1. Articular Cartilage Injury
Diagnosis & Classification
Dr. Vipul Vijay
MBBS MS DNB DipSICOT
Att. Consultant, Indraprastha Apollo Hospitals,
New Delhi

2. Tire Analogy
Tread of a tire = articular cartilage

3. Degenerative

4. Traumatic

5. Bad to the Bone

6. History
Type of injury
Timing of injury
Location
Duration of symptoms

7. Symptoms Retro-patellar/peri- patellar pain.
Pain in popliteal fossa – in lesions of the trochlea.
Pain usually secondary to
capsular/synovial irritation
sub-chondral bone overload
Locking
Clicking
Feeling of giving way
Activity related knee swelling
Increased pain with prolonged flexed knee position and stair climbing

8. Examination ROM Joint swelling Joint line tenderness
Gait analysis, to assess
Intoeing
Hip abductor weakness
Valgus mal-alignment of the limb
(these predispose knee to injury and alters PF joint biomechanics)
Palpation of medial & lateral patellar retinaculum for tenderness
Patellar mobility, tilt & subluxation in ML plane
Quadriceps wasting especially of VMO

9. Examination
Q angle
Should be measured in both extension and 300 flexion
laterally subluxed patella in full extension can falsely decrease the Q-angle
Patella should be repositioned in the central sulcus before measuring the Q-angle
J-sign
Patient slowly extends knee from full flexion, patella subluxe laterally once it leaves the constraints of trochlear groove near full extension
(may suggest patho laxity of the medial soft tissues, specially the MPFL)

10. Imaging Radiographs *Standing anteroposterior (AP)
*45° flexion posteroanterior (PA “Rosenberg”)
*Flexion lateral
*Shallow angle axial (Merchant)
*Long leg axial
True lateral radiograph useful in assessing trochlear dysplasia
Patellar tilt not always appreciated on Merchant view

11. X-rays

12. Imaging CT of the patello-femoral joint
Tibial tubercle to trochlear groove (TT-TG distance)
-superposition of two CT images, one through the patello-femoral articulation, the other through the tibial tubercle
-calculate the distance between the centre of the TG and the centre of the TT are marked, and medial-to-lateral distance between two is measured
- 15 mm normal
- >20 mm, consider tibial tubercle osteotomy

13. Imaging Magnetic resonance imaging Arthroscopy - gold standard for
- 100% sensitivity and 81.5% specificity
- Allows staging of chondral lesions
- May detect very early intra cartilaginous lesions
- PD and T2 images are useful
Arthroscopy - gold standard for
assessing articular injury

14. Imaging of articular cartilage - MRI
Accurate assessment of cartilage thickness
Demonstrate changes of cartilage surface
Demonstrate changes in internal cartilage signal intensity
Allow evaluation of sub-chondral bone for signal intensity abnormalities

15. Imaging of articular cartilage - MRI
Standard techniques
FSE / TSE
SPOILED GRE IMAGES
DRIVEN EQUILIBRIUM FOURIER TR.
STEADY STATE FREE PRECESSION
Physiologic imaging
T2 MAPPING
Na+ IMAGING
DIFFUSION WEIGHTED IMAGING
CONTRAST ENHANCED IMAGING

16. MRI – cartilage lesions
T1 WI
FSE T2 – Fat Sat

17. FSE T2 WI
FSE T2 Fat Sat
FSE PD Fat Sat
3D SPGRE
Fat Sat

18. recalled gradient acquisition
Partial thickness Cartilage defect
These set of images demonstrate partial thickness cartilage defect – on 3D SPGRE & FSE T2 WI.
3D SPGR
3 dimensional spoiled
recalled gradient acquisition
FSE T2 WI

19. Focal Cartilage damage
d/to trauma
These again show focal cartilage damage following trauma. Marrow edema is an excellent marker for cartilage injury, but is not seen with relatively T1 weighted SPGRE technique.
3D SPGR
FSE T2 WI

20. Cartilage Fissure FSE T2 WI 3D SPGR
Sag. FSE T2 WI shows this cartilage fissure outlined by bright synovial fluid. But the underlying cartilage is better seen on SPGRE image.
FSE T2 WI
3D SPGR

21. 3D SPGRE image shows this cartilage ‘step-off’
3D SPGRE image shows this cartilage ‘step-off’. Note FSE T2 WI shows less detail of the cartilage. This is the arthroscopy picture of the same site.
3D SPGR

22. Subchondral Osteophyte
FSE T2 WI
3D SPGR
Subchondral osteophyte is a sign of cartilage damage.
Subchondral Osteophyte

23. Delaminating Cartilage injury
Sag 3D SPGRE image shows delamination of the trochlear cartilage. Another adjacent slice shows piece of delaminated cartilage in the joint.
Delaminating Cartilage injury

24. Grading of cartilage lesions
Outerbridge RE. The aetiology of chondromalacia patellae. J Bone Joint Surg [Br] 1961;43-B:752-7.

25. Cartilage Lesion Classification

26. Cartilage Lesion Classification

27. Cartilage Lesion Classification

28. Cartilage Lesion Classification

29. Baeur & Jackson classification
Chronic degrading
has the worst
prognosis

30. Grading of Chondral lesions

31. Grading of Chondral lesions

32. Inter-observer variations in grading
Compared 2 trainees with one senior surgeon
Rating system used was not discussed
Concluded variation in experience was the primary determinant of disagreement.
Javed A, Siddique M, Vaghela M, Hui AC. Interobserver variations in
intra-articular evaluation during arthroscopy of the knee. J Bone Joint
Surg Br. 2002;84:48-49.

33. Inter-observer variations in grading
Classified 19 knees using Outerbridge, Collins & French Society of Arthroscopy scores
4 surgeons
Good inter- and intra-rater reliability of ll grading systems
Brismar BH, Wredmark T, Movin T, Leandersson J, Svensson O.
Observer reliability in the arthroscopic classification of osteoarthritis
of the knee. J Bone Joint Surg Br. 2002;84:42-47.

34. Inter-observer variations in grading
6 cadaver knees underwent arthroscopy and then arthrotomy
Outerbridge classification was used
Surgeons with more than 5 years in practice had a κ of 0.72 compared to a κ of 0.50 among fellows and surgeons with fewer than 5 years in practice.
A κ of 1.00 means perfect agreement and 0.00 means agreement completely by chance.
Cameron ML, Briggs KK, Steadman JR. Reproducibility and reliability
of the Outerbridge classification for grading chondral lesions of the
knee arthroscopically. Am J Sports Med. 2003;31:83-86.

35. Inter-observer variations in grading
Less than 25% variation in the assessment of full thickness cartilage lesions amongst surgeons.
Arthroscopy remains the gold standard.
Agreement in Arthroscopic and Arthrotomy Assessment of Full-Thickness Articular
Cartilage Lesion. Asbjørn Årøen, Cartilage : 214

36. Conclusion Number of classification systems are available.
Moderate to good agreement b/w orthopaedic surgeons using any classification.
Arthroscopic grading classification can be used for multi-center studies which involve multiple surgeons.
Agreement improves with the experience of the orthopeadic surgeon.
Arthroscopic evaluation remains the gold standard but newer MRI techniques are catching up.

37. Thank you