10 minute read
Osteochondral Lesions of the Knee
FEATURE / FOOTBALL ASSOCIATION MEDICAL SOCIETY
Osteochondral lesions of the knee was the topic for the final FA Medical Society evening lecture of this 2021/22 season. This is a hugely important topic as the management of players with these injuries is notoriously complex and challenging. Below is summary of each speaker’s presentation for those that could not attend.
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Radiological assessment of cartilage defects in the knee - Professor Rowena Johnson
Hyaline cartilage is composed of a low density of chondrocytes surrounded by an abundant extracellular matrix of which approximately 80% will be water. This can act as a cushion distributing the impact of compressive forces with collagen fibers anchoring the underlying subchondral bone. The main function of hyaline cartilage includes absorption and distribution of loading forces.
Imaging modalities to assess for osteochondral defects
Radiographs tend to be the main imaging modality in epidemiological studies. On an X-Ray, cartilage cannot be seen unless calcified. A reduction in joint space tends to be secondary to cartilage loss but may be due to extrusion of the meniscus. On ultrasound one can note low echogenicity at joint margins, while a detached body tends to look white. MRI is the main imaging modality as it provides high-spatial resolution, multiplanar imaging and excellent tissue contrast. Different imaging sequences can be used in MRI. T1 provides limited assessment of joint structures, while better contrast definitions are achieved with PDFS rather than with T2FS. Sensitivity of MRI may be reduced due to thick slices which may mask osteochondral lesions. Moreover, 3T provides greater spatial resolution when compared to 1.5T.
Nuclear medicine imaging is used for troubleshooting in cases were athletes have adjacent abnormalities, with very few patients being selected for this imaging modality. Nuclear medicine imaging is used
particularly in cases to assess whether the patient needs surgery or to highlight if the osteochondral lesion is in fact driving current symptoms. However, it is not a first line investigation.
The Outerbridge classification of chondral lesions is used in arthroscopy (see image below) and is a simple and reproducible grading system of articular cartilage lesions. The most reliable sign of instability within adults is if there is high signal at it’s base. On the other hand, for the paediatric / adolescent population tiny subchondral cysts is a potential sign of instability.
Take home messages: • MRI is the main imaging modality to assess for osteochondral defects. • Proton-density fat saturation is the desirable MRI sequence as the fluid will show up as bright and allow for clear differentiation to the darker joint surfaces. • The most reliable sign of instability within adults is if there is high signal at it’s base. • The Outerbridge classification is a simple and reproducible grading system of articular cartilage lesions. • Try not to re-image the knee too soon following surgery as the images will always lag behind and they will not look as good as you hope!
Surgical considerations for the professional footballer with an osteochondral defect- Mr Andy Williams
Articular cartilage is an almost frictionless bearing surface with little healing capacity as it is aneural, avascular and without lymphatics. Articular cartilage damage can be well tolerated with most cases not requiring surgery however symptoms experienced by the athlete include swelling, pain, locking, and instability. The severity of these symptoms may necessitate surgery. Chondral damage in athletes can occur secondary to direct trauma, attritional wear, osteochondritis dissecans (frequently present late as it’s normal for young footballers to feel pain) or osteochondritis which results in avascular necrosis (mainly secondary to overpressure).
1. Direct trauma: Usually associated with other injuries (e.g. ACL) but not all require surgery. Surgery would be indicated if a loose fragment is noted or if the patient fails to progress and presents with persist synovitis. Another cause is an intra-articular fracture.
2. Attritional Chondral Damage: Athletes overload their lower limb and may accelerate the process of OA formation. One needs to be aware of joint effusions which is a sign that the joint is not coping with the load or that there is knee joint pathology. Exacerbating factors for this type of injury include inflammation, malalignment, meniscal deficiency, ligament deficiency and repetitive impingement (characteristically seen in javelin throwers). Moreover, steroids should not be used to overload the joint before its ready.
3. Meniscal deficiency: Lateral meniscectomy is less tolerated especially when players are in varus. This is because the lateral meniscus (LM) takes a greater proportion of the load through the joint and is very mobile. In view of this, whenever possible, lateral meniscal tears should be repaired. A study by Nawabi et al., 2014 (ASJM) noted that the median time to return to play, was longer in the lateral group than the medial group (7 weeks vs 5 weeks). Lateral meniscectomy has a higher incidence of adverse events in the early recovery period, including pain, swelling, and the need for further arthroscopy. It is also associated with a significantly lower rate of return to play. These findings form the basis of an important discussion that must be had with the player and the club before a lateral meniscectomy is performed in elite soccer athletes.
4. Malalignment: Most footballers have retroverted hips driving the knees in varus which means an overload into the medial compartment of the knee. Return to sport after osteotomy is difficult but it helps to off load the joint.
5. Ligament laxity: PCL deficiency results in point loading.
6. Chronic repetitive impingement: Damage related to repetitive loading occurs due to anteromedial femoral impingement commonly seen in fast bowlers and strikers. This can also be seen acutely with mechanisms such as knee hyperextension when landing from a header. If this doesn’t settle conservatively, then surgical options would be indicated such as debridement +/-microfracture bone procedure.
One must be wary of the “angry knee”. Carrying a persistent effusion within the knee is not normal and a knee with an effusion has reduced shock-absorption ability as the fluid within the joint is not as thick as a normal joint fluid. It also carries inflammatory mediators which again exposes the articular cartilage to further damage. Interventions to halt synovitis include rest, NSAIDS, PRP, intraarticular corticosteroids (used with caution with the player resting for a period of at least 3 weeks), and rehabilitation. Genetics also play a role in the development of the angry knee.
Take home messages: • Chondral lesions are normal in athletes and only a minority need surgery. It is important to treat the athlete and not the MRI, whilst doing as little as one can to achieve the desired result. • Chondral damage in athletes can occur secondary to direct trauma, attritional wear, osteochondritis dissecans, or osteochondritis which results in avascular necrosis.
Surgical and orthobiological approaches to restore cartilage health - Professor Bert Mandelbaum
The prevalence of cartilage injuries has widely increased in the football population with the highest risk in elite players. Furthermore, these injuries have become more prevalent in athletic population than in the general population (36% vs 18%). Over time, loss of volume in articular cartilage has been noted.
Currently, an array of orthobiologics are being used including PRP, hyaluronic acid, and stem cell procedures. The data suggests that management of articular cartilage injuries of the knee is becoming more nonsurgical. Particulated Autologous ChondralPlatelet-Rich Plasma Matrix Implantation is a new and potentially exciting development in articular cartilage injury management.
In terms of resurfacing options there is no superiority, but they all appear superior to microfracture. Moreover, a femoral condyle and patella femoral algorithm has been developed which helps to make decisions based upon the size and location of the lesion (image below).
Take home messages: • Cartilage injuries have become more prevalent in athletic population than in the general population. • Management of articular cartilage injuries of the knee is becoming more non-surgical. • In terms of resurfacing options there is no superiority, but they all appear superior to microfracture. Promoting Joint Health in the Ageing Footballer- Professor David Hunter
Modern definitions of osteoarthritis (OA) describe OA as a disease of the whole joint, meaning even the synovial joint tissue can be affected. 1 in 8 adults suffer from OA, and because of changing demographics data demonstrates that OA is occurring earlier. In fact, the age at which people are becoming affected by OA is getting younger, reducing from 69.4 years old to 55.8 years old in the space of just 20 years. Risk factors for Knee OA include obesity, previous injury, and occupation. Most injuries can be prevented via neuromuscular training.
There is a big window for us to intervene and prevent disease progression. When diagnosing the disease this should be based on symptoms or signs while using EULAR or ACR criteria. History and physical examination are usually sufficient when diagnosing, as imaging may drive up rates of surgery. It is also useful to keep in mind that anxiety and stress can influence expression of pain and disability.
With regards to treatment for knee OA, most guidelines do not advocate for the use of PRP. Furthermore, the current recommendation is to restrict the use of mesenchymal stem cells to clinical research trials only. With the use of DMOAD (disease modifying OA drugs) some structural modification was noted (increase in cartilage thickness) however, from a symptom point of view there was no improvement. Dietary supplements such as glucosamine and/or chondroitin are not recommended on current guidelines. The core treatment, as per guidelines, include education, self-management, physical activity and to maintain healthy weight. Exercise should include strength, aerobic, stretching, and neuromuscular training at around 30 minutes per day.
Take home messages: • OA is a disease of the whole joint. • Age in which people are being diagnosed with OA is getting younger. • History and physical examination are usually sufficient when diagnosing as imaging may drive up rates of surgery. • Treatment like PRP, dietary supplements like glucosamine, mesenchymal stem cells are not recommended on current guidelines.
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‘Why do players suddenly experience a catastrophic loss of form?’ [Online Presentation]
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