Articular cartilage is a load-bearing, deformable tissue that contains few cells and does not contain nerves, vessels and lymph vessels. It is quite thin in many areas and shows significant stiffness against compression forces during loading. When the incoming load exceeds the endurance strength, injuries and therefore losses occur in the cartilage. Articular cartilage lesions may develop slowly due to a chronic disease, or they may begin or accelerate with a traumatic process. The most common pathology in the chronic process is primary or secondary joint disease.
Some risk factors can be mentioned in primary joint disease. These are reasons such as age, gender, genetic factors, obesity, and occupational factors.
In secondary joint disease, there is an underlying cause. Intra-articular fractures caused by trauma, ligament injuries causing instability in the joint, infection, congenital anomalies, rheumatoid arthritis, systemic lupus erythematosus, bleeding diseases, endocrine diseases such as diabetes and hyperparathyroidism, systemic metabolic diseases such as ochranosis and hemachromatosis, some neurological diseases, joint Intravenous cortisone applications can be counted among these reasons.
Cartilage injuries caused by trauma frequently occur due to reasons such as sports and sometimes traffic accidents, and they usually occur in young people. Trauma mostly occurs with direct blows to the joint. It is most commonly seen in the knee and ankle joints and may accompany meniscus and cruciate ligament tears and even joint dislocations. In this way, cartilage or bone-cartilage injuries, fractures and, accordingly, osteochondritis dissecans may develop. Another pathology is cartilage and bone death.
- Cartilage and Bone-Cartilage injuries and fractures
Concerning the articular cartilage and the underlying bone. Cartilage and bone-cartilage lesions may occur with direct or indirect trauma. It usually occurs in the knee region as a result of direct blows to the femur or patella, or in conjunction with acute kneecap dislocation, and is seen on the medial or lateral femoral condyle or the articular surface of the kneecap bone.
Cartilage fractures occur in adults, and bone cartilage fractures affect skeletal development. incomplete child and development It's common in China. The trauma mechanism that leads to their formation is of two types. The first is the avulsion mechanism or crushing caused by a direct impact. The other more common mechanism involves flexion-rotation strain of the knee. Fracture occurs as a result of rotational strain and collision between the tibia and femur or femur and patella.
Cartilage and bone-cartilage fractures must be considered in knee trauma. Otherwise, diagnosis may become difficult and time will be wasted. Cartilage fractures usually do not cause additional symptoms and can lead to cartilage degeneration over time. They may be associated with chronic meniscus and ligament tears.
In bone-cartilage fractures, the trauma is often followed by a louder picture and large intra-articular bleeding. It is quite painful and the knee is bent 15-20 degrees. It may not be possible for the patient to even walk or stand. If there is no sign of ligament injury and the fluid withdrawn from the joint is bleeding and contains fat globules, a bone-cartilage fracture should be suspected, and if the fracture only involves cartilage tissue, most of the time, no pathology may be visible on the radiograph. Some patients may experience episodes of locking and pain in changing positions, in which case diagnosis is easier. For diagnosis, anteroposterior, lateral, tangential, tunnel and oblique knee radiographs should be taken. Tangential radiographs are especially valuable for the kneecap. Since the intercondylar notch will appear wider on tunnel radiographs, the likelihood of a bone-cartilage fracture increases. In more suspicious cases, a definitive diagnosis can be made with computed tomography (CT) and magnetic resonance (MR) techniques. Especially MRI is a reliable method in diagnosis. It is valuable not only in determining the injury but also in showing whether it has been separated from the main bone and the condition of the joint surface. Nevertheless, the best and latest method in diagnosis is arthroscopy, and in addition to the diagnosis, it can provide precise information about the size and location of the pathology.
In the ankle, bone-cartilage injuries are most frequently observed on the roof of the talus bone. Talar bone-cartilage injuries should be considered especially in persistent pain after an ankle sprain. It has been reported that 50% of ligament and bone injuries of the ankle occur due to bone-cartilage injury. He was enlarged. In most cases, complaints begin after a major trauma, while in some cases, they follow a more chronic course. In addition to persistent pain in the ankle, other symptoms include swelling, weakness and limitation of movement. It increases with load and sports activity. Locking is rare, there may be complaints of ejaculation. It may accompany chronic ankle instability. Pain may occur due to injuries in the front when the ankle is pulled back, or in the back when it is bent down. If the symptoms persist for more than 4-6 weeks after the ligament injury in the ankle, bone-cartilage injury should be suspected. Locking and loosening are symptoms of a displaced bone fragment.
Radiography and MRI may be taken for diagnosis. Anteroposterior, lateral, mortis and especially loading radiographs should be taken as direct radiographs. However, in 50% of cases, direct radiographs are inconclusive and therefore diagnosis can be made especially with T2-weighted MRI sequences. The most common location on the roof after trauma is the anterior-external and posterior-internal regions, and the lesions on the inner side are found to be more frequent and generally larger and deeper than the outer ones.
- Osteochondritis dissecans
It develops after a major trauma or repeated small traumas, when the nutrition of the bone under the cartilage is impaired and the unfed bone, together with the cartilage on it, separates from the main bone and falls into the joint. Apart from trauma, local bone nutrition deterioration, systemic vascular diseases, endocrine, metabolic and genetic factors have also been blamed as causes.
The most common complaint is poorly localized anterior knee pain and recurrent swelling. If the tissue becomes detached and falls into the joint, mechanical symptoms such as locking and snagging may occur.
The most common and classic location is the outer side of the medial femoral condyle, around the attachment point of the posterior cruciate ligament. On direct radiography, the lesion appears as a slightly whitened island of bone separated by a thin line from the underlying bone. MRI is the gold standard for evaluating the articular cartilage and underlying bone and determining prognosis. In T2 weighted sections, a high density line is observed between the separated piece and the main bone.
- Osteonecrosis (Bone death)
It is a pathology that occurs in the bones forming the knee joint and often in the medial condyles of the femur and tibia. It is a condition that is very difficult to treat and is frequently observed to deteriorate. Among the causes, there are reasons such as trauma, cortisone use, alcoholism, fat storage diseases, sickle cell anemia.
Osteonecrosis defines three different conditions: Spontaneous osteonecrosis, secondary osteonecrosis and postarthroscopic osteonecrosis.
Primary osteonecrosis is also called spontaneous or idiopathic osteonecrosis. It is more common in women and over the age of 60. Usually, a sudden increase in pain occurs with a minor trauma in a previously mildly painful knee. It takes 6-8 weeks and heals gradually. It is mostly located in the medial femoral condyle, and is more rarely seen in the lateral femoral condyle and tibial plateau.
Secondary osteonecrosis is more common under the age of 55 and there is an underlying cause. Involvement is more common. It can occur in both knees and even other joints. The most common cause is cortisone use due to another disease. Other causes include alcoholism, some autoimmune diseases, rheumatoid arthritis, sickle cell anemia, Gaucher disease, inflammatory bowel diseases, renal transplantation, familial hyperlipidemia, Caisson disease.
Another reason is that arthroscopy is often required in elderly patients. It is osteonecrosis seen in the postoperative period. In these cases, while there is no sign of osteonecrosis before the surgery, the postoperative picture becomes evident, and in some cases, not enough time has passed for osteonecrosis to become visible.
In the clinic, the onset is usually sudden and there is local tenderness in the knee area. In primary osteonecrosis, there is chronic mild pain in the anamnesis, as mentioned before, and the patient mentions a minor trauma. There is limitation of movement, inability to walk long distances, and swelling. No pathology can be detected on direct radiographs taken in the early period. On examination, osteonecrosis should be suspected if widespread and intense tenderness is detected in the femur or tibia condyles, but not in the joint space. Sometimes it may be accompanied by a meniscus tear. The patient should be questioned about a chronic disease, cortisone and alcohol use, and the possibility of secondary osteonecrosis should be investigated.
In radiological examination, anteroposterior, lateral, tangential and tunnel radiographs should be taken. It may not cause any symptoms at first, but over time, the injury to the bone under the cartilage may become visible. Over time, it is observed as a flattening of the shape of the condyle and a radiolucent area in the subchondral region and surrounding sclerosis. If the event progresses, joint disease with narrowing of the joint space and bone protrusions completes the event over the years.
MRI is the most valid diagnostic method in osteonecrosis. It has become the first preferred diagnostic method because it provides early images, shows the relationship of the lesion with the articular cartilage and its age. Signal changes begin to be observed on MRI approximately 4-6 weeks after the onset of symptoms. Spontaneous osteonecrosis is typically observed as extensive edema extending to the bone marrow and a focus showing low signal intensity in the area under the cartilage. Temporary bone density decrease, inflammation, joint disease, and infiltrative tumors should be considered in the differential diagnosis.
In secondary osteonecrosis, the lesions are larger, affecting both femoral and tibial condyles and even both knee joints and other joints. It is common.
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