The Sobering Reality of Treating Articular Cartilage Lesions

    In his presentation on chondroplasty and microfracture for The Athlete’s Knee, a 1-day course co-sponsored by the International Congress for Joint Reconstruction and the Mid-America Orthopedic Association, David E. Hamming, MD, painted a sobering picture of the management of patients with lesions of the knee’s articular cartilage.

    These lesions are difficult to manage, and no matter what the orthopaedic surgeon does, he or she cannot recreate the highly organized structure of natural cartilage, Dr. Hamming said. At best, some type 2 collagen may reformat. More likely, though, the defect will be filled with type 1 cartilage.

    What’s more, the natural history of these lesions is always the same: They will further degrade, regardless of the surgical treatment. The unknown is how soon this will occur following treatment.

    Dr. Hamming, who is from the Illinois Bone and Joint Institute, said that seeing a lesion on an MRI is not necessarily an indication for surgery. Surgery should only be done when the patient is symptomatic, typically with pain, swelling, and catching. Surgery can also be considered if non-operative measures fail, he said.

    He listed the following as contraindications:

    • Malalignment
    • Kissing lesions
    • Arthritis
    • Ligamentous instability
    • Non-compliant patient

    Chondroplasty may be indicated to remove the irritation in a partial-thickness chondral lesion, with debridement of the unstable and damaged areas. However, Dr. Hamming noted there is very little evidence – and most of it is case studies – showing the benefits of chondroplasty.

    Some authors have suggested that irrigation to rinse away inflammatory cytokines during the procedure can be beneficial. Dr. Hamming said that if that’s true, it’s only a very temporary solution.

    Microfracture delivers marrow cells to the chondral defect to promote healing with type 1 collagen. This procedure is most appropriate for contained, full-thickness lesions, Dr. Hamming said.

    There is more evidence of the benefits of this procedure, although much of it is case studies and case series. Dr. Hamming cited 2 prospective studies:

    In 2007, Knutsen et al reported 5-year follow-update data for 80 patients with a single lesion who were randomized to either microfracture or autologous chondrocyte implantation. They found 77% patient satisfaction in both group, with no other clinical or histopathologic differences between groups.

    In 2014, Solheim et al reported 12-year follow-up of a prospective cohort of 110 patients who had been treated with microfracture. More than one third of the group (43 patients, 39%) needed further surgery, with some of them going on to total knee arthroplasty.

    Despite some success with microfracture, there are serious issues to be considered, with no definitive answers:

    • Do clinical failures occur earlier with microfracture than with other techniques?
    • Does microfracture injure the subchondral plate, and if so, what are the ramifications?
    • Do patients who undergo microfracture have worse outcomes with future procedures, such as total knee arthroplasty?

    Click the image above to watch Dr. Hamming’s presentation.