Articular Cartilage Lesion – Chondral Defect

Normal Anatomy Hyaline cartilage covering the articular surface of the tibia and femur Function Lower friction on gliding surfaces Shock absorption Average depth of 2 -4 mm Avascular 65-80% is water, 10-20% is type II Collagen (Tensile Strength) and the other 10-20% is Proteoglycans (Compressive Strength)

Mechanism of Injury Traumatic Non Traumatic Direction compaction injury Rotational Injury- pivoting on a fixed foot Normally associated with ACL tears, meniscal injuries, patellofemoral dislocation and subluxation Non Traumatic Degeneration of articular cartilage (OA)

Classification Grade 0: Normal cartilage Grade I: Softening, blistering or swelling of the cartilage Grade II: Partial thickness fissures and clefts <1 cm diameter Grade III: Full thickness fissures, to subchondral bone >1 cm diameter Grade IV: Exposed subchondral bone

Associated Pathologies ACL or other ligament tears Menisci injury Patellofemoral Dislocation or Subluxation Osteochondritis Dissecans Chondramalacia patella

Subjective Usually traumatic Twisting/pivoting/rotational movement with a planted foot Direct compaction injury Localised pain around the joint line and pain on movement Swelling and oedema Locking may be present if loose body limits or blokes movement Giving way Can also get pain on prolonged inactivity such as sitting for long periods

Objective Significant swelling if acute Reduced range of movement Pain on movement Pain on closed chain loading activity such as squatting Pain around joint line may be present. Joint locking is a loose body is present Quadriceps wasting may be present if gone undetected for a long period of time

Further Investigation X-ray MRI Arthroscopy

Management Conservative management has varying success depending on size of lesion Surgical opinion is always recommended for early diagnosis and appropriate management plan Injections can be used for pain relief and allow physiotherapy to continue

Conservative - Management Progress weight bearing as able Protect articular cartilage lesion as pain allows Enough stress to stimulate a healing response Too little stress – no healing response Too much stress – increases injury References contain in depth rehabilitation protocols

Conservative - Management Restore Normal Range of Movement Decrease inflammation if present with massage, ice, NSAID’s, rest from aggravating activities Decrease tone of muscle spasm with soft tissue techniques (Soft Tissue Techniques) Increase mobility of tibiofemoral and patellofemoral joint (Joint Mobilisations) Regular joint motion to stimulate articular cartilage repair Restore Normal Motor Control and Strength Quadriceps Hamstrings Glutes Abdominals Restore Dynamic Stability Exercises that challenge the stability of the entire lower limb kinetic chain in a pain free range Return to sport/activity specific exercises

Surgical - Management 4 main options for surgical intervention Arthroscopic Lavage and Debridement Washing out the loose fragments Removing flaps of damaged cartilage and removing loose bodies Microfracture Preferred in lesions >2cm due to its simplicity and cost effectiveness Autolouge Chondrocyte Implantation Usually used on full thickness chondral defects Attempts to slow the progression of severe OA 2-3 biopsy's are taken form healthy cartilage from the lateral femoral condyle and then grown/cultivated Osteochondral transplantation