Introduction

Early Osteoarthritis (OA) and its prevention has become an important topic in many meetings on cartilage repair and induced probably one of the most important shifts of paradigm in the treatment algorithm of cartilage defects. Early OA includes on one hand a still circumscribed lesions of the joint surface, but it also covers early signs of the ongoing process of degeneration and inflammation leading to OA. This combination seems to be the most prominent pathophysiology in patients leading to medical treatment. Isolated Cartilage defects which are only circumscribed lesions are rare and not representative for the clinical problems orthopedic surgeons are seeing in their daily practice. Therefor clinical studies do not reflect the actual patients population, where surface defects are often associated with synovitis, general changes in the biological environment in the synovial fluid and also morphological changes of the menisci and ligaments as well as background factors like joint alignment and bodyweight. So, the cartilage repair technologies have arrived in the real world. Cartilage registries clearly see early OA as the dominant indication for cartilage surgery.

Content

Early OA is characterized by the progredient loss of cartilage integrity and cellularity which eventually leads to the functional impairment of the joint. A hallmark of the osteoarthritic degenerative process is the exuberant production of proinflammatory cytokines (e.g., IL-1β, TNF-α), matrix metalloproteinases (e.g., MMP-1, -3, -13), and reactive oxygen and nitrogen species (ROS, RNS) by chondrocytes and synoviocytes. Thereby these cells become integral players in the vicious circle driving disease progression. So overall, OA is a complex process of biomechanically induced degeneration, reactive inflammation, and a general aging process with changing cellular activity.

Conservative therapies of OA include nutrients, drugs and injectables like corticosteroids, hyaluronic acid, and platelet-rich plasma as well as mesenchymal stem cells. However, the progress of the disease and persistence of symptoms might indicate early surgery and not to await the development of a full OA.

Working groups of ICRS have taken on the problem and developed a systematic approach to early OA and recently published a book with that focus. The definition or early OA is related to joint symptoms like tenderness on the joint space or crepitation, radiological Kellgren Lawrence grades between around one and two. MRI changes generally reflecting ICRS grades 1-2 with one area more than that. Furthermore, unnormal joint alignment, partial meniscus defects and functional or structural instability of the joint might be associated with the condition described above. The later mentioned conditions are obviously the hallmark of indicating surgery in early OA, since the biomechanical situation of the joint with regards to alignment, meniscus deficiency and instability is probably the most important factor in progressing OA conditions. The indication is even more critical if a cartilage defect or zonal degeneration is associated with the biomechanical malcondition. In the knee a femoro-tibial malalignment of more than 5 degrees is considered substantial and should be addressed at the same time as the cartilage defect on the overloaded joint-compartment. Same applies for instable situations after ACL ruptures, because a cartilage repair procedure will just be successful in a stable joint. Acute meniscus ruptures should be addressed immediately anyway, even more so if a suture is possible. Degenerative lesions are depending on symptoms of locking or painful movement, whereas asymptomatic degeneration of the meniscus should be observed to what degree the lesion might contribute the clinical situation. There is still discussion in the priority of the surgical procedures which can be concomitant or sequential, however the plan has to be discussed with the patient and his needs and compliance.

The most critical decision for surgery is the defect of the local osteoarthritic process or defect on the joint surface itself. A symptomatic defect bigger than 2 square centimeters is obviously an indication for surgery, although the question is how much degenerative changes in the knee beside the defect do we accept? Age is obviously a fact, but individual age (genetic background) has to be considered. Most of treatment-studies with regenerative surgery like microfracture with biomaterial (AMIC) or chondrocyte transplantation show better results below the age of 40. Defects with ICRS grades 1 or 2 might not be an indication for direct surgery since the prognosis is uncertain and there is no evidence for such lesions. In cases of persistent pain, the presence of bone edema has to be assessed by MRI, because other options like subchondroplasty, drilling or osteoporotic drugs might be more be more favorable, sometimes unloading of the joint can overcome the symptoms. Other surgical options like allografts have widened the indication of local OA since they immediately provide a stable situation of the replaced joint surface and provide a sustainable solution. Due to the lack of fresh allografts in Europe partial joint replacement and synthetic resorbable implants have become popular, however they are often just an in-between solution on the way to total joint replacement.

As a conclusion surgery is clearly indicated regarding the background-factors like alignment and instability and acute meniscus lesions in early OA because the benefit of osteotomies, ACL reconstruction and meniscus surgery including allograft is evident with regards to OA progression prevention.

The preventive effect of cartilage surgery on the defect itself is more critical to be discussed depending on age, expectation, compliance and goals of the patient. So it is more important to treat the patient, than just to concentrate too much on the surgery in this complex process of early OA.

References

1. Lattermann C, Madry H, Nakamura N, Kon E. Early Osteoarthritis: State-of-the-Art Approaches to Diagnosis, Treatment and Controversies. Springer Nature; 2021.

2. Gomoll AH, Filardo G, de Girolamo L, Espregueira-Mendes J, Esprequeira-Mendes J, Marcacci M, et al. Surgical treatment for early osteoarthritis. Part I: cartilage repair procedures. Knee Surg Sports Traumatol Arthrosc. 2012 Mar;20(3):450–66.

3. Gomoll AH, Filardo G, Almqvist FK, Bugbee WD, Jelic M, Monllau JC, et al. Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures. Knee Surg Sports Traumatol Arthrosc. 2012 Mar;20(3):468–86.

4. Moser LB, Bauer C, Jeyakumar V, Niculescu-Morzsa E-P, Nehrer S. Hyaluronic Acid as a Carrier Supports the Effects of Glucocorticoids and Diminishes the Cytotoxic Effects of Local Anesthetics in Human Articular Chondrocytes In Vitro. Int J Mol Sci. 2021 Oct 25;22(21):11503.

5. Kon E, Engebretsen L, Verdonk P, Nehrer S, Filardo G. Clinical Outcomes of Knee Osteoarthritis Treated With an Autologous Protein Solution Injection: A 1-Year Pilot Double-Blinded Randomized Controlled Trial. Am J Sports Med. 2018 Jan;46(1):171–80.

Acknowledgments

None

Introduction

Articular cartilage injuries in the knee are observed with increasing incidence in both amateur and elite athletes. These injuries can be found either as a concomitant or as a stand-alone injury and result from acute and chronic joint stress associated with high impact sports. Recent surgical treatment options have been shown to successfully restore articular cartilage surfaces and allow athletes to return to high-impacts sports after a tailored and individualized rehabilitation program has been successfully completed. The rehabilitation program should take into consideration the biology of the cartilage repair technique, the defect characteristics and the athlete´s sport-specific demands. Further, progression within rehabilitation should be stepwise and criteria-based and rehabilitation should aim not only to achieve the pre-injury level, but also to continue sport participation, reduce the risk for reinjury and the progression to further joint degeneration. Rehabilitation after cartilage consists of three different phases:

Protection and joint activation

Joint loading and functional restoration

Activity restoration

The third phase is the transition phase for returning to sports and should therefore include sport-specific elements, reconditioning and on-field rehabilitation. This phase should allow a continued recovery and should address any remaining impairments in muscle power, sensorimotor control, metabolic impairment and sport-specific movement patterns. The principles of motor learning and in particular the advantages of the external focus of attention might help to optimize movement strategies, to regain confidence and to avoid fear avoidance mechanism. The use of modern technologies (virtual reality, movement apps, …) seems to be beneficial in terms of motivation and increasing athlete´s compliance.

The progression from one phase to the next should be criteria-based. These criteria should include subjective and objective outcomes and should ideally include all components of the International Classification of Functioning, Disability and Health (ICF). Patient education including understanding the issues of cartilage injuries and the importance of complying with the rehabilitation measures is critical to a successful return to sports. The decision of safely return athletes to sports after cartilage surgery is a critical decision and vary greatly for similar conditions and circumstances. Moreover, the question of how quickly to allow patients to return to sports and what are clinical factors and criteria that influence this decision has not been clearly answered so far.

Content

Articular cartilage injuries in the knee are observed with increasing incidence in both amateur and elite athletes. These injuries can be found either as a concomitant or as a stand-alone injury and result from acute and chronic joint stress associated with high impact sports. Recent surgical treatment options have been shown to successfully restore articular cartilage surfaces and allow athletes to return to high-impacts sports after a tailored and individualized rehabilitation program has been successfully completed. The rehabilitation program should take into consideration the biology of the cartilage repair technique, the defect characteristics and the athlete´s sport-specific demands. Further, progression within rehabilitation should be stepwise and criteria-based and rehabilitation should aim not only to achieve the pre-injury level, but also to continue sport participation, reduce the risk for reinjury and the progression to further joint degeneration. Rehabilitation after cartilage consists of three different phases:

Protection and joint activation

Joint loading and functional restoration

Activity restoration

The third phase is the transition phase for returning to sports and should therefore include sport-specific elements, reconditioning and on-field rehabilitation. This phase should allow a continued recovery and should address any remaining impairments in muscle power, sensorimotor control, metabolic impairment and sport-specific movement patterns. The principles of motor learning and in particular the advantages of the external focus of attention might help to optimize movement strategies, to regain confidence and to avoid fear avoidance mechanism. The use of modern technologies (virtual reality, movement apps, …) seems to be beneficial in terms of motivation and increasing athlete´s compliance.

The progression from one phase to the next should be criteria-based. These criteria should include subjective and objective outcomes and should ideally include all components of the International Classification of Functioning, Disability and Health (ICF). Patient education including understanding the issues of cartilage injuries and the importance of complying with the rehabilitation measures is critical to a successful return to sports. The decision of safely return athletes to sports after cartilage surgery is a critical decision and vary greatly for similar conditions and circumstances. Moreover, the question of how quickly to allow patients to return to sports and what are clinical factors and criteria that influence this decision has not been clearly answered so far.

References

Measuring physical activity and sports participation after autologous cartilage implantation: a systematic review.

Santos-Magalhaes AF, Hambly K.J Sport Rehabil. 2014 Aug;23(3):171-81. doi: 10.1123/jsr.2013-0044. Epub 2014 Apr 3.PMID: 24700540 Review

Return-to-Sport Review for Current Cartilage Treatments.

Skelley NW, Kurtenbach C, Kimber K, Piatt B, Noonan B.J Knee Surg. 2021 Jan;34(1):39-46. doi: 10.1055/s-0040-1721669. Epub 2021 Jan 3.PMID: 33389739 Review

Rehabilitation, Restrictions, and Return to Sport After Cartilage Procedures.

Wagner KR, Kaiser JT, DeFroda SF, Meeker ZD, Cole BJ.Arthrosc Sports Med Rehabil. 2022 Jan 28;4(1):e115-e124. doi: 10.1016/j.asmr.2021.09.029. eCollection 2022 Jan.PMID: 35141543

Rehabilitation and Return-to-Play Criteria After Fresh Osteochondral Allograft Transplantation: A Systematic Review.

Stark M, Rao S, Gleason B, Jack RA 2nd, Tucker B, Hammoud S, Freedman KB.Orthop J Sports Med. 2021 Jul 27;9(7):23259671211017135. doi: 10.1177/23259671211017135. eCollection 2021 Jul.PMID: 34377714

Introduction

Sport shows many positive effects on the general health. However, the effects of sports participation on joints and especially on osteoarthritic joints are still under debate. Intense sports participation leads to a marked increase in joint loading. During jogging a force of 3-5x times body weight is absorbed in the hip with every step. In a 70kg runner with a speed of 7km/h and a body height of around 170cm about 1250 steps are made per km, resulting in an absorption between 1300-2100 tons in each hip in a 10km run (Bergmann 1993). Nonetheless, low impact sports does not seem to have adverse effects on healthy joints and even high level runners do most likely not show increased osteoarthritis (OA) rates (Timmins 2016) in contrast for example to professional soccer players (Freiberg 2021). The development of OA is multifactorial and depended on many factors (e.g. age, body weight, joint injury, joint loading, quadriceps weakness, genetics, …) and many studies showed a higher incidence of OA in knees of former high-impact sports players compared to the normal population (e.g. Kujala 1995).

Content

Sport in osteoarthritic joints can reduce pain, restore joint motion and strengthen surrounding muscles and is an important part of conservative therapy (Fransen 2015). A recent systematic review has shown, that active exercise and sport are effective to improve pain and physical function in elderly people with osteoarthritis (Zampogna 2020). Additional weight loss and positive effects on body metabolism (diabetes, hypertension, fat) are reported in newer studies. Weight loss is an important modifiable risk factor for progression of osteoarthritis in the knee. Thereby, it is hoped that low impact sport can slow down progression of osteoarthritis. Numerous studies show the detrimental effect of meniscal, cartilage and ligamentous instability as well as malalignment on the development of (post-traumatic) osteoarthritis. To improve the outcome, joint integrity should be restored as good as possible before participating in sports. Whether osteoarthritis and sports are possible, depends on many factors. It is important to know, that osteoarthritis and well selected sports can delay the progression of osteoarthritis. An individualized approach to sports participation for each patient is necessary, no performance goals and good technique and equipment are important.

References

Hip joint loading during walking and running, measured in two patients. Bergmann G, Graichen F, Rohlmann A. J Biomech. 1993 Aug;26(8):969-90. doi: 10.1016/0021-9290(93)90058-m.

Running and Knee Osteoarthritis: A Systematic Review and Meta-analysis. Timmins KA, Leech RD, Batt ME, Edwards KL. Am J Sports Med. 2017 May;45(6):1447-1457. doi: 10.1177/0363546516657531. Epub 2016 Aug 20.

The Risk of Knee Osteoarthritis in Professional Soccer Players-a Systematic Review With Meta-Analyses. Freiberg A, Bolm-Audorff U, Seidler A.Dtsch Arztebl Int. 2021 Jan 29;118(4):49-55. doi: 10.3238/arztebl.m2021.0007.

Knee osteoarthritis in former runners, soccer players, weight lifters, and shooters. Kujala UM, Kettunen J, Paananen H, Aalto T, Battié MC, Impivaara O, Videman T, Sarna S. Arthritis Rheum. 1995 Apr;38(4):539-46. doi: 10.1002/art.1780380413.

Exercise for osteoarthritis of the knee: a Cochrane systematic review. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Br J Sports Med. 2015 Dec;49(24):1554-7. doi: 10.1136/bjsports-2015-095424. Epub 2015 Sep 24.

The Role of Physical Activity as Conservative Treatment for Hip and Knee Osteoarthritis in Older People: A Systematic Review and Meta-Analysis. Zampogna B, Papalia R, Papalia GF, Campi S, Vasta S, Vorini F, Fossati C, Torre G, Denaro V. J Clin Med. 2020 Apr 18;9(4):1167. doi: 10.3390/jcm9041167.