Table Of ContentArticular Cartilage Lesions
Springer Science+Business Media, LLC
J.
Brian Cole, MD, MBA
As ociate Profes or, Department of Orthopaedics and Anatomy,
Diiector Ru h Cartilage Restoration Center,
Rush University Medical Center, Chicago, Illinois
M. Mike Malek, MD
Washington Orthopaedic and Knee Clinic, Inc., Faiifax, Virginia
Articular Cartilage Lesions
A Practical Guide to Assessment
and Treatment
With 302 Illustrations in 547 Parts, 301 in Full Color
Springer
Brian J. Cole, MD, MBA M. Mike Malek, MD
Associate Professor Washington Orthopaedic and Knee
Departments of Orthopaedics and Anatomy Clinic, Inc.
Director, Rush Cartilage Restoration Center Fairfax, VA 22031
Rush University Medical Center USA
Chicago, IL 60612
USA
Library of Congress Cataloging-in-Publication Data
Cale, Brian J.
Articular cartilage lesions : a practica! guide to assessment and treatment / Brian J. Cale,
M. Mike Malek
p. cm.
Includes bibliographical references and index.
ISBN 978-1-4757-9289-8 ISBN 978-0-387-21553-2 (eBook)
DOI 10.1007/978-0-387-21553-2
1. Articular cartilage-Wounds and injuries. 2. Articular cartilage-Surgery. I. Malek,
M. Mike, II. Title.
RD560.C64 2004
617.472044-dc22 2003063338
ISBN 978-1-4757-9289-8 Printed on acid-free paper.
© 2004 Springer Science+Business Media New York
Originally published by Springer-Verlag New York, Inc. in 2004
Softcover reprint of the hardcover 1s t edition 2004
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Foreword
For more than 250 years, surgeons have been trying to find ways to restore articular carti
lage surfaces, efforts that for most of the last quarter of a millennium yielded little progress.
In the last few decades, however, advances in understanding of articular cartilage biology
and biomechanics have led to new approaches to restoring articular cartilage, including
stimulating cartilage repair from marrow and synovial cells, chondrocyte transplantation,
osteochondral autografts and allografts, and alterations of joint loading, including joint
distraction. These new approaches to the treatment of articular cartilage injuries have
created considerable public interest and led patients and orthopaedic surgeons to believe
that restoration of articular cartilage structure and function is possible.
Yet, many questions concerning the treatment of articular cartilage injuries remain,
leaving patients and surgeons uncertain about the current best treatment for a specific
injury, or if surgical treatment should be attempted. Some of this uncertainty results from
the difficulties in performing well-designed prospective studies of different approaches to
restoring articular surfaces. Does chondrocyte transplantation produce better results than
microfracture repair for specific types of articular cartilage injury? Or, do fresh osteochon
dral allografts produce better results than chondrocyte transplantation? Answers toques
tions like these will require expensive and time-consuming prospective clinical research
and the cooperation of large numbers of patients.
In addition, the natural history of many types of articular cartilage injuries has not been
defined, so it is not clear which injuries should be treated surgically. Understandably, most
patients with articular cartilage injuries turn to their orthopaedic surgeons to provide them
with clear treatment recommendations. Yet, many knowledgeable surgeons have limited
experience with the spectrum of current treatments for articular cartilage injuries.
For these reasons, there is a clear need to critically analyze the available information
to help patients and surgeons make treatment decisions concerning articular cartilage
injuries. This book will help orthopaedic surgeons evaluate the massive and often confus
ing information about articular cartilage injuries and their treatment to help make the best
possible decisions. The book takes the refreshing approach of examining the various ap
proaches to treatment of articular cartilage and then uses case studies that help illustrate
and explain the decision-making process and the treatment of patients. The next decades
will bring substantial new information about chondral injuries and new treatments, but
this book fills a clear and important present need, and the authors and editors deserve great
credit for this effort to improve the care of patients with articular cartilage injuries.
Joseph A. Buckwalter, MD
Professor and Chair
Department of Orthopaedic Surgery
University of Iowa Hospitals and Clinics
Iowa City, IA
v
Preface
In the last 20 years, the subspecialty of cartilage repair has gradually emerged in the
field of orthopaedics. It offers options where none previously existed. In the early 1990s,
not uncommonly, knee arthroscopies were performed on young patients who were unable
to remain active because of joint pain, swelling, and mechanical symptoms that resulted
from their articular cartilage disease. As residents, we remember feeling helpless when
postoperatively these patients were told to live with their disease because no reliable treat
ments were available. The only option-besides the eventual knee arthroplasty that many
of these patients would predictably undergo in the future-was debridement and lavage or
marrow stimulation. The situation was even more complex because patients experienced
a combination of pathology including articular cartilage defects, meniscal deficiency, liga
ment disruption, and malalignment. Thus, any biologic solution used as an alternative to
arthroplasty would, by necessity, be multifactorial. This complimentary approach would
seek to maximize the treatment outcome.
Articular cartilage defects are unlike traditional orthopaedic pathology, in which sur
geons are accustomed to evaluating, treating, and predicting a likely outcome. In the case
of articular cartilage disease, very little is known about its cause and incidence-and even
less about the natural history of the incidental defect in an otherwise healthy knee. But
because articular cartilage defects can and do cause pain and disability in some patients,
many of us remain committed to critical investigation of the basic science and clinical
results of the existing and emerging technology. Unlike solutions used to treat traditional
orthopaedic pathology, the solutions for treating articular cartilage disease and meniscal
deficiency have a relatively short track record, are resource intense, and may require a pro
longed period of time before the patient actually has demonstrable relief of pain and
increased function. These factors create an especially difficult, but warranted, approach to
the management of articular cartilage disease and meniscal deficiency.
Few subspecialties are held to the standards that are intrinsic to the field of cartilage
repair. Clearly, the concerted efforts of the basic scientists and clinicians who cross multi
ple disciplines will lead to an evidence-based approach to the decision making required to
manage this patient population. Although successful clinical outcomes can be anticipated
in the majority of patients who are appropriately indicated for cartilage repair procedures,
we must continue to indicate our patients wisely. Remembering that not all articular
cartilage defects will become symptomatic and that not all meniscectomized knees will
become arthritic is of primary importance. Furthermore, those who are appropriately indi
cated may only be provided a greater number of pain-free years, and the natural history of
the underlying disease process and inevitable outcome may not always be avoidable. Thus,
because our success is primarily predicated upon a reduction in the patient's symptoms and
increases in function, we should avoid treating solely for the purpose of eliminating the
need for knee arthroplasty in the future. It is critical to avoid choosing treatment options
early in the disease process that can potentially burn bridges for the implementation of
future options, or even worse, create new problems for patients who were otherwise mini
mally symptomatic. At this juncture, our judgment is guided by our experience and emerg
ing peer-reviewed clinical outcomes.
Rene Descartes taught that "our eyes do not see what our minds do not know." I think
that this is especially true of articular cartilage and meniscal pathology. Although we have
become comfortable attributing a patient's symptoms to specific pathoanatomy, it is
imperative that we avoid the temptation to think linearly about a patient's problem. In
other words, the mere existence of an articular defect or a post-meniscectomized state is
not always synonymous with a symptomatic state. Knee pain has many causes, both
known and unknown. Ascribing a patient's symptoms to an incidentally discovered defect
that may have no clinical relevance can lead to the eventual implementation of an inap-
vii
viii PREFACE
propriate treatment option. We often tell patients that articular cartilage defects are a bit
like real estate-location counts. For example, an 18-year-old woman without swelling or
mechanical symptoms who has a known defect of the posterior medial femoral condyle but
who only complains of anterior knee pain going up and down stairs has patellofemoral pain
treatable with appropriate physical therapy until proven otherwise. Because the available
technology used to treat these patients is perceptively seductive to patients and physicians
alike, we have an unprecedented obligation to implement these technologies both respon
sibly and ethically.
As orthopaedic surgeons, we traditionally focus on techniques and the "how to" rather
than when to implement a solution that is likely to match or exceed our patient's expec
tations. Despite volumes of clinical and basic science research literature, more questions
than answers remain. Adoption of a single technique is based upon the composite influence
of what we know, what we think we know, and what we have little knowledge about. How
do we fill these voids? How do we make the best decisions with our patients? With so
much technology and so much difficulty arriving at a consensus regarding the indications
for these procedures, it is imperative that an up-to-date composite body of work be avail
able as a practical guide to manage these lesions.
Articular Cartilage Lesions: A Practical Guide to Assessment and Treatment reflects
our commitment to fill the current void in the management of articular cartilage disease
and meniscal deficiency. We have asked experts to contribute to this book with a very
specific mission in mind: to help you develop an evidence-based decision-making frame
work to be used as a practical guide for the assessment and management of patients with
articular cartilage lesions and meniscal deficiency. Because clinical outcomes are
rapidly appearing in the literature, and new technology is emerging at a feverish pace, we
mandated that this project be completed in an expedited manner. To maximize the qual
ity and accuracy of the contents herein, the entire project was completed within eighteen
months.
The book is divided into three logical parts. Part I, Background and Patient Assessment,
provides a framework to understand the underlying pathoanatomy, evaluate the prospec
tive patient, consider nonoperative or palliative management, and offer a potential treat
ment algorithm. Part II, Surgical Techniques, includes a concise compendium of every
available treatment option with a step-by-step approach to each technique ranging from
arthroscopy and debridement through unicondylar arthroplasty. Part III, Case Studies,
highlights the decision-making process through case-based learning. Nearly 40 illustrated
cases have been completely prepared with preoperative planning and postoperative out
comes. They include virtually every permutation and combination of cartilage repair cur
rently in clinical use.
Articular Cartilage Lesions: A Practical Guide to Assessment and Treatment is timely,
comprehensive, and up to date. We would like to thank the contributing authors who have
put forth enormous effort to help create what we believe will remain a primary reference
for orthopaedic surgeons, fellows, residents, basic scientists and any clinician committed
to implementing sound judgment, excellence in surgical technique and perioperative
management of the patient with articular cartilage disease and meniscal deficiency. We
would also like to thank Rob Albano, Peter Bak, and Barbara Chernow for helping to assure
that this project was completed on time and with excellence from the time the cover is
opened until the final case is presented.
Brian J. Cole, MD, MBA
M. Mike Malek, MD
Genzyme Biosurgery is proud to have collaborated with Springer-Verlag to support the
publication of this book. We are committed to improving patient care through education,
research and advancing the field of cartilage repair. We applaud the efforts of the books'
contributors and believe this text will be a valuable reference for clinicians seeking expert
guidance in this emerging field.
Genzyme Biosurgery
A division of Genzyme Corporation
Cambridge, MA
Contents
Foreword by Joseph A. Buckwalter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Part I Background and Patient Assessment ......... .
Basic Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Michael {. Langworthy, Fred R. T. Nelson, and Richard D. Coutts
2 Patient Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Laurence D. Higgins
3 Nonoperative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Kenneth R. Zaslav and Jeffrey R. Dugas
4 Cartilage Injury: Overview and Treatment Algorithm 35
Bert R. Mandelbaum and Steve A. Mora
5 Radiofrequency Energy for Cartilage Treatment 47
Yan Lu and Mark D. Markel
Part II Surgical Techniques ............................. .
57
6 Arthroscopic Debridement of the Degenerative Knee . . . . . . . . . . . . . . . . . . . . 59
Gregory C. Fanelli and Daniel R. Orcutt
7 Bone Marrow Stimulation Techniques: Microfracture,
Drilling, and Abrasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Thomas {. Gill and {. Richard Steadman
8 Osteochondral Autograft Replacement 73
AndrewS. Levy and Steven W. Meier
9 Osteochondral Allograft Transplantation 82
William D. Bugbee
10 Autologous Chondrocyte Implantation for Focal
Chondral Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Scott D. Gillogly and Mats Brittberg
11 Autologous Chondrocyte Implantation in the
Osteoarthritic Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lOS
Tom Minas
12 Osteochondritis Dissecans: Current Treatment Options 119
Lyle{. Micheli and L. Pearce McCarty, III
ix
X CONTENTS
13 Meniscal Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Tack Parr and Wayne K. Gersoff
14 Realignment of the Femur and Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Justin P. Roe and Peter f. Fowler
15 Realignment of the Patellofemoral Joint 170
Giles R. Scuderi
16 Emerging Technologies in Cartilage Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Daniel A. Grande ·
17 Unicondylar Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
R. Michael Meneghini and Mitchell B. Sheinkop
Part III Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
193
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
