Stav Gare

Literature Review
11/02/15
ENC1102
Articular Cartilage in the Knee
Since the beginning of history, people use their knees on a daily basis.
However, in more recent years because of the fact that the lifespan of the
average human has grown, there has been more prominent damage to the
knee specifically in the articular cartilage. Articular cartilage is the layer of
cartilage covering the end of a bone that forms a joint surface, providing,
among its many functions, shock absorption, even distribution of load across
the joint and nutrition of the underlying bone(Livingstone). Because
articular cartilage damage is very prevalent, especially in Florida because of
the large amount of elderly people, there are various facets that need to be
taken into consideration to prevent degeneration of cartilage. In each article
in this annotated bibliography there are many different aspects of articular
cartilage that are being discussed, but some information is beyond the scope
of this research conversation. For example, the measurements of each injury
werent included in this annotated bibliography nor were illustrations of
criterion that was included or excluded because it isnt relevant for this
conversation. This literature review focuses on inconclusive studies, short-

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midterm results, the difficulty on the physician, and prior injuries that
negatively affect articular cartilage.
The sources in this conversation are primarily from academic journals
because this is an academic profession. The authors of these academic
journals include doctors of medicine, PhDs, researchers, and students in
medical schools. This academic profession, the medical field, grows
exponentially every year and new information is constantly discovered. Even
though the history in medicine is important because it gives a base for new
discoveries, in order to stay up to date and discuss the most relevant
conversation the cited information stems from 2010 until present. Although
there are constant changes in this field, doctors from all over the world are
updated with the most current and best techniques making the medical field
a global conversation. Furthermore, because the medical field incorporates
many specific terms this conversation is meant for seniors in college
majoring in biomedical sciences.
By investigating injuries and procedures implemented on articular
cartilage, the layer of cartilage covering the end of a bone that forms a joint
surface, providing, among its many functions, shock absorption, even
distribution of load across the joint and nutrition of the underlying
bone(Livingstone), there are noticeably a few common threads. One
common thread is that in the past twenty years there has been an influx of
damage to the articular cartilage in the knee predominantly because the

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lifespan of humans has grown exponentially. The older humans get, the more
common degeneration of cartilage becomes. The more defects of articular
cartilage leads to more treatments being required. By being a physician,
doctors have one of the most difficult decisions to make by deliberating
which method is best suited for their patient (Emre et al, Schindler). Some of
these procedures include nonsurgical treatments, but if the injury doesnt
heal with non-operative techniques then surgery is vital. Some surgical
methods include: microfracture, osteochondral allograft transplant,
osteochondral autograft transfer, autologous chondrocyte implantation,
abrasion arthroplasty, radiofrequency chondroplasty, autologous matrixinduced chondrogensis, chondrotissue, biological approaches, osteotomies,
stem-cell-coated titanium implants in osteochondral defects, and
chondroprotection with pulsed electromagnetic fields. (Camp, Stuart, Krych,
Donaldson, Tudor, Mcdermott, Rodriguez,).
As evident there are a bountiful amount of procedures performed to
repair damage to the articular cartilage in the knee, but why do these
surgeries need to be implemented? Through numerous amounts of studies
and experiments, articular cartilage degeneration is understood to be caused
by past injuries/surgeries and/or how active a person is. Through the use of
TAS scale that plays a significant part in scaling activity of an individual after
repairing articular cartilage damage, it is evident that the prior damage and
surgery on the knee affects the long-term outcome of the knee (Hambly).
One surgery that is proven to have long term effects on articular cartilage in

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the knee is anterior cruciate ligament (ACL) reconstruction. Although ACL

surgery has specific criterion and is deemed successful for short term results,
in long terms is has been proven to have several negative effects on articular
cartilage (Anderson, Anderson, Ji-Hoon et al, Li et al). Besides surgeries that
affect long term degeneration of articular cartilage in the knee,
immobilization of joints from surgeries, running, and body mass index also
are proven to adverse effects on the knee (Maldonda et al, Subburaj et al,
Widmyer et al).
The most prominent thread is that although great deal of studies have
been done on repair techniques, most the data is inconclusive (Biant et al,
Chang et al, Gudas et al, Maldonda et al, Schuttler et al, Ravnihar et al).
Some studies including ACI, an effective procedure on damaged articular
cartilage in the knee that has a potential to produce hyaline cartilage, PRP, a
regenerative therapy that uses injections that are a natural concentrate of
autologous growth factors from the blood, OAT, a one-step surgery that repairs
fibrocartilage in the knee, and cell free collagen matrix 1, a one step
procedures that use former matrices in a stand-alone, cell-free manner to serve as a carrier
for chondrocytes to colonize the defect in vivo, are inconclusive because they are
newer procedures(Biant et al, Chang et al, Gudas et al, Schuttler et al). Other
inconclusive studies include an experiment on rats proving joint
immobilization stimulates degeneration of articular cartilage and an
experiment discussing the toxic effects of anesthetics on articular cartilage
(Maldonda et al, Ravnihar, Brolic, Drobnik).

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An intertwining thread to the inconclusive experiments includes

surgeries that have short term (one to three years) to midterm
successes(four to fifteen years). Short term results include any study that
has been tracked from one to three years and midterm results include
studies that have follow ups from four until fifteen years. Studies with short
term results include microfracture, a form of bone marrow stimulation used
on nonathletic people, platelet rich plasma(PRP) injections that only last up
to twelve months, and shorter midterm outcomes include cell free collagen
matrix 1 that only had follow-ups after forty eight months (Camp Stuart,
Krych, Chang et al, Schuttler et al). Experiments resulting in midterm
successes of ten years include autologous chondrocyte implantation (ACI ) in
which ninety eight percent of patients were satisfied and osteochondral
autologous transplantation(OAT) in which more athletes returned to preinjury
activity( Biant et al, Gudas et al). The reason for their being primarily
short/midterm results for these procedures are because these experiments
have only been focused on in the past twenty years.

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The largest research gap in the damage of articular cartilage in the

knee is the long term repair techniques. As seen most the research stated
has been inconclusive and short term to midterm techniques, but the
common niche that is missing is long-term restoration methods, which merits
having more research. In order for this to happen, experiments and studies
will continuously need to be performed over the next twenty years. Each
year there should be an examination of the knee and a survey of how active
the person has become. Through meta-analysis of these procedures from the
beginning of the process until the death of the person, researchers will be
able to further examine the knee and how it affects daily activities.
Furthermore, there should be an education class during physical education in
all schools describing the negative effects of straining and damaging
articular cartilage in the knee. By doing this may prevent damage from
occurring because children will then be more aware of risks that may occur in
the future. With gathering criterion for each surgery for long term results and
having an education class on prevention of articular cartilage injuries in the
knee, hopefully one day there will a procedure that will indefinitely repair
previous damage.

Project Proposal:
To address this research gap .
Also citing each person only include authors name not date.

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Add header, but not on first page. Look up page layout for

Work Cited:
Anderson, Allen F., and Christian N. Anderson. "Correlation Of Meniscal And
Articular Cartilage Injuries In Children And Adolescents With Timing Of
Anterior Cruciate Ligament Reconstruction." American Journal Of Sports
Medicine 43.2 (2015): 275-281. SPORTDiscus. Web. 10 Oct. 2015.
Biant, Leela C, et al. "Long-Term Results Of Autologous Chondrocyte
Implantation In The Knee For Chronic Chondral And Osteochondral Defects."
The American Journal Of Sports Medicine 42.9 (2014): 2178-2183. MEDLINE.
Web. 22 Oct. 2015.
Camp, Christopher L., Michael J. Stuart, and Aaron J. Krych. "Current
Concepts Of Articular Cartilage Restoration Techniques In The Knee." Sports
Health: A Multidisciplinary Approach 6.3 (2014): 265-273. SPORTDiscus. Web.
11 Oct. 2015.
Chang, Ke-Vin, et al. "Comparative Effectiveness Of Platelet-Rich Plasma
Injections For Treating Knee Joint Cartilage Degenerative Pathology: A

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Systematic Review And Meta-Analysis." Archives Of Physical Medicine &

Rehabilitation 95.3 (2014): 562-575. SPORTDiscus. Web. 12 Oct. 2015.
Donaldson, James, Francois Tudor, Ian D. McDermott. "(Iv) Treatment Options
for Articular Cartilage Damage In The Knee." Orthopaedics & Trauma 29.1
(2015): 24-30 7p. CINAHL Plus with Full Text. Web. 10 Oct. 2015.
Emre, Tuluhan Yunus, et al. "Factors Affecting The Outcome Of Osteochondral
Autografting (Mosaicplasty) In Articular Cartilage Defects Of The Knee Joint:
Retrospective Analysis Of 152 Cases." Archives Of Orthopaedic And Trauma
Surgery 133.4 (n.d.): 531-536. Biological Abstracts 1969 - Present. Web. 22
Oct. 2015.
Gudas, Rimtautas, et al. "Ten-Year Follow-Up Of A Prospective, Randomized
Clinical Study Of Mosaic Osteochondral Autologous Transplantation Versus
Microfracture For The Treatment Of Osteochondral Defects In The Knee Joint
Of Athletes." American Journal Of Sports Medicine 40.11 (2012): 2499-2508.
SPORTDiscus. Web. 22 Oct. 2015.
Hambly, Karen. "The Use Of The Tegner Activity Scale For Articular Cartilage
Repair Of The Knee: A Systematic Review." Knee Surgery, Sports
Traumatology, Arthroscopy 19.4 (2011): 604-614. SPORTDiscus. Web. 12 Oct.
2015.

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Ji-Hoon, BAE, et al. "Articular Cartilage Of The Knee 3 Years After ACL
Reconstruction." Acta Orthopaedica 86.5 (2015): 605-610. SPORTDiscus.
Web. 19 Oct. 2015.
Li, Hong, et al. "Quantitative MRI T2 Relaxation Time Evaluation Of Knee
Cartilage: Comparison Of Meniscus-Intact And -Injured Knees After Anterior
Cruciate Ligament Reconstruction." American Journal Of Sports Medicine 43.4
(2015): 865-872. SPORTDiscus. Web. 12 Oct. 2015.
Maldonado, Diogo Correa, et al. "The Effects Of Joint Immobilization On
Articular Cartilage Of The Knee In Previously Exercised Rats." Journal Of
Anatomy 222.5 (2013): 518-525. Academic Search Premier. Web. 19 Oct.
2015.
Schindler, Oliver S. "(Iv) Articular Cartilage Surgery In The Knee."
Orthopaedics & Trauma 24.2 (2010): 107-120 14p. CINAHL Plus with Full
Text. Web. 12 Oct. 2015.
Schttler, Karl, et al. "Use Of Cell-Free Collagen Type I Matrix Implants For
The Treatment Of Small Cartilage Defects In The Knee: Clinical And Magnetic
Resonance Imaging Evaluation." Knee Surgery, Sports Traumatology,
Arthroscopy 22.6 (2014): 1270-1276. SPORTDiscus. Web. 12 Oct. 2015.
Subburaj, Karupppasamy, et al. "The Acute Effect Of Running On Knee
Articular Cartilage And Meniscus Magnetic Resonance Relaxation Times In

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Young Healthy Adults." American Journal Of Sports Medicine 40.9 (2012):

2134-2141. SPORTDiscus. Web. 12 Oct. 2015.
Ravnihar, Klemen, Ariana Barli, and Matej Drobni. "Effect Of Intra-Articular
Local Anesthesia On Articular Cartilage In The Knee." Arthroscopy: The
Journal Of Arthroscopic & Related Surgery: Official Publication Of The
Arthroscopy Association Of North America And The International Arthroscopy
Association 30.5 (2014): 607-612. MEDLINE. Web. 19 Oct. 2015.
Rodriguez-Merchan, EC. "Regeneration Of Articular Cartilage Of The Knee."
Rheumatology International 33.4 (n.d.): 837-845. Science Citation Index.
Web. 22 Oct. 2015.
Widmyer, Margaret R., et al. "High Body Mass Index Is Associated With
Increased Diurnal Strains In The Articular Cartilage Of The Knee." Arthritis &
Rheumatism 65.10 (2013): 2615-2622 8p. CINAHL Plus with Full Text. Web.
19 Oct. 2015.