Knee Cartilage, Diagnosis, Modern Imaging and Treatments- A comprehensive guide for
Published at: 26/12/2023

Knee Cartilage, Diagnosis, Modern Imaging and Treatments- A comprehensive guide for

Knee cartilage is a vital component of joint health, crucial for movement and weight-bearing activities. Understanding its structure, pathologies, and treatment options is essential for effective management of knee-related issues.

Understanding the Knee Joint:

The knee joint comprises the femur (thighbone), tibia (shinbone), and patella (kneecap). These bones are lined with articular cartilage, which acts as a shock absorber during movement. Another type of cartilage, the meniscus, is found in the knee, providing additional cushioning.

Nature of Cartilage Injuries:

Unlike muscle and bone, cartilage lacks a direct blood supply, limiting its natural healing capacity. Damage to articular cartilage can manifest as pain, inflammation, a clicking noise, a catching sensation, and reduced range of motion. Injuries exceeding a centimeter in size may worsen over time, potentially leading to osteoarthritis.

Common Causes:

Knee cartilage injuries often result from repetitive actions, such as stairs, traumatic events, or intense physical activities. They can also occur alongside other knee injuries like meniscus tears and ligament damage.

Diagnosing Knee Cartilage Injuries

 

Symptoms and Physical Examination:

Pain, swelling, reduced motion, and sensations like clicking or locking are typical symptoms of cartilage damage. A physical examination assesses tenderness, pain, and knee motion range.

MRI is the Gold standard for detecting cartilage problem

X-ray or CT scan are only helpful in very severe stage or for pre-op planning

Advanced Imaging Techniques in Cartilage Diagnosis

MRI - The Cornerstone of Diagnosis:

MRI is a noninvasive tool critical for visualizing knee joint structures and assessing cartilage defects. It provides detailed images of the knee's soft tissues, including the cartilage.

Advanced MRI Techniques:

Innovations like T2 mapping, dGEMRIC, T1ρ imaging, sodium imaging, and diffusion-weighted imaging offer deeper insights into the knee cartilage's collagen network and proteoglycan content. These techniques are instrumental in evaluating the composition and integrity of knee cartilage, aiding in the diagnosis and assessment of cartilage-related pathologies (Crema et al., 2011; Ding et al., 2005).

Ultra-High-Field MRI:

Recent developments in ultra-high-field MRI present new methods for indirectly assessing the integrity and structural changes of articular cartilage (Kohl et al., 2015).

Treatment Approaches for Knee Cartilage Pathologies

Conservative Management and Physiotherapy:

Initial management often involves conservative methods and physiotherapy, focusing on pain reduction and improving knee movement and strength. It is controversial, as the damage cartilage might or might not repair oe heal itself.

Injection Therapy:

Regenerative Medicine and Emerging Treatments: Emerging therapies like cell and growth fractor treatments show promise in regenerating damaged cartilage. These innovative approaches are reshaping the treatment landscape for knee cartilage injuries. 

  • mFAT, lipogems, uFat, NFat
  • PRP, A-PRP, B-PRP, C-PRP
  • PRF, Arthrozheal 
  • n-Stride, Cellamartix, Gold
  • Medicinal Signaling Cells 
  • BMAC
  • Exsosome
  • Arthrosamid, iPAAG, Hydrogel

Please check here to find out more about injection therapy for cartigle 

Surgical Interventions:

In the realm of orthopaedic surgery, various advanced techniques have been developed to address the complexities of cartilage repair in the knee. These interventions range from minimally invasive procedures to more complex surgical techniques, each tailored to address specific types of cartilage damage and to cater to individual patient needs. This section delves into an array of surgical interventions, discussing their methodologies, applications, and the nuances that make each technique unique in its approach to restoring knee function and alleviating pain. From the debated microfracture technique to innovative procedures like Liquid Cartilage Therapy and Autologous Chondrocyte Implantation (ACI), these interventions represent the cutting edge of cartilage repair and regeneration. We also explore Matrix-Induced Autologous Chondrocyte Implantation (MACI), Autologous Matrix-Induced Chondrogenesis (AMIC), Osteochondral Autograft Transplantation (OAT), and other advanced techniques that signify remarkable progress in orthopaedic surgery. Each method brings its strengths and considerations, contributing to a comprehensive approach to treating cartilage lesions in the knee.

Microfracture: a technique used for cartilage repair, has been subject to debate due to its limitations and potential adverse outcomes. The limitations of microfracture include the potential for subchondral bone overgrowth, the formation of fibrocartilage instead of hyaline cartilage, and the lack of long-term durability. These factors raise concerns about the efficacy and long-term outcomes of microfracture as a sole treatment for cartilage defects. (Green et al., 2016) (Mohan et al., 2015) (Kim et al., 2015).

Liquid Cartilage Therapy: Liquid Cartilage Therapy, a novel, minimally invasive treatment, involves injecting a collagen-based solution into the damaged joint to stimulate natural cartilage regeneration.

Autologous Chondrocyte Implantation (ACI): ACI is a well-established surgical technique for treating isolated cartilage lesions, involving the implantation of autologous chondrocytes. This process promotes the formation of hyaline-like cartilage, aiming to restore the cartilage's integrity (Gille et al., 2010).

Matrix-Induced Autologous Chondrocyte Implantation (MACI): MACI is particularly effective for chondral defects in the patellofemoral joint. Research has demonstrated that MACI offers a more efficacious alternative to microfracture, with a similar safety profile for treating symptomatic articular cartilage defects of the knee (Kim, J., Heo, J., & Lee, D., 2020).

Characterized Chondrocyte Implantation (CCI) and MACI: The evolution of techniques such as CCI and MACI reflects significant advancements in cartilage repair, providing a range of options for managing knee cartilage lesions (Frank et al., 2018).

Autologous Matrix-Induced Chondrogenesis (AMIC): Gille et al. (2010) and subsequent studies (Kim et al., 2020; Volz et al., 2017) have shown that AMIC, which combines the microfracture technique with a collagen scaffold, is effective in reconstructing damaged cartilage surfaces and has long-term efficacy.

Osteochondral Autograft Transplantation (OAT): OAT is a technique where healthy hyaline cartilage is transplanted from a non-weight-bearing region of the knee to a damaged area. It has shown success in managing chondral or osteochondral defects of the patella (Redondo et al., 2018).

Mega-OATS: Though less common, Mega-OATS is used for large osteochondral defects at the weight-bearing region of the femoral condyles, especially in young individuals (Jungmann et al., 2015).

Hyalofast with Microfracture: Hyalofast grafting, combined with microfracture, presents a minimally invasive treatment for joint cartilage defects. This method offers a new approach for biological resurfacing of grade IV articular cartilage ulcers in the knee joint (Tan et al., 2020).

Osteochondral Plug Allograft Transplantation: This surgical approach repairs cartilage and underlying bone defects in the knee. It has demonstrated efficacy in addressing cartilage lesions (Bowland et al., 2018).

Silk-Fibroin-Gelatin Scaffolds for Cartilage Repair: Shi et al. (2017) demonstrated the effectiveness of these scaffolds in providing a suitable microenvironment for mesenchymal stem cell proliferation and cartilage repair.

The Role of Gait Mechanics and Deep Learning: Gait mechanics significantly influence cartilage morphology and the development of osteoarthritis (Andriacchi et al., 2009). Additionally, deep learning models based on MRI are being explored for automated detection of knee joint motion injuries (Mei et al., 2022).

Conclusion

MRI plays a pivotal role in diagnosing and assessing knee cartilage pathologies, with advanced techniques providing comprehensive evaluations. These diagnostic advancements, combined with emerging treatments, offer promising avenues for managing knee cartilage injuries and enhancing patient outcomes.

References:

  1. Andriacchi, T., Koo, S. & Scanlan, S., 2009. Gait mechanics influence healthy cartilage morphology and osteoarthritis of the knee. The Journal of Bone and Joint Surgery (American), 91(Supplement_1), pp. 95-101. Available at: https://doi.org/10.2106/jbjs.h.01408.

  2. Crema, M., Roemer, F., Marra, M., Burstein, D., Gold, G., Eckstein, F., … & Guermazi, A., 2011. Articular cartilage in the knee: current MR imaging techniques and applications in clinical practice and research. Radiographics, 31(1), pp. 37-61. Available at: https://doi.org/10.1148/rg.311105084.

  3. Ding, C., Garnero, P., Cicuttini, F., Scott, F., Cooley, H. & Jones, G., 2005. Knee cartilage defects: association with early radiographic osteoarthritis, decreased cartilage volume, increased joint surface area and type II collagen breakdown. Osteoarthritis and Cartilage, 13(3), pp. 198-205. Available at: https://doi.org/10.1016/j.joca.2004.11.007.

  4. Englund, M., Guermazi, A., Gale, D., Hunter, D., Aliabadi, P., Clancy, M., … & Felson, D., 2008. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. New England Journal of Medicine, 359(11), pp. 1108-1115. Available at: https://doi.org/10.1056/nejmoa0800777.

  5. Gong, R., Hase, K., WANG, S. & Ota, S., 2022. A novel attempt for diagnosing Outerbridge classification of articular cartilage damage via vibration transmission. Journal of Biomechanical Science and Engineering, 17(3), 21-00319-21-00319. Available at: https://doi.org/10.1299/jbse.21-00319.

  6. Kohl, S., Meier, S., Ahmad, S., Bonel, H., Exadaktylos, A., Krismer, A., … & Evangelopoulos, D., 2015. Accuracy of cartilage-specific 3-tesla 3d-dess magnetic resonance imaging in the diagnosis of chondral lesions: comparison with knee arthroscopy. Journal of Orthopaedic Surgery and Research, 10(1). Available at: https://doi.org/10.1186/s13018-015-0326-1.

  7. Mei, X., Liu, Y. & Cai, X., 2022. Automated detection model based on deep learning for knee joint motion injury due to martial arts. Computational and Mathematical Methods in Medicine, 2022, pp. 1-7. Available at: https://doi.org/10.1155/2022/3647152.

  8. Oak, S. & Spindler, K., 2020. Measuring outcomes in knee articular cartilage pathology. The Journal of Knee Surgery, 34(01), pp. 011-019. Available at: https://doi.org/10.1055/s-0040-1716362.

  9. Wang, K., Xing, D., Dong, S. & Lin, J., 2019. The global state of research in nonsurgical treatment of knee osteoarthritis: a bibliometric and visualized study. BMC Musculoskeletal Disorders, 20(1). Available at: https://doi.org/10.1186/s12891-019-2804-9.

  10. Youssef, M. & Abdelwahab, U., 2020. T2 mapping sequence in the assessment of articular cartilage of knee joint. Is there added value? The Medical Journal of Cairo University, 88(6), pp. 1089-1095. Available at: https://doi.org/10.21608/mjcu.2020.110845.

  11. Gille, J., Schuseil, E., Wimmer, J., Gellissen, J., Schulz, A. & Behrens, P., 2010. Mid-term results of autologous matrix-induced chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery Sports Traumatology Arthroscopy, 18(11), pp. 1456-1464. DOI: 10.1007/s00167-010-1042-3.

  12. Kim, J., Heo, J. & Lee, D., 2020. Clinical and radiological outcomes after autologous matrix-induced chondrogenesis versus microfracture of the knee: a systematic review and meta-analysis with a minimum 2-year follow-up. Orthopaedic Journal of Sports Medicine, 8(11), 232596712095928. DOI: 10.1177/2325967120959280.

  13. Frank, R., Cotter, E., Strauss, E., Gomoll, A. & Cole, B., 2018. The utility of biologics, osteotomy, and cartilage restoration in the knee. Journal of the American Academy of Orthopaedic Surgeons, 26(1), e11-e25. DOI: 10.5435/jaaos-d-17-00087.

  14. Redondo, M., Beer, A. & Yanke, A., 2018. Cartilage restoration: microfracture and osteochondral autograft transplantation. The Journal of Knee Surgery, 31(03), pp. 231-238. DOI: 10.1055/s-0037-1618592.

  15. Jungmann, P., Brucker, P., Baum, T., Link, T., Foerschner, F., Minzlaff, P., … & Bauer, J., 2015. Bilateral cartilage T2 mapping 9 years after Mega-OATS implantation at the knee: a quantitative 3T MRI study. Osteoarthritis and Cartilage, 23(12), pp. 2119-2128. DOI: 10.1016/j.joca.2015.06.013.

  16. Tan, S., Tho, S. & Tho, K., 2020. Biological resurfacing of grade IV articular cartilage ulcers in the knee joint with Hyalofast. Journal of Orthopaedic Surgery, 28(1), 230949902090515. DOI: 10.1177/2309499020905158.

  17. Bowland, P., Ingham, E., Fisher, J. & Jennings, L., 2018. Simple geometry tribological study of osteochondral graft implantation in the knee. Proceedings of the Institution of Mechanical Engineers Part H Journal of Engineering in Medicine, 232(3), pp. 249-256. DOI: 10.1177/0954411917751560.

  18. Mithoefer, K., McAdams, T., Williams, R., Kreuz, P. & Mandelbaum, B., 2009. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee. The American Journal of Sports Medicine, 37(10), pp. 2053-2063. DOI: 10.1177/0363546508328414.

  19. Green, C., Beck, A., Wood, D. & Zheng, M., 2016. The biology and clinical evidence of microfracture in hip preservation surgery. Journal of Hip Preservation Surgery, 3(2), pp. 108-123. DOI: 10.1093/jhps/hnw007.

  20. Mohan, N., Gupta, V., Sridharan, B., Mellott, A., Easley, J., Palmer, R. … & Detamore, M., 2015. Microsphere-based gradient implants for osteochondral regeneration: a long-term study in sheep. Regenerative Medicine, 10(6), pp. 709-728. DOI: 10.2217/rme.15.38.

  21. Kim, J., Cho, H., Young, K., Park, J., Lee, J. & Suh, D., 2015. In vivo animal study and clinical outcomes of autologous atelocollagen-induced chondrogenesis for osteochondral lesion treatment. Journal of Orthopaedic Surgery and Research, 10(1). DOI: 10.1186/s13018-015-0212-

  22. Watanabe, A., Boesch, C., Anderson, S., Brehm, W. & Varlet, P., 2009. Ability of dgemric and t2 mapping to evaluate cartilage repair after microfracture: a goat study. Osteoarthritis and Cartilage, 17(10), pp. 1341-1349. DOI: 10.1016/j.joca.2009.03.022.

  23. Hevesi, M., Bernard, C., Hartigan, D., Levy, B., Domb, B. & Krych, A., 2019. Is microfracture necessary? acetabular chondrolabral debridement/abrasion demonstrates similar outcomes and survival to microfracture in hip arthroscopy: a multicenter analysis. The American Journal of Sports Medicine, 47(7), pp. 1670-1678. DOI: 10.1177/

About Authors
Prof. Paul Lee
(146)
  • Available on Thursday, February 29
View Profile
Related Articles