- Participants should understand the possibilities and problems of arthroscopic approaches in cartilage repair. New innovative arthroscopic treatment options in various joints will be presented and clinical results discussed.
3.1.1 - Arthroscopic Approach to Cartilage Defects in The Knee (Pre-Recorded)
3.1.2 - Arthroscopic Approach to Cartilage Defects – Ankle (Pre-Recorded)
A number of operative treatment options have been reported to treat osteochondral lesions of the talus (OLT). The choice of operative treatment methods are dependent on the grade, size and site of the lesion. Recently, several new techniques have been introduced for the management of such lesions. However, there is a lack randomized or comparative studies to determine whether one technique is superior to the others. Bone marrow stimulation with microfracture arthroplasty is the most common procedure for the management of OLT. It induces repair of localized articular cartilage defects of the talus. The use of additional scaffolds has become increasingly popular with several case series reporting promising results in the treatment of OLT´s in athletes and with the combination of an autologous bone graft in the mid-term.
The treatment with a scaffold has been designed to be performed by an open technique that often involves a medial or lateral malleolar osteotomy. Arthroscopic treatment is believed being advantageous because it is associated with significantly less surgical trauma than the open technique, and it avoids the need for a malleolar osteotomy. Furthermore, arthroscopic evaluation allows the status of the cartilage to be accurately assessed in all parts of the joint. Possible complications of malleolus osteotomy that include direct morbidity by injury to adjacent structures, mid-term morbidity by malunion or non-union of the osteotomy, and long-term morbidity by the development of local cartilage degeneration and the need for hardware removal, which may become symptomatic in an area with a limited soft tissue envelope, can be avoided.
The procedure is performed with the patient under either spinal or general anesthesia in the supine position using standard anteromedial and anterolateral portal approaches for the ankle. The application of a thigh tourniquet at a pressure of 250-300 mmHg is recommended. For distraction, a Hintermann-Spreader or an ankle arthroscopy distraction strap or bandage can be used. Debridement of the lesion is performed in common fashion by creating healthy and stable cartilage borders and vital bleeding subchondral bone by bone marrow stimulation. If a bone graft is needed (recommended in lesions with a depth of >3mm bone defect), enlargement of the portal, by which the lesion is treated, is recommended to a length of about 2cm. The intraarticular fluid needs to be removed after debridement and the OLT dried using cotton sponges. The application of a cannula might facilitate the application of the bone graft and an acellular matrix. Fixation of the matrix might be necessary using a commercially available fibrin glue. The stability of the matrix should be checked within a normal ankle range of motion under direct arthroscopic vision.
Reported complication rates for the arthroscopic approach in the treatment of OLT of the talus are low. Arthroscopic bone marrow stimulation with microfracture alone and with the addition of an acellular matrix with or without a bone graft are effective for the treatment of patients suffering from osteochondral talar lesions. Further research is requested to determine possible differences with respect to possible influencing parameters such as lesion size and its depth.
3.1.4 - The Shoulder & Elbow
The forces applied to the cartilage surfaces of the shoulder and elbow are generally lower than at the weightbearing joints of the lower extremities. Thus, focal chondral or osteochondral defects and early osteoarthritis are considerably less common than in the knee, hip or ankle.
Nonetheless, potentially clinically relevant focal defects can be found in over one fifth of patients with rotator cuff tears, impingement or general shoulder pain. The reasons for focal glenohumeral cartilage defects are manifold and include previous surgeries, trauma, osteochodritis dissecans, infections, avascular necrosis, rheumatoid arthritis, instabilities, or rotator cuff insufficiencies.
The symptoms of glenohumeral cartilage defects include stress-induced shoulder pain or pain at rest, limited sports performance, sharp pain or mechanical obstructions, or progressively increasing pain. However, symptoms are often unspecific and frequently do not allow to diagnose cartilage defects or gauge their significance in shoulder pain. Thus, the treatment of concomitant pathologies is a primary goal when glenohumeral cartilage defects are diagnosed and treated. As cartilage lesions around the shoulder are often an incidental finding and rarely occur in isolation, the influence on outcomes of treating concomitant pathhologies versus addressing cartilage defects is still controversial.
Various treatment options are available today, whereas overall results are very promising independent of chosen treatment modality. According to personal experience and scientific evidence, microfracturing is a simple but reliable treatment option, which leads to improvements of shoulder function and pain reduction. In contrast to microfracturing in the knee, results tend to remain stable even in the longterm. Similar to the knee, microfracturing is the first line treatment for focal, chondral defects of the glenohumeral joint under 2cm2. Larger chondral defects (2-6cm2) can be addressed with various forms of autologous chondrocyte transplantation. If there is bone involvement present (osteochondral lesions), osteochondral transfers from the humerus or knee provide a treatment option for defects <2.5cm2. Larger osteochondral lesions can be treated with partial humeral head resurfacing.
Around the elbow, focal chondral and osteochondral lesions are particularly common at the humeral capitulum in the context of an osteochondrosis dissecans in gymnasts and repetitive overhead or throwing athletes. Osteochondral lesions of the elbow also occur as the result of acute trauma or reduced joint congruency due to instability.
Contrary to the shoulder, microfracturing has not been as reliable around the elbow and has been associated with progressive degeneration and low return to sports rates. Thus, it should be reserved for small defects with limited symptoms when encountered as an incidental finding during arthroscopy for concomitant pathologies. For larger chondral lesions or osteochondral defects, autologous osteochondral transplantation - primarily using osteochondral plugs from the ipsilateral proximal femoral condyle - is the treatment option of choice. This has shown relatively good clinical and radiological results even in the longterm, while progression of degeneration seems to be slower compared to microfracturing. Furthermore, due to its anatomic characteristics and congruent nature of the elbow joint, treatment options are significantly influenced by the exact location of the defect. Treatment of concomitant pathologies (e.g. instabilities, plicae, loose bodies, etc.) and restoration of native joint mechanics are especially important at the elbow.