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Articular cartilage is the white shiny covering over the ends of the bone.

Articular cartilage
has a very unique feature as it is smooth yet tough, and serves well as the bearing surfaces of
the joint. Over time, however, cartilage degeneration can lead to osteoarthritis, pain, and
disability of the joint.

Articular cartilage is produced by chondrocytes, which are cells that divide or multiply very
slowly. This is one of the reasons that articular cartilage injuries do not repair well and can
lead to continued degeneration and deterioration of joint condition. Skin, on the other hand, is
formed by fibroblasts, which have a high turnover rate and thus has a great potential to heal.

Articular cartilage injuries can be focal, which is localized and contained, or global, which
can lead to joint osteoarthritis. Osteoarthritis is a general term used to describe the wearing
out of the articular cartilage. End-stage osteoarthritis, also known as bone-on-bone arthritis,
describes the condition when all of the articular cartilage has worn off. When this happens,
the bone that is covered by the cartilage is exposed. Nerve endings are not present in articular
cartilage but are present in the underlying bone. When bone is exposed, to the patient may
begin to experience pain and joint disability. Unstable cartilage can also lead to swelling of
the joint.

In this KNOL, we will outline some of the signs and symptoms of articular cartilage injuries
and current repair options.

Causes

There are a variety of reasons that cartilage may be injured. Most of the injuries are
traumatic:

 Joint dislocation

 Ligament tear

 Meniscus tear

 Fall/impact

 Infection

 Inflammation (Gout attack, rheumatoid arthritis)

Most cartilage injuries will lead to swelling and pain in the joint. The swelling can persist
with the presence of unstable cartilage. Unstable cartilage can lead to irritation of the
synovium, which is the covering around the joint, causing excessive secretion of synovial
fluid (joint fluid), which causes swelling.

The most common joint with symptomatic cartilage injuries are knee, shoulder, elbow, hip
and knee. All synovial joints can have cartilage injuries, however, the management of smaller
joint cartilage injuries are most limited.

cartilage Chronic Osteoarthritis. These systemic treatments can affect the entire body. it is important to keep the put a layer of cooling device or ice. They are helpful when the patient has generalized inflammation. The best diagnostic tool for cartilage injury is MRI scan. Other injections. motrin. which are products that have similar composition to human synovial fluid. Cool temperature leads to decreased inflammation and lower cellular activity and can decrease symptoms. The diagnosis of fracture can be established using plain radiographs. infection Treatment Medical treatment Anti-inflammatory medication or systemic steroids can be taken to decrease inflammation. unstable cartilage. such as inflammatory arthritis (rheumatoid arthritis) or multiple joint aches. naproxyn and methylprednisolone. Advanced MRI scans are very accurate in diagnosing full thickness or partial thickness cartilage injuries. The latter are also known as artificial joint fluid injections. Significant research has also focused on quantifying the amount of cartilage left. or posterior cruciate ligament hour) tear. anterior cruciate ligament. can also be used. not just the involved joint. These are helpful to determine the significance of the cartilage injuries.Recognition of worrisome joint swelling Joint swelling that is present for more than 1 day following injury is concerning. such as hyaluronic acid. ligament and meniscus injury. When icing the joint. Common medications include ibuprofen. joint dislocation Subacute (2-6 hours) Meniscus. The injured joint should be evaluated by a clinician to rule out fracture. or cartilage injury. decrease pain. Ice or cryotherapy can also be used to decrease swelling of the joint. as displayed in the following table: Onset of joint swelling Causes Immediate (less than 1 Fracture. Ligament and meniscus injuries can be diagnosed with clinical examination or magnetic resonance imaging (MRI) scan. The onset of joint swelling provides clues as to the type of joint injury that has been sustained. Injection Corticosteroid injection directly into the joint can be used to suppress inflammation and thus. using quantitative MRI. These can act as lubricants for the knee and decrease swelling or . or X- rays.

The patient does not need to be on immunosuppressive medications to suppress rejection. the rate of infection is lower. the unstable cartilage is removed using an arthroscopic shaver. For debridement. The effect of injections is dependent on the severity of the problem. For allograft ligaments. Marrow stimulating techniques – arthroscopic surgeries can be performed to resurface the injured cartilage. Allograft– If the damaged cartilage is over a large area. hence. a specialized camera and surgical tools passed through a small incision) or via an open surgical approach. Chondroplasty – an arthroscopic shaver can be used to remove the unstable cartilage and stimulate the underlying bone to bleed and form a blood clot over the exposed area. the tissue can be processed and cleaned. can be used. Cadaveric tissue. Most of the cartilage and bone are taken from areas that are not weight-bearing. The blood clot can mature and form fibrocartilage. The tissue used is fresh and the procurement from the cadaver must be sterile and disease-free to avoid infection. Replacement– Besides stimulation techniques. . Mosaicplasty– this procedure can be performed either arthroscopically (surgeries performed using an arthroscope. Resurfacing procedures 1. the blood clot can mature and form into fibrocartilage. it can cover the exposed bone and can decrease symptoms. 2. This can lead to access to bone marrow cells which can form a blood clot over the exposed area. Allograft cartilage replacements are usually fresh osteochondral transplants. Very similar to chondroplasty. Unstable cartilage or loose cartilage fragment can still lead to persistent swelling after the effect of the injections has worn off. However. Most surgical procedures are recommended for high grade cartilage injuries that require resurfacing or debridement. however.irritation. or are less important. Fibrocartilage is not articular cartilage. which covers the exposed area. Surgery Cartilage injuries or unstable cartilage can be treated surgically. after which resurfacing can be performed in a variety of ways. This is different from allograft ligament reconstructions where cadaveric ligaments are used for ligament reconstruction. however. Microfracture – microfracture is an arthroscopic procedure where small holes are made on the underlying bone to allow bleeding directly from the bone marrow. The damaged cartilage or exposed bone can be replaced by small cylinders of cartilage and bone obtained from other parts of the joint. or allograft. cartilage can be taken from a cadaver to replace the injured segment. the degenerated cartilage can also be replaced by existing cartilage from other parts of the joint or from a cadaver (allograft). the injection itself does not treat the underlying condition. to cover weightbearing or more important and painful areas of the joint. It normally takes 2-3 days to come into effect and may last up to weeks and months.

other investigators have studied different methods to improve the success rate of chondrocyte implantation. Chondrocyte Transplantation– chondrocytes are very slow growing cells. they are injected back into the defect of the knee. others have studied the use of mechanical pressure to improve the quality of tissue being implanted. Future Treatment Cartilage injuries and repair have made significant improvements over the past 20-30 years. The initial advancement has led to significant amount of interest. In general. Articular cartilage is biopsied or taken from the patient’s knee during arthroscopic surgery. This technique is the first cell-based type treatment of cartilage injuries. Improvement in . the joint can be partially or completely replaced. The chondrocytes from the cartilage are then isolated and grown in the laboratory over a 6-8 week period. Newer designs and improved bearing surfaces will likely lead to longer durability of the implants. and shoulder replacements are fairly common replacement procedures. Joint Replacements– for significant cartilage injuries. other surrounding cartilage may also deteriorate. wrist. joint replacements are reserved for end-stage cartilage injuries and older patients.  Understanding the mechanism of cartilage degeneration – when articular cartilage gets damaged. such as finger. All these exciting investigations are currently under clinical trials and we hope to put it into clinical use in the very near future. While some investigations have focused on the use of scaffolds to hold and deliver the cells. we are finally able to culture and grow human chondrocytes. Partial joint replacements have also become available when only parts of the joint are damaged. better methods of implanting cultured cells. hip. Nonetheless. Unicompartmental knee replacement. Other replacements. and may improve long-term success rates. or cartilage cells. In 1994. this technique has opened doors for significant development and hopefully. the long-term results of ACI are still unknown?. or shoulder hemiarthroplasty are commonly performed partial joint replacements for cartilage injuries. ankle. Brittberg and Peterson first reported the use of cultured human chondrocytes to replace damaged cartilage in the knee. where a periosteal flap covers the defect. and toe have lower success rate but can be very effective for treatment of end-stage cartilage damage in the involved joint. There are a few exciting development that may improve our ability to treat these painful and disabling conditions. only a selective portion of the joint is replaced. All three of these replacements have shown long term success. elbow. 4. however. Autologous chondrocyte implantation (ACI)– this is the first step to culture human chondrocytes and re-implant them to treat cartilage injuries. with higher than 85% success rates after 10-15 years of follow-up. Knee. With the improvement in cell biology and culture. 3. Advanced ACI – since the first report of ACI in 1994. After a sufficient number of chondrocytes has been cultured.

CA 94110 Tel: 415-20-ORTHO .  Early detection and monitoring of disease progression – significant improvement in detection and monitoring cartilage injuries using imaging techniques have been made.  Cartilage replacement – improvement in cartilage resurfacing procedures can lead to less pain and disability to the patient. 2nd Floor San Francisco. Advanced cartilage implantation techniques and more durable joint replacements can lead to better long-term outcome following surgical treatment of cartilage injuries http://orthosurg. are currently being developed to slow down cartilage degeneration or control damage after the initial trauma. Disease Modifying OsteoArthritic Drugs. also known as DMOADs. controlling the deteriorating pathway of cartilage is the next target for the treatment of cartilage degeneration.ucsf. Quantitative MR imaging scans may allow us to monitor cartilage health and degeneration in a more accurate and efficient manner. Better detection and monitoring can lead to better assessment of the severity of injury and choice of medical treatments.edu/oti/patient-care/divisions/sports- medicine/knee/cartilage-injury/ Orthopaedic Trauma Institute 2550 23rd Street Building 9.