Knee cartilage problems in young patients

In this episode of PodMD, experienced Orthopaedic Surgeon Dr Murilo Leie will be discussing the topic of knee cartilage problems in younger patients, including the type of problems that young people see, the main risks involved, the current treatment options, when a GP should refer and more.


  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Murilo Leie

    Dr Murilo Leie is an experienced Orthopaedic Surgeon specialising in conditions of the Hip and knee. Dr Leie is practising in Joondalup as well as the surrounding hospitals.

    Dr Leie completed his MBBS in Brazil in 2011 and went on to achieve a Master’s in Surgical Science in 2017. Murilo pursued multiple fellowships, including Knee Surgery in Sydney and Perth, focusing on ACL surgery, knee replacement, and robotic procedures. In 2021, he finalised his studies with a fellowship in Robotic Hip and Knee Arthroplasty and is now qualified in five different subspecialties and fellowships.

    Today, we’ll be discussing the topic of Knee cartilage problems in younger patients.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Murilo, thanks for talking with us on PodMD today.

    Murilo : Thank you for having me.

    Question 1
    The topic of today’s discussion is Knee Cartilage problems in young patients. Can you describe for our listeners the type of knee cartilage problems young people see?

    Murilo: Well, first of all, we have to define what is young people. Yeah, and this is quite relative, but we usually consider 40 years old as younger to that being younger and after 40, so you would considering other type of treatments. OK for this group of younger patients. So the cartilage problems can be classified first of all as purely cartilage involvement or chondral sometimes you will say or involving both bone and cartilage, and that’s what we will call osteochondral defects.

    So the injuries can be classified by location in one or multiple area. But most commonly, it’s on the femoral condyles of the knee as well as tibial plateau, but patellofemoral joint as well need to be looked at. So we can classify them based in on time of injury and presentation. So acute the ones with within four weeks from initial injury or chronic, those who are longer than four weeks since initial injury, your presentation, so you also can classify them as a traumatic or atraumatic most of time there is a mechanism of injury. There is an accident or the patient being tackled, sports, but sometimes there’s no history of trauma and that’s why we have to suspect as well.

    Question 2
    How would a patient with knee cartilage problems typically present?

    Murilo: Typically, a patient will present with a history of recent trauma from pain by pain or clicking sensation or feeling of internal knee movement. That’s how the patients report. Sometimes they say I feel something moving inside. For instances, the knee locks and that may occur if the control lesion detaches completely from the native location and can be jammed between femur and tibia, so, but as I said, similar symptoms and complaints can manifest in absence of trauma history. Always be aware.

    Question 3
    What are the risks of the condition?

    Murilo: So essentially chondral lesions of the knee of great concern because there is limited ability of the cartilage to heal and potential for chronicity of the lesion. OK. Also, patients are usually young and they are involved in high level of competitive sports so. If they diagnose, missed lesions become chronic and there will be limited options of treatment, lighter, OK, and there’s nothing worse than manage young patient with chronic pain in the rooms. Where there are limited options of treatment. However, if the lesion is diagnosed earlier, the success rates of current treatments can be quite high, so it’s very important ongoing monitoring as well and managing to ensure there’s possible outcome and best knee function for our patients.

    Question 4
    What are the treatment options?

    Murilo: So the treatment of osteochondral or chondral lesions of the knee will depend on the size of the lesion location as well as patient demands and level of participation in sports. Microfracture procedure is the most common treatment for chondral injuries of the knee, and this is an arthroscopic day procedure involving key holes, right? So the surgeon softens the edge of the defect, maintaining a certain level of containment and perform micro perforations on the subchondral bone, using a one or two millimetre drill. So this stimulates stem cells to produce fibre calculus. Their own. But note that this procedure is only indicated for small lesions at 2 square centimetres in low demand patients.

    We also have another procedure called Maciwhich is spelled MACI and that stands for matrix autologous chondrocyte implementation. This is a 2 step procedure which is indicated for patients who present with larger lesions purely or involving cartilage with no bone involvement and usually in high demand or high level of participation in sports patient. So the first step involves a simple Arthroscopy where health is small sample of the cartilage harvest and that’s sent to the lab for individual growth. This process takes on average six weeks, so after that the second step involves in planting the newly grown cells back into the patients knee and a [inaudible] is typically used to and suture into the defect. So this procedure has level A evidence supports. It’s used in patients with overall 90% of survivorship of the MACI graft around 20 years Mark. So this is the preferred method for treating large lesions in high demand patients.

    However, when the patient has osteochondral defects, so this is why it’s so important to define. If it’s a purely cartilage or cartilage and bone involved. If this is the situation. We have to repair or reconstruct bone and cartilage, so the options are essentially. One, it’s called mosaic plastic, so it’s also a keyhole procedure. Sometimes a mini open arthrotomy is performed and that consists of autologous which means graft coming from the own patient where we have. Best small plugs of bone and cartilage from a non-weight bearing area of the knee, usually medial or lateral edge edge of the [inaudible] to insert into the defect, which is usually in a weight bearing area. Most important the medial femoral [inaudible].

    But if the lesion is too large and by too large, I would say more than 10-15 square millimetres, so we would considering osteochondral allograft transplantation. And when we say that allograph means. The graft come from a donor. And for this procedure we need to find a size and a shape specific donor to harvest a matching size and shape of the osteochondral defect. So this procedure is performed in one stage. But it might take some time until a matching donor is found, so it’s very specific protocols needed, such as MRI and CT scans, to find that matching donors. So. So those are the overall most common treatment options for control or osteochondral lesions of the knee in young patients.

    Question 5
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Murilo: So of course, as I said, carpal injury in the knee in young population is a significant problem. So this issue has led to numerous research studies and development of new techniques, all aiming to achieving better outcomes for this patient. So one of the trials currently in place. Is assessing the long term results of a different procedure known as [inaudible], Autologous cartilage implantation, so this procedure is essentially involves an Arthroscopy, it’s a keyhole procedure, single stage operation where a special device, a unique shaver allows the surgeon to harvest non weight bearing and non-important outside minced cartilage samples from the patients knee.

    So these samples are then implanted into the defect during the same procedure. However, we do not have yet long term results for this procedure and we don’t have a comparison yet with MACI, which is the golden standard so far. But the trials are being run and I’m sure we will have results soon and I’m excited to see what will be.

    Question 6
    Are there any warning signs a GP or their patient can look out for?

    Murilo: Yes, I would say there are some warning signs for GPs to look for. And firstly, history, if there is a recent trauma, as I said, most of the time precedes the diagnosis. Also, patients will complain of locking sensation or they have sensation of something moving inside the knee as they say priority on examination you can find from infusion in the knee. Sometimes the range of motion is limited. Or even the knee can be locked. If the fragment is jamming the joint, so those are the red flags in history and examination, I would recommend that GP to look for a potential osteochondral lesion of the knee.

    Question 7
    What is the likelihood of recurrence of the condition?

    Murilo: I would say a recurrence is not very common if the surgical procedure is accurately performed. However, what’s important is always to look at the contralateral side. Some conditions such as osteochondritis dissecans of the knee or OCD as it’s known, can affect the contralateral siding 50% of the time. So even if patient is asymptomatic. Always look to the other side and sometimes treatment is recommended even in plain X-rays. Requested X-ray to the other side for comparison.

    Question 8
    When should a GP refer?

    Murilo: So as I have stated, chondral lesions of any young patients are we’re concerned as soon as the diagnosis is made and usually we need imaging for that. I would be happy to see your patient and define treatment so it can be complex to decide who needs an operation or not. Essentially if a patient has a chondral injury of the knee and is symptomatic. Most of the time, surgery was recommended so as earlier the we intervene better for the patient to prevent further damage of the remaining cartilage.

    Question 9
    What role does the GP play in the treatment of the condition?

    Murilo: So GPS are essential in treatment of chondral injuries in young patients, especially because they are the first suspect. And you’ll be the first to make to diagnose. So how do we make the diagnosis? Most of the time is with imaging. OK, so plain X-rays can show large defect, or if the defect has already been detached. So this is called an unstable lesion. Sometimes you can even see a floating loose bodyinside the knee. But most of the time, an MRI scan will be required. So if you suspect and if you see change in X-rays such as a joint lining, congruity or a loose body, please request an MRI. You will give us more information regarding size, location, stability of the lesion or if bone involvement or purely a cartilage involvement. So that’s critical another scan.

    I always recommend it’s Mackey view X-rays and Mackey view consists of a long length view of both legs and with that we can define what’s the alignment of the patient in some situations. If the patient has a more alignment such as severe, various or valgus. I mean, sometimes we need to address or correct the patients alignment prior to doing osteochondral procedures. So you GP are the first suspect and to make the diagnosis and this is critical.

    Unfortunately, there are limited applicability for conservative treatment. If a patient has osteochondral lesions. So sometimes for small stable lesions, which are the ones that we look at on MRI and there is the lesions still attach it to the native one and especially if the patient has open growth plate, we can also non operative treatment, right. So basically consists of non-weight bearing or protective weight bearing for six weeks with a repeated MRI. So the purpose is to look at if the chondral lesion has healed in six weeks, but if there’s not much progress made, this would be the time to request and refer to a orthopaedic surgeon.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on ACL surgery.

    Murilo: Of course, if you take these three messages home, my mission is accomplished alright, first suspect, right? If a young patient who participate in sports, present with pain and clicking in the knee, this should be the first suspicions

    Secondly, right image. Ensure the correct images of time, so this should include a non weight bearing AP latter and Skyline X-ray of both knees for comparison. Additionally, a Mackey view of the lower limbs and of course an MRI scan.

    Thirdly, quick action if there isn’t certainty regarding whether the lesion is stable or unstable or if it can be treated non opportunity or if the type of injury requires an operation promptly contact your an orthopaedic surgeon. So share these scans. Discuss the case. The sooner the better. I’m always available and happy to discuss guys, even on phone.

    Thanks for your time and the insights you’ve provided.

    Murilo: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.