meniscus, articular cartilage and the degenerative knee in ...forms.acsm.org/tpc/pdfs/32 ott.pdf ·...
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Meniscus, Articular Cartilage and the Degenerative knee in the Athlete Susan M. Ott DO, FACSM ACSM’s Team Physician Course Miami, Florida 2013
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Meniscus, Articular cartilage and the Degenerative knee in the athlete =MAD
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Meniscus Semi-lunar cartilages Triangular in cross section tapering to a thin
free edge centrally 2 in each knee Attached peripherally by the coronary
ligaments
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Meniscus: Function Increases surface area Lubrication Load transmission Articular cartilage nutrition Joint staility “shock absorber”
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Lateral Meniscus Smaller than the medial, rounder and more
mobile Peripheral 10-25% has a blood supply
(medial and lateral geniculate arteries) Less vascular in the popliteal hiatus AP excursion of 11 mm in flexion and
extension (twice that of the medial)
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Lateral meniscus Discoid : Disc shaped Relatively uncommon Often presents in a child Insidious onset of lateral knee pain with clicking
and locking Sometimes will present in an adult
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Medial meniscus More ‘C’ shaped than the lateral Peripheral 20-30% has a blood supply
(medial and lateral geniculate arteries) Less mobile than the lateral Torn 3 times more often than the lateral
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Meniscus Often a twisting injury Meniscus gets caught between the distal
femur and proximal tibia Shearing force Often seen with ligamentous injuries Seen less commonly with patellofemoral
disease/injuries
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Meniscus types of tears Degenerative/complex Radial longitudinal Transverse Bucket handle Parrot beak
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Meniscus: history Adult: seem to fall into 2 categories no specific injury, joint line pain, sometimes
have swelling, hurts to plant and twist (ie: get out of the car), can’t squat or kneel Specific plant and twist injury, swelling, joint
line pain, pain with plant and twist activities
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Athlete Cleat got caught Plant and twist (kicking the soccer ball) Hit from the outside Jumped up for a ball and landed awkwardly Seen with ACL injury
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Meniscus treatment : non surgical Injection PT NSAIDs Bracing Seems to work better in older folks with
degenerative tears
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Meniscus treatment : Surgical 2 options Trim it out (partial menisectomy) Fix it (meniscus repair)
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Meniscus treatment: Partial menisectomy Tears in the white white zone (avascular) Degenerative tears Old tears Patient concerns Compliance issues
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Meniscus treatment : Meniscus repair Red-Red or Red-White zones Inside out, outside in sutures Many meniscal repair devices on the market
for all inside repair Darts Arrows Suture
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Meniscus Beware MRI scans Will miss some tears Will over diagnose in older folks An asymptomatic patient with an MRI
showing a meniscal injury doesn’t need an immediate ortho consult and probably doesn’t need surgery
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Articular Cartilage injury Partial thickness Full thickness Bone bruise Challenging to treat
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Articular Cartilage Function Reduces joints stress Reduces friction Absorbs load Durable
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Articular Cartilage composition 75-80% water Extra-cellular matrix 50-75% collagen II :
insoluble tightly woven fibers Proteoglycan macromolocules 15-30% Chondrocytes occupy less than 10% of the
tissue
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Articular Cartilage 4 zones from surface to subchondral bone Zone 1 superficial layer making up about
10% of the cartilage. Top portion of the superficial layer is also called lamina splendens Zone 2 Intermediate or transitional layer
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Articular Cartilage Zone 3 Deep layer Zone 4 calcified layer joins the deep zone to
subchondral bone
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Articular Cartilage Poor blood supply Exchanges gasses, nutrients and waste
products via diffusion As we age cartilage looses potential for
healing and repair Will heal with fibrocartilage which does not
handle load as well
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Articular Cartilage injury Partial thickness Full thickness…osteochondral injury Knee accounts for 75% of osteochondral
injuries Most often due to a specific trauma Osteochondritis Dessicans (OCD)
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Articular Cartilage injury : OCD Due to microtrauma AKA stress reaction Usually active patient Often in skeletally immature Typical location is the lateral aspect of the
medial femoral condyle
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Articular Cartilage injury : trauma Patella dislocation ACL Injury Twisting injuries
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Articular Cartilage injury Case 1 13 year old male presents to my office with a
history of being away over the summer and dislocating his patella. He was taken to the operating room for closed reduction and had no rehab. He has been home for several months now and complains of persistent effusion locking and catching
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Articular Cartilage injury case 1 xray
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Articular Cartilage injury case 1 xray
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Articular Cartilage injury case 1
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Articular cartilage injury case 1
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Articular Cartilage injury case 1
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Articular cartilage injury case 1
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Articular Cartilage injury case 1 Removed loose body tethered in the supra
patella pouch Removed multiple small loose bodies Large lesion of the trochlear groove Debridement with microfracture Took cells for possible ACI
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Articular Cartilage injury case 2 43 year old male with an initial injury to his
knee when he fell on the deck of a boat at his work as a marine welder.
Seen and treated by another orthopedist initially
Had an ACL reconstruction, partial medial menisectomy and microfracture of the medial femoral condyle
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Articular cartilage injury case 2 Was told he could weight bear
immediately and was told he could run 3 weeks post op. And he had trouble Presents to me about 1 year after his
index procedure.
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Articular cartilage injury case He complains of swelling and medial
knee pain. He is unable to run and walks with a limp On PE he has a moderate effusion,
medial and lateral joint line pain, pain with McMurrays and is ligamentously stable
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Articular cartilage injury case 2 At the time of my arthroscopy he had both
medial and lateral meniscus tears, ACL graft was intact and the lesion on the MFC is not healed with a flap loose
Did partial medial and lateral menisectomies, debridement of osteochondral lesion and took osteochondral biopsies for ACI
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Articular cartilage injury case 2
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Articular cartilage injury case 2
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Articular cartilage injury case 2
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Articular cartilage injury case 2 ACI = Autologus chondrocyte implantation Take the cells and they grow them Staged procedure At the second procedure the lesion is curretted Harvest a flap of periosteum from the proximal
tibia
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Articular cartilage injury case 2
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Articular cartilage injury case 2
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Articular cartilage injury case 2
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Articular cartilage injury case 2 Sew the periosteum over the defect and inject
the baby cells under the periosteum Non weight bearing for 6-8 weeks PT Gradual return to activities over the course of a
year At 5 years he is doing well. He recently
completed an ironman triathlon
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Osteochondral lesions Microfracture OATS Allograft ACI
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Bone bruises Diagnosed on MRI Commonly seen in the lateral
compartment with ACL injuries Probably not a great thing for the articular
cartilage
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Bone bruise
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Bone bruise
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The degenerative knee in the athlete Often have had remote injuries which
may or may not have been treated +/- surgery Meniscus injury on top of degenerative
articular cartilage
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MAD: DJD in the athlete
Case 1: 45 year old semi pro golfer with medial knee pain and examination and history consistent with a diagnosis of a meniscal injury
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MAD: DJD in the athlete
Post operatively did well initially and gradually returned to golf.
Continued to have medial knee pain secondary to his degenerative changes
Injected, NSAIDs, Rehab, medial unloader brace all helped but not enough
Referred for unicompartmental arthroplasty but put it off and then ended up doing well
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MAD: DJD in the athlete
Case 2 : 36 year old male college basketball coach presents with a long history of medial knee pain. Has had multiple injuries over the years and has had an arthroscopy for a medial meniscus injury. New injury recently and states it feels like his previous meniscus tear.
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MAD: DJD in the athlete
Case 2 : Radiographs
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MAD: DJD in the athlete
Case 2 : Radiographs
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MAD: DJD in the athlete
Case 2 : Arthroscopic findings
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MAD: DJD in the athlete
Case 2 : Arthroscopic findings
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MAD: DJD in the athlete
Case 2 : PE He has some subtle laxity to his ACL that is more evident on examination under anesthesia. Did partial medial menisectomy and
microfracture of his osteochondral injury Was prepared to take cells for ACI Kept non weight bearing 6 weeks then
rehabilitated
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MAD: DJD in the athlete
Case 2 : Post op Placed him in a medial unloader for
sports which is working very well for him 1 year post op he was pain free and
playing basketball without restriction 4 years post op began having problems Was looking into HTO with or without
meniscal transplant
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MAD: DJD in the athlete
Arthroscopy NSAIDs Strength/normal weight Injections (steroid or visico
supplementation) Unloader brace Osteotomy Arthoplasty
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MAD: conclusions
Joint line pain could represent any of these problems Use your history, PE and imaging to
define your diagnosis We don’t have all the answers especially
with articular cartilage injuries