Cartilage tissue is a metabolically active tissue. Healthy cartilage has an intercellular substance (matrix) rich in glucosaminoglycan glycoproteins, which hold a high amount of water in its hyaline cartilage structure. It is not a tissue that has the ability to repair itself, except for superficial losses. Since the cartilage cell is not capable of regeneration, the losses can be covered up to 1 mm by matrix production, without cellular migration, which is not the case for the cartilage cell. This type of healing is the healing of hyaline cartilage without scarring..

In superficial losses, if the injury does not reach the subchondral tissue, hyaline healing is achieved without the need for any cellular migration. In full-thickness injuries, we see that a non-cartilaginous tissue plays a role in the defect filled with fibrin and mesenchymal cells after cartilage repair and bleeding. In this case, the repair tissue is in the form of fibrocartilage scar tissue. Scar tissue is a rough, non-slippery tissue on the cartilage surface. It acts like a dead tissue with no active metabolism. The healing margin is uncertain and raised from the surface. The rough surface leads to a situation requiring intervention, which constantly wears and wears, resulting in a painful joint.

Hyaline cartilage provides a smooth and smooth surface as well as providing lubricity, which is one of the basic functions of cartilage. Fibrocartilage, on the other hand, serves as a filling function as a scar tissue and prepares the ground for the inflammatory response with PDGF and TGF-ß mediators released from mesenchymal cells, which have an important place in the physiopathology of arthritis.

Closure of the cartilage defect may be in the form of excessive scar tissue and this tissue may create a mechanical barrier. Osteophyte (bone protrusion-horn) formations are the hard osseous healing tissue of mesenchymal cells with stem cell characteristics, which are involved in the formation of fibrocartilage tissue. Therefore, in addition to the acute inflammatory response, the problems in the late period will be the healing tissue that disrupts the mechanical barrier. Unfortunately, this condition is painless following the recovery of the acute situation after trauma.

DIAGNOSIS

Whether the cartilage injury is traumatic, infection or aging, the diagnosis of the cartilage problem is very difficult after the acute condition (swelling, pain, feeling of being stuck) has disappeared. Examination and analysis of limitations in the patient’s daily life are of great importance in early diagnosis. Magnetic resonance imaging (MRI) is insufficient in the diagnosis of superficial lesions without contrast (arthrography). Findings found close to normal such as increased fluid in MRI reports; tripping, difficulty in climbing/descending stairs are sometimes very obvious, but they may not be innocent. In cases suggesting a mechanical problem, even if the history of the harvest and the findings of the examination do not support the findings of the MRI examination, “Diagnostic Arthroscopy” should not be avoided.

TREATMENT

Cartilage lesions that do not create mechanical barriers can be treated with recessive methods such as anti-inflammatory drugs, ice, and rest when it is sure that the body is within its healing capacity. Physical therapy is very effective in returning the patient to his normal life quickly. This should not exceed 3 weeks. Hyaluronic acid injection (viscosupplementation) and oral intake of glucosaminoglycan drugs (at least 6 months) during cartilage healing complete the treatment. Viscosupplementation has a mechanical and chemical contribution to the regulation of the metabolism of the cartilage matrix. In this respect, it is combined after arthroscopy treatment. If the complaints have not completely disappeared, arthroscopic surgery is the gold standard in cases that cause mechanical obstruction or cannot heal spontaneously.

Arthroscopic Surgical Treatment

It can be Diagnostic, Excisional or Reconstructive.

Diagnostic Arthroscopy is used in the early diagnosis of the cause of joint complaints despite radiological criteria. During arthroscopy, joint examination is performed; Meniscus tears, cartilage softening, cartilage tears, joint mouse (free parts) and ligament lesions are detected and promptly intervened. The intervention may include simple procedures such as removal of the lesion (excision-debridement) or complex applications in the form of repair (reconstructive).

Simple Arthroscopy (Excision-Debridement)

These are procedures such as meniscus tear, removal of cartilage pieces and plica cutting.

The healing potential of hyaline cartilage should be used in superficial cartilage lesions. The parts that are about to break off from the mechanical barrier surface should be taken out and the cartilage should be protected as much as possible.

When a cartilage lesion is detected, innocent folds that may be the cause are investigated and the cause is eliminated.

Arthroscopic Repair:

It covers meniscus repair, ligament repair and cartilage transplantation. If the cartilage loss involves a single surface and has not severely damaged the opposite surface, repair is required if it is a full-thickness injury. In this case, it can be done by providing autologous (own cartilage) from another donor (allograft, xenograft). In addition to arthroscopic applications such as mosaicplasty, there are cartilage transfer surgeries performed by opening the joint.

Considering the advantages of hyaline cartilage healing, similar mechanical problems may be encountered if the tissue formed in cartilage transfers is not aligned with the surface. The hyaline cartilage implanted with the appropriate technique allows the defect to enter the superficial healing process and reshape.

Carbon fiber filler, which is another method used for the closure of the cartilage defect, aims to stimulate the formation of a smooth surface hyaline matrix while preventing excessive development of fibrocartilage tissue. However, since the cartilage surface formed after the method does not provide the expected lubricity, such methods are rarely applied.

In conclusion, arthroscopic treatment is the indisputable gold standard in the diagnosis and treatment of cartilage lesions. However, planning by considering cartilage healing physiology during treatment directly affects patient satisfaction and treatment success.

 

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