Cartilage Committee Seminar: Algorithms and Flowcharts for the Treatment of Cartilage Pathology

  • Mats BrittbergEmail author
  • Alberto Gobbi
  • Anup Kumar
  • Henning Madry
  • Andreas H. Gomoll
  • Deepak Goyal


There are many published reports on the outcomes of total joint replacement based on clinical scores and radiographic evaluations.


Subchondral Bone Cartilage Defect Cartilage Repair Cartilage Lesion Fibrin Sealant 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Outerbridge RE (1961) The aetiology of chondromalacia patellae. J Bone Joint Surg Br 43-B:752–757PubMedGoogle Scholar
  2. 2.
    Brismar BH, Wredmark T, Movin T, Leandersson J, Svensson O (2002) Observer reliability in the arthroscopic classification of osteoarthritis of the knee. J Bone Joint Surg Br 84(1):42–47PubMedCrossRefGoogle Scholar
  3. 3.
    Cameron ML, Briggs KK, Steadman RJ (2003) Reproducibility and reliability of the outerbridge classification for grading chondral lesions of the knee arthroscopically. Am J Sports Med 31(1):83–86PubMedGoogle Scholar
  4. 4.
    Spahn G, Klinger HM, Hofmann GO (2009) How valid is the arthroscopic diagnosis of cartilage lesions? Results of an opinion survey among highly experienced arthroscopic surgeons. Arch Orthop Trauma Surg 129(8):1117–1121, Epub 2009 Apr 15PubMedCrossRefGoogle Scholar
  5. 5.
    Niemeyer P, Pestka JM, Erggelet C, Steinwachs M, Salzmann GM, Südkamp NP (2011) Comparison of arthroscopic and open assessment of size and grade of cartilage defects of the knee. Arthroscopy 27(1):46–51, Epub 2010 Oct 13PubMedCrossRefGoogle Scholar
  6. 6.
    Brittberg M, Winalski CS (2003) Evaluation of cartilage injuries and repair. J Bone Joint Surg Am 85-A(Suppl 2):58–69PubMedGoogle Scholar
  7. 7.
    Dzioba RB (1988) The classification and treatment of acute articular cartilage lesions. Arthroscopy 4(2):72–80PubMedCrossRefGoogle Scholar
  8. 8.
    Guhl JF (1982) Arthroscopic treatment of osteochondritis dissecans. Clin Orthop 167:65–74PubMedGoogle Scholar
  9. 9.
    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):312–315PubMedCrossRefGoogle Scholar
  10. 10.
    von Engelhardt LV, Kraft CN, Pennekamp PH, Schild HH, Schmitz A, von Falkenhausen M (2007) The evaluation of articular cartilage lesions of the knee with a 3-Tesla magnet. Arthroscopy 23(5):496–502CrossRefGoogle Scholar
  11. 11.
    Krampla W, Roesel M, Svoboda K, Nachbagauer A, Gschwantler M, Hruby W (2009) MRI of the knee: how do field strength and radiologist’s experience influence diagnostic accuracy and interobserver correlation in assessing chondral and meniscal lesions and the integrity of the anterior cruciate ligament? Eur Radiol 19(6):1519–1528, Epub 2009 Jan 30PubMedCrossRefGoogle Scholar
  12. 12.
    Cain EL, Clancy WG (2001) Treatment algorithm for osteochondral injuries of the knee. Clin Sports Med 20:321–342PubMedCrossRefGoogle Scholar
  13. 13.
    Kocher MS, Micheli LJ, Yaniv M, Zurakowski D, Ames A, Adrignolo AA (2001) Functional and radiographic outcomes of juvenile osteochondritis dissecans of the knee treated with transarticular drilling. Am J Sports Med 29:562–566PubMedGoogle Scholar
  14. 14.
    Anderson AF, Pagnani MJ (1997) Osteochondritis dissecans of the femoral condyles: long term results of excision of the fragment. Am J Sports Med 25:830–834PubMedCrossRefGoogle Scholar
  15. 15.
    Blevins FT, Steadman JR, Rodrigo JJ, Silliman J (1998) Treatment of articular cartilage defects in athletes: an analysis of functional outcome and lesion appearance. Orthopedics 21:761–767PubMedGoogle Scholar
  16. 16.
    Gobbi A, Nunag P, Malinowski K (2004) Treatment of chondral lesions of the knee with microfracture in a group of athletes. Knee Surg Sports Traumatol Arthrosc 13:213–221PubMedCrossRefGoogle Scholar
  17. 17.
    Mithoefer K, Steadman JR (2006) The microfracture technique. Tech Knee Surg 5(3):140–148CrossRefGoogle Scholar
  18. 18.
    Gudas R, Kelesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Benotavicius 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 21:1066–1075PubMedCrossRefGoogle Scholar
  19. 19.
    Gudas R, Stankevicius E, Monastyreckiene E, Pranys D, Kalesinkas 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 14:834–842PubMedCrossRefGoogle Scholar
  20. 20.
    Knutsen G, Drogset JO, Engebretsen L, Grøntvedt 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 89:2105–2112PubMedCrossRefGoogle Scholar
  21. 21.
    Kreuz PC, Steinwachs M, Erggelet C, Lahm A, Krause S, Ossendorf C, Meier D, Ghanem N, Uhl M (2007) Importance of sports in cartilage regeneration after autologous chondrocyte implantation: a prospective study with a 3-year follow-up. Am J Sports Med 35:1261–1268PubMedCrossRefGoogle Scholar
  22. 22.
    Gill TJ, MacGillivray JD (2001) The treatment of articular cartilage defects in the knee. Oper Tech Orthop 11:105–107CrossRefGoogle Scholar
  23. 23.
    Kreuz PC, Erggelet C, Steinwachs MR, Krause SJ, Lahm A, Niemeyer P, Ghanem N, Uhl M, Südkamp N (2006) Is microfracture of chondral defects in the knee associated with different results in patients aged 40 years or younger? Arthroscopy 22:1180–1186PubMedCrossRefGoogle Scholar
  24. 24.
    Kreuz PC, Steinwachs MR, Erggelet C, Krause SJ, Konrad G, Uhl M, Südkamp N (2006) Results after microfracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage 14:1119–1125PubMedCrossRefGoogle Scholar
  25. 25.
    Strauss EJ, Barker JU, Kercher JS, Cole BJ, Mithoefer K (2010) Augmentation strategies following the microfracture technique for repair of focal chondral defects. Cartilage 1(2):145–152CrossRefGoogle Scholar
  26. 26.
    Vrahas MS, Mithoefer K, Joseph D (2004) Long-term effects of articular impaction. Clin Orthop Relat Res 423:40–43PubMedCrossRefGoogle Scholar
  27. 27.
    Nejadnik H, Hui JH, Feng Choong EP, Tai BC, Lee EH (2010) Autologous bone marrow-derived mesenchymal stem cells versus autologous chondrocyte implantation: an observational cohort study. Am J Sports Med 38(6):1110–1116PubMedCrossRefGoogle Scholar
  28. 28.
    Mithoefer K, Gill TJ, Cole BJ, Williams RJ, Mandelbaum BR (2010) Clinical outcome and return to competition after microfracture in the athlete’s knee: an evidence-based systematic review. Cartilage 1(2):113–120CrossRefGoogle Scholar
  29. 29.
    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):235–246PubMedCrossRefGoogle Scholar
  30. 30.
    Saris DB, Vanlauwe J, Victor J, Almqvist KF, Verdonk R, Bellemans J, Luyten FP, TIG/ACT/01/2000&EXT Study Group (2009) Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med 37(Suppl 1):10S–19SPubMedCrossRefGoogle Scholar
  31. 31.
    Minas T, Gomoll AH, Rosenberger R, Royce RO, Bryant T (2009) Increased failure rate of autologous chondrocyte implantation after previous treatment with marrow stimulation techniques. Am J Sports Med 37:902–908PubMedCrossRefGoogle Scholar
  32. 32.
    Peterson L, Minas T, Brittberg M, Lindahl A (2003) Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am 85(Suppl 2):17–24PubMedGoogle Scholar
  33. 33.
    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 33:1639–1646PubMedCrossRefGoogle Scholar
  34. 34.
    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 85:185–192PubMedGoogle Scholar
  35. 35.
    Kon E, Filardo G, Berruto M, Benazzo F, Zanon G, Della Villa S, Marcacci M (2011) Articular cartilage treatment in high-level male soccer players: a prospective comparative study of arthroscopic second-generation autologous chondrocyte implantation versus microfracture. Am J Sports Med 39(12):2549–2557PubMedCrossRefGoogle Scholar
  36. 36.
    Marcacci M, Kon E, Delcogliano M, Filardo G, Busacca M, Zaffagnini S (2007) Arthroscopic autologous osteochondral grafting for cartilage defects of the knee: prospective study results at a minimum 7-year follow-up. Am J Sports Med 35(12):2014–2021PubMedCrossRefGoogle Scholar
  37. 37.
    Tew S, Redman S, Kwan A, Walker E, Khan I, Dowthwaite G, Thomson B, Archer CW (2001) Differences in repair responses between immature and mature cartilage. Clin Orthop Relat Res 391(Suppl):S142–S152PubMedCrossRefGoogle Scholar
  38. 38.
    Wei X, Messner K (1998) Age- and injury-dependent concentrations of transforming growth factor-beta 1 and proteoglycan fragments in rabbit knee joint fluid. Osteoarthritis Cartilage 6:10–18PubMedCrossRefGoogle Scholar
  39. 39.
    Aroen A, Loken S, Heir S, Alvik E, Ekeland A, Granlund OG, Engebretsen L (2004) Articular cartilage lesions in 993 consecutive knee arthroscopies. Am J Sports Med 32:211–215PubMedCrossRefGoogle Scholar
  40. 40.
    Buckwalter JA (1990) Articular cartilage: composition, structure, response to injury, and methods of facilitating repair. In: Ewing J (ed) Articular cartilage and knee joint function: basic science and arthroscopy. Raven, New York, pp 19–56Google Scholar
  41. 41.
    Centers for Disease Control and Prevention (2001) Prevalence of disabilities and associated health conditions among adults-United States, 1999. Morb Mortal Wkly Rep 50:120–125Google Scholar
  42. 42.
    Centers for Disease Control and Prevention (2002) Prevalence of self-reported arthritis or chronic joint symptoms among adults-United States, 2001. Morb Mortal Wkly Rep 50:948–950Google Scholar
  43. 43.
    Centers for Disease Control and Prevention (2004) Prevalence of doctor-diagnosed arthritis and possible arthritis-30 states, 2002. Morb Mortal Wkly Rep 53:383–386Google Scholar
  44. 44.
    DeBock GH, Kaptein AA, Touw-Otten F, Mulder J (1995) Health-related quality of life in patients with osteoarthritis in a family practice setting. Arthritis Care Res 8:88–93CrossRefGoogle Scholar
  45. 45.
    Dexter P, Brandt K (1994) Distribution and predictors of depressive symptoms in osteoarthritis. J Rheumatol 21:279–286PubMedGoogle Scholar
  46. 46.
    Ethgen O, Vanparijs P, Delhalle S, Rosant S, Bruyere O, Reginster J-Y (2004) Social support and health-related quality of life in hip and knee osteoarthritis. Qual Life Res 13:321–330PubMedCrossRefGoogle Scholar
  47. 47.
    Felson DT (2004) An update on the pathogenesis and epidemiology of osteoarthritis. Radiol Clin North Am 42:1–9PubMedCrossRefGoogle Scholar
  48. 48.
    Mankin HJ (1982) Current concepts review. The response of articular cartilage to mechanical injury. J Bone Joint Surg Am 64A:460–466Google Scholar
  49. 49.
    Mankin HJ, Mow VC, Buckwalter JA (2000) Articular cartilage repair and ostearthritis. In: Buckwalter JA, Einhorn TA, Simon SR (eds) Orthopaedic basic science: biology and biomechanics of the musculoskeletal system. American Academy of Orthopaedic Surgeons, RosemontGoogle Scholar
  50. 50.
    Minas T (2001) Autologous chondrocyte implantation for focal chondral defects of the knee. Clin Orthop Relat Res 391:S349–S361PubMedCrossRefGoogle Scholar
  51. 51.
    Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, Dragomir A, Kalsbeek WD, Luta G, Jordan JM (2008) Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 59:1207–1213PubMedCrossRefGoogle Scholar
  52. 52.
    Yelin E, Lubeck D, Holman H, Epstein W (1987) The impact of rheumatoid arthritis and osteoarthritis: the activities of patients with rheumatoid arthritis and osteoarthritis compared to controls. J Rheumatol 14:710–717PubMedGoogle Scholar
  53. 53.
    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 347:81–88PubMedCrossRefGoogle Scholar
  54. 54.
    Lonner JH, Hershman S, Mont M, Lotke PA (2000) Total knee arthroplasty in patients 40 years of age and younger with osteoarthritis. Clin Orthop Relat Res 380:85–90PubMedCrossRefGoogle Scholar
  55. 55.
    Gomoll AH, Farr J, Gillogly SD, Kercher J, Minas T (2010) Surgical management of articular cartilage defects of the knee. J Bone Joint Surg Am 92:2470–2490PubMedGoogle Scholar
  56. 56.
    Iwasa J, Engebretsen L, Shima Y, Ochi M (2009) Clinical application of scaffolds for cartilage tissue engineering. Knee Surg Sports Traumatol Arthrosc 17(6):561–577, Epub 2008 Nov 20. ReviewPubMedCrossRefGoogle Scholar
  57. 57.
    Vanlauwe J, Almqvist F, Bellemans J, Huskin JP, Verdonk R, Victor J (2007) Repair of symptomatic cartilage lesions of the knee: the place of autologous chondrocyte implantation. Acta Orthop Belg 73(2):145–158, ReviewPubMedGoogle Scholar
  58. 58.
    Stepaniak J (2000) The vegan sourcebook. Lowell House, Los Angeles, pp 1–3Google Scholar
  59. 59. Accessed 15 Nov 2011
  60. 60.
  61. 61.
  62. 62.
  63. 63.
  64. 64. Accessed on 15 Nov 2011
  65. 65.
  66. 66.
  67. 67.
  68. 68.
  69. 69.
  70. 70.
  71. 71.
  72. 72.
  73. 73.
  74. 74.
  75. 75.
  76. 76.
  77. 77.
    Knutsen G, Engebretsen L, Ludvigsen TC, Drogset JO, Grøntvedt T, Solheim E, Strand T, Roberts S, Isaksen V, Johansen O (2004) Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am 86:455–464PubMedGoogle Scholar
  78. 78.
    Miller BS, Briggs KK, Downie B, Steadman JR (2010) Clinical outcomes following the microfracture procedure for chondral defects of the knee: a longitudinal data analysis. Cartilage 1(2):108–112CrossRefGoogle Scholar
  79. 79.
    Ochi M, Uchio Y, Kawasaki K, Wakitani S, Iwasa J (2002) Transplantation of cartilage-like tissue made by tissue engineering in the treatment of cartilage defects of the knee. J Bone Joint Surg Br 84:571–578PubMedCrossRefGoogle Scholar
  80. 80.
    Piontek T, Ciemniewska-Gorzela K, Szulc A, Naczk J, Słomczykowski M (2011) All-arthroscopic AMIC procedure for repair of cartilage defects of the knee. Knee Surg Sports Traumatol Arthrosc (Epub ahead of print)Google Scholar
  81. 81.
    Selmi TA, Verdonk P, Chambat P, Dubrana F, Potel JF, Barnouin L, Neyret P (2008) Autologous chondrocyte implantation in a novel alginate-agarose hydrogel: outcome at two years. J Bone Joint Surg Br 90(5):597–604PubMedCrossRefGoogle Scholar
  82. 82.
    Shive MS, Hoemann CD, Restrepo A, Hurtig MB, Duval N, Ranger P, Stanish W, Buschmann MD (2006) New techniques in cartilage surgery. BST-CarGel: in situ chondroinduction for cartilage repair. Oper Tech Orthop 16(4):271–278CrossRefGoogle Scholar
  83. 83.
    Madry H, van Dijk CN, Mueller-Gerbl M (2010) The basic science of the subchondral bone. Knee Surg Sports Traumatol Arthrosc 18(4):419–33, ReviewPubMedCrossRefGoogle Scholar
  84. 84.
    Adachi N, Motoyama M, Deie M, Ishikawa M, Arihiro K, Ochi M (2009) Histological evaluation of internally-fixed osteochondral lesions of the knee. J Bone Joint Surg Br 91(6):823–9PubMedCrossRefGoogle Scholar
  85. 85.
    Nakamura N, Horibe S, Iwahashi T, Kawano K, Shino K, Yoshikawa H (2004) Healing of a chondral fragment of the knee in an adolescent after internal fixation. A case report. J Bone Joint Surg Am 86:2741–6PubMedGoogle Scholar
  86. 86.
    Micheli L, Curtis C, Shervin N (2006) Articular cartilage repair in the adolescent athlete: is autologous chondrocyte implantation the answer? Clin J Sport Med 16(6):465–70PubMedCrossRefGoogle Scholar
  87. 87.
    Brittberg M (2010) Cell carriers as the next generation of cell therapy for cartilage repair: a review of the matrix-induced autologous chondrocyte implantation procedure. Am J Sports Med 38(6):1259–71, ReviewPubMedCrossRefGoogle Scholar
  88. 88.
    Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L (1994) Treatment of deep ­cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 331(14):889–95PubMedCrossRefGoogle Scholar
  89. 89.
    Gomoll AH, Filardo G, de Girolamo L, Espregueira-Mendes J, Marcacci M, Rodkey WG, Steadman JR, Zaffagnini S, Kon E (2011) Surgical treatment for early osteoarthritis. Part I: cartilage repair procedures. Knee Surg Sports Traumatol Arthrosc 20(3):450–66, ReviewPubMedCrossRefGoogle Scholar
  90. 90.
    Vanlauwe J, Saris DB, Victor J, Almqvist KF, Bellemans J, Luyten FP, TIG/ACT/01/2000&EXT Study Group (2011) Five-year outcome of characterized chondrocyte implantation versus microfracture for symptomatic cartilage defects of the knee: early treatment matters. Am J Sports Med 39(12):2566–74PubMedCrossRefGoogle Scholar
  91. 91.
    Niemeyer P, Salzmann GM, Hirschmüller A, Südkamp NP (2011) Factors that influence clinical outcome following autologous chondrocyte implantation for cartilage defects of the knee. Z Orthop Unfall 150(1):83–8PubMedGoogle Scholar
  92. 92.
    Braun S, Minzlaff P, Hollweck R, Wörtler K, Imhoff AB (2008) The 5.5-year results of MegaOATS--autologous transfer of the posterior femoral condyle: a case-series study. Arthritis Res Ther 10(3):R68PubMedCrossRefGoogle Scholar
  93. 93.
    Bonnin M, Judet T, Colombier JA, Buscayret F, Graveleau N, Piriou P (2004) Midterm results of the Salto Total Ankle Prosthesis. Clin Orthop Relat Res 424:6–18PubMedCrossRefGoogle Scholar
  94. 94.
    Birmingham TB, Giffin JR, Chesworth BM, Bryant DM, Litchfield RB, Willits K, Jenkyn TR, Fowler PJ (2009) Medial opening wedge high tibial osteotomy: a prospective cohort study of gait, radiographic, and patient-reported outcomes. Arthritis Rheum 61(5):648–57PubMedCrossRefGoogle Scholar
  95. 95.
    Brinkman JM, Lobenhoffer P, Agneskirchner JD, Staubli AE, Wymenga AB, van Heerwaarden RJ (2008) Osteotomies around the knee: patient selection, stability of fixation and bone healing in high tibial osteotomies. J Bone Joint Surg Br 90(12):1548–57PubMedCrossRefGoogle Scholar

Copyright information

© ESSKA 2012

Authors and Affiliations

  • Mats Brittberg
    • 1
    Email author
  • Alberto Gobbi
    • 2
  • Anup Kumar
    • 2
  • Henning Madry
    • 3
  • Andreas H. Gomoll
    • 4
  • Deepak Goyal
    • 5
  1. 1.Region Halland OrthopaedicsKungsbacka HospitalKungsbackaSweden
  2. 2.Department of Sport and MedicineOrthopaedic Arthroscopic Surgery International- OASIMilanoItaly
  3. 3.Department of Orthopaedic Surgery, Experimental Orthopaedics and Osteoarthritis ResearchSaarland Univesrity Medical CentreHomburgGermany
  4. 4.Department of Orthopaedic SurgeryBrigham and Women’s Hospital, Harvard Medical SchoolChestnut HillUSA
  5. 5.Saumya Orthocare: Centre for Advanced Surgeries of the Knee JointAhmedabadIndia

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