Articular Cartilage Lesions of the Knee

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Clinically Relevant Anatomy

Articular cartilage which covers the ends of bones in joints.

Mechanism of Injury / Pathological Process

Most articular cartilage defects are caused by trauma, which can either be one single impact injury or repeated micro trauma. A specific group of cartilage damage is 'osteochondritis dissecans' where a well-demarcated small area of cartilage and underlying bone loses its blood supply, dies and eventually fragments and separates into the joint.

Grades of articular cartilage lesions and criteria for choosing appropriate therapy.
The Outerbridge scale:
Grade 0: intact articular cartilage
Grade 1: cartilage softening, intact joint surface, focal colour change
Grade 2: superficial fissuring
Grade 3: fissures and fragmentation extending into the matrix
Grade 4: erosion reaching the subchondral bone plate. Eburnated bone

Injuries to the cartilage can be partial thickness (part of the way down to bone) or full-thickness (all the way down to bone).

Clinical Presentation

•Recurrent joint pain and/or swelling (continued activity may not be possible).
•With mechanical degeneration: Stiffness and decreased ROM.
•Movement may be associated with audible 'clunks' or 'clicks'.
•Locking of the knee, which may be due to loose bodies within the joint.

Diagnostic Procedures

The physician examines the joint, looking for decreased ROM, swelling, pain along the joint line, abnormal alignment of the bones making up the joint and ligament or meniscal injury.
Articular cartilage injuries are difficult to diagnose, and evaluation with arthroscopy of MRI may be necessary. Plane X-rays are usually taken to rule out other abnormalities.

Outcome Measures

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Management / Interventions

Some patients with articular cartilage injuries improve with conservative treatment. The treatment includes use of NSAIDs, exercises, and possibly a steroid injection. The exercise may include a home program or formal physical therapy. Depending on the extent of the damage, some patients get better with these treatments and do not require surgery.
If patients do not get better with conservative therapy, or have a large articular cartilage lesion, surgery may be necessary. Defects smaller than 2 cm have the best prognosis and treatment options. Those options include arthroscopic surgery using techniques to remove damaged cartilage and increase blood flow from the underlying bone (e.g. drilling, pick procedure). For smaller articular cartilage defects which are asymptomatic, surgery may not be required. For larger defects, it may be necessary to transplant cartilage from other areas.

The rehabilitation is based on several goals:
1) allowing the tissue to heal;
2) regaining motion;
3) regaining strength;
4) return to sports.
The specific rehabilitation protocol for the physical therapist will depend on the procedure performed, and will be reviewed after surgery. Many of the procedures require you to restrict weight bearing for 6 to 8 weeks, in order to allow the area of cartilage repair to heal.

Differential Diagnosis

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Key Evidence

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Resources

-http://www.eorthopod.com/content/articular-cartilage-problems-knee
-http://www.orthspec.com/pdfs/Cartilage-Injuries.pdf
-http://www.sportsmed.org/secure/reveal/admin/uploads/documents/ST%20Articular%20Cartilage%2008.pdf

Case Studies

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References

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