Please see my chapter about articular cartilage repair in the new edition Oxford Textbook of Sports Injuries (Oxford University Press at
www.oup.co.uk), which will be the standard textbook for sport & exercise medicine physicians.
What’s the Problem?
Chondral or articular surface defects are increasingly recognised as a problem in sportsmen. The bearing surface of all synovial joints is made up of a very specialised material called hyaline cartilage. This material has shock absorbing properties, but it is bizarre in that it has absolutely no blood supply and no nerve supply. It is made up of a matrix of collagen and sugar polymers enclosing cartilage cells in various layers and is exquisitely designed with perfect mechanical properties to form a bearing surface. The friction is much less than that of ice on ice and is much better than anything that man has managed to design. It gets its nutrition from the joint fluid which bathes it because the cartilage cells which produce the bearing surface material have a very low metabolic rate and do not need much “food”. This does mean that the body has little or no capacity to repair any damage to the gristle surface of the joint. This is a shame as once you have stopped growing any damage to the bearing surface of the joint is going to be permanent.
What can we do about it?
There are some things we can do to encourage the healing of articular cartilage defects. We can simply smooth over the edges of the defect to prevent catching. This is more or less like removing the loose bits of tarmac from a pothole in the road. If the pothole is fairly small then drivers will not notice as they drive over it, but once it becomes a big cavity, big enough for a car wheel to fall into it, it is going to cause more trouble and more complaints from the drivers! The typical history that we hear from patients who have articular cartilage defects is that there is a vague dull ache in the joint most of the time, but it is very much exercise-related, so if they have an easy day it is not too bad, if they play a game of football it is going to be much worse the next day, often associated with some swelling for a few days. It will be eased by non steroidal anti inflammatory drugs (such as Brufen, Nurofen or Voltarol), but it often never goes away completely.
There are a number of things that can be done to help this. This is now good evidence that Glucosamine is helpful in joints with early degenerative change, but it needs to be taken at quite a high dose (1500mg daily) for a prolonged period of time (perhaps three months) regularly to feel the benefit. There are various injections which will sometimes help, at least temporarily - the hyaluronans are probably the best at the moment. It is reasonable simply for patients to restrict their activities so as to avoid experiencing the symptoms, but most of the people we see are not happy to do this. There is a relatively small role for braces and splints and really if the symptoms cannot be controlled with simple measures then we are heading towards surgery.
The easiest and probably one of the most reliable ways of treating the symptoms arising from a defect in the bearing surface of the joint is with a technique called marrow stimulation. We are currently using a technique called microfracture to achieve this whereby we use a specially designed awl to penetrate the bone that sits underneath the articular surface and allow small blood vessels to grow out and produce a fibrocartilaginous scar. This fills in the defect very well and gives a reasonably durable bearing surface. It can be compared to the scar you see in the skin after a burn. It is not quite as good as nature intended, but it does the job of keeping the water out quite well. Because we are simply doing an operation to allow blood vessels to grow out and produce this scar there is quite a long period of rehabilitation associated with this. This is very important in that there is a balance between keeping the joint moving and keeping the muscles around the joint in good condition and avoiding stressing the newly formed bearing surface. This rehabilitation is a crucial part of the treatment and cannot be avoided. I usually tell patients that the defect is like a muddy field and the operation involves scattering grass seed onto it. It is obviously important to allow the grass seeds to germinate and produce not only the grass surface, but some decent interlocking roots underneath before starting to play football on it. We have a routine protocol for rehabilitating patients following microfracture, but the duration of recovery in getting back go full sport following this (day case key hole) procedure is a minimum of four months and often a bit longer.
Should this fail or for any reason be inappropriate then there are other techniques for reproducing a bearing surface. We can take a chunk of bone covered in articular surface from a less important part of the joint and put it into the defect. This can also be done by taking a chunk of bone from a dead donor. This obviously has some problems of its own and we are increasingly using the relatively new technique of tissue engineering to generate a new biological bearing surface.
Tissue Engineering Techniques
As noted above, hyaline cartilage has little or no capacity to regenerate itself, however, if we take a specimen from an unimportant part of the lining of the joint we can send it to our laboratory where they will mince it up and encourage the cartilage cells to multiply in a test tube. We can then go back around three weeks later and inject the cells under a membrane stitched over the defect and they will quite reliably continue to produce articular cartilage and over a period of time regenerate the true hyaline cartilage surface of the joint. This is a technique which has been done in Sweden for around twenty years now and we have a very large experience of it in Oswestry with our own dedicated on site laboratory for producing cells www.oscell.enta.net . We have an international Medical research Council funded trial runnning at present at ACTIVE. This is the only purpose built, non-commercial facility in the country and is available to both NHS and private patients. Elsewhere in the country the service is available by sending the biopsies off to a commercial lab elsewhere in Europe or the USA.
Since the cultured cells are in a liquid injected under a membrane this is effectively a blister in the lining of the joint and will obviously, like the microfracture procedure, take quite a long time to rehabilitate from. It is certainly at least a year before there is any kind of decent cartilage surface there and it is probably most appropriate for people looking towards the long term rather than sportsmen who are looking to get back on the field as soon as possible. It is, however, the only way we have of producing a large and integrated hyaline cartilage surface like the one nature intended. The published results of this procedure in ideal cases are extremely good with approaching 90% good and excellent outcomes, but it does involve two operations and prolonged rehabilitation after them.
Patient Advice (PDF) Documents (these are “patient handouts” that cover the operation & what to expect and do afterwards):
Microfracture - Condyle (2.2Mb) Patellofemoral (2.2Mb)
Autologous Chondrocytes - Condyle (2.6Mb) Patellofemoral (2.6Mb)
Physiotherapists’ Protocols (more technical - aimed at professionals)
Femoral condyle autologous chondrocyte transplantation
Trochlea autologous chondrocyte transplantation
For further advice, contact Andrea Bailey, Senior Sports injury Physiotherapist in Oswestry at: firstname.lastname@example.org