Top

Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

Open Access 01-04-2010 | Knee

The subchondral bone in articular cartilage repair: current problems in the surgical management

Authors: Andreas H. Gomoll, Henning Madry, Gunnar Knutsen, Niek van Dijk, Romain Seil, Mats Brittberg, Elizaveta Kon

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 4/2010

Abstract

As the understanding of interactions between articular cartilage and subchondral bone continues to evolve, increased attention is being directed at treatment options for the entire osteochondral unit, rather than focusing on the articular surface only. It is becoming apparent that without support from an intact subchondral bed, any treatment of the surface chondral lesion is likely to fail. This article reviews issues affecting the entire osteochondral unit, such as subchondral changes after marrow-stimulation techniques and meniscectomy or large osteochondral defects created by prosthetic resurfacing techniques. Also discussed are surgical techniques designed to address these issues, including the use of osteochondral allografts, autologous bone grafting, next generation cell-based implants, as well as strategies after failed subchondral repair and problems specific to the ankle joint. Lastly, since this area remains in constant evolution, the requirements for prospective studies needed to evaluate these emerging technologies will be reviewed.

Ahn H, Bhandari M, Schemitsch EH (2009) An evidence-based approach to the adoption of new technology. J Bone Joint Surg Am 91(Suppl 3):95–98CrossRefPubMed

Ahn IE, Ju JH, Park SH, Kim HY (2009) Radiologic observation: repair of focal bone erosions after humanized antitumor necrosis factor antibody adalimumab therapy in a patient with rheumatoid arthritis. Clin Rheumatol (e-pub ahead of print)

Anderson JM (2000) The cellular cascades for wound healing. In: Davis JE (ed) Bone engineering. Em Squared Inc, Toronto, pp 81–93

Armstrong CG (1986) An analysis of the stresses in a thin layer of articular cartilage in a synovial joint. Eng Med 15:55–61CrossRefPubMed

Atkinson TS, Haut RC, Altiero NJ (1998) Impact-induced fissuring of articular cartilage: an investigation of failure criteria. J Biomech Eng 120:181–187CrossRefPubMed

Baratz ME, Fu FH, Mengato R (1986) Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med 14:270–275CrossRefPubMed

Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S, Einhorn TA, Felson DT (2003) The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am 85A:4–9

Boursinos LA, Karachalios T, Poultsides L, Malizos KN (2009) Do steroids, conventional non-steroidal anti-inflammatory drugs and selective Cox-2 inhibitors adversely affect fracture healing? J Musculoskelet Neuronal Interact 9:44–52PubMed

Brandt KD, Radin EL, Dieppe PA, van de Putte L (2006) Yet more evidence that osteoarthritis is not a cartilage disease. Ann Rheum Dis 65:1261–1264CrossRefPubMed

10.

Brittberg M (2008) Autologous chondrocyte implantation–technique and long-term follow-up. Injury 39(Suppl 1):S40–S49CrossRefPubMed

11.

Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L (1994) Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 331:889–895CrossRefPubMed

12.

Brucker PU, Braun S, Imhoff AB (2008) Mega-OATS technique–autologous osteochondral transplantation as a salvage procedure for large osteochondral defects of the femoral condyle. Oper Orthop Traumatol 20:188–198CrossRefPubMed

13.

Burr DB, Radin EL (2003) Microfractures and microcracks in subchondral bone: are they relevant to osteoarthrosis? Rheum Dis Clin North Am 29:675–685CrossRefPubMed

14.

Clines GA (2009) Prospects for osteoprogenitor stem cells in fracture repair and osteoporosis. Curr Opin Organ Transplant (e-pub ahead of print)

15.

Custers RJ, Dhert WJ, Saris DB, Verbout AJ, van Rijen MH, Mastbergen SC, Lafeber FP, Creemers LB (2009) Cartilage degeneration in the goat knee caused by treating localized cartilage defects with metal implants. Osteoarthritis Cartilage (e-pub ahead of print)

16.

Custers RJ, Dhert WJ, van Rijen MH, Verbout AJ, Creemers LB, Saris DB (2007) Articular damage caused by metal plugs in a rabbit model for treatment of localized cartilage defects. Osteoarthritis Cartilage 15:937–945CrossRefPubMed

17.

Custers RJ, Saris DB, Dhert WJ, Verbout AJ, van Rijen MH, Mastbergen SC, Lafeber FP, Creemers LB (2009) Articular cartilage degeneration following the treatment of focal cartilage defects with ceramic metal implants and compared with microfracture. J Bone Joint Surg Am 91:900–910CrossRefPubMed

18.

Daftari TK, Whitesides TE Jr, Heller JG, Goodrich AC, McCarey BE, Hutton WC (1994) Nicotine on the revascularization of bone graft. An experimental study in rabbits. Spine 19:904–911CrossRefPubMed

19.

Davies JE, Hosseii MM (2000) Histodynamics of endosseous wound healing. In: Davies JE (ed) Bone engineering. Em squared Inc, Toronto, pp 1–14

20.

Dhollander AA, Huysse WC, Verdonk PC, Verstraete KL, Verdonk R, Verbruggen G, Almqvist KF (2009) MRI evaluation of a new scaffold-based allogenic chondrocyte implantation for cartilage repair. Eur J Radiol (e-pub ahead of print)

21.

Dorotka R, Bindreiter U, Macfelda K, Windberger U, Nehrer S (2005) Marrow stimulation and chondrocyte transplantation using a collagen matrix for cartilage repair. Osteoarthritis Cartilage 13:655–664CrossRefPubMed

22.

Duarte PM, Nogueira Filho GR, Sallum EA, de Toledo S, Sallum AW, Nociti FH Jr (2001) The effect of an immunosuppressive therapy and its withdrawal on bone healing around titanium implants. A histometric study in rabbits. J Periodontol 72:1391–1397CrossRefPubMed

23.

Esteves JC, Aranega AM, Borrasca AG, Fattah CM, Garcia IR Jr (2008) Repair process of surgical defects filled with autogenous bone grafts in tibiae of diabetic rats. J Appl Oral Sci 16:316–320CrossRefPubMed

24.

Garrett JC (1994) Fresh osteochondral allografts for treatment of articular defects in osteochondritis dissecans of the lateral femoral condyle in adults. Clin Orthop Relat Res 303:33–37PubMed

25.

Ghazavi MT, Pritzker KP, Davis AM, Gross AE (1997) Fresh osteochondral allografts for post-traumatic osteochondral defects of the knee. J Bone Joint Surg Br 79:1008–1013CrossRefPubMed

26.

Gillogly SD (2003) Treatment of large full-thickness chondral defects of the knee with autologous chondrocyte implantation. Arthroscopy 19(Suppl 1):147–153PubMed

27.

Gold GE, Bergman AG, Pauly JM, Lang P, Butts RK, Beaulieu CF, Hargreaves B, Frank L, Boutin RD, Macovski A, Resnick D (1998) Magnetic resonance imaging of knee cartilage repair. Top Magn Reson Imaging 9:377–392CrossRefPubMed

28.

Gudas R, Kalesinskas RJ, Kimtys V, Stankevicius E, Toliusis V, Bernotavicius G, Smailys A (2005) A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy 21:1066–1075PubMed

29.

Hangody L, Fules P (2003) Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am 85A(Suppl 2):25–32

30.

Harding AK, Aspenberg P, Kataoka M, Bylski D, Tagil M (2008) Manipulating the anabolic and catabolic response in bone graft remodeling: synergism by a combination of local BMP-7 and a single systemic dosis of zoledronate. J Orthop Res 26:1245–1249CrossRefPubMed

31.

Hasselbach C, Witzel U (2007) Klinik und Biomechanik des Knorpelersatzimplantates HemiCAP. In: Deutscher Kongress fuer Orthopaedie und Unfallchirurgie

32.

Hunter DJ, Zhang YQ, Niu JB, Tu X, Amin S, Clancy M, Guermazi A, Grigorian M, Gale D, Felson DT (2006) The association of meniscal pathologic changes with cartilage loss in symptomatic knee osteoarthritis. Arthritis Rheum 54:795–801CrossRefPubMed

33.

Jakobsen RB, Engebretsen L, Slauterbeck JR (2005) An analysis of the quality of cartilage repair studies. J Bone Joint Surg Am 87:2232–2239CrossRefPubMed

34.

Jiang CC, Chiang H, Liao CJ, Lin YJ, Kuo TF, Shieh CS, Huang YY, Tuan RS (2007) Repair of porcine articular cartilage defect with a biphasic osteochondral composite. J Orthop Res 25:1277–1290CrossRefPubMed

35.

Johnson LL (2001) Arthroscopic abrasion arthroplasty: a review. Clin Orthop Relat Res 391:S306–S317CrossRefPubMed

36.

Jones DG, Peterson L (2007) Autologous chondrocyte implantation. Instr Course Lect 56:429–445PubMed

37.

Judex S, Gupta S, Rubin C (2009) Regulation of mechanical signals in bone. Orthod Craniofac Res 12:94–104CrossRefPubMed

38.

Kirker-Head CA, Van Sickle DC, Ek SW, McCool JC (2006) Safety of, and biological and functional response to, a novel metallic implant for the management of focal full-thickness cartilage defects: preliminary assessment in an animal model out to 1 year. J Orthop Res 24:1095–1108CrossRefPubMed

39.

Knutsen G, Engebretsen L, Ludvigsen TC, Drogset JO, Grontvedt T, Solheim E, Strand T, Roberts S, Isaksen V, Johansen O (2004) Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am 86A:455–464

40.

Kon E, Delcogliano M, Filardo G, Altadonna G, Marcacci M (2009) Novel nano-composite multi-layered biomaterial for the treatment of multifocal degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc 17:1312–1315CrossRefPubMed

41.

Kon E, Delcogliano M, Filardo G, Montaperto C, Marcacci M (2008) Second generation issues in cartilage repair. Sports Med Arthrosc 16:221–229CrossRefPubMed

42.

Kreuz PC, Steinwachs MR, Erggelet C, Krause SJ, Konrad G, Uhl M, Sudkamp N (2006) Results after microfracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage 14:1119–1125CrossRefPubMed

43.

Lattermann C, Romine SE (2009) Osteochondral allografts: state of the art. Clin Sports Med 28:285–301CrossRefPubMed

44.

Lazarovici TS, Yahalom R, Taicher S, Elad S, Hardan I, Yarom N (2009) Bisphosphonate-related osteonecrosis of the jaws: a single-center study of 101 patients. J Oral Maxillofac Surg 67:850–855CrossRefPubMed

45.

Lee SJ, Aadalen KJ, Malaviya P, Lorenz EP, Hayden JK, Farr J, Kang RW, Cole BJ (2006) Tibiofemoral contact mechanics after serial medial meniscectomies in the human cadaveric knee. Am J Sports Med 34:1334–1344CrossRefPubMed

46.

Lo GH, Hunter DJ, Zhang Y, McLennan CE, Lavalley MP, Kiel DP, McLean RR, Genant HK, Guermazi A, Felson DT (2005) Bone marrow lesions in the knee are associated with increased local bone density. Arthritis Rheum 52:2814–2821CrossRefPubMed

47.

Lo GH, Niu J, McLennan CE, Kiel DP, McLean RR, Guermazi A, Genant HK, McAlindon TE, Hunter DJ (2008) Meniscal damage associated with increased local subchondral bone mineral density: a Framingham study. Osteoarthritis Cartilage 16:261–267CrossRefPubMed

48.

Mach DB, Rogers SD, Sabino MC, Luger NM, Schwei MJ, Pomonis JD, Keyser CP, Clohisy DR, Adams DJ, O’Leary P, Mantyh PW (2002) Origins of skeletal pain: sensory and sympathetic innervation of the mouse femur. Neuroscience 113:155–166CrossRefPubMed

49.

Magnussen RA, Dunn WR, Carey JL, Spindler KP (2008) Treatment of focal articular cartilage defects in the knee: a systematic review. Clin Orthop Relat Res 466:952–962CrossRefPubMed

50.

Marlovits S, Singer P, Zeller P, Mandl I, Haller J, Trattnig S (2006) Magnetic resonance observation of cartilage repair tissue (MOCART) for the evaluation of autologous chondrocyte transplantation: determination of interobserver variability and correlation to clinical outcome after 2 years. Eur J Radiol 57:16–23CrossRefPubMed

51.

McKinley TO, English DK, Bay BK (2003) Trabecular bone strain changes resulting from partial and complete meniscectomy. Clin Orthop Relat Res 407:259–267CrossRefPubMed

52.

McNickle AG, L’Heureux DR, Yanke AB, Cole BJ (2009) Outcomes of autologous chondrocyte implantation in a diverse patient population. Am J Sports Med 37:1344–1350CrossRefPubMed

53.

Minas T, Gomoll AH, Rosenberger R, Royce RO, Bryant T (2009) Increased failure rate of autologous chondrocyte implantation after previous treatment with marrow stimulation techniques. Am J Sports Med 37:902–908CrossRefPubMed

54.

Mithoefer K, McAdams TR, Scopp JM, Mandelbaum BR (2009) Emerging options for treatment of articular cartilage injury in the athlete. Clin Sports Med 28:25–40CrossRefPubMed

55.

Mithoefer K, Williams RJ 3rd, Warren RF, Potter HG, Spock CR, Jones EC, Wickiewicz TL, Marx RG (2005) The microfracture technique for the treatment of articular cartilage lesions in the knee. A prospective cohort study. J Bone Joint Surg Am 87:1911–1920CrossRefPubMed

56.

Morshed S, Tornetta P 3rd, Bhandari M (2009) Analysis of observational studies: a guide to understanding statistical methods. J Bone Joint Surg Am 91(Suppl 3):50–60CrossRefPubMed

57.

Moyad TF, Minas T (2008) Opening wedge high tibial osteotomy: a novel technique for harvesting autograft bone. J Knee Surg 21:80–84PubMed

58.

Nagura I, Fujioka H, Kokubu T, Makino T, Sumi Y, Kurosaka M (2007) Repair of osteochondral defects with a new porous synthetic polymer scaffold. J Bone Joint Surg Br 89:258–264CrossRefPubMed

59.

Niederauer GG, Slivka MA, Leatherbury NC, Korvick DL, Harroff HH, Ehler WC, Dunn CJ, Kieswetter K (2000) Evaluation of multiphase implants for repair of focal osteochondral defects in goats. Biomaterials 21:2561–2574CrossRefPubMed

60.

Odgaard A, Pedersen CM, Bentzen SM, Jorgensen J, Hvid I (1989) Density changes at the proximal tibia after medial meniscectomy. J Orthop Res 7:744–753CrossRefPubMed

61.

Paletta GA Jr, Manning T, Snell E, Parker R, Bergfeld J (1997) The effect of allograft meniscal replacement on intraarticular contact area and pressures in the human knee. A biomechanical study. Am J Sports Med 25:692–698CrossRefPubMed

62.

Petersen MM, Olsen C, Lauritzen JB, Lund B, Hede A (1996) Late changes in bone mineral density of the proximal tibia following total or partial medial meniscectomy. A randomized study. J Orthop Res 14:16–21CrossRefPubMed

63.

Peterson L, Minas T, Brittberg M, Lindahl A (2003) Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am 85A(Suppl 2):17–24

64.

Pridie E (1959) A method of resurfacing knee joints. J Bone Joint Surg Br 41:618–619

65.

Radin EL, Rose RM (1986) Role of subchondral bone in the initiation and progression of cartilage damage. Clin Orthop Relat Res 213:34–40PubMed

66.

Recht M, Bobic V, Burstein D, Disler D, Gold G, Gray M, Kramer J, Lang P, McCauley T, Winalski C (2001) Magnetic resonance imaging of articular cartilage. Clin Orthop Relat Res 391:S379–S396CrossRefPubMed

67.

Schagemann JC, Erggelet C, Chung HW, Lahm A, Kurz H, Mrosek EH (2009) Cell-laden and cell-free biopolymer hydrogel for the treatment of osteochondral defects in a sheep model. Tissue Eng Part A 15:75–82CrossRefPubMed

68.

Schlichting K, Schell H, Kleemann RU, Schill A, Weiler A, Duda GN, Epari DR (2008) Influence of scaffold stiffness on subchondral bone and subsequent cartilage regeneration in an ovine model of osteochondral defect healing. Am J Sports Med 36:2379–2391CrossRefPubMed

69.

Shirazi R, Shirazi-Adl A (2009) Computational biomechanics of articular cartilage of human knee joint: effect of osteochondral defects. J Biomech 42:2458–2465CrossRefPubMed

70.

Simon WH (1970) Scale effects in animal joints. I. Articular cartilage thickness and compressive stress. Arthritis Rheum 13:244–256CrossRefPubMed

71.

Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG (2003) Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy 19:477–484PubMedCrossRef

72.

Steadman JR, Rodkey WG, Rodrigo JJ (2001) Microfracture: surgical technique and rehabilitation to treat chondral defects. Clin Orthop Relat Res 391:S362–S369CrossRefPubMed

73.

Sugita T, Kawamata T, Ohnuma M, Yoshizumi Y, Sato K (2001) Radial displacement of the medial meniscus in varus osteoarthritis of the knee. Clin Orthop Relat Res 387:171–177CrossRefPubMed

74.

Unay K, Poyanli O, Akan K, Guven M, Demircay C (2009) The relationship between bone marrow edema size and knee pain. Knee Surg Sports Traumatol Arthrosc 17:1298–1304CrossRefPubMed

75.

Vadher SP, Nayeb-Hashemi H, Canavan PK, Warner GM (2006) Finite element modeling following partial meniscectomy: effect of various size of resection. Conf Proc IEEE Eng Med Biol Soc 1:2098–2101CrossRefPubMed

76.

Verhagen R (2004) Thesis: Diagnostic guidelines for chronic ankle pain. 2004, Amsterdam

77.

W-Dahl A, Toksvig-Larsen S (2007) No delayed bone healing in Swedish male oral snuffers operated on by the hemicallotasis technique: a cohort study of 175 patients. Acta Orthop 78:791–794CrossRefPubMed

78.

Wasiak J, Clar C, Villanueva E (2006) Autologous cartilage implantation for full thickness articular cartilage defects of the knee. Cochrane Database Syst Rev 3:CD003323

79.

White AP, Vaccaro AR, Hall JA, Whang PG, Friel BC, McKee MD (2007) Clinical applications of BMP-7/OP-1 in fractures, nonunions and spinal fusion. Int Orthop 31:735–741CrossRefPubMed

80.

Williams RJ, Gamradt SC (2008) Articular cartilage repair using a resorbable matrix scaffold. Instr Course Lect 57:563–571PubMed

81.

Wilson W, van Rietbergen B, van Donkelaar CC, Huiskes R (2003) Pathways of load-induced cartilage damage causing cartilage degeneration in the knee after meniscectomy. J Biomech 36:845–851CrossRefPubMed

82.

Wise SK, Harvey RJ, Neal JG, Patel SJ, Frankel BM, Schlosser RJ (2009) Factors contributing to failure in endoscopic skull base defect repair. Am J Rhinol Allergy 23:185–191CrossRefPubMed

83.

Zengerink M, Struijs P, Tol J, van Dijk C (2009) Treatment of osteochondral lesions of the talus: systematic review. KSSTA (e-pub ahead of print)

84.

Zielinska B, Donahue TL (2006) 3D finite element model of meniscectomy: changes in joint contact behavior. J Biomech Eng 128:115–123CrossRefPubMed

85.

Ziran BH, Hendi P, Smith WR, Westerheide K, Agudelo JF (2007) Osseous healing with a composite of allograft and demineralized bone matrix: adverse effects of smoking. Am J Orthop 36:207–209PubMed

Title: The subchondral bone in articular cartilage repair: current problems in the surgical management
Authors: Andreas H. Gomoll
Henning Madry
Gunnar Knutsen
Niek van Dijk
Romain Seil
Mats Brittberg
Elizaveta Kon
Publication date: 01-04-2010
Publisher: Springer-Verlag
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 4/2010
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-010-1072-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The subchondral bone in articular cartilage repair: current problems in the surgical management

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 4/2010

Microfracture treatment of single or multiple articular cartilage defects of the knee: a 5-year median follow-up of 110 patients

Autologous chondrocyte implantation versus microfracture for knee cartilage injury: a prospective randomized trial, with 2-year follow-up

Non-operative treatment of degenerative posterior root tear of the medial meniscus

Meniscal repair using the FasT-Fix device in patients with chronic meniscal lesions

Disease-specific clinical problems associated with the subchondral bone

Platelet-rich plasma: intra-articular knee injections produced favorable results on degenerative cartilage lesions