Cartilage Injuries

By Asheesh Bedi, MD

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Since seven-time All-Star Tracy McGrady of the Houston Rockets opted for season-ending microfracture surgery on his knee Feb. 24, 2009 new attention has been focused on cartilage injuries in athletes. Cartilage injuries in the knee are common in collegiate and professional athletes in all sports, although contact and high-impact activities greatly increase the risk factor.

There are two types of cartilage in the knee: articular cartilage and the meniscus. Articular cartilage provides a smooth surface for bones to glide against one another and as a shock absorber. Unlike most tissues in the body, the articular cartilage that lines the surfaces of our joints has no inherent ability to regenerate. We are born with what we have and protecting it is of paramount importance, as progressive cartilage injury and loss can lead to degenerative wear and arthritis. Focal cartilage injuries from trauma can affect any of the surfaces of the knee including the femoral, tibial and patellar surfaces. Bipolar or “kissing” defects occur when opposing surfaces of a joint have pathologic lesions. These are among the most difficult and problematic to treat.

Cartilage injuries often result from a twisting or pivoting motion. Patients complain of sharp pain in the knee, usually localized to the area of the cartilage injury. Swelling, catching, clicking or locking in the knee may occur. X-rays and MRIs are both extremely useful in diagnosing the condition. Certain cartilage injuries respond well to a period of rest, anti-inflammatory medication and physical therapy. Sometimes, however, surgery is necessary. If a piece of cartilage is missing, leaving exposed bone, the goal of surgery is to try to fill the defect with repair tissue.

According to Dr. Thomas Wickiewicz, a sports medicine specialist at Hospital for Special Surgery and the former president of the American Orthopedic Society for Sports Medicine, “Microfracture surgery has become a widely used first line treatment for focal cartilage injuries in athletic individuals.”

Microfracture is a marrow stimulation that is commonly utilized to treat focal, symptomatic cartilage defects in the knee. In a microfracture surgery, small channels are created by the surgeon, which provide access to the bone marrow deep to the cartilage surface. Stem cells can then migrate from the marrow to fill the defect and form an enriched blood clot. The cells then differentiate into a cartilage-like tissue that fills the defect and provides a smooth contact surface. This procedure is done arthroscopically, with patients going home the same day of the surgery.

“There is variability in the clinical success, but in those that get a reasonable ‘fill’ on the defect with fibrocartilage, the improvements have been noticeable,” says Wickiewicz.

Outcomes can be influenced by a number of factors, including the severity and size of the defect, number of defects, patient age, compliance and rehabilitation. A number of NBA players, including Amare Stoudemire, Jason Kidd, and Antonio McDyess, have returned following microfracture surgery and continue to play at the highest level. Others, such as Anfernee Hardaway and Jamal Mashburn struggled in their returns from surgery. Wickiewicz concludes that “lingering concerns about the long-term durability of the repair tissue remain,” but hopefully McGrady will be in the group of players that get back to the NBA and have a long, productive career.

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