International Cartilage Research Society Research Articles

Characteristics of medial plica syndrome complicated with cartilage damage.

This study was designed to evaluate the characteristics of patients with medial plica syndrome and associated cartilage damage. The study subjects included 44 patients with 57 knees arthroscopically diagnosed with medial plica syndrome. Subjects were divided into those with severe cartilage damage, defined as International Cartilage Research Society (ICRS) stage 2 or higher, and those with mild cartilage damage, defined as ICRS stage 1 or lower. Local findings, period from onset to surgery, arthroscopic findings, and postoperative results were compared in the two groups. The shapes of the medial synovial plica were types C and D of the Sakakibara classification in the severe group, and types A, B, and C in the mild group. Patellar ballottement tended to be more common in the severe than in the mild group (P = 0.059). The duration from onset to surgery was significantly longer in the severe than in the mild group (29.0 vs. 11.6 months, P = 0.043). Postoperative results were significantly better in the mild than in the severe group (P = 0.0017). The shape of the medial synovial plica and the duration between symptom onset and surgery were associated with cartilage damage. Surgical treatment should be considered when the medial synovial plica covers part of the anterior aspect of the medial femoral condyle or ruptures, or when pain persists over a long period, thus reducing the potential for cartilage damage. Level IV.

Arthroscopic Fragment Fixation Using Hydroxyapatite/Poly-L-Lactate Acid Thread Pins for Treating Elbow Osteochondritis Dissecans

Background: Various procedures, such as arthroscopic debridement, osteochondral transplantation, and bone plug fixation, have been described for the treatment of osteochondritis dissecans (OCD) of the humeral capitellum. However, the use of hydroxyapatite/poly-L-lactate acid (HA/PLLA) thread pins to fix the osteochondral fragment in an OCD lesion is a recent development. Hypothesis: Adolescent throwing athletes would return to preinjury levels of function after arthroscopic osteochondral fragment fixation using HA/PLLA thread pins. Study Design: Case series; Level of evidence, 4. Methods: Enrolled in this prospective cohort study were 18 adolescent baseball players (mean age, 14.2 years; range 12-16, years) with elbow OCD who underwent arthroscopic fragment fixation with HA/PLLA thread pins between 2006 and 2009. All patients were affected on their dominant side. Plain radiographs taken before surgery showed an open physis in 13 patients (72%) and a closed physis in 5 patients (28%). During surgery, the condition of the OCD lesion was evaluated by use of the International Cartilage Research Society (ICRS) classification system; there were 5 grade II, 11 grade III, and 2 grade IV cases. Outcomes were assessed after 3 years (mean, 39 months; range, 36-50 months). Elbow function was measured using the Timmerman and Andrews score and the Mayo Elbow Performance Index. Return to sports activity was assessed as higher than preinjury, same level, lower level, or no return to sports. Results: The mean Timmerman and Andrews score improved significantly from 126.6 ± 6.5 to 197.5 ± 1.5, and the mean Mayo Elbow Performance Index improved significantly from 68.0 ± 2.1 to 98.06 ± 0.9 (P = .0001 for both). Mean elbow extension improved significantly from −10° ± 10.4° to −0.8° ± 5.2° (P = .006), and mean flexion improved significantly from 123.1° ± 17.9° to 138.6° ± 6.1° (P = .001). Three patients had a loss of extension greater than 5°. Five patients returned to a higher level of sports activity, 10 patients returned to the same level, and 2 patients returned to a lower level. A remaining patient did not return to baseball. In one patient, the lesion did not heal, resulting in fragmentation at 1 year after surgery. This patient consequently underwent revision arthroscopy to remove the lesion, and he eventually returned to sports at the same level of activity. Conclusion: Arthroscopic fragment fixation using HA/PLLA thread pins provides a beneficial clinical outcome to adolescent baseball players with humeral capitellar OCD.

Correlation of MRI T2 mapping sequence with knee pain location in young patients with normal standard MRI.

To assess the correlation of T2 mapping abnormalities to knee pain location, in young adults with normal standard knee MRI at 3.0 Tesla. Twenty-three consecutive patients were included prospectively from September 2011 to April 2012. Inclusion criteria were age under 50 years old, knee pain without surgical history, and normal knee MRI at 3.0 Tesla (sagittal T1-weighted images, and sagittal, axial and coronal proton-density-weighted images with saturation of fat signal). Ten asymptomatic volunteers were also included as a control group. Patients and controls had a cartilage T2 mapping MRI sequence in addition to the standard MRI protocol. Two musculoskeletal radiologists, blinded to the patient/control condition and pain location, independently reviewed the T2 mapping images. T2 values below 40 ms were considered normal. They rated the number of hyaline cartilage lesions and their grade according to an ICRS-like score (inspired by the International Cartilage Research Society score) in each anatomical compartment (medial and lateral femoro-tibial and anterior patello-femoral joints). In addition, the T2 value of the largest lesion was measured. Patient's pain location was classified in the following categories: anterior, lateral, medial and global. T2 mapping findings were compared to pain location, and retrospectively to the initial standard sequences. Sensitivity and specificity were calculated for MRI with T2 mapping according to pain location for each reader. Kappa coefficient was calculated for inter-reader agreement. We used variance analysis in a linear regression to compare T2 values and ICRS-like classification in each compartment. Sensitivity of MRI with T2 mapping, according to the symptomatic compartment, was respectively: 78% and 87% for Reader 1 and Reader 2 and specificity was 70% for both readers. Kappa coefficient for T2 mapping abnormalities location and pain location was good, with a calculated value of 0.64. There was no significant correlation between ICRS-like classification and T2 values of lesions (p = 0.18). Our results suggest that T2 mapping is an interesting MRI sequence for the exploration of young patients knee pain in case of normal MRI with a standard protocol, with a good correlation between pain location and focal prolongations of the cartilage T2 relaxation time.

MRI T2 mapping sequence concordance with CT-arthrography for knee cartilaginous lesions in traumatic and degenerative lesions

ObjectiveTo assess the concordance of MRI T2 mapping sequence with CT-arthrography for traumatic and degenerative chondral lesions. Subjects and methodsFifteen consecutive patients were included prospectively from September 2011 to April 2012. They referred for CT-arthrography examination for degenerative or traumatic knee pain and had also knee 3T MRI with T2 mapping sequences. CT-arthrography was used as benchmark diagnostic test for chondral lesion, read in a consensual way by two senior musculo-skeletal radiologists. The same, blinded to CT-arthrography results, independently reviewed standard and T2 Mapping MRI sequences and rated number of hyaline cartilage lesions, and their grade according to the International Cartilage Research Society Score (ICRS) in each anatomical compartment. Size and T2 value of the largest lesion was measured. We used Mac Nemar test to assess concordance between MRI and CT-arthrography findings, a regression model to compare CT-arthrography ICRS classification to T2 values, and Wilcoxon test for inter-reader agreement. ResultsBecause of artifact and loss to follow-up, 11 patients were finally included. Concordance of T2 mapping MRI with CT-arthrography for reader 1 and reader 2 were respectively 90% and 80% in medial compartment, 50% and 70% in lateral compartment, 90% and 70% in anterior compartment. There was no significant correlation between CT-arthrography ICRS classification and T2 values (P>0.06). No significant differences between reader 1 and reader 2 were observed when evaluating the prevalence of knee lesions (P=0.25 for the medial compartment, P=0.62 for the lateral compartment and P=1 for the anterior zone). ConclusionT2 mapping is a reproducible imaging technique, with a good concordance to CT-arthrography for detection and size of chondral lesions, with no correlation between CT-arthrography ICRS grade and T2 values.

Osteochondral Lesions of the Talus: A Ten-Year Prospective Clinical Experience (SS-55)

Osteochondral Lesions of the Talus: A Ten-Year Prospective Clinical Experience (SS-55)

Osteochondral autografts in full thickness patella cartilage lesions

The purpose of this study was to evaluate clinical, functional and imaging results of full thickness patella cartilage lesions treated with osteochondral autografts (OCA). We studied a consecutive case series of 10 patients. At follow-up, Lysholm and International Knee Documentation Committee (IKDC) scores were obtained. Magnetic resonance imaging (MRI) evaluation was performed at an average of 8 months post-op. The average cartilage lesion area was 1.2 cm 2. An average of 1.9 grafts was used per patient. The average Lysholm scores were: pre-op 73.8 ± 8.36; post-op 95 ± 4.47 points ( p < 0.05). The average IKDC post-op score was 95 ± 1.74 points. No postoperative complications were registered. In the MRI analysis we found that in all cases, OCA presented flush characteristics when compared with adjacent cartilage. The majority of cases presented no fissures in the graft–receptor interface (60%). In 80% we observed mild bone marrow edema around the graft. According to the International Cartilage Research Society (ICRS) cartilage lesions classification, all grafts were considered 1A; in the periphery cartilage was classified as 1A in 60%. We conclude that patellar OCA is a good alternative for the treatment of full thickness patellar cartilage lesions, offering good clinical, functional and imaging results at midterm follow-up.

A New Histology Scoring System for the Assessment of the Quality of Human Cartilage Repair: ICRS II

Background A reliable and reproducible method is needed to assess cartilage repair. Purpose This study was undertaken to test the reproducibility of 2 established histological scoring systems, the Modified O'Driscoll Scale (MODS) and International Cartilage Research Society (ICRS) Visual Assessment Scale (ICRS I), and subsequently to develop and evaluate a new grading system for cartilage repair. Study Design Cohort study; Level of evidence, 2. Methods A total of 107 cartilage biopsy specimens were graded using MODS and ICRS I, and the reader variability was measured. The new grading system, ICRS II, was developed and the inter- and intrareader variability determined by 3 independent readers. Collagen type II deposition was assessed immunohistochemically. Results The MODS and ICRS I demonstrated high interreader variability, with MODS also showing high intrareader variability. A new histological scoring system, ICRS II, was developed comprising 14 criteria to assess parameters related to chondrocyte phenotype and tissue structure. The ICRS II demonstrated lower inter- and intrareader variability compared with MODS or ICRS I. The overall assessment and matrix staining scores had the best correlation coefficients for inter- and intrareader variability (r = .81 and .82, respectively). The extent of collagen type II in cartilage, considered a marker of differentiation toward hyaline cartilage, could represent a measure of good cartilage repair. A correlation coefficient of .56 was obtained between the extent of collagen type II staining and the overall assessment score. Conclusion The ICRS II represents an improvement over current histological cartilage repair grading systems in terms of reader reproducibility. The clinical relevance and its ability to predict long-term repair durability will be assessed once long-term clinical data become available.

Fixation with autogenous osteochondral grafts for the treatment of osteochondritis dissecans (stages III and IV)

This paper presents a clinical and functional assessment of the cases of osteochondritis dissecans (OCD) treated with small mosaicplasty type osteochondral grafts. Between 1999 and 2004, we operated on 12 knees with OCD stages III and IV. They were assessed using the International Cartilage Research Society (ICRS) scale, the Visual Analogue Scale (VAS) scale, X-ray and magnetic resonance imaging (MRI). The study was carried out using a clinical series, was retrospective and had a level of evidence of 4. Before surgery, all patients were in classes III and IV on the ICRS scale (four in class III and eight in class IV). At the time of surgery, the patient age was 27.5 +/- 7.9 years, with male predominance (75%). Eleven of the cases were assessed as classes I and II on the ICRS scale (seven in class I and four in class II), with one patient in class IV. X-ray assessment was less favourable, revealing alterations in the articular space in 75% of cases. The results show that this technique enables the biological fixation of fragments and, functionally, the clinical results obtained were very good. The osteochondral grafts avoid the implantation of foreign material and make use of bone fragments of the same rigidity as the OCD fragment. We conclude that the technique described is an excellent alternative to the techniques normally used for the fixation of stage III and IV OCD.

Autologous chondrocyte implantation for the treatment of retropatellar cartilage defects: clinical results referred to defect localisation

Although autologous chondrocyte implantation (ACI) has become well established for the treatment of full-thickness cartilage defects of the knee joint, nevertheless clinical results of retropatellar lesions are still inferior compared to those of defects located on femoral condyles. We report the clinical results obtained in 70 patients treated with ACI for full-thickness defects of the patella, with special reference to defect location and size, age, body mass index and sports activity. At a follow-up of 38.4 months (range 14-64, follow-up rate 83.3%), patients' subjective functional knee scores (IKDC, Lysholm) were analysed, as were the results of objective examination (according to ICRS). Mean patient age at the time of surgery was 34.3 years (+/-10.1). The mean Lysholm score at the time of follow-up was 73.0 (+/-22.4) and the subjective IKDC score was 61.6 (+/-21.5); normal and nearly normal clinical results according to the objective criteria of the International Cartilage Research Society (ICRS) were achieved in 67.1% of the patients, while abnormal results were achieved in 20.0% of the patients and severely abnormal results, in 12.9%. While different surgical techniques did not seem to have any significant influence on the treatment results, both defect size and defect location within the patella were found to be significantly associated with clinical outcome. The corollaries to this are that larger cartilage lesions of the patella are associated with an inferior outcome (p = 0.007) and that cartilage defects located on the lateral patellar facet are correlated with a better clinical outcome than those located on the medial facet or those involving both facets (p = 0.017). This study demonstrates that within a group of patients treated with ACI for retropatellar cartilage lesion there are significant differences in clinical outcome, which are important and should be taken into account of when a decision has to be made on whether or not ACI is indicated.

Chondral lesions of the knee: A new localization method and correlation with associated pathology

Purpose: We report a new method of describing and recording chondral lesions of the knee at arthroscopy in order to permit a more accurate and meaningful analysis of patterns of articular cartilage damage. Type of Study: Case series study. Methods: Data were collected prospectively at 1,000 consecutive arthroscopies by the senior author and chondral lesions were recorded on anatomic articular maps divided into different functional zones. Ten zones on the femur were determined by tibiofemoral weight-bearing and flexion horizons (namely the 0°, 45°, 90°, and 120° horizons as they pass the anterior meniscosynovial junction). Ten zones were determined on the tibia, principally by meniscal relations, and 6 zones on the patella. This allowed the size, Outerbridge grade, and location to be analyzed in relation to mechanism, chronicity, and associated intra-articular pathologies. The recording methods were tested for interobserver reproducibility in 50 subsequent cases at the same arthroscopy by 2 independent observers. The results were analyzed by a third person, and showed a relatively small interobserver error of 7.2% for size for a set of grade 3 and 4 lesions and only a 3% error for site. The Fisher exact test was used. The data sheets were entered onto a computer spreadsheet database using standard software (Excel; Microsoft, Redmond, WA) to permit analysis of the data. Results: There were 1,553 chondral lesions in 853 patients correlated with associated lesions, including 356 meniscal lesions, 230 ligamentous injuries, 440 synovial lesions, and other pathologies. High degrees of correlation have been found between specific lesions and their opposing surfaces and the progression of these with time. Conclusions: The problem of precision of localization of articular lesions in the knee has been recently acknowledged by the International Cartilage Research Society (ICRS). However, such recording ought to take into account both function and contact with other structures. This would appear essential in the assessment of prognosis and comparisons between different treatment regimes.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 481–490