Articular Cartilage Lesions in Football Players
LARS PETERSON, CHRISTIAN ERNEST
Introduction
The first physician to recognise the clinical problems associated with cartilage injuries is reported to be Hippocrates in 400 BC. His pupil Herodicus was
supposed to be the first sports medicine doctor treating Olympic athletes.
Trauma or impacts, both occasional and repetitive, can cause damages to the
articular cartilage as well as the subchondral bone in a joint. The reparative
response to articular cartilage injuries is limited. The cartilage has no vascular supply, so unless the subchondral bone is involved, an injury does not
cause bleeding and formation of a blood clot that possibly could fill the cartilage defect. The chondrocytes are unable to migrate into and populate the
defect. Local increase of the synthesis of matrix molecules occurs in the
neighbourhood of the defect during the acute phase but ends at about 2
weeks for unknown reason. Untreated acute lesions penetrating the articular
cartilage of the knee down to bone will likely progress to early post-traumatic osteoarthritis by continued enzymatic degradation activity and mechanical wear over time. Osteoarthritis is an irreversible process and may lead to
considerable disability for the player. The challenge is not only to restore
activities of daily life but also to allow athletes to go back to top-level sports
such as football.
Risk for Cartilage Injuries
Articular cartilage injuries are common in football and may be career ending
if not treated properly. In acute and chronic injuries to the knee joint treated
surgically, more than 40% of patients were found to have articular cartilage
injuries down to bone. Noyes et al. found that acute and chronic anterior cruciate ligament (ACL) injuries were 40–70% associated with articular cartilage
injuries [1, 2.] There are also reports that in 40–50% of cases with meniscus
injury also have cartilage damage. Hjelle et al. reported that in 1,000 consec-
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utive patients with symptoms requiring arthroscopy, chondral or osteochondral lesions of any type were found in 61% [3]. In a study by Drawer and
Fuller on retired English professional players, 32% had osteoarthritis [4].
Levy et al. found a higher risk of chondral injuries in highly skilled football
players [5]. It is thought that the increased risk of articular cartilage injuries
and gonarthrosis in football is due to the high joint stresses associated with
repetitive joint impact, rapid acceleration and deceleration, and pivoting as
well as contact with other players. ACL and meniscus injuries are often combined with articular cartilage injuries where the cartilage injury is the most
serious and hardest to treat.
Symptoms and Diagnosis
As cartilage lesions are likely to progress in size and worsening symptoms
and may cause an end to the career for the player, it is important to diagnose
and treat cartilage lesions at an early stage. Symptoms often associated with
articular cartilage lesions are pain and swelling during or after activity, crepitations, and catching or locking. To diagnose a cartilage lesion, a thorough
clinical examination is needed and includes assessment of ligament instability, varus-valgus malalignment, and patella maltracking or malalignment. Xrays, computed tomography (CT), and especially magnetic resonance imaging
(MRI) are useful tools to diagnose damage to the articular cartilage. The definite diagnosis is taken during arthroscopy and probing of the articular surfaces.
Surgical Treatments
Treating chondral lesions has been a known difficult clinical challenge since
Hippocrates. There are today many different treatment options for cartilage
lesions, such as débridement, coblation, drilling, abrasion, microfracturing,
osteochondral transplantation as in mosaic plasty, and autologous chondrocyte transplantation.
Arthroscopic débridement of loose flaps and rugged surfaces gives shortterm relieve of symptoms and may delay or stop further deterioration of a
cartilage surface. Coblation (vaporisation) may be used with caution and
strictly according to instructions. Drilling, abrasion, and micro-fracturing are
all treatments that penetrate the subchondral bone plate into the bone marrow, which will cause bleeding, and stem cells and fibroblasts can migrate into
the cartilage lesion and produce repair tissue of fibrocartilage [6]. However,
the mechanical properties of the fibrous cartilage are inferior to those of hyaline cartilage and are probably not able to withstand the demands of football
Articular Cartilage Lesions in Football Players
257
over a longer period. Mosaicplasty is a treatment with transplantation of fully
developed osteochondral plugs into drill holes in the defect [7]. The technique is limited to smaller defects since there are not so many plugs that can
be harvested from the articular surfaces before causing too much damage to
the joint.
Autologous chondrocyte transplantation (ACT) is indicated for symptomatic, full-thickness, chondral and osteochondral lesions [including osteochondritis dissecans (OCD)] of the knee with an area between 1 to 2 and 16
cm (Fig. 1). An initial arthroscopy is made, and the cartilage lesion is evaluated and documented regarding size, depth, location, containment, and accessibility for transplantation (Fig. 2). Slices of cartilage are harvested from a
minor load-bearing area in the knee, the most common being the proximal
medial edge of the femoral trochlea. From the cartilage specimens, chondrocytes are isolated and cultured for a minimum of 2 weeks.
The joint is opened, and the arthrotomy is adjusted so the lesion is accessible (Fig. 3a). The patella may have to be dislocated. All damaged and undermined cartilage is radically excised, and the defect is carefully debrided to
vertical edges of healthy cartilage. Care must be taken not to cause any bleeding from the subchondral bone. A periosteal flap, harvested from the upper
medial tibia, is placed on top of the defect, with the cambium layer facing the
Fig. 1. Schematic drawing of autologous chondrocyte transplantation
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L. Peterson, C. Ernest
Fig. 2. Arthroscopic assessment of chondral lesion in
the knee
defect. The flap is sutured to the cartilage edges with resorbable, interrupted
sutures, and the intervals between the sutures are sealed with fibrin glue (Fig.
3b). After checking that the periosteal cover is watertight, the chondrocytes
are injected into the defect and the last opening is closed. The arthrotomy is
closed in layers.
If there is an instability or malalignment of the knee, it is imperative to
surgically treat this ailment either before or at the same time as the ACT. If
not treated, the chances for a successful outcome are greatly reduced. If the
meniscus has previously been totally removed, a meniscal allograft should be
considered.
a
b
Fig. 3a, b. Chondral lesion before (a) and after (b) treatment with autologous chondrocyte transplantation
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Articular Cartilage Lesions in Football Players
Postoperative Treatment and Rehabilitation
Postoperatively, antibiotics are given for the first 48 h, and intermittent continuous passive motion is started 6–8 h after surgery. Weight bearing is limited to 20 kg for the first 6 weeks, then gradually increased to full weight
bearing in the following 6 weeks. The rehabilitation following ACT is long and
focuses mainly on functional training and motion training. Return to football
is judged on an individual level. Clinical follow-up, including strength and
endurance tests as well as arthroscopic evaluation and indentation testing of
the stiffness of the repair tissue, are important before allowing the player to
go back to football training. MRI enhanced with gadolinium contrast may be
useful for assessing the healing. The player starts with individual training and
then gradually goes back to individual football training and then to competitive training and matches (Fig. 4).
a
b
c
d
Fig. 4a-d. a Magnetic resonance imaging (MRI) showing osteochondritis dissecans.
b Same lesion after transplantation of autologous chondrocytes. Second-look
arthroscopy at 4 years (c) and MRI at 9 years (d) show complete healing of defect. The
player was able to return to international-level football
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L. Peterson, C. Ernest
Results
While other treatments often have failed after 2–4 years, ACT has proven to
maintain a good result, even at a long-term follow-up. A recent study comparing osteochondral autologous transplantation with microfracture showed a
higher return to sports at the pre-injury level for the osteochondral grafting
group compared with only 52% of those treated with microfracture [8]. A
study by Mithöfer et al. showed decrease in the functional outcome 24 months
after treatment of symptomatic cartilage lesions in the knee with the
microfracture technique. Only 44% of the patients could go back to highimpact activities such as football [9]. In a Swedish study of the first 61 patients
treated with ACT on femur or patella, 50 were clinically considered good or
excellent at a 2-year follow-up. At a second follow-up of the same cohort 5–11
years after surgery, 51 patients were still good or excellent, no patient had
deteriorated, and the failures occurred before the first follow-up [10].
Follow-up 2–9 years postoperative of the first 101 consecutive patients
with chondral or osteochondral lesions of the knee treated with ACT showed
a 77% good to excellent result overall, and 89–96% in OCD and isolated
femoral condyle lesions. According to the Tegner/Wallgren score, the patients
were also able to have an active life, including football. The modified
Cincinnati score was average 9 out of 10, meaning they could return to highlevel sports, including football. The 2-year follow-up results seem to be an
indicator for the long-term result [11].
In another study by Mithöfer et al., 45 players treated with ACT were followed for a mean of 40 months. Players younger than 26 years, high-skill-level
players, and players operated within 12 months after trauma returned to preinjury level in 83% of cases. Time to return from surgery to football was
12–18 months [12].
Using ACT with scaffolds such as Hyalograft and collagen membranes
(MACI) have recently reported promising short-term results but have still to
be evaluated for longer follow-up and return to football [13–16].
Conclusion
ACT is a treatment for symptomatic, full-thickness, chondral and osteochondral lesions of the knee, which is able to produce a hyaline-like repair tissue
and restore knee function. It is possible to return to football and other highlevel competitive sports; 83% of players could return to football if the operation was within 12 months after injury. If the player can comply with the rehabilitation period of 12–15 months, it seems that ACT as the primary treatment
gives best options for return to football with durable results.
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261
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