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PHTH 7212 Pathophysiology > Knee patho (articular cartilage)- Dr Davies > Flashcards

Knee patho (articular cartilage)- Dr Davies Flashcards

1
Q

Chondral Injuries

A 
one of the most common problems in the knee
OA (the most common)
RA
OCD
AVN
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2
Q

some of the things he talks about that can be found when looking for chondral changes

A

medial capsule
rough looking inside the joint
if theses a chunk missing in the cartilage (OCD)
*white defects on an MRI can be an OCD

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3
Q

Hallmarks of OA

Fairbank’s Changes

A

joint space narrowing
bones spurs
Sclerotic borders
Subchondral bone cysts

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4
Q

Non surgical treatment of OA

A 
drug therapy
exercise
weight loss
aerobic exericse
foot wear
surfaces
PT (stretching, strengthening, etc)
OA unloader braces
nutrition supplements
intra-articular injections (synvisc)
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5
Q

Intra-articular injections

A

Synvisc
its like the synovial fluid in the joint space
when a pt is walking on bone on bone (no cartridge), adding a fluid medium can decrease the contact force
the AAOS has come out saying that it is not helpful in controlled studies; however, Dr Davies has had so many pts that swear by them (can prolong getting surgery)

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6
Q

Knee Surgeries

A 
Chondral Lesions
Lavage
Chondroplasty
Microfracture
Mosaiplasty- autograft
OATS- autograft
Osteochondral allograft
ACI
MACI
DeVova
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7
Q

Classification system for the (layers of the bone) Articular cartilage defects

A 
*be able to draw this*
Articular Surface
Superficial Tangential Zone (10-20%)
Middle Zone (40-60%)
Deep Zone (30%)
Subchondral Bone
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8
Q

Superficial Tangential Zone (fibers alignment)

A

horizontal

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9
Q

Middle Zone (fiber alignment)

A

criss- cross- for support

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10
Q

Deep Zone (fiber alignment)

A

vertical

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11
Q

What are the different classification systems for grading articular cartridge

A

Outerbridge Classification
Kellgren and Lawrence Radiographic Criteria for Assessment of OA
ICRS (international cartilage repair society)

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12
Q

Grade 1 classification of cartilage

A

a little bit of fraying on the top in the superficial layer (mostly softening)

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13
Q

Grade 2 classification of cartilage

A

into the superficial layer and some into the middle layer

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14
Q

Grade 3 classification of cartilage

A

into the middle layer and some in the deep layer

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15
Q

Grade 4 classification of cartilage

A

subchondral bone

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16
Q

Bone Contusion

A

80-100% of pts who have an ACL injury will have a geographic bone contusion
*the femoral condyle will hit the tibial plateau when there is that pivot shift that injuries that ACL
Causes trabecular mirco-fractures that result from traumatic injuries to the bone, most commonly about the knee
Has significant impact on what we can do with rehab

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17
Q

Tibial Osteotomy

A

If they have malaligment, they will do an osteotomy to straighten out the tibia
If there is a lot of genu verum (causing pressure/ compression), they will go in and cut a wedge in order to straight out the tibia
There is no point to go in and fix the joint if there will still be a lot of pressure on that joint to cause more damage

18
Q

Arthroscopic Lavage

A

*placebo effect (effective 15-70% of the time)
There is an inflow and outflow cannula to washout the joint. When there is degenerative stuff going on in the joint, there are little pieces of articular cartridge floating around in the synovium. This will cause irritation in the synovium, which causes the synovium to produce more fluid.
It is effective if it is only a grade 2; if it down to subchonrdral bone, it will not be effective.
*Is believed to remove the mediators of inflammation and any loose, free flaps, or pieces of cartilage that may be present; this will relieve the patients symptoms

19
Q

Study by Moseley on Arthroscopic Lavage

A

3 groups: Arthroscopic debridement, Arthroscopic lavage, and placebo (just incisions on the skin)
*in the New England Journal Medical (level 1 study)
*the patients and assessors where blinded
At no point did either of the surgical intervention groups report less pain or better function than the placebo group

20
Q

Surgical Treatment of Arthroscopic lavage (problem)

A

Literature doesn’t show it does a thing! and yet insurance is spending thousands and thousands to do this surgery.
*we cant get money for a fall prevention program (system is broken)

21
Q

Chondroplasty

A

go in and trim off the excess and use a bur to smooth off the articular cartilage
*he doesn’t think it would help anything because it further decreases the amount of articular cartilage

22
Q

Microfracture

A

One of the go to procedure because it is easy
*will use on an OCD lesion
Will trim all the margin out to make it smooth
Will use an awe (used to use a drill, but the heat would kill the chondrocyte cells around it)
Stimulates the mesenchymal stem cells to produce the fibrocartilage (instead of the original hyaline cartilage) at the subchondronal bone level

23
Q

Mosaicplasty- autograft

A

similar to the OATS but Mosaicplasty uses small plugs
*used on OCD lesions
They will harvest bone plugs from a non-weight bearing, non-significant articulating surface, which is usually the superior lateral trochlea
Will fill in the gap if the gap of the OCD lesion with the bone plugs

24
Q

OATS-autografts

A

Osteochondral Autograft Transfer System
Will harvest bone plugs from a non-weight bearing, non-significant articulating surface, which is usually the superior lateral trochlea.
These bone plugs will be larger than the mosaicplasty.
*better long term outcome than the mircofracture because it is true hyaline cartilage

25
Q

Problem with Mosaicplasty and OATS

A

taking away bone in order to use it somewhere else
*Robbing Peter to Pay Paul
Will often weaken the bone; there has been times when fractures occur

Also, have to be careful to make sure that all the bone plugs are level. If they are not level, then a bump will be “proud.” This will create a rough articulating surface against the opposite surface.

26
Q

Osteochondal allograft

A

When you have a large lesion, there may not be enough autograft tissue. It may be better to take the allograft tissue.
The lesion will be smoothed out before the allograft tissue will be inserted.
The allograft tissue can be sized exactly to the large lesion instead of having a few smaller plugs.

27
Q

ACI (what does it stand for)

A

Autologous Chondrocyte Implantation

28
Q

ACI

A

Genyzme or Carticel
Four generations
been around for quite a while

29
Q

First Generation ACI

A

ACI periosteal patch
Have to go in and take a syringe to uptake the chondral cells from the pt
Will send the syringe and have the cells stimulated to multiple
Will prepare the base.
Will take a periosteal flap from the tibial plateau and sow the patch around the defect and inject the new cells into the patch.
Inject from the top; use lots of sutures; glue on top

30
Q

Second Generation ACI

A

matrix ACI patch

31
Q

Third Generation ACI

A

collagen based ACI patch

32
Q

Fourth Generation ACI

A

gel based ACI

inject the cells into the gel so that the cells will not float away

33
Q

DeNova

A

taking juvenile allograft tissue; kids who has passed away- takes the tissue and using this tissue instead of adult tissue
younger tissue heals faster/ much better quality tissue than older tissue
WIll put this tissue into the OCD to enhance the healing

34
Q

Tissue Engineering

A

so much is happening now

ACI (gel based), etc

35
Q

Return to activity (for different surgeries)

A

Chonrdroplasty: 2-4 weeks
Marrow stimulation/ Microfracture: 3-12 months
ACI: 14-18 months
Osteochondral autochondral/ allograft: 6+

36
Q

TKA/ TKR

A

total knee replacement
end stage salvage procedure
older people

37
Q

Compartments that can replaced in a TKR

A

Patellofemoral
Medial
Lateral
*if one is replaced- unicompartmental replacement/ partial knee replacement

38
Q

Components in a TKR

A

Femoral (press fit or cemented)
Patellar (may or may not resurface)
Tibial stem

39
Q

Surgical Incision for TKR

A

Tradition- 20-30 cm
Mini- 12-14 cm
MIS (muscle sparing)- 7-10 cm

40
Q

TKR/TKA Rehab Protocols

A 
Varies with pt
Varies with MC
Varies with co-morbidities
Varies with type of procedures
Varies with type of prosthesis

PHTH 7212 Pathophysiology (12 decks)

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