Sports Medicine: Just the Facts

CHAPTER 9 • ARTICULAR CARTILAGE INJURY 49

flexion weight bearing posteroanterior (PA),

patellofemoral, and non-weight-bearing lateral pro-

jections (Mandelbaum, Romanelli, and Knapp, 2000).

These views allow assessment of joint space narrow-

ing, subchondral sclerosis, osteophytes, and cysts.

Special studies such as long-cassette mechanical axis

view may be necessary to evaluate overall alignment.

If significant joint space narrowing is present on the

45 °flexion PA radiograph, MRI is not indicated. An

MRI is valuable in assessing the status of the knee lig-

aments and menisci, but generally tends to underesti-

mate the degree of cartilage abnormalities seen at the

time of arthroscopy (Khanna et al, 2001). The role of

the bone scan remains controversial: isolated articular

surface defects that do not penetrate subchondral bone

may not be identified by bone scan. Arthroscopy con-

tinues to remain the gold standard for the diagnosis of

articular cartilage injuries.

• The Outerbridge classification system (Outerbridge,
  1961) was initially developed for macroscopic grad-
  ing of chondromalacia patellae and has since been
  modified on numerous occasions. A recent modifica-
  tion by the International Cartilage Repair Society
  (ICRS) (Brittberg, 2000; Brittberg and Peterson,
  1998) classifies chondral injuries into five distinct
  grades (Table 9-3).

NONSURGICAL MANAGEMENT

• Nonsurgical management (Table 9-4) is largely inef-
  fective in symptomatic patients and should be
  reserved for relatively low-demand patients, patients
  wishing to avoid or delay surgery, and patients with
  advanced degenerative osteoarthritis which is a con-
  traindication for articular cartilage restoration proce-
  dures.
  •Traditional methods for treatment of chondral lesions
  include the judicious use of nonsteroidal anti-inflam-
  matory drugs combined with activity modification.
  Oral chondroprotective agents such as glucosamine

and chondroitin sulfate potentially offer some relief

in subjective symptoms. Glucosamine is thought to

stimulate chondrocyte and synoviocyte activity, and

chondroitin is thought to inhibit degradative enzymes

and prevent fibrin thrombi formation in periarticular

tissues (Gosh, 1992; Bucci, 1994; Muller-Fassbender

et al, 1994). Recent studies indicate that pain, joint

line tenderness, range of motion, and walking speed

may be improved with these medications (Barclay,

Tsourounis, and McGart, 1998; DaCamara and

Dowless, 1998). However, there are no clinical data

showing that these oral agents affect the formation of

cartilage (Tomford, 2000). Viscosupplementation

with high-molecular weight hyaluronans remains an

option despite the lack of well-controlled studies

demonstrating efficacy.

• Prolonged nonsurgical management of symptomatic
  chondral lesions may lead to additional joint deterio-
  ration, making surgical intervention more difficult or
  less successful. Suggested indications for referral to
  an orthopedic surgeon with expertise in cartilage
  restoration techniques are presented in Table 9-5.

TABLE 9-3 Modified International Cartilage Repair

Society Classification System for Chondral Injury

GRADE OF INJURY MODIFIED ICRS

Grade 0 Normal cartilage

Grade I Superficial fissuring

Grade II <1/2 cartilage depth

Grade III >1/2 cartilage depth up to

subchondral plate

Grade IV Through subchondral plate, exposing

subchondral bone

TABLE 9-4 Nonsurgical Management of Chondral

Lesions

Oral medications Non-steroidal anti-inflammatory drugs

(NSAIDS)

Acetaminophen

Glucosamine-sulfate—believed to stimulate

chondrocyte and synoviocyte metabolism

Chondroitin-sulfate—believed to inhibit

degradative enzymes and prevent fibrin

thrombi formation in periarticular tissues

Physical modalities Activity modification—avoidance of

high-impact exercises

Physical therapy—quadriceps strengthening

hamstring flexibility

Bracing Knee sleeve for improved proprioception

Unloader brace to protect damaged knee

compartment

Injections Corticosteroids

High-molecular weight hyaluronans

TABLE 9-5 Indications for Referral to an

Orthopedic Surgeon

High-energy injury with direct trauma to the knee

Acute motion loss

Gross deformity

Acute neurovascular deficit

Mechanical symptoms (catching, locking, sensation of a loose body)

Failed nonsurgical management greater than 3 months in duration

Repeated giving way or complaints of instability