meniscus, articular cartilage and the degenerative knee in ...forms.acsm.org/tpc/pdfs/32 ott.pdf ·...

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

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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 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 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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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

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


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


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.


Case 2 : Radiographs


Case 2 : Arthroscopic findings


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


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


Arthroscopy NSAIDs Strength/normal weight Injections (steroid or visico

supplementation) Unloader brace Osteotomy Arthoplasty

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

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THANK YOU Susan M. Ott DO

FACSM [email protected]

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