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Articular Cartilage: Postoperative Imaging
Donna G. Blankenbaker, MD, FACR; Kirkland W. Davis, MD, FACR; Andrew Sonin, MD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        TERMINOLOGY

        • Synonyms

          • Mosaicplasty: trade name for 1 method of performing osteochondral transplant of multiple small osteochondral plugs
        • Definitions

          • Variety of surgical techniques to repair or replace damaged or missing articular cartilage surfaces in knee
          • All techniques begin with removal of abnormal articular cartilage
          • Bone marrow stimulation techniques
            • Appropriate for smaller lesions
            • Puncture of subchondral bone releases pluripotential stem cells that form fibrocartilaginous scar
            • Resulting scar does not have biomechanical properties of normal cartilage
            • Long-term results not as good as with transplant and autologous chondrocyte implantation (ACI) techniques
            • Types of procedures; may be used in combination
              • Microfracture ("pick" procedure)
                • Multiple small holes are created in subchondral bone with awl to promote bleeding → fibrocartilaginous scar
                • Most commonly performed marrow stimulation procedure
                • Integrity of repair may degrade at 18-36 weeks
                • Newer procedures add scaffold or polymer to site to augment process
                • e.g., autologous matrix-induced chondrogenesis: porcine collagen matrix added to surgical site with fibrin glue
                • Considered 1st-line procedure for treatment of cartilage defects
                • Good clinical outcomes for smaller lesions (< 2-4 cm in size, in younger patients)
              • Abrasion arthroplasty
                • Underlying subchondral bone is roughened using arthroscopic burr to promote bleeding and subsequent scar formation in chondral defect
                • Less commonly used due to risk of thermal necrosis and injury to underlying bone
              • Subchondral drilling
                • Drill used to trephine subchondral bone and promote bleeding → fibrocartilaginous scar
                • Less commonly used due to risk of thermal necrosis and injury to underlying bone
          • Biodegradable pin/screw fixation
            • Biodegradable pins used to stabilize lesion
              • In situ unstable osteochondral lesions
              • Cartilage flap tears
            • Pins resorb in 6-24 months
            • Variably threaded metallic screws still used by some surgeons
          • Osteochondral transplantation
            • Osteochondral autograft transfer system (OATS), autologous osteochondral transplant (AOT), and mosaicplasty often used interchangeably in literature and clinical practice: osteochondral autograft will be used to refer to all procedures here
            • Appropriate for lesions 1-4 cm²
            • Osteochondral plugs inserted into lesion
            • Osteochondral autograft
              • Harvested from non-weight-bearing surface, usually lateral trochlea > margin of intercondylar notch
              • Relies on presence of usable donor cartilage
              • Possibility of donor site morbidity
              • Several fragments may be placed to fill 1 large defect (mosaicplasty)
                • Spaces between plugs eventually fill in with fibrocartilaginous grout
            • Osteochondral allograft
              • Cadaveric graft material
              • Used for larger lesions
              • Allows for rectangular or round grafts
              • Original concern for immune response and disease transmission not substantiated in practice
          • ACI
            • Appropriate for lesions 2-12 cm²
            • Patient's own cartilage harvested from non-weight-bearing surface
            • Cells grown in culture for 3-5 weeks to produce chondrocytes
            • Periosteal or synthetic cover/membrane sewn or glued over defect
            • Cultured chondrocytes injected under cover of periosteal sleeve
            • Resulting cartilage hyaline-like, thought to have biomechanical properties similar to native cartilage
              • Commonly complicated by hypertrophy of periosteum
            • Increased long-term durability
          • Matrix-associated chondrocyte implantation (MACI)
            • 3D biologic scaffold optimized for culture of seeded autologous chondrocytes implanted in defect by miniarthrotomy
            • Trimmed to fit defect and glued in place
          • Stem cell transplantation
            • Intraarticular injection of stem cells from various sources
            • Results are variable
            • Controversial
          • Leukocyte-rich, platelet-rich plasma
            • Potential conservative treatment for knee osteoarthritis

        IMAGING

        • General Features

          • CT Findings

            • MR Findings

              • Imaging Recommendations

                PATHOLOGY

                • Microscopic Features

                  CLINICAL ISSUES

                  • Natural History & Prognosis

                    DIAGNOSTIC CHECKLIST

                    • Consider

                      • Reporting Tips

                        Selected References

                        1. Kenmochi M: Clinical outcomes following injections of leukocyte-rich platelet-rich plasma in osteoarthritis patients. J Orthop. 18:143-9, 2020
                        2. Tradati D et al: AMIC-autologous matrix-induced chondrogenesis technique in patellar cartilage defects treatment: a retrospective study with a mid-term follow-up. J Clin Med. 9(4):1184, 2020
                        3. Zamborsky R et al: Surgical techniques for knee cartilage repair: an updated large-scale systematic review and network meta-analysis of randomized controlled trials. Arthroscopy. 36(3):845-58, 2020
                        4. Hede K et al: Combined bone marrow aspirate and platelet-rich plasma for cartilage repair: two-year clinical results. Cartilage. Epub, 2019
                        5. Liu YW et al: MR imaging of cartilage repair surgery of the knee. Clin Imaging. 58:129-39, 2019
                        6. Hayashi D et al: Understanding magnetic resonance imaging of knee cartilage repair: a focus on clinical relevance. Cartilage. 9(3):223-36, 2018
                        7. Oei EHG et al: Cartilage imaging: techniques and developments. Semin Musculoskelet Radiol. 22(2):245-60, 2018
                        8. Redondo ML et al: Preservation of knee articular cartilage. Sports Med Arthrosc Rev. 26(4):e23-30, 2018
                        9. Campbell AB et al: Return to sport after articular cartilage repair in athletes' knees: a systematic review. Arthroscopy. 32(4):651-68.e1, 2016
                        10. Oussedik S et al: Treatment of articular cartilage lesions of the knee by microfracture or autologous chondrocyte implantation: a systematic review. Arthroscopy. 31(4):732-44, 2015
                        11. Forney MC et al: Magnetic resonance imaging of cartilage repair procedures. Magn Reson Imaging Clin N Am. 22(4):671-701, 2014
                        12. Trattnig S et al: MR imaging of postoperative talar dome lesions. Semin Musculoskelet Radiol. 16(3):177-84, 2012
                        13. Hughes RJ et al: Clinical and MRI considerations in sports-related knee joint cartilage injury and cartilage repair. Semin Musculoskelet Radiol. 15(1):69-88, 2011
                        14. Harris JD et al: Treatment of chondral defects in the athlete's knee. Arthroscopy. 26(6):841-52, 2010
                        15. Van Assche D et al: Autologous chondrocyte implantation versus microfracture for knee cartilage injury: a prospective randomized trial, with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc. 18(4):486-95, 2010
                        16. Welsch GH et al: T2 and T2* mapping in patients after matrix-associated autologous chondrocyte transplantation: initial results on clinical use with 3.0-Tesla MRI. Eur Radiol. 20(6):1515-23, 2010
                        17. Gold GE et al: Recent advances in MRI of articular cartilage. AJR Am J Roentgenol. 193(3):628-38, 2009
                        18. Kon E et al: Matrix-assisted autologous chondrocyte transplantation for the repair of cartilage defects of the knee: systematic clinical data review and study quality analysis. Am J Sports Med. 37 Suppl 1:156S-66S, 2009
                        19. Nehrer S et al: Treatment of full-thickness chondral defects with hyalograft C in the knee: a prospective clinical case series with 2 to 7 years' follow-up. Am J Sports Med. Suppl 1:81S-7S, 2009
                        20. Potter HG et al: New techniques in articular cartilage imaging. Clin Sports Med. 28(1):77-94, 2009
                        21. Trattnig S et al: MR imaging of cartilage and its repair in the knee--a review. Eur Radiol. 19(7):1582-94, 2009
                        22. Van Assche D et al: Physical activity levels after characterized chondrocyte implantation versus microfracture in the knee and the relationship to objective functional outcome with 2-year follow-up. Am J Sports Med. 37 Suppl 1:42S-9S, 2009
                        23. Choi YS et al: MR imaging of cartilage repair in the knee and ankle. Radiographics. 28(4):1043-59, 2008
                        24. Domayer SE et al: MRI monitoring of cartilage repair in the knee: a review. Semin Musculoskelet Radiol. 12(4):302-17, 2008
                        25. McNickle AG et al: Overview of existing cartilage repair technology. Sports Med Arthrosc. 16(4):196-201, 2008
                        26. Potter HG et al: Magnetic resonance imaging of cartilage repair. Sports Med Arthrosc. 16(4):236-45, 2008
                        27. Welsch GH et al: Cartilage T2 assessment at 3-T MR imaging: in vivo differentiation of normal hyaline cartilage from reparative tissue after two cartilage repair procedures--initial experience. Radiology. 247(1):154-61, 2008
                        28. Williams Iii RJ et al: Cartilage repair procedures: clinical approach and decision making. Instr Course Lect. 57:553-61, 2008
                        29. Tins BJ et al: Autologous chondrocyte implantation in knee joint: MR imaging and histologic features at 1-year follow-up. Radiology. 234(2):501-8, 2005
                        30. Recht M et al: MR imaging of cartilage repair procedures. Skeletal Radiol. 32(4):185-200, 2003
                        Related Anatomy
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                        Related Differential Diagnoses
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                        References
                        Tables

                        Tables

                        KEY FACTS

                        • Terminology

                          • Imaging

                            • Pathology

                              TERMINOLOGY

                              • Synonyms

                                • Mosaicplasty: trade name for 1 method of performing osteochondral transplant of multiple small osteochondral plugs
                              • Definitions

                                • Variety of surgical techniques to repair or replace damaged or missing articular cartilage surfaces in knee
                                • All techniques begin with removal of abnormal articular cartilage
                                • Bone marrow stimulation techniques
                                  • Appropriate for smaller lesions
                                  • Puncture of subchondral bone releases pluripotential stem cells that form fibrocartilaginous scar
                                  • Resulting scar does not have biomechanical properties of normal cartilage
                                  • Long-term results not as good as with transplant and autologous chondrocyte implantation (ACI) techniques
                                  • Types of procedures; may be used in combination
                                    • Microfracture ("pick" procedure)
                                      • Multiple small holes are created in subchondral bone with awl to promote bleeding → fibrocartilaginous scar
                                      • Most commonly performed marrow stimulation procedure
                                      • Integrity of repair may degrade at 18-36 weeks
                                      • Newer procedures add scaffold or polymer to site to augment process
                                      • e.g., autologous matrix-induced chondrogenesis: porcine collagen matrix added to surgical site with fibrin glue
                                      • Considered 1st-line procedure for treatment of cartilage defects
                                      • Good clinical outcomes for smaller lesions (< 2-4 cm in size, in younger patients)
                                    • Abrasion arthroplasty
                                      • Underlying subchondral bone is roughened using arthroscopic burr to promote bleeding and subsequent scar formation in chondral defect
                                      • Less commonly used due to risk of thermal necrosis and injury to underlying bone
                                    • Subchondral drilling
                                      • Drill used to trephine subchondral bone and promote bleeding → fibrocartilaginous scar
                                      • Less commonly used due to risk of thermal necrosis and injury to underlying bone
                                • Biodegradable pin/screw fixation
                                  • Biodegradable pins used to stabilize lesion
                                    • In situ unstable osteochondral lesions
                                    • Cartilage flap tears
                                  • Pins resorb in 6-24 months
                                  • Variably threaded metallic screws still used by some surgeons
                                • Osteochondral transplantation
                                  • Osteochondral autograft transfer system (OATS), autologous osteochondral transplant (AOT), and mosaicplasty often used interchangeably in literature and clinical practice: osteochondral autograft will be used to refer to all procedures here
                                  • Appropriate for lesions 1-4 cm²
                                  • Osteochondral plugs inserted into lesion
                                  • Osteochondral autograft
                                    • Harvested from non-weight-bearing surface, usually lateral trochlea > margin of intercondylar notch
                                    • Relies on presence of usable donor cartilage
                                    • Possibility of donor site morbidity
                                    • Several fragments may be placed to fill 1 large defect (mosaicplasty)
                                      • Spaces between plugs eventually fill in with fibrocartilaginous grout
                                  • Osteochondral allograft
                                    • Cadaveric graft material
                                    • Used for larger lesions
                                    • Allows for rectangular or round grafts
                                    • Original concern for immune response and disease transmission not substantiated in practice
                                • ACI
                                  • Appropriate for lesions 2-12 cm²
                                  • Patient's own cartilage harvested from non-weight-bearing surface
                                  • Cells grown in culture for 3-5 weeks to produce chondrocytes
                                  • Periosteal or synthetic cover/membrane sewn or glued over defect
                                  • Cultured chondrocytes injected under cover of periosteal sleeve
                                  • Resulting cartilage hyaline-like, thought to have biomechanical properties similar to native cartilage
                                    • Commonly complicated by hypertrophy of periosteum
                                  • Increased long-term durability
                                • Matrix-associated chondrocyte implantation (MACI)
                                  • 3D biologic scaffold optimized for culture of seeded autologous chondrocytes implanted in defect by miniarthrotomy
                                  • Trimmed to fit defect and glued in place
                                • Stem cell transplantation
                                  • Intraarticular injection of stem cells from various sources
                                  • Results are variable
                                  • Controversial
                                • Leukocyte-rich, platelet-rich plasma
                                  • Potential conservative treatment for knee osteoarthritis

                              IMAGING

                              • General Features

                                • CT Findings

                                  • MR Findings

                                    • Imaging Recommendations

                                      PATHOLOGY

                                      • Microscopic Features

                                        CLINICAL ISSUES

                                        • Natural History & Prognosis

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Reporting Tips

                                              Selected References

                                              1. Kenmochi M: Clinical outcomes following injections of leukocyte-rich platelet-rich plasma in osteoarthritis patients. J Orthop. 18:143-9, 2020
                                              2. Tradati D et al: AMIC-autologous matrix-induced chondrogenesis technique in patellar cartilage defects treatment: a retrospective study with a mid-term follow-up. J Clin Med. 9(4):1184, 2020
                                              3. Zamborsky R et al: Surgical techniques for knee cartilage repair: an updated large-scale systematic review and network meta-analysis of randomized controlled trials. Arthroscopy. 36(3):845-58, 2020
                                              4. Hede K et al: Combined bone marrow aspirate and platelet-rich plasma for cartilage repair: two-year clinical results. Cartilage. Epub, 2019
                                              5. Liu YW et al: MR imaging of cartilage repair surgery of the knee. Clin Imaging. 58:129-39, 2019
                                              6. Hayashi D et al: Understanding magnetic resonance imaging of knee cartilage repair: a focus on clinical relevance. Cartilage. 9(3):223-36, 2018
                                              7. Oei EHG et al: Cartilage imaging: techniques and developments. Semin Musculoskelet Radiol. 22(2):245-60, 2018
                                              8. Redondo ML et al: Preservation of knee articular cartilage. Sports Med Arthrosc Rev. 26(4):e23-30, 2018
                                              9. Campbell AB et al: Return to sport after articular cartilage repair in athletes' knees: a systematic review. Arthroscopy. 32(4):651-68.e1, 2016
                                              10. Oussedik S et al: Treatment of articular cartilage lesions of the knee by microfracture or autologous chondrocyte implantation: a systematic review. Arthroscopy. 31(4):732-44, 2015
                                              11. Forney MC et al: Magnetic resonance imaging of cartilage repair procedures. Magn Reson Imaging Clin N Am. 22(4):671-701, 2014
                                              12. Trattnig S et al: MR imaging of postoperative talar dome lesions. Semin Musculoskelet Radiol. 16(3):177-84, 2012
                                              13. Hughes RJ et al: Clinical and MRI considerations in sports-related knee joint cartilage injury and cartilage repair. Semin Musculoskelet Radiol. 15(1):69-88, 2011
                                              14. Harris JD et al: Treatment of chondral defects in the athlete's knee. Arthroscopy. 26(6):841-52, 2010
                                              15. Van Assche D et al: Autologous chondrocyte implantation versus microfracture for knee cartilage injury: a prospective randomized trial, with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc. 18(4):486-95, 2010
                                              16. Welsch GH et al: T2 and T2* mapping in patients after matrix-associated autologous chondrocyte transplantation: initial results on clinical use with 3.0-Tesla MRI. Eur Radiol. 20(6):1515-23, 2010
                                              17. Gold GE et al: Recent advances in MRI of articular cartilage. AJR Am J Roentgenol. 193(3):628-38, 2009
                                              18. Kon E et al: Matrix-assisted autologous chondrocyte transplantation for the repair of cartilage defects of the knee: systematic clinical data review and study quality analysis. Am J Sports Med. 37 Suppl 1:156S-66S, 2009
                                              19. Nehrer S et al: Treatment of full-thickness chondral defects with hyalograft C in the knee: a prospective clinical case series with 2 to 7 years' follow-up. Am J Sports Med. Suppl 1:81S-7S, 2009
                                              20. Potter HG et al: New techniques in articular cartilage imaging. Clin Sports Med. 28(1):77-94, 2009
                                              21. Trattnig S et al: MR imaging of cartilage and its repair in the knee--a review. Eur Radiol. 19(7):1582-94, 2009
                                              22. Van Assche D et al: Physical activity levels after characterized chondrocyte implantation versus microfracture in the knee and the relationship to objective functional outcome with 2-year follow-up. Am J Sports Med. 37 Suppl 1:42S-9S, 2009
                                              23. Choi YS et al: MR imaging of cartilage repair in the knee and ankle. Radiographics. 28(4):1043-59, 2008
                                              24. Domayer SE et al: MRI monitoring of cartilage repair in the knee: a review. Semin Musculoskelet Radiol. 12(4):302-17, 2008
                                              25. McNickle AG et al: Overview of existing cartilage repair technology. Sports Med Arthrosc. 16(4):196-201, 2008
                                              26. Potter HG et al: Magnetic resonance imaging of cartilage repair. Sports Med Arthrosc. 16(4):236-45, 2008
                                              27. Welsch GH et al: Cartilage T2 assessment at 3-T MR imaging: in vivo differentiation of normal hyaline cartilage from reparative tissue after two cartilage repair procedures--initial experience. Radiology. 247(1):154-61, 2008
                                              28. Williams Iii RJ et al: Cartilage repair procedures: clinical approach and decision making. Instr Course Lect. 57:553-61, 2008
                                              29. Tins BJ et al: Autologous chondrocyte implantation in knee joint: MR imaging and histologic features at 1-year follow-up. Radiology. 234(2):501-8, 2005
                                              30. Recht M et al: MR imaging of cartilage repair procedures. Skeletal Radiol. 32(4):185-200, 2003