Sideline Consult

For Articular Cartilage Injury, a Holistic Approach Is Best

Bert R. Mandelbaum, MD, DHL (Hon)


February 19, 2016

Individualizing Treatment

Sometimes patients have already injured their cartilage so badly by the time they come to me that improving their biomechanics won't fix it.

So the next step is to assess the damage. Using MRI, I grade the articular cartilage defect by diameter and depth, using the Outerbridge Classification for Grading Chondral Lesions of the Knee Arthroscopically or the International Cartilage Repair Society Cartilage Lesion Classification System.

The knee can't send a text or email; it communicates with pain and swelling. So I ask my patients about these symptoms and about the extent of their disability. I situate these patient-reported outcomes on a scale. If you're training and competing and your knee swells every 2-3 weeks, it's very different from "I can't run at all."

I also need to know how that disability is affecting the patient's life. Is this a marathon runner who is competing as part of his or her career? A collegiate athlete? Or a recreational runner?

My mind keeps coming back to the question, How can I return this athlete to sport? Medicine and technology are important, but sports are at the beginning and the end of the work we do with athletes.

In most cases, timing is everything. Recovery from articular cartilage resurfacing surgery usually takes 6-12 months. Sometimes it takes even more time to fully return to sport. So if it's January and the patient is training for the Los Angeles Marathon in February, I don't schedule an operation right away. There's a 100% chance the patient won't have recovered in time to compete.

Instead, I might try a performance-enhancing adjuvant such as injections of hyaluronic acid, platelet-rich plasma (PRP), stem cells, or some combination. Then the patient might have a 50% chance of being able to compete. The choice of which of these adjuvants can be used may depend on the patient's insurance coverage and ability to pay for them. I try to stay on top of this quickly evolving field and make sure that I don't overpromise and underperform.

A lot depends as well on what the patient has already tried that has succeeded or failed. Patients who have tried everything else without success may benefit from surgery. I'll describe my approach to that in my next column.


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