- row, which will cause bleeding, and stem cells and fibroblasts can migrate into the cartilage lesion and produce repair tissue of fibrocartilage [6]. However, the mechanical properties of the fibrous cartilage are inferior to those of hya- line cartilage and are probably not able to withstand the demands of football
over a longer period. Mosaicplasty is a treatment with transplantation of fully developed osteochondral plugs into drill holes in the defect [7]. The tech- nique is limited to smaller defects since there are not so many plugs that can be harvested from the articular surfaces before causing too much damage to the joint.
Autologous chondrocyte transplantation (ACT) is indicated for sympto- matic, full-thickness, chondral and osteochondral lesions [including osteo- chondritis dissecans (OCD)] of the knee with an area between 1 to 2 and 16 cm (Fig. 1). An initial arthroscopy is made, and the cartilage lesion is evaluat- ed and documented regarding size, depth, location, containment, and accessi- bility for transplantation (Fig. 2). Slices of cartilage are harvested from a minor load-bearing area in the knee, the most common being the proximal medial edge of the femoral trochlea. From the cartilage specimens, chondro- cytes are isolated and cultured for a minimum of 2 weeks.
The joint is opened, and the arthrotomy is adjusted so the lesion is acces- sible (Fig. 3a). The patella may have to be dislocated. All damaged and under- mined cartilage is radically excised, and the defect is carefully debrided to vertical edges of healthy cartilage. Care must be taken not to cause any bleed- ing from the subchondral bone. A periosteal flap, harvested from the upper medial tibia, is placed on top of the defect, with the cambium layer facing the
Fig. 1.Schematic drawing of autologous chondrocyte transplantation
defect. The flap is sutured to the cartilage edges with resorbable, interrupted sutures, and the intervals between the sutures are sealed with fibrin glue (Fig.
3b). After checking that the periosteal cover is watertight, the chondrocytes are injected into the defect and the last opening is closed. The arthrotomy is closed in layers.
If there is an instability or malalignment of the knee, it is imperative to surgically treat this ailment either before or at the same time as the ACT. If not treated, the chances for a successful outcome are greatly reduced. If the meniscus has previously been totally removed, a meniscal allograft should be considered.
Fig. 2.Arthroscopic assess- ment of chondral lesion in the knee
a b
Fig. 3a, b.Chondral lesion before (a) and after (b) treatment with autologous chondro- cyte transplantation
Postoperative Treatment and Rehabilitation
Postoperatively, antibiotics are given for the first 48 h, and intermittent con- tinuous passive motion is started 6–8 h after surgery. Weight bearing is lim- ited to 20 kg for the first 6 weeks, then gradually increased to full weight bearing in the following 6 weeks. The rehabilitation following ACT is long and focuses mainly on functional training and motion training. Return to football is judged on an individual level. Clinical follow-up, including strength and endurance tests as well as arthroscopic evaluation and indentation testing of the stiffness of the repair tissue, are important before allowing the player to go back to football training. MRI enhanced with gadolinium contrast may be useful for assessing the healing. The player starts with individual training and then gradually goes back to individual football training and then to compet- itive training and matches (Fig. 4).
Fig. 4a-d. a Magnetic resonance imaging (MRI) showing osteochondritis dissecans.
b Same lesion after transplantation of autologous chondrocytes. Second-look arthroscopy at 4 years (c) and MRI at 9 years (d) show complete healing of defect. The player was able to return to international-level football
a b
c d
Results
While other treatments often have failed after 2–4 years, ACT has proven to maintain a good result, even at a long-term follow-up. A recent study compar- ing osteochondral autologous transplantation with microfracture showed a higher return to sports at the pre-injury level for the osteochondral grafting group compared with only 52% of those treated with microfracture [8]. A study by Mithöfer et al. showed decrease in the functional outcome 24 months after treatment of symptomatic cartilage lesions in the knee with the microfracture technique. Only 44% of the patients could go back to high- impact activities such as football [9]. In a Swedish study of the first 61 patients treated with ACT on femur or patella, 50 were clinically considered good or excellent at a 2-year follow-up. At a second follow-up of the same cohort 5–11 years after surgery, 51 patients were still good or excellent, no patient had deteriorated, and the failures occurred before the first follow-up [10].
Follow-up 2–9 years postoperative of the first 101 consecutive patients with chondral or osteochondral lesions of the knee treated with ACT showed a 77% good to excellent result overall, and 89–96% in OCD and isolated femoral condyle lesions. According to the Tegner/Wallgren score, the patients were also able to have an active life, including football. The modified Cincinnati score was average 9 out of 10, meaning they could return to high- level sports, including football. The 2-year follow-up results seem to be an indicator for the long-term result [11].
In another study by Mithöfer et al., 45 players treated with ACT were fol- lowed for a mean of 40 months. Players younger than 26 years, high-skill-level players, and players operated within 12 months after trauma returned to pre- injury level in 83% of cases. Time to return from surgery to football was 12–18 months [12].
Using ACT with scaffolds such as Hyalograft and collagen membranes (MACI) have recently reported promising short-term results but have still to be evaluated for longer follow-up and return to football [13–16].
Conclusion
ACT is a treatment for symptomatic, full-thickness, chondral and osteochon- dral lesions of the knee, which is able to produce a hyaline-like repair tissue and restore knee function. It is possible to return to football and other high- level competitive sports; 83% of players could return to football if the opera- tion was within 12 months after injury. If the player can comply with the reha- bilitation period of 12–15 months, it seems that ACT as the primary treatment gives best options for return to football with durable results.
References
1. Noyes FR, Bassett RW, Grood ES, Butler DL (1980) Arthroscopy in acute traumatic hemarthrosis of the knee: incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am 62:687–695
2. Noyes FR, Matthews DS, Mooar PA, Grood ES (1983) The symptomatic anterior cru- ciate deficient knee: Part 1. The long-term functional disability in athletically acti- ve individuals. J Bone Joint Surg Am 65:163–174
3. Hjelle K, Solheim E, Strand T et al (2002) Articular cartilage defects in 1000 knee arthroscopies. Arthroscopy 18:730–734
4. Drawer S, Fuller CW (2001) Propensity for osteoarthritis and lower limb joint pain in retired professional soccer players. Br J Sports Med 35:402–408
5. Levy AS, Lohnes J, Sculley S et al (1996) Chondral delamination of the knee in soc- cer players. Am J Sports Med 24:634–639
6. Steadman JR, Rodkey WG, Briggs KK (2002) Microfracture to treat full-thickness chondral defects. J Knee Surg 3:170–176
7. Hangody L, Füles P (2003) Autologous osteochondral mosaicplasty for the treat- ment of full-thickness defects of weight-bearing joints: Ten years of experimental and clinical experience. J Bone Joint Surg Am 85:25–32
8. Gudas R, Kalesinskas RJ, Kimtys V et al (2005) A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes.
Arthroscopy 21:1066–1075
9. Mithöfer K, Williams RJ, Warren R et al (2005) High-impact athletics after knee arti- cular cartilage repair: A prospective evaluation of the microfracture technique.
American Orthopaedic Society for Sports Medicine, Annual Meeting, Keystone (Iowa)
10. Peterson L, Brittberg M, Kiviranta I et al (2002) Autologous chondrocyte transplan- tation: Biomechanics and long-term durability. Am J Sports Med 30:2–12
11. Peterson L, Minas T, Brittberg M et al (2000) Two-to 9-year outcome after autolo- gous chondrocyte transplantation of the knee. Clin Orthop Relat Res 374:212–234 12. Mithöfer K, Peterson L, Mandelbaum BR, Minas T (2005) Articular cartilage repair
in soccer players with autologous chondrocyte transplantation: functional outcome and return to competition. Am J Sports Med 33:1639–1646
13. Bentley G, Biant LC, Carrington RW et al (2003) A prospective, randomized compa- rison of autologous chondrocyte implantation versus mosaicplasty for osteochon- dral defects in the knee. J Bone Joint Surg Br 85:223–230
14. Guillen Garcia P, Abelow S, Fernandez Jaen T (2003) Membrane/matrix autologous chondrocyte implantation. Presented at the UCSF Comprehensive Knee Cartilage Symposium: State of the art, San Francisco (California)
15. Marcacci M, Kon E, Zaffagnini S (2005) Tissue engineering of cartilage: 2nd gene- ration autologous chondrocyte transplantation. Presented at the 5th Biennial ISA- KOS Congress, Hollywood (Florida)
16. Nehrer S, Schatz K, Marlovits S et al (2002) Preliminary results of matrix-assisted chondrocyte transplantation using a hyaluronan martix. Presented at the ICRS Symposium, Toronto
