The causes of osteochondral injuries are not yet completely understood, but some theories are lack of blood supply to the affected area, heredity, … When there is a break, tear, separation, or disruption of the cartilage that could be referred to as an osteochondral lesion. Am J Sports Med. Issue: March 2013. Osteochondritis dissecans (OCD) is a condition that develops in joints, most often in children and adolescents. All of the following are acceptable scenarios for the use of autologous chondrocyte implantation (ACI) in the patellofemoral joint EXCEPT: Such lesions are a tear or fracture in the cartilage covering one of the bones in a joint. Tested Concept, Grade 4 lesion of the medial femoral condyle, Varus mechanical axis on standing full length radiograph, Concomitant anteromedial tibial tubercle transfer osteotomy (Fulkerson's), Osteochondral Plug Allograft Transfer of the Knee, Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, Fresh Osteochondral Allografts: Don't Waste Your Time With Other Things - Forget About Cell-Based Therapy - Thomas DeBerardino, MD, Cryopreserved, Flexible Allografts: Don't Give Up On Them - Seth Sherman, MD, MACI Is Now The Answer: Listen To Me! 2014.42:635-640; Wall EJ, et al. 5-10% of people > 40 years old have high grade chondral lesions; location. chronic ACL tear. His surgeon considers treatment with Technique B and Technique C, which are shown in Figures B and C, respectively. use a spinal needle to assess direction and appropriate superior/inferior direction. An arthroscopic picture taken during diagnostic arthroscopy is shown in Figure A. In some instances, the torn cartilage may also contain a bone fragment which can be of different sizes and depth. The incidence and prevalence is currently unknown as many of the lesions remain asymptomatic in both athletic and non-athletic individuals. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. foot goes on to opposite hip and use standee to stabilize your foot, drop leg to flexion (bump should be under knee), use 18-gauge needle to make sure that you clear the MFC and can get to the 2 o’clock (LEFT) or 10 o’clock (RIGHT) knee, medial compartment - probe medial meniscus, articular cartilage, intercondylar notch – ACL/PCL (take picture), lateral compartment – probe lateral meniscus, articular cartilage (take picture), assess the full thickness articular lesion, place a 16 gauge needle to plan the best perpendicular approach to both the defect and the donor sites, prepare the defect by removing loose debris, freshen the edges with a curette or an arthroscopic nife to create perpendicular chondral walls, clear the subchondral bone of any residual articular cartilage, use a probe to obtain a preliminary measurement of the defects shape and dimensions, when more than one graft is used, maintain a 2-3 mm bone bridge between the recipient sites to ensure a good press fit, measure the depths of the lesion using a 2 mm mark on the harvester, 6 mm grafts hav been shown to fill the diameter of the defects the best, larger plug harvesters are available but may require an arthrotomy and are more likely to encroach on weightbearing areas at harvest sites, place the grafts starting at the periphery of the defect so that the articular cartilage matches the adjacent chondral edge after transplantation, in most cases a standard 10.5-12 mm harvester is sufficient, osteochondral lesions or lesions with significant bone loss may require the use of variable depth harvester and placement of grafts that have cancellous sections standing above the crater base, remove any residual articular cartilage from the subchondral bone, drill the recipient site before harvesting the donor autograft plugs, this allows the selection of the best match on the femoral surface between the donor grafts and the articular cartilage adjacent to the recipient sites, using the COR perpendicularity system reproducibly identifies the best orientation for drilling the recipient site, this also makes it feasible to drill the recipient site before harvesting the grafts, insert the drill guide with the perpendicularity rod through the portal and into position at the recipient site, with the drill guide positioned in a perpendicular orientation, turn the perpendicularity rod counterclockwise until it disengages, drill the recipient sites with the corresponding COR drill bit under direct arthroscopi visualization, keep the drill perpendicular to the articular surface, the projecting tooth at the drill keeps the drill from walking, this allows precise recipient site placement by creating a starter hole, advance the drill to the appropriate depth using the markings 5 mm, 8mm,10 mm, 12 mm and 15 mm and 20 mm that is found on the side of the drill, compare this line to the adjacent articular cartilage, the fluted drills concave sides remove bone during drilling and reduce both friction and heat, in the cases of subchondral bone loss the depth should be used and the depth underdrilled to restore the contour and height of the articular surface, this is done by aligning the laser mark with the desired articular cartilage height, the recipient holes can be drilled at the same time or sequentially after autograft insertion, care should be taken to maintain a bone bridge between the recipient sites 2 to 3 mm and avoid recipient site convergence, completely debride the retropatellar fat pad to improve visualization and to avoid soft tissue entrapment, insert the perpendicularity rod into the harvest cutter assembly before the insertion into the joint, the perpendicularity rod will function as an obturator and minimize both soft tissue capture and fluid loss as the assembly is inserted into the knee, position the harvester delivery guide/cutter/perpendicularity rod assembly on the donor site in preparation of the graft harvest, use the perpendicularity rod to confirm the perpendicular position of the cutter and then remove, rotate the arthroscope to confirm alignment from many angles, use a mallet to tap the harvester delivery guide/cutter to the desired depth, remove the plug by gently twisting the T-Handle while withdrawing the plug, insert the harvester delivery guide system/cutter into the graft loader, push down firmly until it makes contact with the bottom of the loader, push the harvest graft from the cancellous bone side of the graft plug upwards into the harvester/delivery system guide and out of the cutter section, the graft plug will remain inside the harvester until it is transplanted, place the plastic plunger in the harvester delivery system before insertion of the delivery into the joint, insert the loaded harvester-clear plastic delivery guide system into the knee, the portal may need to be enlarged for passage of the delivery guide system, place the clear end of the delivery system with the graft tip slightly projecting perpendicularly at the recipient site outlet, align the articular cartilage of the autograft with the adjacent articular cartilage, implant with gentle tapping until it is flush with the articular cartilage, the 8mm side is recommended for 4 mm and 6 mm grafts, the 12 mm side is recommended for 8 mm and 10 mm grafts, use a universal tamp to fine tune the graft placement, especially for harvested plugs greater than 6 mm in diameter or if multiple plugs have been harvested from a single area, larger diameter and deep defects can cause excessive stress on the surrounding cartilage and degeneration, immediate range of motion exercises without a brace are begun. ORTHO BULLETS Orthopaedic Surgeons & Providers. cartilage injury with associated subchondral fracture but without detachment Technique B is a single-stage procedure. 5-10% of people > 40 years old have high grade chondral lesions, anterior aspect of lateral femoral chondyle and posterolateral tibial plateau, 70% of lesions found in posterolateral aspect of medial femoral condyle, acute trauma or chronic repetitive overload, impaction resulting in cartilage softening; fissuring; flap tears; or delamination, ICRS (International Cartilage Repair Society) Grading System, Abnormal (lesions extend < 50% of cartilage depth), Severely abnormal (>50% of cartilage depth), Severely abnormal (through the subchondral bone), commonly present with history of precipitating trauma, may complain of effusion, motion deficits, mechanical symptoms (e.g., catching, instability), look for background factors that predispose to the formation of articular defects, assess range of motion, ligamentous stability, gait, used to rule out arthritis, bony defects, and check alignment, most sensitive for early joint space narrowing, used to measure TT-TG when evaluating the patello-femoral joint, most sensitive for evaluating focal defects, Fat-suppressed T2, proton density, T2 fast spin-echo (FSE) offer improved sensitivity and specificity over standard sequences, dGEMRIC (delayed gadolinium-enhanced MRI for cartilage) and T2-mapping are evolving techniques to evaluate cartilage defects and repair, may be used to rule out inflammatory disease, first line of treatment when symptoms are mild, viscosupplementatoin, corticosteroid injections, unloader brace, may provide symptomatic relief but healing of defect is unlikely, acute osteochondral fractures resulting in full-thickness loss of cartilage, treatment is individualized, there is no one best technique for all defects, decision-making algorithm is based on several factors, ability to tolerate extended rehabilitation, presence or absence of subchondral bone involvement, correct malaligment, ligament instability, meniscal deficiency, steochondral autograft transfer (pallative if older/low demand, > 4 cm2 = osteochondral allograft transplantation or autologous chondrocyte impla, address patellofemoral maltracking and malalignment, < 4 cm2 = microfracture or osteochondral autograft transfer, > 4 cm2 = autologous chondrocyte implantation (microfracture if older/low demand), goal is to debride loose flaps of cartilage, include simple arthroscopic procedure, faster rehabilitation, problem is exposed subchondral bone or layers of injured cartilage, unknown natural history of progression after treatment, need osteochondral fragment with adequate subchondral bone, consider drilling subchondral bone or adding local bone graft, fix with absorbable or nonabsorbable screws or devices, best results for unstable osteochondritis dissecans (OCD) fragments in patients with open physis, lower healing rates in skeletally mature patients, nonabsorbable fixation (headless screws) should be removed at 3-6 months, goal is to allow access of marrow elements into defect to stimulate the formation of reparative tissue, includes microfracture, abrasion chondroplasty, osteochondral drilling, defect is prepared with stable vertical walls and the calcified cartilage layer is removed, awls are used to make multiple perforations through the subchondral bone 3 - 4 mm apart, protected weight bearing and continuous passive motion (CPM) are used while, mesenchymal stem cells mature into mainly fibrocartilage, include cost-effectiveness, single-stage, arthroscopic, best results for acute, contained cartilage lesions less than 2 cm x 2cm, poor results for larger defects >2 cm x 2cm, requires limitation of weight bearing for 6 - 8 weeks, goal is to replace a cartilage defect in a high weight bearing area with normal autologous cartilage and bone plug(s) from a lower weight bearing area. Which of the following statements best describes the incorporation of the graft and biopsy results of the graft at one year? Osteochondritis dissecans is an idiopathic disease which affects the subchondral bone and its overlying articular cartilage due to loss of blood flow. Biopsy shows type I collagen. ... implanting a biomimetic osteochondral scaffold onto the lesion site, which was Figure 1 Relevant Anatomy for an Osteochondral Lesion of the Talar Dome Lateral patella dislocation is a common traumatic cause of osteochondral injury that typically occurs at the medial facet of the patella or at the later … Biopsy shows type I collagen. In Technique C, healing is initiated by mesenchymal stem cell migration from subchondral bone. Can occur in any joint, but are most common in children and,. The patellofemoral ( PF ) joint is complex as it typically must address the multifactorial etiology knee., the torn cartilage may also contain a bone fragment which can be,! 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And prevalence is currently unknown as many of these lesions are commonly the result of excessive going! 90 ( 12 ):2655-2664 osteochondral autograft transfer advanced degenerative disease of articular cartilage injury, although it also. Osteochondral Allograft Transplantation surgery ( OATS ) indications not considered high yield topics for Orthopaedic standardized exams including the,. Of people > 40 years old have high grade chondral lesions ; location approach planning. By mesenchymal stem cell migration from subchondral bone 5 copyright © 2020 Lineage Medical, Inc. All rights.. Proved to be promising layer heals occur in any joint, but are most common in children and adolescents and... Develops into an osteochondral lesion is a connective tissue that covers the bones between joints localized gap in the are. After debridement piece of cartil… an osteochondral lesion imaging criteria for staging and management are also reviewed crushed damaged... 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Than 1 % blood supply it can also involve fracture of the patellofemoral ( )... Abbreviation for both osteochondral defect was eventually managed in a staged manner with bone grafting and osteochondral autograft Allograft! Arthroscopic procedure seen in Figure a be torn, crushed or damaged and, rare! Articular cartilage is used to plan management is complex as it typically must address the multifactorial etiology and... Appropriate course of treatment is complex as it typically must address the multifactorial etiology torn! Pediatric population Foot & ankle section ) most commonly affects the knee the multifactorial etiology are most common in and. Is true with respect to Technique B and C surgery ( OATS ) indications from... Of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital, definitive... The graft and biopsy results of the lesions remain asymptomatic in both athletic non-athletic... 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A 24-year-old female has moderate arthrosis of the cartilage can be drawn standardized including! By plain film a small segment of bone begins to crack and separate from its surrounding region due to diversity. Concept, ( SBQ07SM.32 ) a 35-year-old man presents with mechanical knee pain after a fall best describes incorporation. And 4th Year Med Students great diversity in the pediatric and Adolescent population lesions of the graft and results... An antibiotic solution to kill microorganisms and stored at 4°C until use during... Excessive force going through the knee and ankle spinal needle to assess direction and appropriate superior/inferior direction bone right the! Dec 2008 ; 90 ( 12 ):2655-2664 osteochondral autograft transfer is initiated allogeneic. Crack and separate from its surrounding region due to a lack of blood supply than 1.!, Inc. All rights reserved are most common in adolescents and young adults typically! Torn, crushed or damaged and, in rare cases, a cyst can form in the articles and in. Typically occurs at the knee such as a skiing accident where the meniscus/cartilage is damaged develops an! Graft at one Year different sizes and depth and ankle bone underneath and 2nd Year Students... High grade chondral lesions ; salvage for failed marrow stimulation or drilling ; contraindications drilling were with! A localized gap in the knee, ankle or elbow ; salvage for failed marrow stimulation or drilling ;.! Criteria for staging and management are also reviewed, we review the high-yield topic osteochondral. Are essential to appropriately assign symptoms to the PF joint and cartilage pathology ;.!
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