Chondral damage within the knee commonly occurs during sport following direct trauma or following degeneration through overuse. Radio frequency energy chondroplasty (RFC) can be used as an alternative to mechanical chondroplasty in the arthroscopic treatment of chondral lesions. Current literature supports the theoretical advantage of RFC and purports to in vitro improvements in cartilage structure and function following RFC. We conducted a retrospective study of patients undergoing RFC for isolated chondral lesions in the knee and assessed the short term clinical benefits. Retrospective analysis was completed of operative notes and arthroscopic images of all patients who underwent arthroscopic chondroplasty at the royal Devon and Exeter Hospital between January 2009 and June 2012. Inclusion criteria included 1 to 2 defined chondral lesions, less than 2cm2, of Outerbridge grade II-IV, treated via arthroscopic RFC. Exclusion criteria included diffuse articular cartilage damage, additional pathologies affecting the knee or subsequent further injuries or invasive procedures to the knee. Data was collected via a subjective and objective questionnaire assessing patient outcome. 35 patients met the inclusion criteria, 32 were successfully followed up. Male: female ratio was 16:16, with a mean age of 39.5 (range 19–60). 84% (n=27) of patients experienced a significant reduction in pain (mean reduction of 51%, p < 0.001) lasting until the time of study (median of 21 months, range 9 to 31 months). There was no correlation between change in symptoms and site and grade of chondral lesion. Pre-operative instability symptoms did not significantly improve following RFC. Satisfaction with treatment was in direct correlation with pain relief achieved. Our study appears to support current literature by suggesting short term improvements to pain following the use of RFC on chondral lesions. Greater population size and longer follow-up are required to provide more significant conclusions

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2–58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7 %(38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

Glenohumeral osteoarthritis (OA) is a challenging clinical problem in young patients. Given the possibility of early glenoid component loosening in this population with total shoulder arthroplasty (TSA), and subsequent need for early revision, alternative treatment options are often recommended to provide pain relief and improved range of motion. While nonoperative modalities including nonsteroidal anti-inflammatory medications and physical therapy focusing on rotator cuff strengthening and scapular stabilization may provide some symptomatic relief, young patients with glenohumeral OA often need surgery for improved outcomes. Joint preserving techniques, such as arthroscopic debridement with removal of loose bodies and capsular release, with or without biceps tenotomy or tenodesis, remains a viable nonarthroplasty option in these patients. Clinical studies evaluating the outcomes of arthroscopic debridement for glenohumeral OA in young patients have had favorable outcomes. Evidence suggests that earlier stages of glenohumeral OA have more favorable outcomes with arthroscopic debridement procedures, with worse outcomes being observed in patients with complete joint space loss and bipolar chondral lesions. More advanced arthroscopic options include inferior osteophyte excision and axillary neurolysis or microfracture of chondral lesions, both of which have demonstrated favorable early clinical outcomes. Patients with some preserved joint space and small osteophytes can avoid arthroplasty and have improved functional outcomes after arthroscopic debridement for glenohumeral OA. Caution should be advised when indicating this procedure for patients with large osteophytes, grade IV bipolar lesions, biconcave glenoids, and complete loss of joint space

Over recent years chondrocyte implantation (MACI) has become a recognised procedure. This paper presents the results of two players in the national rugby league competition who play first grade football and have undergone the procedure. Professional sports medical care can be difficult. Demands from players, the public and coaches are beyond our normal requirements as surgeons. Faced with two high-profile players with career ending focal grade 4 chondral lessions and not responding to our normal treatment methods, I performed chondrocyte implantation (MACI) to deal with this. Both players have responded well to treatment and returned to first grade football. The two players in question had focal grade 4 chondral lesions. They had not responded to treatment and had recurrent effusions restricting their ability to play. Player A required a revision acl reconstruction as he was to be away from the game for a year. I treated his chondral lesion with MACI. His effusion settled and he returned to play with no further delays other than those expected from the acl surgery. Encouraged by this result, I performed the second procedure on a very high- profile player who had recurrent pain and effusion and had been treated with arthroscopies with little improvement. Faced with retirement, he opted for the procedure and returned to first grade the following season

Introduction. Magnetic resonance imaging with intraarticular contrast (arthro-MRI) and radial cuts is the gold standard to quantify labral and chondral lesions in the setting of femoroacetabular impingement. To date, no study exists that has evaluated these findings as potential predictors of outcome for the long term follow-up after surgical treatment of FAI. Objectives. The purpose of this study was to detect potential predictors for failure after surgical hip dislocation for FAI based on specific preoperative arthro-MRI of the hip at a minimum follow-up of 10 years. Methods. Retrospective case series of 97 hips (75 patients) undergoing surgical hip dislocation for FAI between July 2001 and March 2003. Minimum follow-up was 10 years. Twelve radiographic factors were preoperatively evaluated on specific arthro-MRIs with radial cuts of the hips. Patients were then evaluated clinically and radiographically at latest follow-up (mean followup of 11 years, range 10–13 years). The following endpoints were chosen: conversion to total hip arthroplasty (THA), radiographic evidence of progression of osteoarthritis (OA), and/or a Merle d'Aubigné-Postel score of less than 15 indicating a poor clinical result. Univariate and multivariate Cox-regression analysis were performed with these endpoints as failures. Results. Hips with failure at 10-year follow up after surgical hip dislocation where more likely to show typical signs like decentration of the femoral head (52.9% compared to 17% in hips with good long term outcome; p = 0.007) in preoperative arthro-MRI evaluation. The strongest arthro-MRI based predictors of failure at the 10 year follow-up were a ‘double fond’ (hazard ratio with 95% confidence interval, 3.4 [3.2–3.7], p = 0.001), decentration of the femoral head (3.0 [2.8–3.3], p = 0.004) and posterior-inferior femoral osteophytes (3.3 [3.1–3.6], p = 0.002). Conclusions. Factors like double fond, decentration of the femoral head and postero-inferior femoral osteophytes in preoperative arthro-MRI predict inferior long term outcome after surgical hip dislocation for FAI. Therefore we recommend preoperative evaluation with arthro-MRI in addition to conventional radiography

Difficulties arise when counselling younger patients on the long-term sequelae of a minor knee chondral defect. This study assesses the natural history of patients with grade 2 Outerbridge chondral injuries of the medial femoral condyle at arthroscopy. We reviewed all arthroscopies performed by one surgeon over 12 years with Outerbridge grade 2 chondral defects. Patients aged 30 to 59 were included. Meniscal injuries found were treated with partial menisectomy. All patients had five-year follow up minimum. Primary outcome measure was further interventions of total or unicondylar arthroplasty or high tibial osteotomy. We analysed 3,344 arthroscopies. Average follow up was 10 years (Range 5–17 years). A total of 357 patients met inclusion criteria of which 86 had isolated medial femoral condyle disease. Average age was 50 at the time of arthroscopy. Average BMI at surgery was 31.7 and average chondral defect area was 450 mm. 2. Isolated MFC chondral disease had a 10.5% intervention rate. Intervention occurred at a mean of 8.5 years post primary arthroscopy. In young patients Outerbridge II chondral injuries affecting ≥2 compartments have a high rate of further intervention within a decade. This information is crucial in counselling young patients on long-term sequelae of benign chondral lesions

Chondral defects on the patella are a difficult problem in the young active patient and there is no consensus on how to treat these injuries. Fresh osteochondral allografts are a valid option for the treatment of full-thickness osteochondral defects and can be used to restore joint function and reduce pain. The primary purpose of this study was to investigate the clinical and subjective outcomes of a series of patients following fresh osteochondral allograft transplantation for isolated chondral defects of the patella. A series of 5 patients underwent surgery using an open approach for graft transplantation. A strict protocol for the allograft tissue was followed. Transplant recipients must be aged <60, have a full-thickness, isolated chondral lesion and have failed previous traditional treatments. The fresh allografts are hypothermically stored at 4°C in X-VIVO10 media for up to 30 days to maintain cartilage viability. Pre- and post-operative clinical measures including knee stability, range of motion, and quadriceps girth were completed. Post-operative plain radiographs were completed including weight-bearing AP, lateral and skyline views. Patient-centred outcome measures including the Knee Osteoarthritis Outcome Score (KOOS) and the Knee Society Score (KSS) were gathered a minimum of 1-year post-operative. Descriptive and demographic data were collected for all patients. A paired t-test was employed to determine the difference between the pre-operative and post-operative outcomes. All patients were female, with a mean age of 27.4 (SD 3.65). Knee ligament stability was similar pre- and post-operatively. Knee ROM assessment of flexion and extension demonstrated a less than 10° increase from pre to post-operative. Quadriceps girth measurements demonstrated a mean change of 0.5 cm from pre- to post-operative for the surgical limb. Post-operative radiographs demonstrated incorporation of the graft in 4/5 cases within 6-months of surgery. One patient developed fragmentation of the graft after 18-months, and one patient had a subsequent trochleoplasty for persistent pain. The mean KOOS domain scores demonstrated significant improvement (p<0.05) as follows: Symptoms pre-op = 28.57, post-op = 55; Pain pre-op 28.89, post-op = 57.22; ADLs pre-op = 48.92, post-op = 66.18; Sports/Recreation pre-op = 6, post-op = 32; and QoL pre-op = 12.5, post-op = 42.5. Mean pre-op surgical versus non-surgical limb KSS scores were 107.4 and 179 respectively. The mean post-op surgical versus non-surgical limb KSS scores were 166 and 200. Isolated chondral defects of the patella can cause substantial pain, reduced function, and can be challenging to address surgically. This series of 5 cases demonstrated improved function, KOOS and KSS for 4/5 patients. To our knowledge this is a novel biological procedural technique for this problem, which has shown promising results making it a viable treatment option for young active patients with osteochondral defects of the patella

Background:. Different surgical approaches have been proposed for the treatment of chondral lesions. However surgical management of osteochondral defects of the knee joint involving subchondral bone are still under debate. Purpose:. The aim of this prospective non-randomized uncontrolled clinical investigation is to confirm the effectiveness of a commercially available biomimetic osteochondral scaffold in regenerating cartilage and subchondral bone of severe osteochondral lesions of the knee joint with one step surgery. Methods:. The biomimetic scaffold has a multilayer structure consisting of a combination of type I collagen and type I collagen/hydroxyapatite, mimicking the osteochondral connective tissue of the knee joint. From 2009 to 2011, sixty-one patients affected by grade III or IV osteochondral lesions of the knee, according to Outerbridge Classification, were admitted to three centers and received the biomimetic scaffold. Four-nine patients were evaluated using the International Knee Documentation Committee (IKDC), Tegner and VAS scores, and MRI at 1-, 2- and 3-year follow-ups. Biopsies were carried out in 5 patients at an average time of 19.2 months to histologically evaluate the quality of the newly-formed tissue. Results:. All patients tolerated the surgery well; no major adverse events were observed in the early postoperative period. Clinical evaluation of the 49 patients showed a statistically significant improvement in all scores at 1- 2- and 3-year follow-ups as compared to preoperative baseline scores. Improvement in the scores and functional recovery seemed to reach a plateau after 2 years; no significant improvement was seen between the 2- and the 3-year follow-up. Conclusions:. A synthetic biomimetic scaffold used in one-step surgery for the treatment of severe osteochondral knee lesions significantly improved symptoms and joint function, as demonstrated by subjective and objective scoring system evaluation. Furthermore, the athletic subpopulation exhibited a significantly better outcome than the non-athletic subpopulation

The role of magnetic resonance arthrography (MRA) in the evaluation of patients with femoroacetabular impingement (FAI) to assess femoral head-neck junction asphericity and labral pathology is well established. However, in our experience, the presence of acetabular cysts on MRA, which may signify underlying full thickness articular cartilage delamination and progression towards arthropathy, is also an important feature. We retrospectively reviewed 142 hips (mean age 32 years, 47 men, 95 women), correlating the findings on MRA with those found at the time of open surgical hip debridement to ascertain the prevalence of acetabular cysts and the association with underlying acetabular changes. Fourteen MRAs demonstrated features consistent with underlying acetabular cystic change. At the time of surgery, this was confirmed in eleven cases that demonstrated a full thickness articular chondral flap in all cases and an underlying acetabular cyst. The sensitivity, specificity, positive predictive value and negative predictive value of MRA in relation to acetabular cysts was 55%, 97.5%, 78.5% and 92.9% respectively. We believe acetabular cysts on MRA to be a significant finding. Such patients are likely to have an associated full thickness chondral lesion and features of early degenerative change, influencing outcome and prognosis. Our clinical practice has changed to reflect this finding. For those patients with cysts on MRA, we offer open debridement only to the severely affected young and favour arthroscopic debridement in older patients with smaller cams. We believe hip preservation surgeons should be aware of the significance of acetabular cysts and be prepared to adjust treatment accordingly

The role of magnetic resonance arthrography (MRA) in the evaluation of patients with femeroacetabular impingement (FAI) to assess femoral head-neck junction asphericity and labral pathology is well established. However, in our experience the presence of acetabular cysts on MRA, which may signify underlying full thickness articular cartilage delamination and progression towards arthropathy, is also an important feature. We retrospectively reviewed 142 hips (mean age 32 years, 47 men, 95 women), correlating the findings on MRA with those found at the time of open surgical hip debridement to ascertain the prevalence of acetabular cysts and the association with underlying acetabular changes. Fifteen MRA's demonstrated features consistent with underlying acetabular cystic change. At the time of surgery, this was confirmed in eleven cases that demonstrated a full thickness articular chondral flap (carpet lesion) and an underlying acetabular cyst. The sensitivity, specificity, positive predictive value and negative predictive value of MRA in relation to acetabular cysts was 55%, 96.7%, 73.3% and 92.9% respectively. We believe acetabular cysts on MRA to be a significant finding. Such patients are likely to have an associated full thickness chondral lesion and features of early degenerative change, influencing outcome and prognosis. Our clinical practise has changed to reflect this finding. For those patients with cysts on MRA, we are less likely to offer open debridement and favour arthroscopic intervention followed by arthroplasty when symptoms dictate. We believe hip preservation surgeons should be aware of the significance of acetabular cysts and be prepared to adjust treatment options accordingly

Introduction. In recent years, there has been a significant advancement in our understanding of femoro-acetabular impingement and associated labral and chondral pathology. Surgeons worldwide have demonstrated the successful treatment of these lesions via arthroscopic and open techniques. The aim of this study is to validate a simple and reproducible classification system for acetabular chondral lesions. Methods. In our classification system, the acetabulum is first divided into 6 zones as described by Ilizalithurri VM et al [Arthroscopy 24(5) 534-539]. The cartilage is then graded as 0 to 4 as follows: Grade 0 – normal articular cartilage lesions; Grade 1 softening or wave sign; Grade 2 - cleavage lesion; Grade 3 - delamination and Grade 4 –exposed bone. The site of the lesion is further typed as A, B or C based on whether the lesion is 1/3 distance from acetabular rim to cotyloid fossa, 1/3 to 2/3 distance from acetabular rim to cotyloid fossa and > 2/3 distance from acetabular rim to cotyloid fossa. For validating the classification system, six surgeons reviewed 14 hip arthroscopy video clips. All surgeons were provided with written explanation of our classification system. Each surgeon then individually graded the cartilage lesion. A single observer then compared results for observer variability using kappa statistics. Results. We observed a high inter-observer reliability of the classification system with a kappa coefficient of 0.89 (range 0.78 to 0.91) and high intra-observer reliability with a kappa coefficient of 0.91 (range 0.89 to 0.96). In conclusion we have developed a simple reproducible classification system for acetabular cartilage lesions seen at hip arthroscopy

We present a hip mapping system to describe chondral lesions within the hip, and an assessment of its inter-observer reliability and ease of use. The mapping system divides the acetabular articular surface into ten zones (five inner and five outer) and the femoral head into five zones using easily identifiable features. This study was performed by six surgeons during hip arthroscopy of 60 patients. During each operation, one of the surgeons identified up to three small intra-articular features to several (one, two or three) of the other five surgeons. Each surgeon examined the hip independently without discussion and recorded the locations on a hip map. If two surgeons had observed a point, this provided one pair to assess agreement; three or four surgeons provided three or six pairs respectively. Each observation of a point by a pair of surgeons (a point-pair) provided one opportunity for assessment of agreement. One Hundred and Fifty Four points were mapped by two, three or four surgeons, giving 353 point-pairs for assessment. In 325 cases (92%), the pair of surgeons were in agreement, designating the point as within the same zone. On 23 (8%) occasions, there was disagreement but always across a boundary between adjacent zones. Disagreements were more common about points on the femoral head (15) than on the acetabulum (13). Disagreements in acetabulum occurred equally at each radial boundary but only rarely between inner and outer acetabular zones. All surgeons reported that they found the system easy to use. There was no difference in the level of disagreement between more and less experienced surgeons or a learning effect with time. Inter-observer reliability of this mapping system was 92%, supporting the use of a zone based mapping system in clinical practice. This map shows a good balance between precision and reliability

Purpose. The prevalence of focal chondral lesions reported inthe literature during knee arhroscopy can be as high as 63%. Of these, more than half are either grade III or grade IV lesions (Outerbridge). Full thickness cartilage lesions ranging from 2cm2 to 10cm2 are the most challenging to treat. To goal of this study was to evaluate clinical outcomes of pain, function and quality of life, along with radiological outcomes of cartilage repair using microfracture, autologous minced cartilage and polymeric scaffold. Method. A cohort of thirty-eight patients with Outerbridge grade III or IV cartilage injuries larger than 2cm2 in the knee's femoral condyle, trochlea or patella were prospectively folowed since 2008. They were all treated with microfracture, fresh minced autologous cartilage grafting and a polymeric scaffold technique through mini-arthrotomy of the knee. Autografts and scaffolds were secured to subchondral bone using fibrin glue and tran-sosseous resorbable sutures. Patients were evaluated pre and postoperatively using VAS scores for pain, WOMAC and IKDC scores for knee function and SF-36 questionnaire for quality of life. Clinical evaluations were done by physical examination, and imaging was done using X-Rays, MRI and arthro-CT. Results. Mean follow-up time was14.64.6 months. Mean age was 48.39.3 years old. Pre-op lesions averaged 3.51.5 cm2. VAS pain scores were significantly reduced after surgery (7,62 to 2,52.3, p<. 0001). Improvement in knee function using IKDC score improved from 26,717.5 to 55,415.3, p<. 001). In addition, WOMAC total scores showed significant reduction from 55,520.3 to 27,517.6. SF-36 quality of life Physical Component Summary improved from 26,411.4 to 45,812.3, p<. 01; Mental Component Summary improved from 41,916.8 to 49,411.2, p<. 048). Imaging results indicate sustained cartilage thickness from 6 to 18 months. One patient was an early failure due to scaffold loosening, and two patients had no clinical improvement and no significant cartilage regeneration on MRI and Arthro-CT imaging at 6 months post-op. Conclusion. The combination of microfractures, fresh minced autologous cartilage grafting and polymeric scaffold fixation seems to be an effective treatment option for post-traumatic and focal cartilage lesions of the knee in the short term. A longer-term follow-up to evaluate the sustainability of these results is ongoing. Shortcomings of this study are its short term, the lack of second look arthroscopies and cartilage biopsies to evaluate cartilage microstructure, and the absence of a gold standard treatment for full-thickness cartilage lesions larger than 2cm2 that could be used as a control

Degenerate chondral surfaces can be assessed in many ways, but arthroscopy is often performed without proper categorisation, mapping, zoning or sizing of lesions. Progression of disease in un-resurfaced compartments is well-recognised to occur, but is only one of several failure mechanism in partial knee replacement. A validated ‘Functional Zone’ mapping method was used to document articular surface damage in 250 sequential cases of knee arthroscopy in patients over the age of 40. Size, shape, location and severity of each chondral lesion were noted using the Outerbridge classification. Analysis determined rates of involvement of particular compartments and assessed potential for partial replacement or local treatment and also to consider the risk of future progression. Radiographs including antero-posterior standing, postero-anterior flexion views (Rosenberg), lateral and skyline views were graded (Kellgren and Lawrence) and compared with the arthroscopic findings. Our results showed that out of the 210 knees with Grade 3 or greater damage 13.3% of knees showed ‘isolated’ medial disease of Outerbridge Grade 3 or worse. Isolated lateral disease was noted in 1.4%, patello-femoral disease in 24.3%, bi-compartmental (Medial/PFJ) disease in 30.9% with tibio-femoral and tri-compartmental disease seen in 15.2%. The combination of lateral and patello-femoral disease was seen in 14.8%. Provided that Grade 1 and 2 changes (which were found in other compartments in high percentages) were ignored and ACL status considered, this information seemed to indicate that at the time these procedures were performed, 13.3% of cases were suitable for a medial uni-compartmental device, with sub-analysis of lesion sizes indicating that 17 out of 28 cases (60.7%) were suitable for a localised resurfacing. Lateral uni-compartmental replacement seemed suitable for only 1.4%, patello-femoral replacement in 24.3%, bi-compartmental in 30.9% and total knee replacement in 30%. The mean age for partial resurfacing was 53years and 59 years for total joint replacements. Radiological analysis found that the antero-posterior standing views had only 66% sensitivity and 73% specificity for the presence of Grade 3 changes or worse in the medial compartment in comparison with Rosenberg views having a sensitivity of 73% and a specificity of 83%. Skyline views had a sensitivity of 56% and 100% specificity. This study indicates that a large proportion of cases may be suited to local and limited resurfacing. Cases suitable for Patello-femoral and Bi-compartmental replacements were very common, but with the patella-femoral joint's tendency to be more forgiving in terms of symptoms, meaning that indications for uni-compartmental replacement might well be much higher than the arthroscopic findings suggested. On the other hand, the presence of high levels of Grade 1 and 2 changes in other compartments seems to indicate a need for caution particularly in younger patients. This study also indicates a need for better methods of assessing local cartilage health such as enhanced MRI scanning or spectroscopy