From the Guidelines
Chondral fissuring of the knee should be treated with a combination of non-pharmacological and pharmacological modalities, prioritizing conservative measures such as rest, ice, compression, and elevation (RICE protocol), as well as weight management and physical therapy, before considering surgical interventions like arthroscopic debridement or microfracture. The optimal management of knee osteoarthritis (OA), which often involves chondral fissuring, requires a tailored approach considering factors like knee risk factors, general risk factors, level of pain intensity and disability, signs of inflammation, location and degree of structural damage, and non-pharmacological treatment options including regular education, exercise, appliances, and weight reduction 1.
Conservative Management
Conservative management strategies are crucial in the initial treatment phase. These include:
- Rest, ice, compression, and elevation (RICE protocol) to reduce inflammation
- Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen for pain and inflammation management
- Physical therapy focusing on quadriceps and hamstring strengthening
- Weight management to reduce pressure on damaged cartilage
Pharmacological Interventions
Pharmacological interventions may be necessary for managing pain and inflammation. Key considerations include:
- Paracetamol as the first-line oral analgesic
- Topical applications like NSAIDs or capsaicin for localized relief
- NSAIDs for patients unresponsive to paracetamol, with consideration for gastrointestinal risk and the use of gastroprotective agents or selective COX-2 inhibitors
Surgical Options
For severe or persistent cases, surgical options may be considered:
- Arthroscopic debridement to smooth irregular cartilage edges
- Microfracture to stimulate new cartilage growth
- Other joint-preserving surgical options like osteochondral allograft transplantation (OAT) or autologous chondrocyte implantation (ACI), though these are less commonly used and their application in the knee is less established compared to the hip 1.
Classification and Management
Understanding the classification of chondral damage is essential for guiding treatment. The Outerbridge and Beck classifications are commonly used to grade the severity of chondral lesions, which helps in deciding the appropriate management strategy 1.
Given the complexity and the potential for significant morbidity associated with chondral fissuring of the knee, a stepwise approach starting with conservative management and progressing to more invasive treatments only when necessary is recommended, prioritizing the patient's quality of life, minimizing morbidity, and reducing the risk of mortality associated with surgical complications 1.
From the Research
Chondral Fissuring Knee
- Chondral fissuring of the knee refers to a condition where there are cracks or fissures in the cartilage of the knee joint.
- According to 2, the goals of rehabilitation in chondral lesions are to relieve clinical symptoms, obtain painless full range of motion and muscle strength, and improve function.
- The rehabilitation program should be modified depending on the surgical procedure, and each phase of the rehabilitation program should be designed considering the type of surgical procedure, estimated healing time, restoration of joint mobility and muscle strength, and the extent of pain and effusion.
Causes and Risk Factors
- Chondral injury can occur due to various reasons, including patellofemoral instability, which affects a predominantly young age group 3.
- Biomechanical abnormalities, such as trochlear dysplasia, patella alta, and increased tibial tuberosity-trochlear groove distance, can predispose to both recurrent dislocations and patellofemoral arthrosis.
Treatment Options
- Intra-articular hyaluronic acid injections can provide anti-inflammatory relief and are a viable therapeutic option in treating knee osteoarthritis and suppressing inflammatory responses 4.
- Intra-articular non-steroidal anti-inflammatory drug injections can be an alternative therapy to minimize systemic side effects while maintaining efficacy 5.
- Surgical methods, such as autologous osteochondral transplants and autologous chondrocyte implantation, can be effective in managing chondral lesions, and the choice of treatment depends on the size and location of the lesion, as well as patient factors 6.