|Chondral; Defect; Arthroscopy; Drilling; Knee
|Articular cartilage defects in the knee do not heal and may
dispose a predisposition for an early onset of osteoarthritis . Large
osteochondral defects are associated with mechanical instability
and are accepted indications for surgical intervention to prevent
development of degenerative joint disease . The treatment of
cartilage defects represents a common, complex and multifaceted task
for orthopaedic surgeons; particularly, in young patients suffering
from large cartilage defects, there are only limited conservative and
surgical treatment options. Thus, several efforts to restore articular
cartilage were undertaken. Ideally, a large osteochondral defect should
be repaired with a graft that can provide mechanical stability and allow
early postoperative function under physiologic loading condition .
Disagreement exists for treatment of lesions over 2-3 cm2, while both
Osteochondral Cylinder Transplantation (OCT, OATS) or the different
modalities of Autologous Chondrocyte Transplantation (ACT) as well
as Matrix-Assisted Chondrocyte Transplantation (MACT) techniques
are being applied. Furthermore, novel techniques, such as autologous
matrix induced chondrogenesis or one-step procedures  do or
will stand by for execution in the desired patient, while arthroscopic
techniques  are described with increasing frequency. Cartilage repair
is applied with a constantly increasing frequency, while there is both,
no internationally accepted algorithm for treatment of cartilage defects
or survey to describe how experienced surgeons handle cartilage lesions
. No internationally accepted algorithm for treatment of cartilage
defects or survey to describe how experienced surgeons handle cartilage
lesions. Also, the increased complication rate of autologous or artificial
bone graft in management of osteochondral defects of the knee beside
lack of experience and also for economic reasons in many places all
over the world it was our hypothesis of this study to show that the over
drilling is effective, safe method of treatment for knee osteochondral
defects among 2-3 cm2.
|Twenty six patients (18 men and 8 women) with focal full-thickness
cartilage lesions of the knee on the medial or lateral femoral condyle,
or trochlea were included in this study through the period from 2006-
2010. Age of the patients ranged from 23 years to 49 years (mean
36.7 years). All patients were complaining of symptom-like pain or
dysfunction of the knee joint. Patients with at least one of the following
criteria were excluded from this study: severe osteoarthritis; small
lesions <2 cm2, age over 50 years, presence of active infection; and limb
malalignment and presence of radicular pain. Eighteen patients had
previous operations Patients included meniscectomies (in 6 patients)
and reconstructions of the anterior cruciate ligament (in 12 patients).
Presence and grade of meniscal and cartilage lesions as well as Bone
Marrow Edema Pattern (BMEP) were assessed using a modified whole
organ MRI score (WORMS) . There were 12 patient’s grade 5 and
the rest were grade 6.
|Lysholm and Gillquist  score was used for evaluation of
outcome. Clinical evaluation and scoring were done preoperatively
and at follow-up. The surgical technique is through subchondral
drilling. This technique enhances chondral resurfacing by providing a suitable environment for tissue regeneration and by taking advantage
of the body’s own healing potential. Multiple perforations into the
subchondral bone plate were done. The perforations are made as close
together as necessary, but not so close that one breaks into another.
Consequently, the drilling holes are approximately three to four
millimeters apart (or 3 to 4 holes per square centimeter). Importantly,
the integrity of the subchondral bone plate is maintained. The released
marrow elements form a “super clot” which provides an enriched
environment for tissue regeneration. Postoperatively, CPM was used
for all patients from the 2nd day of operation and patients were allowed
for partial weight bearing for 6 weeks.
|Analyses were performed using Sigma Plot 10.0 and Sigma Stat
(SPSS). The level of significance was defined at P=0.05.
|The patients had complained of pain for 3- 15 months preoperatively.
Nineteen of them reported rest pain. Clinical evaluation of the patients
revealed Mild knee effusion in 19 patients and moderate in 7, tenderness
over the affected area was noted in all patients. Limitation of range of
motion of the affected knee was observed in all cases (average flexion:
93.4°, Average extension: -9°).
|The mean follow up was 38 months (range 25-54 months). In 17
patients, the lesion sized 2 cm2, between 2-3 cm2 in 3 patients and it
was 3 cm2 in the rest of the patients. Postoperatively, pain disappeared
in 23 patients and was mild in 3 patients. Knee effusion disappeared in
all patients. Average range of motion improved to 140° flexion and -0.5
º extensions respectively. Lysholm score was 43.0 ± 12 preoperatively,
improved to 88.0 ± 9 postoperatively (P<0.0001). Only 2 patients were
complaining of slight impairment of climbing stairs and one patient
was complaining of difficulty in squatting.
|Radiologically using MRI, complete healing of the defect was
observed in all cases (Figures 1-6) except 2 (Both were WORMS’s grade
6). No progression of the lesion or development of osteoarthritis was
noted tell the end of follow-up period.
|Treatments for managing articular cartilage defects of the knee
are not always effective. When they are, long-term benefits may not
be maintained and osteoarthritis may develop. Marrow stimulation techniques such as drilling or micro fracture are first-line treatment
options for symptomatic cartilage defects. Common knowledge
holds that these treatments do not compromise subsequent cartilage
repair procedures with autologous chondrocyte implantation . Autologous osteochondral mosaicplasty may be an alternative for
small and medium-sized focal chondral and osteochondral defects of
weight bearing surfaces of the knee and other weight bearing synovial
joints . There is at present no evidence of significant difference
between articular cartilage implantation and other interventions .
Autologous osteochondral transplant systems have shown encouraging
results but there are still problems. Graft matching and contouring to
the recipient articular surface is difficult. Donor sites can be a limiting
factor. Furthermore, the fibro cartilaginous interface between the
donor and recipient site may contribute to breakdown in the long run.
Also, the technique is expensive and is technically difficult to perform
. Long-term functional outcome is still a significant question
mark. In addition, it has not been shown that autologous chondrocyte
implantation can prevent degenerative changes. It was previously
mentioned that marrow-stimulation techniques such as drilling, micro
fracture, or abrasion arthroplasty fail to yield long-term solutions
because they typically promote the development of fibrocartilage.
Fibrocartilage lacks the durability and many of the mechanical
properties of the hyaline cartilage that normally covers articular surfaces
. Experimentally, it was proven that subchondral drilling had
increased fibro cartilaginous healing with time, with a slight increase in
degenerative changes. Drilling may result in a longer-lived repair than
abrasion arthroplasty in the treatment of full-thickness lesions .
Recent systematic review comparing Micro fracture technique with
chondrocyte implantation (ACI) and osteochondral autograft transfer
demonstrated no clear superiority of ACI over micro fracture in line
with the findings published by other authors [15-17]. Micro fracture
technique can be done arthroscopically with faster recovery after
surgery and with better cosmetical results. Autologous Chondrocyte
Implantation (ACI) involves an open technique with inherent
disadvantages such as adhesions and prolonged recovery  the size
and localization of the defect can be assessed by MRI. It also helps in
detection of any other intra-articular lesions . Drilling via intraarticular
approach has been performed in the past with poor results
. This may be due to open surgery techniques with its associated
complications. Patients of this study showed highly significant
increases in the respective scores used for outcome measurement
demonstrating major improvements in activities of daily living and
ability to work. None of our patients complained of knee pain after
surgery. Mobilization of the affected knee could be started immediately.
Our present results are in line with the available literature. Forst et al.
 reported on the results of core decompression with resolution
of pain in 94% of patients when followed for a mean of 35.4 months.
Mont et al. found good or excellent results in 73% of patients at mean
follow-ups of 11 years . Marulanda et al.  avoided progression
to TKA in 97% of patients at a mean follow-up of 3 years treated with
percutaneous drilling. Bouwmeester et al.  concluded that at 10 years follow-up no difference was observed between debridement
and drilling and perichondrium transplantation for treatment of an
isolated cartilage defect. Imade et al.  also had the same conclusion
where they stated that no differences in clinical scores were found in
patients with a concomitant ACL rupture and an osteochondral lesion
treated by drilling or autologous osteochondral grafting at a minimum
follow-up of 1year, regardless of the differences at arthroscopic grading
. Size of the lesion in the cartilage is also important in deciding
the method of management. Profeen et al.  in their review of the
regenerative treatment options in management of cartilage lesions
stated that although evidence-based studies comparing microfracture
and ACI have not found significant differences in the clinical outcome,
the literature does show that choosing the treatment based on the size
and characteristics of the osteochondral lesion might be beneficial.
The American Association of Orthopedic Surgeons suggests that
contained lesions <4 cm2 should be treated by microfracture, lesions
bigger than that by autologous chondrocyte implantation . In
comparing our techniques with other techniques: Attmanspacher et al.
 studied the outcomes in 18 patients after arthroscopically placed
osteochondral autograft transfers for a variety of underlying disorders
including osteonecrosis, osteochondrosis dissecans, and osteochondral
defects secondary to instability in anterior cruciate ligament-deWcient
knees. Short-term outcomes were very good with an average Lysholm
score of 90 points (range 78–92 points), suggesting that this procedure
is an effective treatment for focal chondral and osteochondral defects
. Despite the overall good results in this study, the small number
of patients is still a limitation. Larger number with longer follow up
period is needed to prove the long term efficacy of this technique.
|Subchondral drilling can be an effective approach for the treatment
of osteochondral defects sized 2-3 cm2. Using this method, most
patients who failed non-operative treatment successfully avoided
the need for joint arthroplasty after a single joint preserving surgical
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