Anterior cruciate ligament (ACL) ruptures are commonly associated with articular cartilage injuries, and the presence of these defects influences both short- and long-term outcomes. Multiple variables are predictive of this pathology including time from injury, age, and sex. Revision ACL reconstructions demonstrate higher rates of chondral injury than primary reconstructions. Successful outcomes with multiple treatment options for chondral injuries in conjunction with ACL reconstruction have been reported. On the other hand, high-grade chondral defects have the most consistent and potentially largest negative effect on long-term patient-reported outcomes; however, some natural healing response of chondral injuries following ACL reconstruction. Optimal treatment has been also controversial to expect successful results with several modalities including benign neglect. Recent studies suggest that achieving anatomic graft placement is critical to restoring native ACL function and normal knee kinematics. Knees with grafts that more closely restored normal ACL function, and thus knee motion, experienced less focal cartilage deterioration than did those that experienced abnormal knee motion. Thus, achieving anatomic graft placement is a critical factor in restoring normal knee motion and potentially slowing the development of degenerative changes after ACL reconstruction.
For evaluation of cartilage morphology, Magnetic resonance imaging (MRI) has become the preferred modality for imaging the pathology. Due to the diverse pathology, complex anatomy, and various injury mechanisms of the knee, the MRI knee protocol and sequences should ensure detection of both soft tissue and osseous structures in detail and with accuracy. Recent advances in MRI techniques allow for improved imaging in the postoperative knee changes including cartilage. As treatment and operative management techniques evolve, understanding the correct application of these advancements in MRI of the knee will prove to be valuable to clinical practice.
This presentation will provide latest topics on ACL and Cartilage, which could lead to better strategic planning to prevent osteoarthritis.
The main topic are as follows:
1. How chondral lesions affect the symptoms and outcomes of patients with ACL injury.
2. Natural healing course of chondral lesions in patients with ACL injury.
3. Imaging of cartilage condition following ACL injury and reconstruction
4. How ACL reconstruction affects articular surface and the progression of osteoarthritis.
5. Emerging technologies to treat patients with the combined pathologies.
6. Future perspective.
1. The protective effect of anterior cruciate ligament reconstruction on articular cartilage: a systematic review of animal studies. Deckers C, Stephan P, Wever KE, Hooijmans CR, Hannink G. Osteoarthritis Cartilage. 2019 Feb;27(2):219-229.
2. Knee Imaging Following Anterior Cruciate Ligament Reconstruction: The Surgeon's and Radiologist's Perspectives. Srinivasan R, Wan J, Allen CR, Steinbach LS.Semin Musculoskelet Radiol. 2018 Sep;22(4):386-397.
3. Recurrent Instability Episodes and Meniscal or Cartilage Damage After Anterior Cruciate Ligament Injury: A Systematic Review. Sommerfeldt M, Raheem A, Whittaker J, Hui C, Otto D. Orthop J Sports Med. 2018 Jul 24;6(7):2325967118786507.
4. Factors that affect patient reported outcome after anterior cruciate ligament reconstruction-a systematic review of the Scandinavian knee ligament registers. Hamrin Senorski E, Svantesson E, Baldari A, Ayeni OR, Engebretsen L, Franceschi F, Karlsson J, Samuelsson K. Br J Sports Med. 2019 Apr;53(7):410-417.
5. Risk factors for radiographic joint space narrowing and patient reported outcomes of post-traumatic osteoarthritis after ACL reconstruction: Data from the MOON cohort. Jones MH, Spindler KP. J Orthop Res. 2017 Jul;35(7):1366-1374.
6. Effects of ACL graft placement on in vivo knee function and cartilage thickness distributions. DeFrate LE. J Orthop Res. 2017 Jun;35(6):1160-1170.
7. Surgical Indications and Technique for Anterior Cruciate Ligament Reconstruction Combined with Lateral Extra-articular Tenodesis or Anterolateral Ligament Reconstruction. Vundelinckx B, Herman B, Getgood A, Litchfield R. Clin Sports Med. 2017 Jan;36(1):135-153.
8. Outcomes and Risk Factors of Rerevision Anterior Cruciate Ligament Reconstruction: A Systematic Review. Liechti DJ, Chahla J, Dean CS, Mitchell JJ, Slette E, Menge TJ, LaPrade RF. Arthroscopy. 2016 Oct;32(10):2151-2159.
We thank Dr. Christian Latterman, Takashi Nishii and Shuji Horibe for substantial discussion in preparation.
The meniscus is essential for joint homeostasis. When the meniscus is injured or deficient, increased contact forces over decreased contact area lead to wearing of the articular cartilage. When considering cartilage restoration, it is critical to evaluate and restore meniscus function.
Meniscus tissue is characterized by low cell density and a dense extracellular matrix (ECM), which mainly consists of water, type I collagen, glycosaminoglycans (GAGs) and elastin. With their semilunar wedge-shaped structure, the menisci play an important role in shock absorption, load transmission and stability of the knee. Damage to the meniscus is a very common injury, which leads to loss of its role in chondroprotection in the knee. Especially in young patients with high activity levels, loss of meniscus function can lead to an increased risk of developing early osteoarthritis (OA). (Partial) meniscectomy used to be the first choice in treatment of meniscus tears; however, due to the high risk of developing post-meniscectomy osteoarthritis secondary to increased contact pressure on cartilage, meniscus repair is becoming more popular. Meniscus repair is not suitable for all types of tears; therefore, meniscus restoration using allograft transplantation or biodegradable meniscus scaffolds are of interest.
Meniscus repair provides improved long-term outcomes, better clinical outcome scores, and less severe degenerative changes seen radiographically compared with partial meniscectomy. Advancements in surgical techniques have expanded the capability for meniscal repair, while the implementation of biologic augmentation appears to improve healing rates. However, clinical data remain sparse, and prospective randomized trials are needed. It is critical that surgeons treating meniscal tears be familiar with the evolving repair techniques to optimize the health and longevity of the knee joint.
Similarly, advances in meniscus allograft transplantation and partial meniscus replacement have improved recently. Future advances will include approaches to meniscus regeneration through available scaffolds, MSCs, and recycled meniscus cells. It would be cost effective, a lower patient burden, and logistically attractive to use these cells in a one-stage procedure for meniscus regeneration. Recently, a clinical study showed the safety and feasibility of a combination of recycled autologous chondrons with allogeneic Mesenchymal stromal cells (MSCs) in cartilage repair.(de Windt and Saris et al., 2017) This and other studies suggest that allogeneic MSCs provide stimulatory and immunomodulatory factors for tissue repair, and could positively stimulate a smaller number of meniscus cells. Further investigation is needed.
In summary, the meniscus is essential to normal knee joint homeostasis. Preservation of the meniscus--by avoiding total meniscectomy, and repair of the meniscus when possible--is vital to normal articular cartilage function. When the mensicsu is absent, meniscus allograft transplantation is a good option. Further efforts need to be made for partial meniscus restoration and regeneration solutions.
Woodmass JM, LaPrade RF, Sgaglione NA, Nakamura N, Krych AJ. Meniscal Repair: Reconsidering Indications, Techniques, and Biologic Augmentation. J Bone Joint Surg Am. 2017 Jul 19;99(14):1222-1231
Moatshe G, Cinque ME, Godin JA, Vap AR, Chahla J, LaPrade RF. Comparable Outcomes After Bucket-Handle Meniscal Repair and Vertical Meniscal Repair Can Be Achieved at a Minimum 2 Years' Follow-up. Am J Sports Med. 2017 Nov;45(13):3104-3110.
Cinque ME, Geeslin AG, Chahla J, Dornan GJ, LaPrade RF. Two-Tunnel Transtibial Repair of Radial Meniscus Tears Produces Comparable Results to Inside-Out Repair of Vertical Meniscus Tears. Am J Sports Med. 2017 Aug;45(10):2253-2259.