Advertisement

Management of knee articular cartilage injuries in athletes: chondroprotection, chondrofacilitation, and resurfacing

  • Iain R. MurrayEmail author
  • Michael T. Benke
  • Bert R. Mandelbaum
Knee

Abstract

Articular cartilage defects of the knee are common among athletes where the physical demands of sport result in significant stresses on joints. Chondral defects are associated with pain and functional impairment that limit sporting participation and may progress to joint degeneration and frank arthritis. Management of established chondral lesions aims to allow athletes to return to high-impact sports and can be considered in terms of protection of existing cartilage, chondrofacilitation, and resurfacing. Repaired and regenerated cartilage must closely resemble and function like normal hyaline cartilage, and this ability may be the most significant factor for the return to sport. Based on our experiences and the available literature, we outline how athletes can best protect their cartilage, how physicians can facilitate intrinsic repair of established lesions, and which methods of cartilage restoration or resurfacing should be used in different situations.

Level of evidence

IV.

Keywords

Cartilage injury Return to sport Knee articular cartilage Cartilage resurfacing 

Notes

Acknowledgments

The authors are grateful to Mr Ivan Brenkel for his comments on the manuscript.

References

  1. 1.
    Arendt E, Dick R (1995) Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 23(6):694–701CrossRefPubMedGoogle Scholar
  2. 2.
    Bannuru RR, Natov NS, Obadan IE, Price LL, Schmid CH, McAlindon TE (2009) Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Rheum 61(12):1704–1711CrossRefPubMedGoogle Scholar
  3. 3.
    Bartlett W, Skinner JA, Gooding CR, Carrington RW, Flanagan AM, Briggs TW, Bentley G (2005) Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg Br 87(5):640–645CrossRefPubMedGoogle Scholar
  4. 4.
    Bentley G, Biant LC, Carrington RW, Akmal M, Goldberg A, Williams AM, Skinner JA, Pringle J (2003) A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg Br 85(2):223–230CrossRefPubMedGoogle Scholar
  5. 5.
    Bonnin MP, Laurent JR, Zadegan F, Badet R, Pooler Archbold HA, Servien E (2013) Can patients really participate in sport after high tibial osteotomy? Knee Surg Sports Traumatol Arthrosc 21(1):64–73CrossRefPubMedGoogle Scholar
  6. 6.
    Bradley JD, Heilman DK, Katz BP, Gsell P, Wallick JE, Brandt KD (2002) Tidal irrigation as treatment for knee osteoarthritis: a sham-controlled, randomized, double-blinded evaluation. Arthritis Rheum 46(1):100–108CrossRefPubMedGoogle Scholar
  7. 7.
    Brophy RH, Rodeo SA, Barnes RP, Powell JW, Warren RF (2009) Knee articular cartilage injuries in the National Football League: epidemiology and treatment approach by team physicians. J Knee Surg 22(4):331–338CrossRefPubMedGoogle Scholar
  8. 8.
    Brophy RH, Zeltser D, Wright RW, Flanigan D (2010) Anterior cruciate ligament reconstruction and concomitant articular cartilage injury: incidence and treatment. Arthroscopy 26(1):112–120CrossRefPubMedGoogle Scholar
  9. 9.
    Bugbee WD (2002) Fresh osteochondral allografts. J Knee Surg 15(3):191–195PubMedGoogle Scholar
  10. 10.
    Chubinskaya S, Hurtig M, Rueger DC (2007) OP-1/BMP-7 in cartilage repair. Int Orthop 31(6):773–781CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Cole BJ, Farr J, Winalski CS, Hosea T, Richmond J, Mandelbaum B, De Deyne PG (2011) Outcomes after a single-stage procedure for cell-based cartilage repair: a prospective clinical safety trial with 2-year follow-up. Am J Sports Med 39(6):1170–1179CrossRefPubMedGoogle Scholar
  12. 12.
    Crawford DC, DeBerardino TM, Williams RJ 3rd (2012) NeoCart, an autologous cartilage tissue implant, compared with microfracture for treatment of distal femoral cartilage lesions: an FDA phase-II prospective, randomized clinical trial after two years. J Bone Joint Surg Am 94(11):979–989CrossRefPubMedGoogle Scholar
  13. 13.
    Dozin B, Malpeli M, Cancedda R, Bruzzi P, Calcagno S, Molfetta L, Priano F, Kon E, Marcacci M (2005) Comparative evaluation of autologous chondrocyte implantation and mosaicplasty: a multicentered randomized clinical trial. Clin J Sport Med 15(4):220–226CrossRefPubMedGoogle Scholar
  14. 14.
    National Institute for Health and Clinical Excellence (NICE) (2008) Osteoarthritis: the care and management of osteoarthritis in adults. Clinical guideline 59. http://www.nice.org.uk/guidance/cg59
  15. 15.
    Farr JY, Yao JQ (2011) Chondral defect repair with particulated juvenile cartilage allograft. Cartilage 2:346–353CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Figueroa D, Calvo R, Vaisman A, Carrasco MA, Moraga C, Delgado I (2007) Knee chondral lesions: incidence and correlation between arthroscopic and magnetic resonance findings. Arthroscopy 23(3):312–315CrossRefPubMedGoogle Scholar
  17. 17.
    Flanigan DC, Harris JD, Trinh TQ, Siston RA, Brophy RH (2010) Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc 42(10):1795–1801CrossRefPubMedGoogle Scholar
  18. 18.
    Fortier LA, Potter HG, Rickey EJ, Schnabel LV, Foo LF, Chong LR, Stokol T, Cheetham J, Nixon AJ (2010) Concentrated bone marrow aspirate improves full-thickness cartilage repair compared with microfracture in the equine model. J Bone Joint Surg Am 92(10):1927–1937CrossRefPubMedGoogle Scholar
  19. 19.
    Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA (2009) Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 37(11):2259–2272CrossRefPubMedGoogle Scholar
  20. 20.
    Ghazavi MT, Pritzker KP, Davis AM, Gross AE (1997) Fresh osteochondral allografts for post-traumatic osteochondral defects of the knee. J Bone Joint Surg Br 79(6):1008–1013CrossRefPubMedGoogle Scholar
  21. 21.
    Ghodadra N, Mall NA, Karas V, Grumet RC, Kirk S, McNickle AG, Garrido CP, Cole BJ, Bach BR Jr (2013) Articular and meniscal pathology associated with primary anterior cruciate ligament reconstruction. J Knee Surg 26(3):185–193CrossRefPubMedGoogle Scholar
  22. 22.
    Gobbi A, Nunag P, Malinowski K (2005) Treatment of full thickness chondral lesions of the knee with microfracture in a group of athletes. Knee Surg Sports Traumatol Arthrosc 13(3):213–221CrossRefPubMedGoogle Scholar
  23. 23.
    Gross AE, Shasha N, Aubin P (2005) Long-term followup of the use of fresh osteochondral allografts for posttraumatic knee defects. Clin Orthop Relat Res 435:79–87CrossRefPubMedGoogle Scholar
  24. 24.
    Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, Smailys A (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(9):1066–1075CrossRefPubMedGoogle Scholar
  25. 25.
    Gudas R, Stankevicius E, Monastyreckiene E, Pranys D, Kalesinskas RJ (2006) Osteochondral autologous transplantation versus microfracture for the treatment of articular cartilage defects in the knee joint in athletes. Knee Surg Sports Traumatol Arthrosc 14(9):834–842CrossRefPubMedGoogle Scholar
  26. 26.
    Hangody L, Dobos J, Balo E, Panics G, Hangody LR, Berkes I (2010) Clinical experiences with autologous osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study. Am J Sports Med 38(6):1125–1133CrossRefPubMedGoogle Scholar
  27. 27.
    Harris JD, Brophy RH, Siston RA, Flanigan DC (2010) Treatment of chondral defects in the athlete’s knee. Arthroscopy 26(6):841–852CrossRefPubMedGoogle Scholar
  28. 28.
    Hoemann CD, Sun J, McKee MD, Chevrier A, Rossomacha E, Rivard GE, Hurtig M, Buschmann MD (2007) Chitosan-glycerol phosphate/blood implants elicit hyaline cartilage repair integrated with porous subchondral bone in microdrilled rabbit defects. Osteoarthr Cartil 15(1):78–89CrossRefPubMedGoogle Scholar
  29. 29.
    Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R (2003) Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am 85-A(2):185–192PubMedGoogle Scholar
  30. 30.
    International Cartilage Repair Society Documentation and Classification System (1998) Freibourg, Switzerland, Newsletter, pp 5–8Google Scholar
  31. 31.
    Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D’Ascanio LM, Pope JE, Fowler PJ (2008) A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 359(11):1097–1107CrossRefPubMedGoogle Scholar
  32. 32.
    Knutsen G, Drogset JO, Engebretsen L, Grontvedt T, Isaksen V, Ludvigsen TC, Roberts S, Solheim E, Strand T, Johansen O (2007) A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Joint Surg Am 89(10):2105–2112CrossRefPubMedGoogle Scholar
  33. 33.
    Koh JL, Wirsing K, Lautenschlager E, Zhang LO (2004) The effect of graft height mismatch on contact pressure following osteochondral grafting: a biomechanical study. Am J Sports Med 32(2):317–320CrossRefPubMedGoogle Scholar
  34. 34.
    Kon E, Mandelbaum B, Buda R, Filardo G, Delcogliano M, Timoncini A, Fornasari PM, Giannini S, Marcacci M (2011) Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: from early degeneration to osteoarthritis. Arthroscopy 27(11):1490–1501CrossRefPubMedGoogle Scholar
  35. 35.
    Korver TH, van de Stadt RJ, Kiljan E, van Kampen GP, van der Korst JK (1992) Effects of loading on the synthesis of proteoglycans in different layers of anatomically intact articular cartilage in vitro. J Rheumatol 19(6):905–912PubMedGoogle Scholar
  36. 36.
    Krych AJ, Robertson CM, Williams RJ 3rd (2012) Return to athletic activity after osteochondral allograft transplantation in the knee. Am J Sports Med 40(5):1053–1059CrossRefPubMedGoogle Scholar
  37. 37.
    Longo UG, Loppini M, Berton A, Marinozzi A, Maffulli N, Denaro V (2012) The FIFA 11+ program is effective in preventing injuries in elite male basketball players: a cluster randomized controlled trial. Am J Sports Med 40(5):996–1005CrossRefPubMedGoogle Scholar
  38. 38.
    McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M (2014) OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil 22(3):363–388CrossRefPubMedGoogle Scholar
  39. 39.
    Milano G, Sanna Passino E, Deriu L, Careddu G, Manunta L, Manunta A, Saccomanno MF, Fabbriciani C (2010) The effect of platelet rich plasma combined with microfractures on the treatment of chondral defects: an experimental study in a sheep model. Osteoarthr Cartil 18(7):971–980CrossRefPubMedGoogle Scholar
  40. 40.
    Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum BR (2009) Return to sports participation after articular cartilage repair in the knee: scientific evidence. Am J Sports Med 37(Suppl 1):167S–176SCrossRefPubMedGoogle Scholar
  41. 41.
    Mithoefer K, Hambly K, Logerstedt D, Ricci M, Silvers H, Della Villa S (2012) Current concepts for rehabilitation and return to sport after knee articular cartilage repair in the athlete. J Orthop Sports Phys Ther 42(3):254–273CrossRefPubMedGoogle Scholar
  42. 42.
    Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR (2009) Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med 37(10):2053–2063CrossRefPubMedGoogle Scholar
  43. 43.
    Mithoefer K, McAdams TR, Scopp JM, Mandelbaum BR (2009) Emerging options for treatment of articular cartilage injury in the athlete. Clin Sports Med 28(1):25–40CrossRefPubMedGoogle Scholar
  44. 44.
    Mithoefer KPL, Saris DBF, Mandelbaum BR (2012) Evolution and current role of autologous chondrocyte implantation for treatment of articular cartilage defects in the football (Soccer) player. Cartilage 3(suppl 1):25S–30SGoogle Scholar
  45. 45.
    Mithoefer K, Scopp JM, Mandelbaum BR (2007) Articular cartilage repair in athletes. Instr Course Lect 56:457–468PubMedGoogle Scholar
  46. 46.
    Mithoefer K, Williams RJ 3rd, Warren RF, Wickiewicz TL, Marx RG (2006) High-impact athletics after knee articular cartilage repair: a prospective evaluation of the microfracture technique. Am J Sports Med 34(9):1413–1418CrossRefPubMedGoogle Scholar
  47. 47.
    Mithofer K, Minas T, Peterson L, Yeon H, Micheli LJ (2005) Functional outcome of knee articular cartilage repair in adolescent athletes. Am J Sports Med 33(8):1147–1153CrossRefPubMedGoogle Scholar
  48. 48.
    Mithofer 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(11):1639–1646CrossRefPubMedGoogle Scholar
  49. 49.
    Moseley JB Jr, Anderson AF, Browne JE, Mandelbaum BR, Micheli LJ, Fu F, Erggelet C (2010) Long-term durability of autologous chondrocyte implantation: a multicenter, observational study in US patients. Am J Sports Med 38(2):238–246CrossRefPubMedGoogle Scholar
  50. 50.
    Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP (2002) A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 347(2):81–88CrossRefPubMedGoogle Scholar
  51. 51.
    Murray IR, Corselli M, Petrigliano FA, Soo C, Peault B (2014) Recent insights into the identity of mesenchymal stem cells: implications for orthopaedic applications. Bone Joint J 96-B(3):291–298CrossRefPubMedGoogle Scholar
  52. 52.
    Noyes FR, Heckmann TP, Barber-Westin SD (2012) Meniscus repair and transplantation: a comprehensive update. J Orthop Sports Phys Ther 42(3):274–290CrossRefPubMedGoogle Scholar
  53. 53.
    Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A (2002) Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med 30(1):2–12PubMedGoogle Scholar
  54. 54.
    Pro SL, Blatz BW, McAdams TR, Mandelbaum BR (2012) Chondropenia Severity Score: an Arthroscopic Stratification tool of Structural Cartilage Changes in the Knee as Correlated to Patient Reported Outcomes (SS-28). Arthroscopy 28(6):e16CrossRefGoogle Scholar
  55. 55.
    Robertson CM WR (2010) Return to sport after fresh osteochondral allograft transplantation. In: Paper presented at the annual meeting of the American orthopaedic society for sports medicine (AOSSM), Providence, RI, July 17Google Scholar
  56. 56.
    Rutjes AW, Juni P, da Costa BR, Trelle S, Nuesch E, Reichenbach S (2012) Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med 157(3):180–191CrossRefPubMedGoogle Scholar
  57. 57.
    Sanchez M, Fiz N, Azofra J, Usabiaga J, Aduriz Recalde E, Garcia Gutierrez A, Albillos J, Garate R, Aguirre JJ, Padilla S, Orive G, Anitua E (2012) A randomized clinical trial evaluating plasma rich in growth factors (PRGF-Endoret) versus hyaluronic acid in the short-term treatment of symptomatic knee osteoarthritis. Arthroscopy 28(8):1070–1078CrossRefPubMedGoogle Scholar
  58. 58.
    Saris DB, Vanlauwe J, Victor J, Haspl M, Bohnsack M, Fortems Y, Vandekerckhove B, Almqvist KF, Claes T, Handelberg F, Lagae K, van der Bauwhede J, Vandenneucker H, Yang KG, Jelic M, Verdonk R, Veulemans N, Bellemans J, Luyten FP (2008) Characterized chondrocyte implantation results in better structural repair when treating symptomatic cartilage defects of the knee in a randomized controlled trial versus microfracture. Am J Sports Med 36(2):235–246CrossRefPubMedGoogle Scholar
  59. 59.
    Steadman JR, Miller BS, Karas SG, Schlegel TF, Briggs KK, Hawkins RJ (2003) The microfracture technique in the treatment of full-thickness chondral lesions of the knee in National Football League players. J Knee Surg 16(2):83–86PubMedGoogle Scholar
  60. 60.
    Stein T, Mehling AP, Welsch F, von Eisenhart-Rothe R, Jager A (2010) Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med 38(8):1542–1548CrossRefPubMedGoogle Scholar
  61. 61.
    Surgeons AAoO (2013) Treatment of osteoarthritis (OA) of the knee. Evidence-based guideline, 2nd edn. American Academy of Orthopaedic Surgeons, RosemountGoogle Scholar
  62. 62.
    Wang CT, Lin YT, Chiang BL, Lin YH, Hou SM (2006) High molecular weight hyaluronic acid down-regulates the gene expression of osteoarthritis-associated cytokines and enzymes in fibroblast-like synoviocytes from patients with early osteoarthritis. Osteoarthr Cartil 14(12):1237–1247CrossRefPubMedGoogle Scholar
  63. 63.
    Wang DA, Varghese S, Sharma B, Strehin I, Fermanian S, Gorham J, Fairbrother DH, Cascio B, Elisseeff JH (2007) Multifunctional chondroitin sulphate for cartilage tissue-biomaterial integration. Nat Mater 6(5):385–392CrossRefPubMedGoogle Scholar
  64. 64.
    Williams RJ, Gamradt SC (2008) Articular cartilage repair using a resorbable matrix scaffold. Instr Course Lect 57:563–571PubMedGoogle Scholar
  65. 65.
    Zorzi C, Dall’Oca C, Cadossi R, Setti S (2007) Effects of pulsed electromagnetic fields on patients’ recovery after arthroscopic surgery: prospective, randomized and double-blind study. Knee Surg Sports Traumatol Arthrosc 15(7):830–834CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  • Iain R. Murray
    • 1
    Email author
  • Michael T. Benke
    • 2
  • Bert R. Mandelbaum
    • 3
  1. 1.Department of Trauma and OrthopaedicsThe University of EdinburghEdinburghUK
  2. 2.Active Orthopaedics and Sports MedicineHackensackUSA
  3. 3.Santa Monica Orthopaedic and Sports Medicine GroupSanta MonicaUSA

Personalised recommendations